Living-donor liver transplantation at 17 weeks gestation for hepatitis B virus-related acute liver failure with hepatic encephalopathy with emergency cesarean delivery at 34 weeks: a case report.

Liver transplantation during pregnancy is rare but may be lifesaving in cases of acute liver failure occurring before fetal viability. A primigravida with chronic hepatitis B virus (HBV) infection developed HBV-related acute liver failure with grade III hepatic encephalopathy at 17 weeks gestation. Because delivery could not improve fetal survival, the multidisciplinary team prioritized transplantation while pregnancy continued. Laboratory investigations demonstrated severe thrombocytopenia and hypofibrinogenemia. Anesthetic management was guided by predefined maternal physiologic and hematologic targets to support uteroplacental perfusion and included temporary portosystemic shunting. Staged fetal ultrasonography confirmed viability. Surgery lasted 10 h 55 min, with 2,410 mL blood loss. The mother recovered. Following preterm premature rupture of membranes, breech presentation prompted an emergency cesarean delivery at 34 weeks with spinal anesthesia, followed by neonatal intensive care. This case shows that when delivery cannot offer fetal rescue, urgent transplantation and continued pregnancy can be integrated through multidisciplinary decision-making and specialized perioperative management.