Acute-on-chronic liver failure triggered by postpartum variceal bleeding in a patient with alcohol-associated liver disease

Pregnancy in women with cirrhosis carries substantial maternal risk, with variceal bleeding being one of the leading causes of mortality. Acute-on-chronic liver failure (ACLF) is a distinct clinical entity, yet cases triggered by postpartum variceal bleeding are uncommon. We describe a 41-year-old woman with alcohol-associated cirrhosis who conceived through in vitro fertilization and had no varices on endoscopy performed one year before delivery. On postpartum day 4 after cesarean section, she developed massive hematemesis from newly developed esophageal varices, culminating in ACLF with grade 4 hepatic encephalopathy and coagulopathy. Endoscopic variceal ligation successfully controlled the hemorrhage, while therapeutic plasma exchange and hemodiafiltration were required to manage hepatic encephalopathy. She ultimately made a complete recovery without liver transplantation. This case underscores the immediate postpartum period as a uniquely vulnerable window in women with cirrhosis, during which rapid hemodynamic shifts may precipitate variceal rupture and ACLF. It also suggests that repeat endoscopic screening during pregnancy may be warranted for selected high-risk patients.