Elective caesarean birth in a patient with autoimmune hepatitis with cirrhosis and extensive rectus sheath varices

Cirrhosis in pregnancy poses significant anaesthetic challenges, particularly when complicated by extensive abdominal wall varices, an exceptionally uncommon and high-risk finding with minimal published guidance. We report a 30-year-old primigravida at 36 weeks' gestation with autoimmune cirrhosis and extensive rectus sheath varices undergoing elective caesarean birth. Given the anticipated potential for major haemorrhage, robust multidisciplinary planning was undertaken with hepatobiliary surgeons for performing modified abdominal entry in a specialist theatre environment. Goal-directed coagulation treatment was guided by serial thromboelastography supporting surgical haemostasis. Postoperative recovery was uncomplicated following an admission to a specialist intensive care unit. This case discusses potential limitations of conventional coagulation tests in cirrhosis and supports viscoelastic testing for individualised targeted therapy. We highlight the importance of adapting anaesthetic planning to the competing principles of major haemorrhage preparedness and obstetric anaesthesia and emphasise the critical role of multidisciplinary coordination and surgical adaptation in reducing risk.