With clock ticking, surgery saves mother and child

Lucile Packard Children's Hospital

Leonard Mattingly feels doubly blessed after the unprecedented back-to-back cesarean-section delivery and liver transplant operation that rescued both his son John and his wife Michelle.

Michelle Mattingly's liver was failing so fast that doctors at Lucile Packard Children's Hospital thought the baby she was carrying—still 14 weeks before his due date—was doomed. It would be miraculous enough if they and their colleagues at Stanford Hospital & Clinics could save the life of the mother, who had fallen into a coma.

"We were thinking we'd be lucky to get one live person out of this situation, and we didn't know which it would be," said William Benitz, MD, chief of neonatology at Packard Children's.

Michelle and her husband, Leonard, feel fortunate that their whole family is now safe at home, having just celebrated their infant son's first Christmas. Michelle and baby John survived the crisis thanks to an unprecedented operation in August that required intense collaboration among medical experts and a dash of down-to-the-wire luck. Never before have back-to-back cesarean and liver transplant surgeries rescued both a mother so ill and an infant so premature.

"We were treading into unknown territory," said Maurice Druzin, MD, the obstetrician who delivered John. Druzin is chief of obstetrics at Lucile Packard Children's Hospital and specializes in high-risk deliveries.

It certainly was dramatic. Michelle was nauseated and in pain when she and Leonard came on Aug. 3 to Packard Children's labor and delivery department. The couple, married three years and parents of a toddler daughter, had wanted to be sure everything was OK for Michelle and their eagerly awaited son. As the Packard staff monitored Michelle, they detected an alarming spike in blood indicators of liver failure. They rushed her next door to the adult intensive care unit at Stanford Hospital.

Over the next several hours, Michelle's liver stopped filtering toxins from her bloodstream. The toxic buildup in her blood caused her to slip into a coma the next day, on the evening of Aug. 4.

As Michelle grew sicker, Stanford's adult liver transplantation team carefully evaluated her case. After determining that the liver failure was not caused by pregnancy, the team decided against an immediate cesarean.

"With the mother in that condition, she would have died, no question," said Carlos Esquivel, MD, PhD, chief of the division of transplantation surgery at Packard Children's and Stanford. "Patients in liver failure cannot tolerate the stress of surgery."

The liver makes blood-clotting factors, and Michelle's clotting-factor levels were so low that her risk of bleeding to death during cesarean was extreme. With her pregnancy just six months along, an immediate cesarean risked the baby's life, too. Leonard Mattingly and Michelle's doctors had to make some extraordinarily difficult choices.

"We decided we would do whatever it took to save Michelle, even if it meant losing the baby," said Tami Daugherty, MD, clinical assistant professor of gastroenterology and hepatology who coordinated Michelle's care by the transplant team. The team hoped they could ensure Michelle's safe return to her life as a homemaker and as the mother to daughter Elektra.

The doctors opted to stabilize Michelle and wait for a donor liver, placing her on the national list for an urgent transplant on Aug. 5. They gave her steroids to help the baby's lungs mature and transfused blood to reduce her levels of blood toxins and to raise her clotting-factor levels. They had to find a donor organ before Michelle died or suffered permanent brain damage from the toxins in her blood.

"They told us we had 72 hours to get her a new liver," said Leonard, who is stationed in Sunnyvale, Calif., as a petty officer second class with the U.S. Navy.

Over the next few days, the transplant team had to reject two donor livers. The first did not match Michelle's immune system; the second contained cancerous cells. Finally, with time running out, a third liver became available.

"They told me if that liver wasn't a match, Michelle's chances were very slim," Leonard said.

But the organ matched.

At 11:03 a.m. on Aug. 8, Druzin's high-risk obstetrics team delivered John, who was rushed to the neonatal intensive care unit at Packard Children's. Esquivel's transplant team immediately began operating to give Michelle a new liver. The transplant worked. "To end up with the mom and child surviving all this is unbelievable," said Esquivel.

Added Druzin: "The strength of being at a place like Packard is the ability to have world experts in all fields collaborate on very unusual cases like this."

After the operation, Michelle spent about a month in the hospital, gradually regaining awareness and healing from her surgeries. As a preemie, John stayed nearly three months at Packard Children's before his mom, dad and sister welcomed him home in November.

Michelle is still adjusting to her unexpected transplant and the unexpected birth of her son while she was in a coma. "When I was told what happened, I thought, OK, it's done," she said. "I wasn't mad or angry. I just thought, what am I supposed to learn from this? What can I teach someone else?"

Among the things that she and her husband have gained is a new appreciation for organ donation. "You don't realize what it means until you see it in action," Leonard said.

Doctors at Packard Children's and at Stanford Hospital say both mom and baby have excellent prospects, and the family celebrated John's first Christmas with much joy. "We went a little crazy with gifts for the kids," Michelle said happily. "It was definitely their Christmas this year."