Pregnancy in the liver transplant recipient

Pregnancies in Women After Liver Transplant due to Wilson's Disease-Case Series

Wilson's disease is a rare autosomal recessive disorder. Due to a defect in membrane copper transporter, copper is not excreted in the bile and accumulates in the tissues. The only treatment for acute liver failure in Wilson's disease is a liver transplant.

AIM

Assessment of the course of pregnancies and comparison of obstetric outcomes in female liver transplant recipients in the course of Wilson's disease.

METHODOLOGY

Retrospective analysis of data of women, who were pregnant and gave birth in the years: 2017 to 2023. Evaluation of their liver function used pharmacotherapy and obstetric outcomes.

RESULTS

We recorded 11 pregnancies in liver transplantation recipients due to Wilson's disease. Ten single pregnancies and 1 twin (DCDA) were observed. In all pregnancies, graft functions and immunosuppressive drug concentrations were monitored. Three women suffered from epilepsy, one was diagnosed with psychiatric disorder. Two were diagnosed with cholestasis, and another 2 with gestational diabetes. Two of them were treated for pregnancy-induced hypertension and 2 developed preeclampsia. Deterioration of liver function parameters in pregnancy was observed in 2 cases. In total, 8 full-term babies were born and 4 late-preterm, including twins at 35 weeks of gestation. Seven pregnancies were delivered by caesarean section and 4 delivered vaginally. No complications in early postpartum period have been reported.

CONCLUSIONS

Women with Wilson's disease treated with organ transplantation have a chance of successful pregnancies and deliveries.

Family Planning and Assessment of the Frequency of Exposure to Drugs Contraindicated in Pregnancies After Kidney or Liver Transplantation: A Retrospective Cross-Sectional Study

BACKGROUND

A successful organ transplant restores gonadal function in the first months after surgery, which leads to the normalization of menstrual cycles and increases the chance of pregnancy. Recipients of organ transplants should effectively prevent pregnancy for a minimum of 1 year and optimally up to 2 years after surgery. This study aimed to evaluate the incidence of unplanned pregnancies in female organ transplant recipients METHODS: A cross-sectional, single-center survey study of 46 pregnant organ recipients who were hospitalized at the Department of Obstetrics and Gynaecology.

RESULTS

In the post-transplant period, we recorded 46 patients, including 27 kidney recipients (59%) and 19 liver recipients (41%). Forty-nine respondents reported 66 pregnancies, of which 52 ended in live births (79%). Twenty of the pregnancies were not planned. In that group, 16 pregnancies ended in labor, 2 in miscarriage, and 2 in termination. In 10 of the unplanned pregnancies, the women were treated with potentially teratogenic drugs in the first trimester. The duration of the pregnancy was shorter in the group of women who had not planned their pregnancies and had conceived during potentially teratogenic therapy (30.66 ± 3.61 weeks) than in women who had planned their pregnancies (34.95 ± 4 weeks, P < .0215).

CONCLUSION

Women after organ transplantation are at high risk for pregnancy complications. Therefore, conception planning is an important element of post-transplant care, especially because the percentage of unplanned pregnancies in this group remains high despite the use of potentially teratogenic drugs.

Successful full-term pregnancy after preterm event in a liver transplant patient: a case report

BACKGROUND

Pregnancy after liver transplantation poses a significant challenge to both the patient and the transplant team.

CASE PRESENTATION

We present the case of a 19-year-old European patient who underwent liver transplantation 5 years previously owing to autoimmune hepatitis. Poor compliance with immunosuppressive therapy and missed follow-up visits during the patient's first pregnancy likely contributed to her liver function deterioration, hospitalization, and failed pregnancy. Owing to the patient's complex medical history, combined immunosuppressive treatment, and risks to the fetus, her second pregnancy was high risk. However, close outpatient monitoring and adherence to treatment led to a successful, uneventful, full-term pregnancy and healthy delivery.

CONCLUSION

Liver transplant recipients who desire to become pregnant require careful planning and management to ensure optimal outcomes for both the mother and the fetus. A personalized strategy is necessary to balance the potential benefits of childbirth with the risks involved in pregnancy after liver transplantation.

Liver and Biliary Disease of Pregnancy and Anesthetic Implications: A Review

Liver and biliary disease complicates pregnancy in varying degrees of severity to the mother and fetus, and anesthesiologists may be asked to assist in caring for these patients before, during, and after birth of the fetus. Therefore, it is important to be familiar with how different liver diseases impact the pregnancy state. In addition, knowing symptoms, signs, and laboratory markers in the context of a pregnant patient will lead to faster diagnosis and treatment of such patients. This review article discusses changes in physiology of parturients, patients with liver disease, and parturients with liver disease. Next, general treatment of parturients with acute and chronic liver dysfunction is presented. The article progresses to specific liver diseases with treatments as they relate to pregnancy. And finally, important aspects to consider when anesthetizing parturients with liver disease are discussed.

Pregnancy Outcomes After Liver Transplantation: A Systematic Review and Meta-Analysis

INTRODUCTION

Liver transplantation (LT) remains the gold standard for treatment of end-stage liver disease. Given the increasing number of liver transplantation in females of reproductive age, our aim was to conduct a systematic review and meta-analysis evaluating pregnancy outcomes after LT.

METHODS

MEDLINE, Embase, and Scopus databases were searched for relevant studies. Study selection, quality assessment, and data extraction were conducted independently by 2 reviewers. Estimates of pregnancy-related outcomes in LT recipients were generated and pooled across studies using the random-effects model.

RESULTS

A comprehensive search identified 1,430 potential studies. Thirty-eight studies with 1,131 pregnancies among 838 LT recipients were included in the analysis. Mean maternal age at pregnancy was 27.8 years, with a mean interval from LT to pregnancy of 59.7 months. The live birth rate was 80.4%, with a mean gestational age of 36.5 weeks. The rate of miscarriages (16.7%) was similar to the general population (10%-20%). The rates of preterm birth, preeclampsia, and cesarean delivery (32.1%, 12.5%, and 42.2%, respectively) among LT recipients were all higher than the rates for the general US population (9.9%, 4%, and 32%, respectively). Most analyses were associated with substantial heterogeneity.

DISCUSSION

Pregnancy outcomes after LT are favorable, but the risk of maternal and fetal complications is increased. Large studies along with consistent reporting to national registries are necessary for appropriate patient counseling and to guide clinical management of LT recipients during pregnancy.

Long-term Management of the Adult Liver Transplantation Recipients

The survival of liver transplantation (LT) recipients has been improved remarkably in short-term. The major causes of mortality in long-term include nonimmunological causes such as cardiovascular, de novo malignancy, chronic kidney disease, and recurrence of primary disease. Rejection-related mortality is rare in the long-term after LT. We discuss nonrejection causes of long-term morbidity/mortality, risk factors, and management strategies in LT recipients. In addition, we discuss osteoporosis, contraception, and pregnancy in LT recipients.

Pregnancy in Liver Transplantation Recipients Is Associated With Increased Complications and Healthcare Utilization

INTRODUCTION

Given the increased rates of pregnancy in liver transplant recipients, evaluating the safety of pregnancy is crucial. We aim to evaluate pregnancy-related complications and outcomes in liver transplant recipients.

METHODS

A retrospective nationwide review comparing pregnancy outcomes in liver transplant recipients vs the general population was performed between 2005 and 2013. Propensity-matched and multivariable regression analyses were performed to study pregnancy- and delivery-related complications in addition to patient and hospital outcomes.

RESULTS

A total of 38,449,030 pregnancy-related admissions were evaluated in this study including 1,469 (0.004%) admissions in liver transplant recipients. Liver transplant recipients were more likely to undergo a caesarean delivery (60% vs 36%) and have a pregnancy-related complication (56% vs 27%) including miscarriage, intrauterine growth restriction, portpartum hemorrhage, hypertension, preeclampsia, and thromboembolism (P < 0.001) compared with the general population. Propensity-weighted analysis revealed higher rates of pregnancy complications (odds ratio 2.11, 95% confidence interval [CI] 1.63-2.73), cost ($3,023, 95% CI $850-$5,197), and longer length of stay (1.52 days, 95% CI 0.62-2.41) in transplant recipients. Liver transplant recipients experienced zero inpatient mortalities compared with 0.01% of the general population. Transplant recipients with at least 1 complication had a longer length of stay (2.45 days, 95% CI 1.44-3.45) and higher cost of admission ($5,205, 95% CI $2,848-$7,561) compared with transplant recipients without a complication.

DISCUSSION

Pregnancy after liver transplant is associated with higher rates of complications and worse outcomes without an increased risk of mortality.

Obstetrical and gynecologic challenges in the liver transplant patient

An increasing number of childbearing agewomen undergo liver transplantation (LT) in the United States. Transplantation in this patient subgroup poses a significant challenge regarding the plans for future fertility, particularly in terms of immunosuppression and optimal timing of conception. Intrapartum LT is only rarely performed as the outcome is commonly dismal for the mother or more commonly the fetus. On the other hand, the outcomes of pregnancy in LT recipients are favorable, and children born to LT recipients are relatively healthy. Counseling on pregnancy should start before LT and continue after LT up until pregnancy, while all pregnant LT recipients must be managed by amultidisciplinary team, including both an obstetrician and a transplant hepatologist. Additionally, an interval of at least 1-2 years after successful LT is recommended before considering pregnancy. Pregnancy-induced hypertension, pre-eclampsia, and gestational diabetes mellitus are reported more commonly during the pregnancies of LT recipients than in the pregnancies of non-transplant patients. As adverse fetal outcomes, such asmiscarriage, abortion, stillbirth, or ectopic pregnancy, may occur more often than in the non-transplant population, early planning or delivery either through a planned induction of labor or cesarean section is critical to minimize the risk of complications. No significant long-term physical or phycological abnormalities have been reported in children born to LT recipients.

Pregnancy Weight Gain as a Predictor of Fetal Wellbeing in Liver Transplant Recipients

BACKGROUND Gestational weight gain (GWG) is an important index influencing perinatal outcomes. Inappropriate weight gain during pregnancy is strongly associated with multiple pregnancy complications. In pregnant liver transplant recipients whose risk of adverse pregnancy outcomes is already high, this aspect may be even more significant. The present study analyzed the gestational weight gain in female liver transplant recipients and its effect on neonatal complications. MATERIAL AND METHODS A cohort study of retrospective data was performed in the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw. There were 23 patients who fulfilled all inclusion criteria. The gestational weight gain was analyzed in the context of pre-pregnancy BMI, immunosuppression, and perinatal outcomes. RESULTS The preterm delivery rate was 39.13% and GWG increased according to the duration of pregnancy. The model adjusted to week of delivery revealed no association between weight gain and the length of pregnancy (p=0.82). GWG in liver transplant recipients did not affect hypotrophy incidence, adverse perinatal outcomes, or caesarian delivery rate. A positive correlation between GWG and neonatal birth weight was observed (p=0.06). One patient, with coexisting PIH, had a stillbirth at 23 weeks. In all other cases, the 5-min Apgar score was 10 points. CONCLUSIONS Current obstetrical recommendations do not consider patients with chronic diseases undergoing immunosuppressive treatment. Proper counselling and preparing liver transplant recipients for pregnancy, especially optimizing maternal pre-pregnancy BMI, may be an important element in improving perinatal outcomes by lowering the risk of maternal complications. GWG itself is not relevant as a predictor of term gestation, but it might be important in achieving eutrophic fetus growth.

Pregnancy Outcomes Following Pediatric Liver Transplantation: A Single-Center Experience in Japan

Background

The number of pregnancies after liver transplantation (LT) is increasing; however, the safety and incidence of complications associated with these pregnancies are still unclear. In this report, we retrospectively assessed the influences and problems associated with post-transplant pregnancy on allografts, recipients, and fetuses.

Material/Methods

A total of 14 pregnancies were identified in 8 female recipients between 2005 and 2018. The original disease was biliary atresia in all recipients. We provide a basic guide for the management of planned pregnancies in female recipients.

Results

Of the 7 planned pregnancies, no recipients took mycophenolate mofetil (MMF) or had allograft liver dysfunction. Among the 7 unplanned conceptions, we judged that the pregnancy was inadequate to continue in 4 recipients due to taking MMF and 2 recipients due to allograft liver dysfunction at conception. However, 4 recipients who immediately stopped taking MMF continued with their pregnancies. Ten pregnancies resulted in live 11 births. Among obstetric complications or fetal and neonatal complications, gestational diabetes mellitus in 3 recipients was the most common. There were 3 miscarriages and 1 planned termination because of MMF medication and liver dysfunction.

Conclusions

Planned pregnancies in LT recipients can lead to the birth of a healthy baby and no influence on either the allograft or the recipient. However, unplanned pregnancies in LT recipients, such as recipients who take MMF or have allograft liver dysfunction, may have an adverse influence on the fetus.

Selected Biochemical Parameters in Children of Mothers After Kidney Transplantation

INTRODUCTION

The number of pregnant kidney graft recipients receiving immunosuppressive drugs is increasing yearly. All potentially nephrotoxic and hepatotoxic immunosuppressive drugs penetrate through the placenta, which raises questions about their long-term effects on offspring.

OBJECTIVES

The study aimed to evaluate the influence of immunosuppressive drugs used by pregnant women after kidney transplantation on the biochemical parameters of their children.

MATERIALS AND METHODS

Forty children born to mothers after kidney transplantation (KTx) and 40 children of healthy mothers from the control group were included in the study. All graft-recipient mothers received immunosuppressive treatment during pregnancy. The study compared biochemical parameters, including urea, creatinine, potassium, and sodium, in both groups.

RESULTS

Elevated creatinine level was observed in 1 newborn in the KTx group and none of the children from the control group (P = .500). All KTx children had normal urea levels, while in the control group, 2 newborns had an increased level of urea (P = .247). Elevated potassium levels were observed in 10% of children in the KTx group and 20% of children in the control group (χ² = 0.881; P = .348). Elevated sodium levels were observed in 22.5% of children in the KTx group and 32.5% of children in the control group (χ² = 1.001; P =.317). No child in the KTx group had hyponatremia; mild hyponatremia was observed in 5% of children in the control group (P = .247).

CONCLUSION

There was no increased risk of an abnormal concentration of urea, creatinine, sodium, and potassium in the offspring of mothers after kidney transplantation using immunosuppressive drugs during pregnancy.

Pre-existing liver disease in pregnancy: Cirrhosis, autoimmune hepatitis and liver transplantation

Liver disease during pregnancy is one of the least studied topics, but it links the interests of hepatologists, gynaecologists and family physicians. Approximately 3% of pregnant woman experience some type of liver disease. Liver disease can occur as a result of pregnancy, before pregnancy and coincidence-related during pregnancy. Pregnancy in women with pre-existing liver disease is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations. So, because of the complications for both mother and child, it is important that liver disease is recognized in a timely manner to avoid undesirable outcomes.

Successful pregnancy in a liver transplant patient of Budd-Chiari syndrome

In recent years, the number of patients undergoing liver transplant has increased. Successful transplant has resulted in better quality of life and improved fertility in younger women. This is a case study a 31-year-old woman, who had history of Budd-Chiari syndrome and underwent liver transplantation in 2014 with uneventful postoperative course. She was clinically stable on tablet tacrolimus and coumarin with no episode of allograft rejection since transplantation. The patient conceived spontaneously, after 4 years of transplant and during pregnancy, she was managed by multidisciplinary team. During the initial period, the graft and pregnancy continued without complications. However, at 33 weeks, the patient presented with sluggish fetal movements, amniotic fluid index of 3.4 and SD ratio of 3.31 for which she underwent caesarean section. She delivered a healthy female baby of 1.4 kg. This case study concludes that vigilant monitoring of fetal growth is pivotal for optimal fetal outcome.

Unintended pregnancies and family planning among women after kidney or liver transplantation

Background: To evaluate the incidence of unplanned pregnancies in female organ transplant recipients.Methods: In a single-center cross-sectional study 252 women aged 18-45 years who underwent kidney or liver transplantation were asked to fill in a survey form.Results: 217 (86%) women were enrolled in the study. Fifty-three percent of women declared 181 pregnancies, of which 30% (54/181) were unplanned. Women more frequently consulted their conception with a doctor post-transplantation (74 versus 88%, p = .064). The number of unplanned pregnancies decreased post-transplantation (34 versus 20%, p = .051). The mean time elapsed from an organ transplant to unintended conception was 27.0 ± 12.5 (3.0-63.0) months. Women with longer (>24 months) rather than shorter (≤24 months) time elapsed from the transplant became pregnant less frequently (38 versus 15%, p = .060). In 70% (38/54) of unplanned pregnancies women did not use any birth control. All cases of conceptions within the post-transplant year were unintentional. Every third woman, who underwent the transplantation up to 1 year before the study enrolment, was unaware of the necessity to prevent the pregnancy.Conclusions: Although unwanted pregnancies occur more frequently in the early post-transplant period, it seems that women after kidney or liver transplantation seem to plan their pregnancies more carefully.

Pregnancy in liver transplant recipients: A single center outcomes

AIM

Liver transplantation (LT) is the only effective treatment for the end-stage liver disease. Although pregnancy after LT is considered to be safe, these patients are difficult to manage for obstetricians. In this study, we aimed to determine maternal and fetal outcomes in pregnancies after LT.

METHODS

We conducted a retrospective review of liver transplant recipients who had received prenatal care and delivered pregnancy at İstanbul University İstanbul Medical Faculty, Department of Obstetrics and Gynecology January 2010 and January 2017.

RESULTS

A total of eight pregnancies were identified during the study period. The mean age of the patients at the time of LT was 25.6 ± 5.3 years (range 19-36 years), and the mean age at conception was 30.1 ± 5.2 years (range 25-41 years). The mean interval between transplantation and conception was 54.2 ± 18.6 months (range 24-82 months). There was no a miscarriage or a stillbirth was observed in any of patients. Mean birth week was 37.2 ± 2.1 weeks and mean birthweight was 2852 ± 562 g (range 2150-3470 g). Three of eight deliveries (37.5%) occurred before 37 gestational weeks. Preeclampsia was detected in one patient, one pregnancy was complicated by intrauterine growth retardation and one case with gestational diabetes mellitus. Mean postnatal follow-up period was 3.2 ± 2.4 years (range 1-7 years) and all of the babies were healthy. Graft rejection occurred in one patient after delivery.

CONCLUSION

More favorable pregnancy outcomes can be achieved with a multidisciplinary team and satisfactory counseling is mandatory either preconception and through the pregnancy to reduce maternal-fetal risks.

Successful pregnancy outcomes following liver transplantation is predicted by renal function

Liver transplantation (LT) is a successful treatment for both acute liver failure and end-stage liver disease. The number of women of reproductive age undergoing LT is increasing. Pregnancy outcomes are favorable, but there is still a lack of prognostic markers. We aimed to identify factors predictive of adverse pregnancy outcomes in LT recipients. An analysis of all pregnancies occurring in LT recipients from 1989 to 2016 at King's College Hospital was performed. Clinical data of 162 conceptions in 93 women were reviewed. Descriptive and regression analyses were done to examine associations between laboratory markers and hepatological scores with pregnancy outcomes of live birth and preterm birth. Median age at LT was 23 years (range, 1-41 years), with a median age at conception of 30 years (range, 18-47 years). The live birth rate was 75% (n = 121). Of live births, 35% (n = 39/110 available) were delivered preterm. Preconception creatinine levels were higher in patients who had a preterm birth (85 versus 74 μmol/L; P = 0.008), with a preconception estimated glomerular filtration rate (eGFR) <90 mL/minute significantly associated with preterm delivery (P = 0.04). Progressive decline in eGFR predicted outcome, with gestational length declining with increasing chronic kidney disease (CKD) stage: CKD 0-1 = 39 weeks (median), CKD 2 = 37 weeks, and CKD 3 = 35 weeks. The risk of preterm birth was greatest in women with an eGFR <60 mL/minute (P = 0.004). Moreover, hypertension-related complications during pregnancy, such as gestational hypertension, preeclampsia, or eclampsia, were also associated with prematurity (P = 0.01). Women taking steroid-based immunosuppression had an increased risk of infection during pregnancy or postpartum (15% versus 4%; P = 0.02). In conclusion, although the majority of women have a successful pregnancy outcome after LT, preconception renal function predicts pregnancy outcome and steroids increase risk of infection during pregnancy or postpartum. Liver Transplantation 24 606-615 2018 AASLD.