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Pregnancy outcomes in women with liver transplants: systematic review and meta-analysis. HPB (Oxford) 2020; 22:1102-1111. [PMID: 32636057 DOI: 10.1016/j.hpb.2020.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/17/2020] [Accepted: 05/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite increasing reports of pregnancy in liver transplant recipients, questions remain about the impact of transplantation in pregnancy. METHODS This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 26th December 2019 for studies reporting pregnancy with liver transplant. A meta-analysis was conducted with the use of random-effects modelling and prospectively registered with the PROSPERO database. RESULTS Of 1239 unique studies, 28 met inclusion criteria, representing 1496 pregnancies in 1073 liver transplant recipients. The live-birth rate was 85.6% (CI95%: 80.5%-90.7%). The rate of other pregnancy outcomes was as follows: induced abortions (5.7%), miscarriages (7.8%) and stillbirths (3.3%). Pooled rates of obstetric complications were hypertension (18.2%), pre-eclampsia (12.8%) and gestational diabetes (7.0%). Pooled rates of delivery outcomes for caesarean section (C-section) and pre-term birth were 42.2% and 27.8%, respectively. CONCLUSION In conclusion, live birth outcomes are good among liver transplant recipients and this favourable trend is consistent at an international level. However, special attention should be given to obstetric complications such as hypertension, pre-eclampsia, and preterm delivery. The high incidence of these complications supports the high-risk classification of post-liver transplant pregnancies and it is necessary for a multidisciplinary team to be involved in the monitoring and counselling of liver transplant recipients both before and during pregnancy. Whilst majority data originate from institutions from high-income countries, data from low-middle income countries (LMIC) are needed owing to rising rates of liver transplantation in LMIC.
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Akarsu M, Unek T, Avcu A, Ozbilgin M, Egeli T, Astarcioglu I. Evaluation of Pregnancy Outcomes After Liver Transplantation. Transplant Proc 2016; 48:3373-3377. [DOI: 10.1016/j.transproceed.2016.09.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/28/2016] [Indexed: 12/27/2022]
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Wiles KS, Tillett AL, Harding KR. Solid organ transplantation in pregnancy. ACTA ACUST UNITED AC 2016. [DOI: 10.1111/tog.12263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kate S Wiles
- Women's Health Academic Centre; Guy's and St. Thomas' NHS Foundation Trust and King's College London; London SE1 7EH UK
| | | | - Kate R Harding
- Guy's and St. Thomas' NHS Foundation Trust; London SE1 7EH UK
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Kubo S, Uemoto S, Furukawa H, Umeshita K, Tachibana D. Pregnancy outcomes after living donor liver transplantation: results from a Japanese survey. Liver Transpl 2014; 20:576-83. [PMID: 24478123 DOI: 10.1002/lt.23837] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 01/18/2014] [Indexed: 02/06/2023]
Abstract
A national survey of pregnancy outcomes after living donor liver transplantation (LDLT) was performed in Japan. Thirty-eight pregnancies in 30 recipients resulted in 31 live births (25 recipients), 3 artificial abortions in the first trimester (3 recipients), 1 spontaneous abortion (1 recipient), and 3 fetal deaths (3 recipients). After the exclusion of the 3 artificial abortions, there were 35 pregnancies in 27 recipients: pregnancy-induced hypertension developed during 6 pregnancies (5 recipients), fetal growth restriction developed during 7 pregnancies (6 recipients), acute rejection developed during 2 pregnancies (2 recipients), and ileus developed during 1 pregnancy (1 recipient). Preterm delivery (<37 weeks) occurred for 10 pregnancies (10 recipients), and cesarean delivery was performed for 12 pregnancies (12 recipients). After delivery, acute rejection developed in 3 recipients. Twelve neonates were born with low birth weights (<2500 g), and 4 of these 12 neonates had extremely low birth weights (<1500 g). Two neonates had congenital malformations. The pregnancy outcomes after LDLT were similar to those reported for cadaveric liver transplantation (LT). The incidence of pregnancy-induced hypertension in recipients who were 33 years old or older at the diagnosis of pregnancy was significantly higher than the incidence in recipients who were less than 33 years old at the diagnosis of pregnancy. The incidences of fetal growth restriction, pregnancy-induced hypertension, and extremely low birth weight were significantly higher in the early group (<3 years after transplantation) versus the late group (≥3 years after transplantation). In conclusion, it is necessary to pay careful attention to complications during pregnancy in recipients who become pregnant within 3 years of LT, particularly if the age at the diagnosis of pregnancy is ≥33 years.
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Affiliation(s)
- Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Deshpande NA, James NT, Kucirka LM, Boyarsky BJ, Garonzik-Wang JM, Cameron AM, Singer AL, Dagher NN, Segev DL. Pregnancy outcomes of liver transplant recipients: a systematic review and meta-analysis. Liver Transpl 2012; 18:621-9. [PMID: 22344967 DOI: 10.1002/lt.23416] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Approximately 14,000 women of reproductive age are currently living in the United States after liver transplantation (LT), and another 500 undergo LT each year. Although LT improves reproductive function in women with advanced liver disease, the associated pregnancy outcomes and maternal-fetal risks have not been quantified in a broad manner. To obtain more generalizable inferences, we performed a systematic review and meta-analysis of articles that were published between 2000 and 2011 and reported pregnancy-related outcomes for LT recipients. Eight of 578 unique studies met the inclusion criteria, and these studies represented 450 pregnancies in 306 LT recipients. The post-LT live birth rate [76.9%, 95% confidence interval (CI) = 72.7%-80.7%] was higher than the live birth rate for the US general population (66.7%) but was similar to the post-kidney transplantation (KT) live birth rate (73.5%). The post-LT miscarriage rate (15.6%, 95% CI = 12.3%-19.2%) was lower than the miscarriage rate for the general population (17.1%) but was similar to the post-KT miscarriage rate (14.0%). The rates of pre-eclampsia (21.9%, 95% CI = 17.7%-26.4%), cesarean section delivery (44.6%, 95% CI = 39.2%-50.1%), and preterm delivery (39.4%, 95% CI = 33.1%-46.0%) were higher than the rates for the US general population (3.8%, 31.9%, and 12.5%, respectively) but lower than the post-KT rates (27.0%, 56.9%, and 45.6%, respectively). Both the mean gestational age and the mean birth weight were significantly greater (P < 0.001) for LT recipients versus KT recipients (36.5 versus 35.6 weeks and 2866 versus 2420 g). Although pregnancy after LT is feasible, the complication rates are relatively high and should be considered during patient counseling and clinical decision making. More case and center reports are necessary so that information on post-LT pregnancy outcomes and complications can be gathered to improve the clinical management of pregnant LT recipients. Continued reporting to active registries is highly encouraged at the center level.
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Affiliation(s)
- Neha A Deshpande
- Department of Surgery, Johns Hopkins School of Medicine, 720 Rutland Avenue, Baltimore, MD 21205, USA
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Goarin AC, Homer L. [Liver transplantation and pregnancy]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2010; 39:529-36. [PMID: 20144511 DOI: 10.1016/j.jgyn.2010.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 12/31/2009] [Accepted: 01/12/2010] [Indexed: 11/27/2022]
Abstract
Management during their sexual life of patients with a liver transplantation is a more or less common situation depending centers. Based on literature review, a focus on management of recipient women was conducted, from contraception to pregnancy, describing the complications related to the status of transplant recipient, but also those that may be related to immunosuppressive agents. If fertility and access to contraception are only slightly modified by graft, complications related to graft or immunosuppressive drugs can affect the pregnancy. On the maternal side, hypertension and preeclampsia are more common, as well as renal dysfunction, iatrogenic diabetes and bacterial or viral infections, acute rejection and graft loss do not appear to be influenced by pregnancy. The fetus is also exposed to risks such as induced prematurity and IUGR. Pregnancy in recipients of hepatic grafts therefore requires joint follow-up by transplant specialist and perinatologist, which leads in most cases to successful outcome for mother and child.
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Affiliation(s)
- A-C Goarin
- Service de gynécologie obstétrique et médecine de la reproduction, hôpital Morvan, CHU de Brest, 2, avenue Foch, 29609 Brest, France
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8
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Abstract
In countries with a high prevalence of chronic hepatitis B, perinatal transmission from mother to infant accounts for the majority of cases of chronic hepatitis B. Passive-active immunoprophylaxis with hepatitis B immunoglobulin and hepatitis B vaccine at birth is 95% efficacious in reducing the risk of HBV transmission but is less effective in HBeAg-positive mothers with very high serum HBV DNA levels. In the last 4 weeks of pregnancy lamivudine may provide additional protection in pregnant women who have high-level viremia. Further studies are needed to evaluate the use of nucleos(t)ide analogues to treat chronic hepatitis B during pregnancy.
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Affiliation(s)
- Maya Gambarin-Gelwan
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College of Cornell University, 1305 York Avenue, 4th floor, New York, NY 10021, USA.
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Jankovic Z, Stamenkovic D, Duncan B, Prasad R, Davies M. Successful outcome after a technically challenging liver transplant during pregnancy. Transplant Proc 2007; 39:1704-6. [PMID: 17580226 DOI: 10.1016/j.transproceed.2007.02.090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 02/23/2007] [Indexed: 10/23/2022]
Abstract
Little is known about the implications of liver transplantation (OLT) during pregnancy. We report the case of a 26-year-old woman with cryptogenic familial biliary cirrhosis that decompensated rapidly. OLT was performed using the donor iliac vein for a retrogastric portal vein conduit to the superior mesenteric vein and the donor iliac artery for an infrarenal aortic conduit. During the latter anastomosis, a viable fetus was noticed. Both donor and recipient were cytomegalovirus positive. Postoperative ultrasound revealed a 13.5-week-old viable fetus. The patient received tacrolimus, azathioprine, and prednisolone. The pregnancy progressed normally with the vaginal delivery of a healthy male infant after 36 weeks gestation. Nineteen months later, both the mother and child were well. This case demonstrated that even technically difficult OLT during pregnancy can have a successful outcome, raising the question of whether transplant patients of childbearing age should be routinely tested for pregnancy.
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Affiliation(s)
- Z Jankovic
- Department of Anesthesia, St. James University Hospital, Leeds, West Yorkshire, United Kingdom.
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Hoffmann P, Feige JJ, Alfaidy N. Placental expression of EG-VEGF and its receptors PKR1 (prokineticin receptor-1) and PKR2 throughout mouse gestation. Placenta 2007; 28:1049-58. [PMID: 17531315 DOI: 10.1016/j.placenta.2007.03.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2006] [Revised: 03/28/2007] [Accepted: 03/29/2007] [Indexed: 11/24/2022]
Abstract
Compelling evidence indicates that vascular endothelial growth factor (VEGF) is an important mediator of placental angiogenesis and appears to be disregulated in pre-eclampsia (PE). Recently, we characterised the expression of EG-VEGF (endocrine gland-derived vascular endothelial growth factor), also known as prokineticin 1 (PK1) in human placenta during the first trimester of pregnancy and showed that this factor is likely to play an important role in human placentation. However, because it is impossible to prospectively study placentation in humans, it has been impossible to further characterise EG-VEGF expression throughout complete gestation and especially at critical gestational ages for PE development. In the present study, we used mouse placenta to further characterise EG-VEGF expression throughout gestation. We investigated the pattern of expression of EG-VEGF and its receptors, PKR1 and PKR2 at the mRNA and protein levels. Our results show that EG-VEGF and VEGF exhibit different patterns of expression and different localisations in the mouse placenta. EG-VEGF was mainly localised in the labyrinth whereas VEGF was mainly present in glycogen and giant cells. EG-VEGF mRNA and protein levels were highest before 10.5days post coitus (dpc) whereas those of VEGF showed stable expression throughout gestation. PKR1 protein was localised to the labyrinth layer and showed the same pattern of expression as EG-VEGF whereas PKR2 expression was maintained over 10.5dpc with both trophoblastic and endothelial cell localisations. Altogether these findings suggest that EG-VEGF may have a direct effect on both endothelial and trophoblastic cells and is likely to play an important role in mouse placentation.
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Kuroda T, Saeki M, Morikawa N, Fuchimoto Y. Biliary atresia and pregnancy: puberty may be an important point for predicting the outcome. J Pediatr Surg 2005; 40:1852-5. [PMID: 16338304 DOI: 10.1016/j.jpedsurg.2005.08.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this study was to study the late clinical features of biliary atresia in relation to pregnancy. MATERIALS AND METHODS Of the 175 patients with biliary atresia operated on at our department, the data for 49 patients (18 males, 31 females) older than 15 years were reviewed and analyzed. RESULTS Six patients delivered 7 newborns (5 with their native liver and 1 with a transplanted liver). Although one of the patients delivered twice after transplantation, another underwent transplantation after delivery. None of the 7 newborns showed any congenital anomalies; however, 6 were small-for-date newborns. Their birth weight tended to be inversely related to the mothers' age at delivery. An additional 13 patients required liver transplantation, of whom 1 died after transplantation and 1 died before transplantation. The remaining 30 patients showed uneventful courses without transplantation. The age at Kasai operation was significantly higher in the 5 patients who delivered babies with their native liver compared with that in these 30 patients (88.0 vs 68.6 days). A significant difference between these 5 patients and those who died or required transplantation before pregnancy was recognized even at the age of puberty in the alanine aminotransferase (36.5 +/- 26.5 vs 126.4 +/- 56.1 IU/L), aspartate aminotransferase (36.2 +/- 26.5 vs 114.2 +/- 48.9 IU/L), and choline esterase (249.7 +/- 64.8 vs 163.5 +/- 40.2 IU/L). CONCLUSIONS The age at Kasai operation may not necessarily impact the late clinical course; however, liver function at puberty may predict the subsequent clinical course, including the safety of pregnancy. The management strategies should be revised after puberty.
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Affiliation(s)
- Tatsuo Kuroda
- Department of Surgery, National Center for Child Health and Development, Tokyo 157-8535, Japan.
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Loreno M, Bo P, Senzolo M, Cillo U, Naoumov N, Burra P. Successful pregnancy in a liver transplant recipient treated with lamivudine for de novo hepatitis B in the graft. Transpl Int 2004. [DOI: 10.1111/j.1432-2277.2004.tb00502.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Liver disease is rare in childhood, but important new developments have altered the natural history and outcome. It is important that clinicians are aware of these diseases and their management. Acute liver failure is most often due to viral hepatitis, paracetamol overdose, or inherited metabolic liver disease. The clinical presentation includes jaundice, coagulopathy, and encephalopathy. Early diagnosis is necessary to prevent complications such as cerebral oedema, gastrointestinal bleeding, and renal failure. Early supportive management, in particular intravenous N-acetylcysteine, may be effective but liver transplantation is usually the definitive treatment and thus early referral to a specialist unit for liver transplantation is mandatory. Chronic liver failure may be due to unresolved neonatal liver disease, either inherited biliary hypoplasia or extrahepatic biliary atresia, while in older children, autoimmune liver disease or cystic fibrosis are the commonest causes. Treatment includes specific medication, nutritional support, and liver transplantation, which now has a 90% survival with good quality life.
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Affiliation(s)
- D A Kelly
- Liver Unit, Birmingham Children's Hospital NHS Trust, UK.
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Coelho JCU, Parolin MB, Matias JEF. Successful twin pregnancy after orthotopic liver transplantation. ARQUIVOS DE GASTROENTEROLOGIA 2002; 39:246-7. [PMID: 12870084 DOI: 10.1590/s0004-28032002000400007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM Report of a case of successful twin pregnancy following liver transplantation. PATIENT AND METHOD A 42-year-old nulliparous-woman was subjected to an orthotopic liver transplantation due to Budd-Chiari syndrome. Sixteen months after the transplantation, an ultrasonography revealed twin pregnancy. Her prenatal course was uneventful, except for mild arterial hypertension. The immunosuppressive agents used during pregnancy were cyclosporine and prednisone. RESULT The patient gave birth to two healthy girls at 37 weeks of gestation. The patient's postpartum course was uneventful with normal liver and renal function tests. CONCLUSION Following successful pregnancy, women may become pregnant and give birth to normal children, including twins
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Affiliation(s)
- Júlio Cezar Uili Coelho
- Department of Surgery and Gynecology and Obstetrics, Federal University of Parana, Curitiba, PR, Brazil
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15
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Abstract
1. Libido returns promptly after liver transplantation; patients should be counseled on contraception and avoidance of sexually transmitted diseases. 2. Women after liver transplantation are at increased risk for cancer and should have regularly scheduled screening for cervical and breast cancer. 3. Immunosuppression during pregnancy is not teratogenic and does not lead to congenital anomalies. 4. Pregnancy after liver transplantation is often successful, but must be regarded as high risk, associated with an increased risk for hypertension and preeclampsia, intrauterine growth retardation, and prematurity. It is best delayed until 1 to 2 years after grafting. 5. Close monitoring of immunosuppressant levels in the blood is crucial during pregnancy to avoid inappropriately low levels of immunosuppression.
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Affiliation(s)
- C A Riely
- Gastroenterology Division, University of Tennessee Health Sciences Center, Memphis, TN 38163, USA.
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Abstract
The first known posttransplantation pregnancy was in 1958 in a renal transplant recipient who had received a kidney from her identical twin sister. The first known posttransplantation pregnancy in a liver transplant recipient was in 1978. Information available from female kidney transplant recipients helped in the decision making involved in the management of this case, as well as those that followed. Over the last 20 years, issues specific to liver transplantation and pregnancy have been identified. Similar to the kidney transplant recipient population, when prepregnancy recipient graft function is stable and adequate, pregnancy appears to be well tolerated. Also similar to kidney transplant recipients, there has been no evidence of a specific malformation pattern among the children, and although prematurity and low birth weight occur, overall newborn outcomes have been favorable. Pregnancy in the setting of recurrent liver disease, such as recurrent hepatitis C, poses a potential problem among liver transplant recipients, as well as the possible adverse effects of immunosuppression on maternal kidney function. Also of significance, peripartum graft deterioration has more severe consequences in this transplant recipient population. Therefore, pregnancy must be considered carefully in this transplant recipient group. Since 1991, the National Transplantation Pregnancy Registry (NTPR) has studied the safety of pregnancy outcomes in solid-organ transplant recipients. The purpose of this review is to catalog studies in the literature, as well as to present current data from the registry with management guidelines.
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Affiliation(s)
- V T Armenti
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
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