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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Peng Q, Zhu T, Huang J, Liu Y, Huang J, Zhang W. Factors and a model to predict three-month mortality in patients with acute fatty liver of pregnancy from two medical centers. BMC Pregnancy Childbirth 2024; 24:27. [PMID: 38178044 PMCID: PMC10765840 DOI: 10.1186/s12884-023-06233-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/27/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Acute fatty liver of pregnancy (AFLP) is an uncommon but potentially life-threatening complication. Lacking of prognostic factors and models renders prediction of outcomes difficult. This study aims to explore factors and develop a prognostic model to predict three-month mortality of AFLP. METHODS This retrospective study included 78 consecutive patients fulfilling both clinical and laboratory criteria and Swansea criteria for diagnosis of AFLP. Univariate and multivariate cox regression analyses were used to identify predictive factors of mortality. Predictive efficacy of prognostic index for AFLP (PI-AFLP) was compared with the other four liver disease models using receiver operating characteristic (ROC) curve. RESULTS AFLP-related three-month mortality of two medical centers was 14.10% (11/78). International normalised ratio (INR, hazard ratio [HR] = 3.446; 95% confidence interval [CI], 1.324-8.970), total bilirubin (TBIL, HR = 1.005; 95% CI, 1.000-1.010), creatine (Scr, HR = 1.007; 95% CI, 1.001-1.013), low platelet (PLT, HR = 0.964; 95% CI, 0.931-0.997) at 72 h postpartum were confirmed as significant predictors of mortality. Artificial liver support (ALS, HR = 0.123; 95% CI, 0.012-1.254) was confirmed as an effective measure to improve severe patients' prognosis. Predictive accuracy of PI-AFLP was 0.874. Area under the receiver operating characteristic curves (AUCs) of liver disease models for end-stage liver disease (MELD), MELD-Na, integrated MELD (iMELD) and pregnancy-specific liver disease (PSLD) were 0.781, 0.774, 0.744 and 0.643, respectively. CONCLUSION TBIL, INR, Scr and PLT at 72 h postpartum are significant predictors of three-month mortality in AFLP patients. ALS is an effective measure to improve severe patients' prognosis. PI-AFLP calculated by TBIL, INR, Scr, PLT and ALS was a sensitive and specific model to predict mortality of AFLP.
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Affiliation(s)
- QiaoZhen Peng
- Department of Obstetrics, Xiangya Hospital, Central South University, Hunan, Changsha, 410008, China
| | - TeXuan Zhu
- Department of Obstetrics and Gynecology, the Third Affiliated Hospital of Zhengzhou University, Henan, Zhengzhou, 450052, China
| | - JingRui Huang
- Department of Obstetrics, Xiangya Hospital, Central South University, Hunan, Changsha, 410008, China
| | - YueLan Liu
- Department of Obstetrics, Xiangya Hospital, Central South University, Hunan, Changsha, 410008, China
| | - Jian Huang
- Department of Obstetrics and Gynecology, the Second Xiangya Hospital, Central South University, Hunan, Changsha, 410011, China
| | - WeiShe Zhang
- Department of Obstetrics, Xiangya Hospital, Central South University, Hunan, Changsha, 410008, China.
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Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, Heneghan M, Marschall HU, Beuers U. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol 2023; 79:768-828. [PMID: 37394016 DOI: 10.1016/j.jhep.2023.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 07/04/2023]
Abstract
Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.
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Mansour D, Masson S, Hammond J, Leithead JA, Johnson J, Rahim MN, Douds AC, Corless L, Shawcross DL, Heneghan MA, Tripathi D, McPherson S, Bonner E, Botterill G, West R, Donnelly M, Grapes A, Hollywood C, Ross V. British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 3: special circumstances. Frontline Gastroenterol 2023; 14:474-482. [PMID: 37862443 PMCID: PMC10579550 DOI: 10.1136/flgastro-2023-102432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023] Open
Abstract
The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Part 1 addresses outpatient management of compensated cirrhosis: screening for hepatocellular cancer, varices and osteoporosis, vaccination and lifestyle measures. Part 2 concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. In this, the third part of the guidance, we focus on special circumstances encountered in managing people with cirrhosis, namely surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.
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Affiliation(s)
- Dina Mansour
- Gateshead Health NHS Foundation Trust, Gateshead, UK
- Newcastle University, Newcastle upon Tyne, UK
| | - Steven Masson
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - John Hammond
- Hepatopancreatobiliary Multidisciplinary team, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Joanna A Leithead
- Addenbrooke's Hospital, Cambridge, UK
- Forth Valley Royal Hospital, Larbert, UK
| | | | | | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital, Kings Lynn, UK
| | - Lynsey Corless
- Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Stuart McPherson
- Newcastle University, Newcastle upon Tyne, UK
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | | | | | | | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
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S. S S, Bako A, Yaqoub SA, Din FM. A case report of a pregnant woman with compensated liver cirrhosis and pancytopenia. Clin Case Rep 2023; 11:e7500. [PMID: 37323253 PMCID: PMC10264935 DOI: 10.1002/ccr3.7500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/21/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023] Open
Abstract
Key Clinical Message Liver cirrhosis may worsen during pregnancy resulting in adverse maternal and fetal outcomes. Proper antenatal evaluation, staging, and variceal screening will facilitate the management. Elective endoscopic variceal ligation (EVL) during the second trimester can prevent unexpected variceal bleeding. A multidisciplinary approach including the planning of delivery and shared decision-making is recommended for favorable pregnancy outcomes. Abstract Pregnancy in women with liver cirrhosis is relatively uncommon. During pregnancy, liver cirrhosis and portal hypertension may worsen significantly, placing both the mother and fetus at an increased risk of serious morbidity and life-threatening events. With the use of a wide variety of diagnostic tools and considerably improved treatment strategies, many women with liver disease in pregnancies are being diagnosed with significantly improved obstetric outcomes. We present a case of a 33-year-old lady with a previous medical history of cryptogenic chronic liver disease and schistosomiasis associated with periportal fibrosis, portal hypertension, splenomegaly, and pancytopenia. The mother presented to our tertiary care center at 18 weeks of gestation. She had EVL twice during the second trimester. With multidisciplinary care and follow-up, she labored spontaneously and was discharged home on third postnatal day.
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Affiliation(s)
- Sreenisha S. S
- Department of Obstetrics & GynaecologyWomen's Wellness and Research Center, Hamad Medical CorporationDohaQatar
| | - Abdulmalik Bako
- Department of Obstetrics & GynaecologyWomen's Wellness and Research Center, Hamad Medical CorporationDohaQatar
| | - Salwa Abo Yaqoub
- Department of Obstetrics & GynaecologyWomen's Wellness and Research Center, Hamad Medical CorporationDohaQatar
| | - Feazlin Mohd Din
- Department of Obstetrics & GynaecologyWomen's Wellness and Research Center, Hamad Medical CorporationDohaQatar
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6
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Fischer SE, de Vries ES, Tushuizen ME, de Boer YS, van der Meer AJP, de Man RA, Brouwer JT, Kuyvenhoven JP, Klemt-Kropp M, Gevers TJG, Tjwa ETTL, Kuiper EMM, Verhagen MAMT, Friederich PW, van Hoek B. Importance of complete response for outcomes of pregnancy in patients with autoimmune hepatitis. Liver Int 2023; 43:855-864. [PMID: 36594353 DOI: 10.1111/liv.15511] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/29/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS While some articles describe outcome of pregnancy in autoimmune hepatitis (AIH), there are less data evaluating influence of AIH control on maternal and perinatal outcomes. This study analysed outcomes of pregnancy and related possible risk factors in AIH. METHOD A retrospective multicentre cohort study on pregnancy in AIH was performed in 11 hospitals in the Netherlands. Maternal and neonatal outcomes were collected from records and completed by interview. Risk factors-including incomplete response, relapse and cirrhosis-for adverse outcomes were identified using logistic regression analysis. RESULTS Ninety-seven pregnancies in 50 women resulted in 70 deliveries (72%) with a live birth rate of 98.5%. AIH relapse occurred in 6% during pregnancy, and in 27% of post-partum episodes. Absence of complete biochemical response at conception was identified as risk factor for the occurrence of gestational and post-partum relapses. Relapse of AIH in the year before conception was a risk factor for the occurrence of both gestational relapses and post-partum relapses. No complete biochemical response increased the risk for hypertensive disorders during pregnancy and intrahepatic cholestasis of pregnancy (ICP). Cirrhosis was found to be a risk factor for miscarriages, but not for other outcomes. CONCLUSION Pregnancy in AIH is related to an increased incidence of maternal and fetal/neonatal complications; in most cases, outcome is good. Incomplete biochemical response at conception or relapse in the year before conception are risk factors for gestational and post-partum relapses, for hypertensive disorders and for ICP. Cirrhosis was a risk factor for miscarriages.
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Affiliation(s)
- Susan E Fischer
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Elsemieke S de Vries
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Maarten E Tushuizen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Adriaan J P van der Meer
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Robert A de Man
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johannes T Brouwer
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Johan P Kuyvenhoven
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Michael Klemt-Kropp
- Department of Gastroenterology and Hepatology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Edith M M Kuiper
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Marc A M T Verhagen
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, the Netherlands
| | - Philip W Friederich
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, the Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
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7
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The Spectrum of Hepatic Critical Care During Pregnancy: A Clinical Review. Clin Obstet Gynecol 2023; 66:176-185. [PMID: 36657053 DOI: 10.1097/grf.0000000000000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hepatic disease during pregnancy can result in the development of critical illness requiring special attention from a multidisciplinary team with a low threshold for tertiary care transfer to provide access to liver transplantation. Management of this population requires taking into consideration the benefit and risks of both mother and fetus. A myriad of diseases has been recognized, some being unique to pregnancy while others are common to the general population. We present a review of the literature on the diagnosis, management, and prognosis of these diseases to aid in the optimization of care in this special population.
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8
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Kelly D, Samyn M, Schwarz KB. Biliary Atresia in Adolescence and Adult Life: Medical, Surgical and Psychological Aspects. J Clin Med 2023; 12:1594. [PMID: 36836128 PMCID: PMC9967626 DOI: 10.3390/jcm12041594] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/06/2022] [Accepted: 12/23/2022] [Indexed: 02/19/2023] Open
Abstract
Prior to 1955, when Morio Kasai first performed the hepatic portoenterostomy procedure which now bears his name, Biliary atresia (BA) was a uniformly fatal disease. Both the Kasai procedure and liver transplantation have markedly improved the outlook for infants with this condition. Although long-term survival with native liver occurs in the minority, survival rates post liver transplantation are high. Most young people born with BA will now survive into adulthood but their ongoing requirements for health care will necessitate their transition from a family-centred paediatric service to a patient-centred adult service. Despite a rapid growth in transition services over recent years and progress in transitional care, transition from paediatric to adult services is still a risk for poor clinical and psychosocial outcomes and increased health care costs. Adult hepatologists should be aware of the clinical management and complications of biliary atresia and the long-term consequences of liver transplantation in childhood. Survivors of childhood illness require a different approach to that for young adults presenting after 18 years of age with careful consideration of their emotional, social, and sexual health. They need to understand the risks of non-adherence, both for clinic appointments and medication, as well as the implications for graft loss. Developing adequate transitional care for these young people is based on effective collaboration at the paediatric-adult interface and is a major challenge for paediatric and adult providers alike in the 21st century. This entails education for patients and adult physicians in order to familiarise them with the long-term complications, in particular for those surviving with their native liver and the timing of consideration of liver transplantation if required. This article focusses on the outcome for children with biliary atresia who survive into adolescence and adult life with considerations on their current management and prognosis.
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Affiliation(s)
- Deirdre Kelly
- Liver Unit, Birmingham Women’s & Children’s NHS Hospital, University of Birmingham, Birmingham B15 2TT, UK
| | - Marianne Samyn
- Paediatric Liver, Gastroenterology and Nutrition Unit, King’s College Hospital NHS Foundation Trust, London WC2R 2LS, UK
| | - Kathleen B. Schwarz
- Pediatric Liver Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Pediatric Liver Center, UCSD School of Medicine/Rady Children’s Hospital, San Diego, CA 92123, USA
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9
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Maternal and perinatal outcome in pregnancies complicated with portal hypertension: a systematic review and meta-analysis. Hepatol Int 2023; 17:170-179. [PMID: 35802227 DOI: 10.1007/s12072-022-10385-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal hypertension is secondary to either cirrhotic or non-cirrhotic causes, and complicating pregnancy poses a challenge to the treating team. A systematic review was performed to determine maternal and perinatal outcomes in women with portal hypertension. Outcomes were compared among those with cirrhotic (CPH) with non-cirrhotic portal hypertension (NCPH) as well as non-cirrhotic portal fibrosis (NCPF) with extra-hepatic portal vein obstruction (EHPVO). METHODS Medline and EMBASE databases were searched for studies reporting outcomes among pregnant women with portal hypertension. Reference lists from relevant papers and reviews were hand-searched for appropriate citations. Data were extracted to describe maternal complications, obstetric and neonatal outcomes. A random-effects model was used to derive pooled estimates of various outcomes, and final estimates were reported as percentages with a 95% confidence interval (CI). Cumulative, sequential and sensitivity analysis was studied to assess the temporal trends of outcomes over the period. RESULTS Information on 895 pregnancies among 581 patients with portal hypertension was included from 26 studies. Portal hypertension was diagnosed during pregnancy in 10% (95% CI 4-24%). There were 22 maternal deaths (0%, 95% CI 0-1%), mostly following complications from variceal bleeding or hepatic decompensation. Variceal bleeding complicated in 14% (95% CI 9-20%), and endoscopic interventions were performed in 12% (95% CI 8-17%) during pregnancy. Decompensation of liver function occurred in 7% (95% CI 3-12%). Thrombocytopenia was the most common complication (41%, 95% CI 23-60%). Miscarriages occurred in 14% (95% CI 8-20%), preterm birth in 27% (95% CI 19-37%), and low birth weights in 22% (95% CI 15-30%). Risk of postpartum hemorrhage was higher (RR 5.09, 95% CI 1.84-14.12), and variceal bleeding was lower (RR 0.51, 95% CI 0.30-0.86) among those with CPH compared to NCPH. Risk of various outcomes was comparable between NCPF and EHPVO. CONCLUSION One in ten pregnancies complicated with portal hypertension is diagnosed during pregnancy, and thrombocytopenia is the most common complication. Hepatic decompensation and variceal bleeding remain the most common cause of maternal deaths, with reduced rates of bleeding and its complications reported following the introduction of endoscopic procedures during pregnancy. CPH increases the risk of postpartum hemorrhage, whereas variceal bleeding is higher among NCPH.
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10
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Karim G, Giri D, Kushner T, Reau N. Evaluation of Liver Disease in Pregnancy. Clin Liver Dis 2023; 27:133-155. [PMID: 36400462 DOI: 10.1016/j.cld.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Liver disease in pregnancy often requires diagnostic and therapeutic considerations that are unique to pregnancy. Liver disease in pregnancy is commonly thought of as either liver disease unique to pregnancy, chronic liver disease, or liver disease coincidental to pregnancy. This review summarizes the approach to evaluation of liver disease in pregnancy.
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Affiliation(s)
- Gres Karim
- Department of Medicine, Mount Sinai Beth Israel, 350 East 17th Street, 20th Floor, New York, NY 10003, USA
| | - Dewan Giri
- Department of Medicine, Mount Sinai Beth Israel, 350 East 17th Street, 20th Floor, New York, NY 10003, USA
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1123, New York, NY 10023, USA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1123, New York, NY 10023, USA.
| | - Nancy Reau
- Division of Hepatology, Rush University Medical Center, 1725 West Harrison Street
- Suite 319, Chicago, IL 60612, USA
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11
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Fouda S, Vennikandam MM, Pappachan JM, Fernandez CJ. Pregnancy and Metabolic-associated Fatty Liver Disease: A Clinical Update. J Clin Transl Hepatol 2022; 10:947-954. [PMID: 36304500 PMCID: PMC9547252 DOI: 10.14218/jcth.2022.00052] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/15/2022] [Accepted: 04/26/2022] [Indexed: 12/04/2022] Open
Abstract
The intricate relationship between metabolic-associated fatty liver disease (MAFLD) and maternal complications has rapidly become a significant health threat in pregnant women. The presence of MAFLD in pregnancy increases the maternal risk of metabolic complications and comorbidities for both mother and baby. The preexistence or development of MAFLD in pregnancy is a complex multifactorial disorder that can lead to further complications for mother and baby. Therefore, as pregnant women are severely underrepresented in clinical research, there is a great need for a fair inclusion of this group in clinical trials. This review aims to explore the effects of MAFLD during pregnancy in the context of maternal complications and outcomes and explore the effects of pregnancy on the development and progression of MAFLD within the context of maternal obesity, altered metabolic profiles, gestational diabetes and altered hormonal profiles. We also addressed potential implications for the presence of MAFLD during pregnancy and its management in the clinical setting.
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Affiliation(s)
- Sherouk Fouda
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Madhu Mathew Vennikandam
- Department of Gastroenterology and Hepatology, Sparrow Hospital, Michigan State University College of Human Medicine, Lansing, MI, USA
| | - Joseph M. Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Faculty of Science, Manchester Metropolitan University, Manchester, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Correspondence to: Joseph M Pappachan, Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Sharoe Green Lane, Preston PR2 9HT, UK. ORCID: https://orcid.org/0000-0003-0886-5255. Tel/Fax: +44-1-7725-22092, E-Mail:
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12
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Shingina A, Sarkar M, Feld L. On the Importance of Safe Access to Reproductive Options for Adolescents and Women With Liver Disease. Gastroenterology 2022; 163:792-794. [PMID: 35752297 DOI: 10.1053/j.gastro.2022.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Alexandra Shingina
- Division of Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Monika Sarkar
- Division of GI/Hepatology, University of California, San Francisco, San Francisco, California
| | - Lauren Feld
- Division of Gastroenterology & Hepatology, University of Washington, Seattle, Washington
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13
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Liver Disease During Pregnancy. Am J Gastroenterol 2022; 117:44-52. [PMID: 36194033 DOI: 10.14309/ajg.0000000000001960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/23/2022] [Indexed: 11/07/2022]
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14
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Rahim MN, Hedley C, Frick A, Chung Y, Penna L, Long L, Williamson C, Heneghan MA. Development of obstetric-hepatology services: defining optimal care and impact of pregnancy counselling on patient experience. Frontline Gastroenterol 2022; 14:124-131. [PMID: 36818790 PMCID: PMC9933593 DOI: 10.1136/flgastro-2022-102106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/29/2022] [Indexed: 02/24/2023] Open
Abstract
Objective Prepregnancy counselling (PPC) is an important aspect of care for women with chronic liver disease (CLD) and liver transplantation (LT), yet its impact has not been well described. This study aims to assess the experience of women attending a joint obstetric-hepatology PPC clinic in a single-centre unit. Design/methods A retrospective questionnaire-based study in a tertiary unit within the UK where patients who attended the PPC clinic between March 2016 and July 2021 were invited to participate by filling in a questionnaire. Descriptive data and free-text content were subsequently analysed. Results 108 women attended the PPC clinic over a 5-year period. Overall, 58/108 (54%) completed the questionnaire. Principal concerns regarding pregnancy included fears around deterioration in health (66%), maternal death (24%), pregnancy loss (66%), medication effects (60%) and disease transmission (36%). 17/58 (14%) patients felt the presence of multiple doctors was intimidating, however, perceptions improved by the end of the consultation.Overall, 44/58 (76%) respondents felt the clinic helped them reach a decision about pursuing pregnancy. Almost all respondents would recommend the clinic to others. There were no major differences in pregnancy outcomes between those that received PPC and those that did not. Conclusion The PPC clinic facilitates a personalised approach to care and is well received by patients with CLD/LT. It is difficult to elucidate whether attendance alone impacts on pregnancy outcomes; registry data may be better placed at addressing this important question.
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Affiliation(s)
| | | | - Alex Frick
- Department of Obstetrics, King’s College Hospital, London, UK
| | - Yooyun Chung
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Leonie Penna
- Department of Obstetrics, King’s College Hospital, London, UK
| | - Lisa Long
- Department of Obstetrics, King’s College Hospital, London, UK
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15
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Chung YY, Heneghan MA. Autoimmune hepatitis in pregnancy: Pearls and pitfalls. Hepatology 2022; 76:502-517. [PMID: 35182079 DOI: 10.1002/hep.32410] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 12/13/2022]
Abstract
Autoimmune hepatitis (AIH) in pregnancy has many unique considerations. Evidence provided from single center studies with patient level data and nationwide population studies provide valuable insight into this complex situation. Because a planned pregnancy is a safer pregnancy, preconception counseling is a crucial opportunity to optimize care and risk stratify women with AIH. Women with chronic liver disease who receive preconception advice and counseling are more likely to achieve stable liver disease at conception and undergo appropriate variceal surveillance. Loss of biochemical response in pregnancy is associated with adverse outcomes in unstable disease. New onset AIH in pregnancy should be managed with classical treatment regimens. The continued use of immunosuppression in pregnancy, with the exception of mycophenolate mofetil, has not shown to adversely affect the rates of stillbirth or congenital malformation. Previously adopted immunosuppression withdrawal paradigms in pregnancy should no longer be considered advantageous, because remission loss postdelivery is likely (12%-86%). Population studies, report improved outcomes with preterm birth rates falling from 20% to 9%-13% in AIH pregnancies over a 20-year period. Newer data have also demonstrated an increased risk of gestational diabetes and hypertensive complications in AIH pregnancy, which has implications for management and preeclampsia prevention with aspirin use. This review aims to provide the framework to guide and manage pregnancy in AIH outlining pearls and pitfalls to ensure optimal outcomes for mother, baby and to reduce variation in practice.
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Affiliation(s)
- Y Y Chung
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, UK.,School of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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16
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Cirrhosis and pregnancy: a single centre experience. Arch Gynecol Obstet 2022; 308:111-116. [PMID: 35904611 DOI: 10.1007/s00404-022-06706-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 07/06/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Cirrhosis is a diffuse pathology characterized by fibrosis of the liver and is the last stage of chronic liver diseases. It is a serious medical condition which seriously impacts reproduction and reproductive life span. The aim of this study is to evaluate the outcomes of pregnancies complicated with liver cirrhosis. METHODS Retrospective chart review of the fetal and maternal results of 20 pregnant women with liver cirrhosis who had undergone antenatal follow-up and delivery at a tertiary center in a 12-year period was performed. RESULTS Chronic hepatitis B was found to be the leading cause of liver cirrhosis in the study group, with a rate of 25% (n: 5/20). The average MELD score was calculated as 8.8 ± 3.5. Only three patients developed hepatic decompensation during pregnancy. Fetal demise was observed in 10% of the cases (n: 2/20, MELD scores 8 and 17). MELD score was significantly higher in the patients with adverse perinatal outcomes. CONCLUSION Even though pregnancy is rarely observed in women with liver cirrhosis, many patients are able to achieve favorable maternal and fetal results without developing hepatic decompensation with appropriate management and close follow-up. The Model for End-Stage Liver Disease (MELD) score is a clinical tool utilized to estimate the severity and survival for chronic liver disease and was previously found to be associated with unfavorable outcomes in pregnant patients. Our study confirms this finding with the current experience from a tertiary care center.
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17
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Pregnancy Is Not Associated with an Increased Risk of Decompensation, Transplant, or Death in Compensated Cirrhosis. Int J Hepatol 2022; 2022:9985226. [PMID: 35845752 PMCID: PMC9279084 DOI: 10.1155/2022/9985226] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/24/2022] [Accepted: 06/02/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND AIMS Childbirth in women with cirrhosis is increasing and associated with a higher risk of perinatal outcomes compared to the general population. Whether pregnancy influences the risk of liver-related events compared to nonpregnant women with cirrhosis is unclear. This study evaluates the association between pregnancy and liver-related outcomes in women with compensated cirrhosis. Approach and Results. Population-based retrospective matched cohort study in Ontario, Canada, using routinely collected healthcare data. Pregnant women with compensated cirrhosis and without prior history of decompensation between 2000 and 2016 were identified and matched to nonpregnant women with compensated cirrhosis on age, etiology of cirrhosis, and socioeconomic status in a 1 : 2 ratio. The association between pregnancy and the composite outcome of nonmalignant decompensation, liver transplant (LT), and death up to two years after cohort entry was estimated using the multivariate Cox proportional hazard regression adjusting for potential confounders. Overall, 5,403 women with compensated cirrhosis were included (1,801 pregnant; 3,602 nonpregnant; median age 31 years (IQR 27-34); 60% nonalcoholic fatty liver disease, 34% viral hepatitis). After two years of follow-up, only 19 (1.1%) pregnant women had a liver-related event compared to 319 (8.9%) nonpregnant women. Pregnant women with compensated cirrhosis had a lower hazard of a liver-related event compared to nonpregnant women (aHR 0.14, 95% CI 0.09-0.22, P < .001). CONCLUSIONS Pregnancy in women with compensated cirrhosis is not associated with increased liver-related events compared to nonpregnant women. These results can facilitate counselling women with cirrhosis of child-bearing age and suggests that pregnancy may not accelerate liver disease progression.
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18
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van der Slink LL, Scholten I, van Etten-Jamaludin FS, Takkenberg RB, Painter RC. Pregnancy in women with liver cirrhosis is associated with increased risk for complications: A systematic review and meta-analysis of the literature. BJOG 2022; 129:1644-1652. [PMID: 35319158 PMCID: PMC9546282 DOI: 10.1111/1471-0528.17156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/04/2021] [Accepted: 06/18/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pregnancy and liver cirrhosis is a rare but increasing combination. Liver cirrhosis can raise the chance of maternal and fetal mortality and morbidity, although the exact risks remain unclear. OBJECTIVE To provide a systematic literature review and meta-analysis on maternal, fetal and obstetric complications among pregnant women with liver cirrhosis. SEARCH STRATEGY We performed a systematic literature search in the databases PubMed/MEDLINE and EMBASE (Ovid) from inception through 25 January 2021. SELECTION CRITERIA Studies including pregnancies with liver cirrhosis and controls were eligible. DATA COLLECTION AND ANALYSIS Two reviewers independently evaluated study eligibility. We used the random effects model for meta-analysis. MAIN RESULTS Our search yielded 3118 unique papers. We included 11 studies, including 2912 pregnancies in women with cirrhosis from 1982-2020. Seven studies were eligible for inclusion in the meta-analysis. The overall maternal mortality rate was 0.89%. Maternal mortality and variceal haemorrhage were lower in recent than in older studies. Most cases of maternal mortality due to variceal haemorrhage (70%) occurred during vaginal delivery. Pregnant women with liver cirrhosis had a higher chance of preterm delivery (OR 6.7, 95% CI 5.1-9.1), caesarean section (OR 2.6, 95% CI 1.7-3.9), pre-eclampsia (OR 3.8, 95% CI 2.2-6.5) and small-for-gestational-age neonates (OR 2.6, 95% CI 1.6-4.2) compared with the general obstetric population. Subgroup analyses could not be conducted. CONCLUSIONS Liver cirrhosis in pregnant women is associated with increases in maternal mortality and obstetric and fetal complications. Large international prospective studies are needed to identify risk factors for unfavourable outcome.
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Affiliation(s)
- Laurine L van der Slink
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Irma Scholten
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Deventer, the Netherlands
| | - Faridi S van Etten-Jamaludin
- Medical Library Academic Medical Centre, Amsterdam UMC, University of Amsterdam, Research Support, Amsterdam, the Netherlands
| | - Robert B Takkenberg
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rebecca C Painter
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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19
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Sujana Kumar V, Qumosani K, Taylor T, Sun D. Primary sclerosing cholangitis: A new case of cirrhosis in pregnancy. Obstet Med 2022; 15:56-58. [PMID: 35444728 PMCID: PMC9014540 DOI: 10.1177/1753495x20972828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/21/2020] [Accepted: 10/07/2020] [Indexed: 11/16/2022] Open
Abstract
Cirrhosis is a multisystemic condition in which pregnancy is uncommon; however, the combination may lead to a higher incidence of spontaneous fetal loss and complications such as progressive jaundice, ascites and variceal bleeding. Here we present a 21-year-old woman who presented at 14 weeks' gestation with new jaundice and a two-month history of melena consistent with pre-existing cirrhosis of unclear aetiology. She delivered a healthy male infant at 34 weeks and five days of gestation vaginally with good haemostasis. In the literature, maternal mortality rates have been reported in up to 61% of these women, however, this risk is likely lower now with modern endoscopic therapies and improved access to blood products. There is limited information about labour and delivery in cirrhosis, although the best outcomes to date have been described in well-compensated women.
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Affiliation(s)
- Vidya Sujana Kumar
- Department of Medicine, Scarborough Health Network, Toronto, Canada,Vidya Sujana Kumar, Department of Medicine,
Scarborough Health Network, 3030 Birchmount Road, Toronto, Ontario M5G 1P7, Canada.
| | - Karim Qumosani
- Department of Medicine, Schulich School of Medicine and Dentistry, Western
University, Toronto, Canada
| | - Taryn Taylor
- Department of Obstetrics and Gynecology, Schulich School of Medicine and
Dentistry, Western University, Toronto, Canada
| | - Dongmei Sun
- Department of Medicine, Schulich School of Medicine and Dentistry, Western
University, Toronto, Canada
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20
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Pregnancies With Cirrhosis Are Rising and Associated With Adverse Maternal and Perinatal Outcomes. Am J Gastroenterol 2022; 117:445-452. [PMID: 34928866 PMCID: PMC8969586 DOI: 10.14309/ajg.0000000000001590] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/19/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cirrhosis incidence in pregnancies from outside the United States (US) is rising, although contemporary data including maternal and perinatal outcomes within the United States are lacking. METHODS Using discharge data from the racially diverse US National Inpatient Sample, temporal trends of cirrhosis in pregnancies were compared with noncirrhotic chronic liver disease (CLD) or no CLD. Outcomes included preterm birth, postpartum hemorrhage, hypertensive complications (preeclampsia, eclampsia, and/or hemolysis, elevated liver enzymes, and low platelets syndrome), and maternal or fetal death. Logistic regression was adjusted for age, race, multiple gestation, insurance status, and prepregnancy metabolic comorbidities. RESULTS Among 18,573,000 deliveries from 2012 to 2016, 895 had cirrhosis, 119,875 had noncirrhotic CLD, and 18,452,230 had no CLD. Pregnancies with cirrhosis increased from 2.5/100,000 in 2007 to 6.5/100,000 in 2016 (P = 0.01). On adjusted analysis, cirrhosis was associated with hypertensive complications (vs no CLD, OR 4.9, 95% confidence intervals [CI] 3.3-7.4; vs noncirrhotic CLD, OR 4.4, 95% CI 3.0-6.7), postpartum hemorrhage (vs no CLD, OR 2.8, 95% CI 1.6-4.8; vs noncirrhotic CLD, OR 2.0, 95% CI 1.2-3.5), and preterm birth (vs no CLD, OR 3.1, 95% CI 1.9-4.9; vs noncirrhotic CLD, OR 2.0, 95% CI 1.3-3.3, P ≤ 0.01). Cirrhosis was statistically associated with maternal mortality, although rarely occurred (≤ 1%). DISCUSSION In this racially diverse, US population-based study, pregnancies with cirrhosis more than doubled over the past decade. Cirrhosis conferred an increased risk of several adverse events, although maternal and perinatal mortality was uncommon. These data underscore the need for reproductive counseling and multidisciplinary pregnancy management in young women with cirrhosis.
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21
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Chung YY, Rahim MN, Heneghan MA. Autoimmune hepatitis and pregnancy: considerations for the clinician. Expert Rev Clin Immunol 2022; 18:325-333. [PMID: 35179437 DOI: 10.1080/1744666x.2022.2044307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Autoimmune hepatitis (AIH) is an immune mediated inflammatory disease of the liver which affects females of reproductive age. AIH poses unique challenges in pregnancy and historically was associated with adverse pregnancy outcomes. AREAS COVERED This report aims to review the current evidence for AIH pregnancy outcomes and the use of medical therapies in pregnancy. The disease course of AIH in pregnancy including loss of biochemical response (LOBR) and hepatic decompensation is also reviewed. The importance of preconception counselling and continued monitoring into the post-partum phase are reinforced. EXPERT OPINION The lack of prognostic markers and targeted immunosuppression are some of the areas for future development, as this will aid the move towards individualised risk stratification and personalised care.
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Affiliation(s)
- Y Y Chung
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK
| | - M N Rahim
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK.,School of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - M A Heneghan
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK.,School of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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22
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Kumar M, Abbas Z, Azami M, Belopolskaya M, Dokmeci AK, Ghazinyan H, Jia J, Jindal A, Lee HC, Lei W, Lim SG, Liu CJ, Li Q, Al Mahtab M, Muljono DH, Niriella MA, Omata M, Payawal DA, Sarin SK, Ségéral O, Tanwandee T, Trehanpati N, Visvanathan K, Yang JM, Yuen MF, Zheng Y, Zhou YH. Asian Pacific association for the study of liver (APASL) guidelines: hepatitis B virus in pregnancy. Hepatol Int 2022; 16:211-253. [PMID: 35113359 DOI: 10.1007/s12072-021-10285-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/06/2021] [Indexed: 12/11/2022]
Abstract
Hepatitis B virus (HBV) infection still remains a major public health issue in the Asia-Pacific region. Most of the burden of HBV-related disease results from infections acquired in infancy through perinatal or early childhood exposure to HBV in Asia-Pacific. Hepatitis B during pregnancy presents unique management issues for both the mother and fetus. These APASL guidelines provide a comprehensive review and recommendations based on available evidence in the literature, for the management of females with HBV infection through every stage of pregnancy and postpartum. These also address the concerns, management challenges, and required follow-up of children born to hepatitis B-positive mothers.
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Affiliation(s)
- Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India.
| | - Zaigham Abbas
- Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
| | - Milad Azami
- Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | | | - A K Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Hasmik Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medial University, Beijing, China
| | - Ankur Jindal
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India
| | - Han Chu Lee
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wei Lei
- Hepatopancreatobiliary Center, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Seng Gee Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chun-Jen Liu
- Department of Internal Medicine and Hepatitis Research Center, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Qiang Li
- Division of Liver Diseases Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Madunil Anuk Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Colombo, Sri Lanka
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Tokyo, Japan
| | - Diana A Payawal
- Fatima University Medical Center Manila, Manila, Philippines
| | - Shiv K Sarin
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India.
| | - Olivier Ségéral
- French Agency for Research on AIDS and Viral Hepatitis, University of Health Science, Phnom Penh, Cambodia
| | - Tawesak Tanwandee
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nirupma Trehanpati
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kumar Visvanathan
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Man-Fung Yuen
- Li Shu Fan Medical Foundation Professor in Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Yingjie Zheng
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
| | - Y H Zhou
- Department of Laboratory Medicine, Department of Infectious Diseases, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
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23
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Elshaarawy O, Abdelaziz R, Zayed N, Hany A, Hammam Z, Mueller S, Yosry A, Shousha HI. Acoustic radiation force impulse to measure liver stiffness and predict hepatic decompensation in pregnancy with cirrhosis: A cohort study. Arab J Gastroenterol 2022; 23:89-94. [DOI: 10.1016/j.ajg.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/15/2021] [Accepted: 01/14/2022] [Indexed: 02/07/2023]
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24
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Dokmak A, Trivedi HD, Bonder A, Wolf J. Pregnancy in Chronic Liver Disease: Before and After Transplantation. Ann Hepatol 2021; 26:100557. [PMID: 34656772 DOI: 10.1016/j.aohep.2021.100557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 02/04/2023]
Abstract
Chronic liver disease poses various challenges for women of reproductive age. Cirrhosis, particularly if decompensated, and liver transplantation may impact gestation and perinatal outcomes. Tailored management of underlying liver disease is critical to optimize maternal and fetal wellbeing. Early education, timely intervention, close monitoring, and a multidisciplinary approach are key elements required to minimize complications and increase chances of a safe and successful pregnancy. In this review, we focus on the pregnancy-related implications of chronic liver disease and liver transplantation on women of reproductive age and highlight disease-specific management considerations.
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Affiliation(s)
- Amr Dokmak
- Department of Hospital Medicine, Catholic Medical Center, Manchester, NH, USA.
| | - Hirsh D Trivedi
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alan Bonder
- Liver Center, Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jacqueline Wolf
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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25
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Birkness-Gartman JE, Oshima K. Liver pathology in pregnancy. Pathol Int 2021; 72:1-13. [PMID: 34818440 DOI: 10.1111/pin.13186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
Liver dysfunction occurs in up to 3% of pregnancies and can be due to pregnancy-associated liver injury, exacerbation of pre-existing liver disease, or co-incident with pregnancy. The most common form of pregnancy-associated liver injury is intrahepatic cholestasis of pregnancy (ICP). This condition is typically benign and self-limited, but is associated with fetal morbidity and mortality with high levels of serum bile acids. Acute fatty liver of pregnancy (AFLP) and the hypertensive disorders of pregnancy (including pre-eclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets [HELLP] syndrome) are more commonly associated with maternal and fetal complications and may necessitate expedient delivery. Histologically, ICP shows nonspecific features of cholestasis, while AFLP and the hypertensive disorders have more characteristic histologic findings. While not a true liver disease, hyperemesis gravidarum can cause elevated liver enzymes. Pregnant patients are at increased risk of developing severe hepatitis E and herpesvirus infections, Budd-Chiari syndrome, and gallstones, and they may also experience worsening of known chronic liver disease. Mass lesions in pregnancy including hemangiomas, focal nodular hyperplasia, and hepatocellular adenomas and carcinomas can present unique challenges for diagnosis and management. This review will explore the pathophysiology, presentation, histologic features, and management of these conditions.
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Affiliation(s)
- Jacqueline E Birkness-Gartman
- Department of Pathology, Division of Gastrointestinal/Liver Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kiyoko Oshima
- Department of Pathology, Division of Gastrointestinal/Liver Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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26
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Prepregnancy Assessment of Liver Function to Predict Perinatal and Postpregnancy Outcomes in Biliary Atresia Patients with Native Liver. J Clin Med 2021; 10:jcm10173956. [PMID: 34501403 PMCID: PMC8432127 DOI: 10.3390/jcm10173956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 11/16/2022] Open
Abstract
Considering that some biliary atresia (BA) survivors with native liver have reached reproductive age and face long-lasting complications, specific attention needs to be paid to pregnant cases. This study aimed to investigate the relationship between liver function, perinatal outcomes, and prognosis. A database review was conducted to identify pregnant BA cases with native liver and perinatal data, and clinical information on BA-related complications was analyzed. Perinatal serum cholinesterase (ChE) levels, model for end-stage liver-disease (MELD) score, and platelet trends were analyzed, and the association between these indicators and perinatal outcomes was investigated. Patients were categorized into three groups according to the perinatal clinical outcomes: favorable (term babies with or without several episodes of cholangitis; n = 3), borderline (term baby and following liver dysfunction; n = 1), and unfavorable (premature delivery with subsequent liver failure; n = 1). Lower serum ChE levels, lower platelet counts, and higher MELD scores were observed in the unfavorable category. Borderline and unfavorable patients displayed a continuous increase in MELD score, with one eventually needing a liver transplantation. Pregnancy in patients with BA requires special attention. Serum ChE levels, platelet counts, and MELD scores are all important markers for predicting perinatal prognosis.
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27
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Salman AA, Kasem MF, Kholaif KM, Ramadan M, Yousef M, Shaaban HE, Atallah M, El Sherbiny M, Ashoush O, Seif El Nasr SM. Outcomes of pregnancy in Child A liver cirrhotic patients: A retrospective multicenter study. ADVANCES IN DIGESTIVE MEDICINE 2021. [DOI: 10.1002/aid2.13205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Mohamed Fikry Kasem
- Faculty of Medicine Gynecology and Obstetrics Department, Cairo University Giza Egypt
| | - Khaled M. Kholaif
- Faculty of Medicine Gynecology and Obstetrics Department, Cairo University Giza Egypt
| | - Mohamed Ramadan
- Faculty of Medicine Gynecology and Obstetrics Department, Cairo University Giza Egypt
| | - Mohamed Yousef
- Faculty of Medicine Tropical Medicine Department, Cairo University Giza Egypt
| | - Hossam El‐Din Shaaban
- Gastroenterology Department National Hepatology and Tropical Medicine Research Institute Cairo Egypt
| | - Mohamed Atallah
- Gastroenterology Department National Hepatology and Tropical Medicine Research Institute Cairo Egypt
| | | | - Omar Ashoush
- Faculty of Medicine Internal Medicine Department, Cairo University Giza Egypt
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28
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Rahim MN, Theocharidou E, Yen Lau KG, Ahmed R, Marattukalam F, Long L, Cannon MD, Heneghan MA. Safety and efficacy of in vitro fertilisation in patients with chronic liver disease and liver transplantation recipients. J Hepatol 2021; 74:1407-1415. [PMID: 33460690 DOI: 10.1016/j.jhep.2020.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/24/2020] [Accepted: 12/16/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Chronic liver disease and liver transplantation (LT) can delay both timing and ability of women to conceive. With increased awareness and availability of in vitro fertilisation (IVF), the need for accurate counselling is paramount. To date, minimal data exist on outcomes of IVF in patients with chronic liver disease, cirrhosis, or post-LT. We report the largest experience of IVF in women with liver-related subfertility (LRSF). METHODS A retrospective analysis was performed on 42 women with LRSF who had undergone 57 IVF cycles between 1990 and 2019. RESULTS Forty-two women with LRSF received IVF; 9 cycles in 6 women with cirrhosis, 14 cycles in 11 women post-LT, and 34 cycles in 25 women without cirrhosis. The main aetiologies of liver disease included HBV, HCV, and autoimmune hepatitis (AIH). Of 57 IVF cycles evaluated, 43 (75%) resulted in successful implantation. Eight (2 post-LT, 3 with cirrhosis, 4 without cirrhosis) resulted in miscarriage. The live birth rate (LBR) was 74% (32/43). Two of 9 (22%) patients with cirrhosis, 4/14 (29%) patients who were post-LT, and 6/34 (18%) patients without cirrhosis had unsuccessful IVF attempts. Nine of 57 (16%) IVF cycles resulted in new liver enzyme derangement during therapy, which improved after treatment completion. Six pregnancies (2 in patients who were post-LT, 4 without cirrhosis) were complicated by obstetric cholestasis (OC). Ovarian hyperstimulation syndrome (OHSS) was rare (n = 3, 7%). One patient with AIH-related cirrhosis decompensated after initiating IVF, warranting discontinuation of therapy. There were no maternal deaths. Three women developed a hypertensive disorder of pregnancy. Half the pregnancies resulted in premature deliveries (range 27-36 weeks). CONCLUSIONS In selected cases, IVF in women with LRSF can be successful. However, patients should be counselled on the potential increased risks of OHSS, OC, and prematurity. LAY SUMMARY Women with liver disease or those who have had a liver transplant can experience difficulties getting pregnant. In this study, we look at whether alternative approaches to achieve pregnancy are harmful in these women. Overall, there were no significant issues with the use of in vitro fertilisation in women with liver disease, but they need to be aware of potential risks, such as early delivery of the baby.
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Affiliation(s)
- Mussarat N Rahim
- Institute of Liver Studies, King's College Hospital, London, UK; King's Liver Pregnancy Research Group, King's College Hospital, London, UK
| | | | - Katherine Gar Yen Lau
- King's Liver Pregnancy Research Group, King's College Hospital, London, UK; Foetal Medicine Research Unit, King's College Hospital, London, UK
| | - Refah Ahmed
- Institute of Liver Studies, King's College Hospital, London, UK; King's Liver Pregnancy Research Group, King's College Hospital, London, UK
| | | | - Lisa Long
- King's Liver Pregnancy Research Group, King's College Hospital, London, UK; Foetal Medicine Research Unit, King's College Hospital, London, UK
| | - Mary D Cannon
- Institute of Liver Studies, King's College Hospital, London, UK; King's Liver Pregnancy Research Group, King's College Hospital, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, UK; King's Liver Pregnancy Research Group, King's College Hospital, London, UK; EASL European Registry for Liver Diseases in Pregnancy, Geneva, Switzerland; European Reference Network - Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.
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29
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Flemming JA, Velez MP. The ART of medicine: Counselling women with liver disease about assisted reproductive technology. J Hepatol 2021; 74:1283-1285. [PMID: 33810873 DOI: 10.1016/j.jhep.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
| | - Maria P Velez
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
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30
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Rahim MN, Pirani T, Williamson C, Heneghan MA. Management of pregnancy in women with cirrhosis. United European Gastroenterol J 2021; 9:110-119. [PMID: 33259738 PMCID: PMC8259114 DOI: 10.1177/2050640620977034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/08/2020] [Indexed: 12/26/2022] Open
Abstract
Although pregnancy is rare in women with cirrhosis, it is increasingly prevalent in an era of modern assisted conception techniques and improved awareness, monitoring and management of underlying liver disease. After overcoming the difficulties of subfertility and becoming pregnant, women undergo a 'high-risk' pregnancy which can be complicated by variceal haemorrhage (≤50%) and hepatic decompensation (≤25%). Management of these complications are similar to non-pregnant individuals. However, there are a few caveats to consider. These pregnancies are associated with adverse maternal and foetal outcomes, such as mortality (0%-8%) and prematurity (19%-67%) in the newborn, and mortality (0%-14%), pregnancy-induced hypertension (5%-22%) and post-partum haemorrhage (5%-45%) in the mother. Pre-pregnancy counselling, use of predictive scores and appropriate variceal screening during pregnancy can stratify patients and improve outcomes. This review focusses on the complications that can occur during pregnancy in women with cirrhosis.
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Affiliation(s)
| | - Tasneem Pirani
- Institute of Liver Studies, King's College Hospital, London, UK
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31
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Sarkar M, Brady CW, Fleckenstein J, Forde KA, Khungar V, Molleston JP, Afshar Y, Terrault NA. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:318-365. [PMID: 32946672 DOI: 10.1002/hep.31559] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Monika Sarkar
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Jean P Molleston
- Indiana University and Riley Hospital for Children, Indianapolis, IN
| | - Yalda Afshar
- University of California, Los Angeles, Los Angeles, CA
| | - Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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32
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Montano-Loza AJ, Allegretti JR, Cheung A, Ebadi M, Jones D, Kerkar N, Levy C, Rizvi S, Vierling JM, Alvarez F, Bai W, Gilmour S, Gulamhusein A, Guttman O, Hansen BE, MacParland S, Mason A, Onofrio F, Santamaria P, Stueck A, Swain M, Vincent C, Ricciuto A, Hirschfield G. Single Topic Conference on Autoimmune Liver Disease from the Canadian Association for the Study of the Liver. CANADIAN LIVER JOURNAL 2021; 4:401-425. [PMID: 35989897 PMCID: PMC9235119 DOI: 10.3138/canlivj-2021-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 11/20/2022]
Abstract
Autoimmune liver disease (AILD) spans a spectrum of chronic disorders affecting the liver parenchyma and biliary system. Three main categories of AILD are autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC). This review condenses the presentation and discussions of the Single Topic Conference (STC) on AILD that was held in Ottawa, Ontario, in November 2019. We cover generalities regarding disease presentation and clinical diagnosis; mechanistic themes; treatment paradigms; clinical trials, including approaches and challenges to new therapies; and looking beyond traditional disease boundaries. Although these diseases are considered autoimmune, the etiology and role of environmental triggers are poorly understood. AILDs are progressive and chronic conditions that affect survival and quality of life. Advances have been made in PBC treatment because second-line treatments are now available (obeticholic acid, bezafibrate); however, a significant proportion still present suboptimal response. AIH treatment has remained unchanged for several decades, and data suggest that fewer than 50% of patients achieve a complete response and as many as 80% develop treatment-related side effects. B-cell depletion therapy to treat AIH is in an early stage of development and has shown promising results. An effective treatment for PSC is urgently needed. Liver transplant remains the best option for patients who develop decompensated cirrhosis or hepatocellular carcinoma within specific criteria, but recurrent AILD might occur. Continued efforts are warranted to develop networks for AILD aimed at assessing geo-epidemiological, clinical, and biochemical differences to capture the new treatment era in Canada.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Cheung
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Maryam Ebadi
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - David Jones
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Nanda Kerkar
- Division of Gastroenterology, Hepatology and Nutrition, Golisano Children's Hospital at Strong, University of Rochester Medical Center, New York, USA
| | - Cynthia Levy
- Schiff Center for Liver Diseases, University of Miami, Miami, Florida, USA
| | - Sumera Rizvi
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Fernando Alvarez
- Department of Pediatrics, Hôpital Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Wayne Bai
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Susan Gilmour
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Aliya Gulamhusein
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Orlee Guttman
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bettina E Hansen
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Sonya MacParland
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Mason
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Fernanda Onofrio
- Ajmera Family Transplant Centre, Toronto General Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Pere Santamaria
- Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Ashley Stueck
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mark Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Catherine Vincent
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gideon Hirschfield
- Toronto Centre for Liver Disease, University Health Network & Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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33
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Flemming JA, Mullin M, Lu J, Sarkar MA, Djerboua M, Velez MP, Brogly S, Terrault NA. Outcomes of Pregnant Women With Cirrhosis and Their Infants in a Population-Based Study. Gastroenterology 2020; 159:1752-1762.e10. [PMID: 32781083 DOI: 10.1053/j.gastro.2020.07.052] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/30/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS The incidence of cirrhosis is increasing among women of childbearing age. Contemporary outcomes of pregnant women with cirrhosis and their infants, as well as liver-related complications, have not been described in North America, to our knowledge. We investigated the association between cirrhosis and perinatal outcomes and evaluated perinatal liver-related events. METHODS We performed a retrospective cohort study using population-based administrative health care data from Ontario, Canada (2000-2017). We identified pregnant women with compensated cirrhosis (n = 2022) using validated case definitions and routine mother-infant linkage; the women were matched to 10,110 pregnant women in the general population (1:5) based on birth year and socioeconomic status. Maternal and infant outcomes up to 6 weeks postpartum and liver-related complications up to 1 year postpartum were evaluated by using multivariate log-binomial regression. RESULTS After we adjusted for demographic and metabolic risk factors, cirrhosis was independently associated with intrahepatic cholestasis of pregnancy (relative risk [RR], 10.64; 95% confidence interval [CI], 7.49-15.12), induction of labor (RR, 1.15; 95% CI, 1.03-1.28), puerperal infections (RR, 1.32; 95% CI, 1.02-1.70), preterm birth (RR, 1.60; 95% CI, 1.35-1.89), infants who were large for gestational age (RR, 1.24; 95% CI, 1.05-1.46), and neonatal respiratory distress (RR, 1.20; 95% CI, 1.02-1.42). Fewer than 2% of pregnant women with cirrhosis had liver-related complications, but these occurred in a significantly higher proportion of women with a history of hepatic decompensation (13%) than women with compensated cirrhosis (1.2%) (P < .001). CONCLUSIONS In a population-based study, we found that cirrhosis is an independent risk factor for adverse perinatal outcomes. However, liver-related complications are rare. Multidisciplinary teams are needed to coordinate care for pregnant women with cirrhosis during pregnancy and postpartum to optimize outcomes.
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Affiliation(s)
- Jennifer A Flemming
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Department of Medicine, University of California San Francisco, San Francisco, California.
| | - Monica Mullin
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Jacquie Lu
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Monika A Sarkar
- Department of Medicine, University of California San Francisco, San Francisco, California
| | | | - Maria P Velez
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; ICES, Queen's University, Kingston, Ontario, Canada; Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
| | - Susan Brogly
- ICES, Queen's University, Kingston, Ontario, Canada; Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Norah A Terrault
- Keck Medicine of University of Southern California, Los Angeles, California
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34
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Faulkes RE, Chauhan A, Knox E, Johnston T, Thompson F, Ferguson J. Review article: chronic liver disease and pregnancy. Aliment Pharmacol Ther 2020; 52:420-429. [PMID: 32598048 DOI: 10.1111/apt.15908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/02/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence of chronic liver disease in women of child bearing age is increasing, leading to a higher incidence of pregnancy in this cohort. Chronic medical conditions have a significant adverse effect on maternal morbidity and mortality. To date, reviews on this topic have been written either from a hepatology or obstetrics viewpoint, and no specific guidelines are available solely for the management of chronic liver disease in pregnancy. AIMS To produce a comprehensive review on the clinical management of women with chronic liver disease during pregnancy, addressing the risks of pregnancy to mother and child, how these risks can be ameliorated, and what additional considerations are required for management of chronic liver disease in pregnancy. METHODS Data were collected up to May 2020 from the biomedical database PubMed, national and international guidelines in gastroenterology and hepatology. RESULTS During pregnancy, women with cirrhosis are more likely to develop decompensated disease, worsening of portal hypertension, and to deliver premature infants. CONCLUSIONS The risks associated with pregnancy can be ameliorated by advanced planning, assessing risk using the model for end stage liver disease score and risk reduction through varices screening. A multidisciplinary approach is paramount in order to minimise complications and maximise the chance of a safe pregnancy and birth for mother and baby.
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Affiliation(s)
| | - Abhishek Chauhan
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Centre for Liver Research, Institute of Immunology and Inflammation, and National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, The Medical School, University of Birmingham, Birmingham, UK
| | - Ellen Knox
- Birmingham Womens' Hospital, Birmingham, UK
| | | | | | - James Ferguson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Centre for Liver Research, Institute of Immunology and Inflammation, and National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, The Medical School, University of Birmingham, Birmingham, UK
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35
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Abstract
Worldwide native liver survival (NLS) for young adults (>20 years) with biliary atresia varies between 14% and 44% with the majority of patients developing complications in adulthood. Cholangitis and portal hypertension with variceal bleeding are the most common complications and development of these during adolescence associated with the need for liver transplantation during adulthood. Adult listing criteria, typically developed on the background of adult liver disease might not be applicable to this patient population and leads to longer waiting time and risk of deterioration of their medical condition. Current data on growth and puberty in young people with biliary atresia surviving with native liver are rare. Pregnancy has been associated with serious complications in particular for those patients with advanced liver disease and, close follow up by specialist teams recommended. The long-term effect of having a chronic liver disease such as biliary atresia on neuro-cognitive and pubertal development has not been sufficiently explored to date despite reports of a high prevalence of additional educational needs in this cohort. In addition, patients and parents report inferior health related quality of life compared to healthy peers and similar to that of children post liver transplantation. Moving on from paediatric to adult services is challenging for young people and their parents and adult health professionals might not be familiar with the condition and complications. Young people deserve to be looked after by specialist, multidisciplinary services who provide holistic care and address their psychosocial needs in addition to the medical needs.
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Affiliation(s)
- Marianne Samyn
- Paediatric Liver, Gi And Nutrition Centre, King's College Hospital NHS Foundation Trust, Denmark Hill, SE5 9RS London, UK.
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36
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Milić S, Tatalović T, Mikolašević I. Pre-existing liver disease in pregnancy: Cirrhosis, autoimmune hepatitis and liver transplantation. Best Pract Res Clin Gastroenterol 2020; 44-45:101668. [PMID: 32359683 DOI: 10.1016/j.bpg.2020.101668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/22/2020] [Accepted: 02/18/2020] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Sandra Milić
- School of Medicine, University of Rijeka, Rijeka, Croatia; Department of Gastroenterology, University Hospital Center Rijeka, Rijeka, Croatia.
| | | | - Ivana Mikolašević
- School of Medicine, University of Rijeka, Rijeka, Croatia; Department of Gastroenterology, University Hospital Center Rijeka, Rijeka, Croatia.
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37
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Cauldwell M, Mackie FL, Steer PJ, Henehghan MA, Baalman JH, Brennand J, Johnston T, Dockree S, Hedley C, Jarvis S, Khan S, McAuliffe FM, Mackillop L, Penna L, Smith B, Trivedi P, Verma S, Westbrook R, Winifield S, Williamson C. Pregnancy outcomes in women with primary biliary cholangitis and primary sclerosing cholangitis: a retrospective cohort study. BJOG 2020; 127:876-884. [DOI: 10.1111/1471-0528.16119] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2020] [Indexed: 12/17/2022]
Affiliation(s)
- M Cauldwell
- Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital London UK
| | - FL Mackie
- Academic Department of Obstetrics and Gynaecology Birmingham Women’s and Children’s NHS Foundation Trust Birmingham UK
| | - PJ Steer
- Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital London UK
| | | | - JH Baalman
- UCD Perinatal Research Centre School of Medicine University College Dublin National Maternity Hospital Dublin Ireland
| | - J Brennand
- Department of Obstetrics Queen Elizabeth Hospital Glasgow Glasgow UK
| | - T Johnston
- Academic Department of Obstetrics and Gynaecology Birmingham Women’s and Children’s NHS Foundation Trust Birmingham UK
| | - S Dockree
- Women’s Centre Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - C Hedley
- Department of Obstetrics King’s College Hospital London UK
| | - S Jarvis
- Department of Obstetrics Queen Charlotte’s and Chelsea Hospital London UK
| | - S Khan
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - FM McAuliffe
- UCD Perinatal Research Centre School of Medicine University College Dublin National Maternity Hospital Dublin Ireland
| | - L Mackillop
- Women’s Centre Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - L Penna
- Department of Obstetrics King’s College Hospital London UK
| | - B Smith
- Department of Hepatology Hammersmith Hospital London UK
| | - P Trivedi
- Liver Unit Queen Elizabeth Hospital Birmingham UK
| | - S Verma
- Department of Clinical and Experimental Medicine Brighton and Sussex Medical School Brighton UK
- Department of Gastroenterology and Hepatology Brighton and Sussex University Hospitals Brighton UK
| | - R Westbrook
- Department of Hepatology Royal Free Hospital London UK
| | - S Winifield
- Department of Obstetrics Leeds Teaching Hospitals Leeds UK
| | - C Williamson
- Department of Women and Children’s Health King’s College London London UK
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38
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Abstract
Liver disease in pregnancy may present as a disorder that is unique to pregnancy or as an acute or chronic liver disease occurring coincidentally in pregnancy. Hepatic diseases that are unique to pregnancy include hyperemesis gravidarum; preeclampsia/eclampsia; the syndrome of hemolysis, elevated liver enzymes, and low platelets; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Acute and chronic forms of primary hepatic disorders that are seen in pregnancy include viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease, and cirrhosis. Because of the need to consider both maternal and fetal health, there are special considerations for the implementation of diagnostic strategies and pharmacologic therapies for liver disease that occurs in pregnancy. An understanding of the pathogenesis and expression of liver diseases in pregnancy has been evolving, and various diagnostic and prognostic tools have been studied in order to determine noninvasive approaches to identifying and staging of such diseases. Investigations have also been underway to evaluate the safety and utility of existing and new therapeutic agents that previously were thought to not be compatible with pregnancy. This review will explore updates in the epidemiology, diagnosis, and management of various liver diseases seen in pregnancy.
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Affiliation(s)
- Carla W Brady
- Division of Gastroenterology Duke University Medical Center Durham NC
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39
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de Vries E, Beuers U. Ursodeoxycholic acid in pregnancy? J Hepatol 2019; 71:1237-1245. [PMID: 31479696 DOI: 10.1016/j.jhep.2019.08.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/19/2019] [Accepted: 08/26/2019] [Indexed: 02/08/2023]
Abstract
The case of a 34-year-old woman with primary biliary cholangitis (PBC) before, during and after pregnancy is described. The use of ursodeoxycholic acid (UDCA) during and after pregnancy is discussed. UDCA has not been approved by the drug regulatory authorities as a pregnancy-safe drug; therefore, the reluctance of clinicians to prescribe UDCA during pregnancy is understandable. This Grand Round aims to provide a detailed analysis of the current evidence, safety data and clinical experience with UDCA (and alternative drugs) during pregnancy and lactation. Based on this analysis, advice for clinicians regarding the use of UDCA during pregnancy and lactation is given.
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Affiliation(s)
- Elsemieke de Vries
- Department of Gastroenterology and Hepatology and Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology and Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands.
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40
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Young People With Biliary Atresia Requiring Liver Transplantation: A Distinct Population Requiring Specialist Care. Transplantation 2019; 103:e99-e107. [PMID: 30461724 DOI: 10.1097/tp.0000000000002553] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Young people (YP) born with biliary atresia (BA) are an emerging population for adult hepatologists with 40% to 45% of children entering adolescence with their native liver intact. For those requiring liver transplantation (LT) during adolescence, disparity on the waiting list and post-LT outcome for young adults compared with younger and older age groups has stimulated discussion about the optimal timing of listing. In this study, we review our experience of YP with BA requiring LT during adolescence and young adulthood. METHODS Retrospective, single-center review of patients with BA requiring LT > 11 years. RESULTS Thirty-six YP (16 male) underwent LT between 1991 and 2014 at a median age of 16.6 (interquartile range [IQR], 14.2 to 19.5) years. The commonest indications for listing were refractory cholangitis (31%), synthetic failure (25%), and variceal bleeding (14%). Patients listed by the adult team (n = 14) waited longer than those listed by the pediatric team (10 [IQR, 7.7 to 24.6] vs 5.8 [IQR, 4.0 to 15.1] months; P < 0.05) and were more likely to require intensive care support at time of listing (29% vs 5%; P < 0.05). Admission to intensive care unit at listing was associated with poorer patient and graft survival and support from a multidisciplinary liver transition service improved survival. Liver disease severity scores did not correlate with time on waiting list or outcome. CONCLUSIONS YP with BA requires close monitoring by specialists familiar with their condition and timing for LT needs to be fine-tuned to avoid clinical decompensation and improve long-term outcomes.
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41
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Abstract
Liver diseases during pregnancy pose a unique clinical challenge because they can affect the lives of both the mother and unborn child. Although severe liver disease is rare, pregnancy-related liver disease affects approximately 3% of pregnancies and can be fatal. Timely recognition and diagnosis are essential in order to institute appropriate management strategies. This article provides an overview of liver diseases during pregnancy and is divided into 2 sections: (1) liver diseases specific to pregnancy, and (2) preexisting or coincident liver diseases during pregnancy.
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Affiliation(s)
- Karen Ma
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Daniel Berger
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Nancy Reau
- Section of Hepatology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 319, Chicago, IL 60612, USA.
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Noninvasive Tests for Prognosticating Outcomes in Patients With Chronic Liver Disease in Pregnancy: Ready for Prime Time? Am J Gastroenterol 2019; 114:209-211. [PMID: 30730857 PMCID: PMC6548179 DOI: 10.14309/ajg.0000000000000101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rates of cirrhosis and pregnancy in women of reproductive age are increasing, making pregnancy-specific prognostic markers of disease severity increasingly important. Gonsalkorala et al. describe albumin-bilirubin score and aspartate aminotransferase-to-platelet ratio index as superior prognostic tools to the Model for End-Stage Liver Disease (MELD) score in predicting live births and gestation beyond 37 weeks in pregnant women with cirrhosis, among 165 pregnancies in women with chronic liver disease. However, further efforts are needed to identify diagnostic and prognostic tools during pregnancy, as well as to refine and implement a multidisciplinary team-centered approach to the care of women with chronic liver disease during pregnancy.
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Non-Invasive Markers (ALBI and APRI) Predict Pregnancy Outcomes in Women With Chronic Liver Disease. Am J Gastroenterol 2019; 114:267-275. [PMID: 29973705 DOI: 10.1038/s41395-018-0181-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Rates of pregnancy in women with cirrhosis are increasing. Risk of hepatic decompensation during pregnancy, therefore, merits tailored obstetric and hepatology care. Prognostic markers that determine pregnancy outcomes are lacking. METHODS Medical records of women who attended hepatology clinic at King's College Hospital with chronic liver disease (CLD) who became pregnant from 1983 to 2017 were reviewed. Information on demographics, clinical history, serology, and outcome of pregnancy was collected. RESULTS In all, 165 pregnancies occurred in 100 women with CLD including 80 pregnancies in 48 women with cirrhosis. Median age of conception in cirrhotic and non-cirrhotic women were 26 years (16-44) and 28 years (16-51) respectively (p = 0.015). Whilst women with cirrhosis had similar live birth rate to non-cirrhotic women (75 vs. 85% p = 0.119), they were significantly less likely to proceed beyond 37 weeks gestation (45 vs. 58% p = 0.033). Women who received preconception counseling were more likely to have stable liver disease at conception (100 vs 86% p = 0.02). Compared with preconception MELD (model for end stage liver disease), preconception Albumin-Bilirubin score (ALBI) more accurately predicted live birth with an area under the receiver-operator curve (AUROC) of 0.741 (p < 0.001), and preconception AST to platelet ratio index (APRI) more accurately predicted ability to proceed beyond 37 weeks gestation with an AUROC of 0.700 (p < 0.001). CONCLUSIONS Most women with cirrhosis who conceived achieved a successful pregnancy outcome. ALBI and APRI scores can prognosticate pregnancy outcomes in women with CLD. Preconception counseling by a hepatologist or specialist obstetrician improved patient care in this group.
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Maraolo AE, Gentile I, Buonomo AR, Pinchera B, Borgia G. Current evidence on the management of hepatitis B in pregnancy. World J Hepatol 2018; 10:585-594. [PMID: 30310536 PMCID: PMC6177570 DOI: 10.4254/wjh.v10.i9.585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/26/2018] [Accepted: 06/09/2018] [Indexed: 02/06/2023] Open
Abstract
Hepatitis B virus (HBV) infection is one of the main public health problems across the globe, since almost one third of the world population presents serological markers of contact with the virus. A profound impact on the epidemiology has been exerted by universal vaccination programmes in many countries, nevertheless the infection is still widespread also in its active form. In the areas of high endemicity (prevalence of hepatitis B surface antigen positivity > 7%), mother-to-child transmission represents the main modality of infection spread. That makes the correct management of HBV in pregnancy a matter of utmost importance. Furthermore, the infection in pregnancy needs to be carefully assessed and handled not only with respect to the risk of vertical transmission but also with respect to gravid women health. Each therapeutic or preventive choice deserves to be weighed upon attentively. On many aspects evidence is scarce or controversial. This review will highlight the latest insights into the paramount steps in managing HBV in pregnancy, with particular attention to recommendations from recent guidelines and data from up-do-date research syntheses.
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Affiliation(s)
- Alberto Enrico Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Antonio Riccardo Buonomo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Biagio Pinchera
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
| | - Guglielmo Borgia
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples 80131, Italy
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Hagström H, Höijer J, Marschall H, Williamson C, Heneghan MA, Westbrook RH, Ludvigsson JF, Stephansson O. Outcomes of Pregnancy in Mothers With Cirrhosis: A National Population-Based Cohort Study of 1.3 Million Pregnancies. Hepatol Commun 2018; 2:1299-1305. [PMID: 30411076 PMCID: PMC6211327 DOI: 10.1002/hep4.1255] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/13/2018] [Indexed: 12/19/2022] Open
Abstract
There are limited data on pregnancy outcomes in women with cirrhosis. To address this gap, we examined the records of singleton births from Sweden’s National Patient Register (NPR), Cause of Death Register (CDR), and Medical Birth Register (MBR) between 1997 and 2011 to assess exposure and pregnancy‐related and liver‐related outcomes of pregnant women with cirrhosis. Exposure status was defined as having an International Classification of Diseases (ICD) code for cirrhosis obtained prior to or during pregnancy. Poisson regression with cluster‐robust standard errors was used to estimate relative risks (RRs) adjusted for maternal age, smoking, and body mass index (BMI). We identified 103 pregnancies in women with cirrhosis and compared these to 1,361,566 pregnancies in women without cirrhosis. Pregnancies in women with cirrhosis were at increased risk of caesarean delivery (36% versus 16%, respectively; adjusted RR [aRR], 2.00; 95% confidence interval [CI], 1.47‐2.73), low birth weight (15% versus 3%; aRR, 3.87; 95% CI, 2.11‐7.06), and preterm delivery (19% versus 5%; aRR, 3.51; 95% CI, 2.16‐5.72). Rates of maternal mortality during pregnancy (no cases), gestational diabetes, preeclampsia, small for gestational age, congenital malformations, and stillbirth were not increased when compared to the pregnant women without cirrhosis. There were 12 hospitalizations during pregnancy due to liver‐related events, including one case with bleeding esophageal varices. Conclusion: Women with cirrhosis are at increased risk for adverse pregnancy outcomes. However, severe maternal and fetal adverse events were rare in our study, and most pregnancies in women with cirrhosis ended without complications.
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Affiliation(s)
- Hannes Hagström
- Center for Digestive Diseases, Division of HepatologyKarolinska University HospitalStockholmSweden
- Clinical Epidemiology Unit, Department of MedicineSolna, Karolinska InstituteStockholmSweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental MedicineKarolinska InstituteStockholmSweden
| | - Hanns‐Ulrich Marschall
- Department of Molecular and Clinical Medicine and Wallenberg Laboratory, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
| | | | | | | | - Jonas F. Ludvigsson
- Department of Medical Epidemiology and BiostatisticsKarolinska InstituteStockholmSweden
- Department of PediatricsÖrebro University Hospital, Örebro UniversityÖrebroSweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of MedicineSolna, Karolinska InstituteStockholmSweden
- Department of Women’s and Children’s HealthKarolinska InstituteStockholmSweden
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Heneghan MA, Cannon MD. Hepatic diagnostics in pregnancy: Biopsy, biomarkers, and beyond. Hepatology 2018; 68:401-403. [PMID: 29486519 DOI: 10.1002/hep.29859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 02/21/2018] [Accepted: 02/23/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Mary D Cannon
- Institute of Liver Studies, King's College Hospital, London, UK
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Mikolasevic I, Filipec-Kanizaj T, Jakopcic I, Majurec I, Brncic-Fischer A, Sobocan N, Hrstic I, Stimac T, Stimac D, Milic S. Liver Disease During Pregnancy: A Challenging Clinical Issue. Med Sci Monit 2018; 24:4080-4090. [PMID: 29905165 PMCID: PMC6034557 DOI: 10.12659/msm.907723] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
One of the least studied topics in the field of obstetrics is liver disease during pregnancy, which creates a challenge for both gynecologists and hepatologists. Approximately 3% of pregnant women are affected by some form of liver disease during pregnancy. Some of these conditions can be fatal for both the mother and child. In addition, 3 types of liver disease need to be differentiated during pregnancy. One type is liver disease directly related to pregnancy, which can occur at a specific time during pregnancy. Another type is liver disease not related to pregnancy, which can occur at any time, such as viral- or drug-induced hepatitis. Furthermore, pregnancy can occur in women with pre-existing liver disease. It is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations, especially when emergency delivery is needed and must not be postponed.
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Affiliation(s)
- Ivana Mikolasevic
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Tajana Filipec-Kanizaj
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivan Jakopcic
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Iva Majurec
- Department of Anesthesiology and Intensive Care Unit, University Hospital Merkur, Zagreb, Croatia
| | - Alemka Brncic-Fischer
- Department of Obstetrics and Gynecology, University Hospital Center (UHC) Rijeka, Rijeka, Croatia
| | - Nikola Sobocan
- Department of Gastroenterology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Irena Hrstic
- Department of Internal Medicine, General Hospital Pula, Pula, Croatia
| | - Tea Stimac
- Department of Obstetrics and Gynecology, University Hospital Center (UHC) Rijeka, Rijeka, Croatia
| | - Davor Stimac
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
| | - Sandra Milic
- Department of Gastroenterology, University Hospital Center (UHC) Rijeka, School of Medicine, University of Rijeka, Rijeka, Croatia
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Abstract
The oldest survivors from the Kasai portoenterostomy originate in Sendai, Japan and are approaching their 60th birthday. These represent the tip of an expanding cohort of adults born with this previously fatal condition. Increasingly transition to adult-biased hepatologists and physicians will be the expectation of many with this condition. However unlike their usual patients with alcohol, drugs, virally mediated liver disease these are different with different expectations of health and quality of life. Cure is not on the cards for most of these and they survive still with impaired bile flow and increased liver fibrosis and cirrhosis with the threat of cholangitis and portal hypertension still apparent. We review the reported statistics on long-term survival essentially from Japan and Western Europe (such as the UK and France) and the range of complications that may still beset this group.
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Affiliation(s)
- Arun Kelay
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS
| | - Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London SE5 9RS.
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Abstract
OBJECTIVE To evaluate clinical characteristics and obstetric outcomes in pregnant women with liver cirrhosis. METHODS This was a retrospective matched cohort study of women with liver cirrhosis between January 2005 and January 2016 in a university hospital. Women in a case group were matched to women in a control group according to year of delivery, age, body mass index, and parity in a 1:4 ratio. Bivariable and multivariable analyses were performed to compare the prevalence of the primary composite outcome, which included any one of the following: fetal or neonatal demise, placental abruption, preeclampsia, preterm delivery at less than 37 weeks of gestation, and small-for-gestational age neonate between women in the case group and those in the control group. RESULTS During the study period, the number of deliveries was approximately 110,000. Of these, 33 women with liver cirrhosis were identified, yielding an estimated frequency of cirrhosis of 1 per 3,333 pregnancies [95% confidence interval (CI) 3,313-3,353]. Thirty-one of these 33 women met all inclusion criteria. The most common etiology of cirrhosis was alcoholic liver disease. The rate of the primary outcome was 61% in women with cirrhosis and 12% in women in the control group. There were no cases of maternal death, and the livebirth rate was 97%. Women with cirrhosis were more likely to be non-Hispanic black, have chronic hypertension, and use alcohol. Multivariable logistic regression demonstrated that cirrhosis in pregnancy was associated with the composite outcome (adjusted odds ratio 9.4, 95% CI 3.4-26.2). CONCLUSION Despite lower rates of maternal and fetal mortality compared with earlier studies, pregnancy in women with liver cirrhosis is still associated with a high risk of adverse obstetric outcomes.
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50
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Cannon MD, Heneghan MA. Endoscopy in Pregnant Women With Liver Cirrhosis. Gastroenterology 2017; 153:329-330. [PMID: 28579271 DOI: 10.1053/j.gastro.2017.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/11/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Mary D Cannon
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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