[Primary biliary cirrhosis and pregnancy]

Primary biliary cholangitis first demonstrated in pregnancy: a case report

Background

We present a case of primary biliary cholangitis diagnosed during pregnancy. Diagnosis of this entity in pregnancy is infrequent, and when everything seemed to point to a simple obstetric cholestasis, close attention to the details of the clinical history was required to raise suspicion of the true diagnosis.

Case presentation

We present a 37-year-old Portuguese Caucasian patient who complained of generalized pruritus and showed alteration in hepatic function tests with a cholestatic pattern. The first diagnostic hypothesis was intrahepatic cholestasis of pregnancy, and she began treatment with ursodeoxycholic acid, which resulted in slight improvement of cholestasis. Her pregnancy was also complicated with occlusive hemorrhagic placenta, and at 30 weeks she underwent emergency cesarean section due to heavy blood loss. However, careful observation of clinical and laboratory findings, postpartum evolution, and a multidisciplinary approach to the patient led to the probable diagnosis of primary biliary cholangitis.

Conclusions

Physiological changes during pregnancy can mimic chronic liver disease that can only be revealed at this stage, having an impact not only on the pregnancy but on the entire future of the woman.

Successful pregnancy and follow-up after in vitro fertilization of a kidney transplant patient with systemic lupus erythematosus, primary biliary cholangitis, and hypothyroidism

This report describes the case of a female kidney transplant patient with systemic lupus erythematosus, primary biliary cholangitis, and postsurgical hypothyroidism due to Grave's disease who had a healthy newborn after in vitro fertilization (IVF). Cases of successful pregnancy involving women who underwent IVF after kidney transplantation have been reported. Normal and stable renal function, adequate immunosuppressant therapy, and well-managed blood pressure are requirements to be eligible for IVF and pregnancy. Primary biliary cholangitis without cirrhosis does not seem to worsen during pregnancy and IVF must be individualized in patients with systemic lupus erythematosus. There are no similar case reports involving kidney transplant patients or individuals with autoimmune disorders, so the decision to perform IVF had to be individualized in order to avoid complications for the mother and fetus.

AISF position paper on liver disease and pregnancy

The relationship between liver disease and pregnancy is of great clinical impact. Severe liver disease in pregnancy is rare; however, pregnancy-related liver disease is the most frequent cause of liver dysfunction during pregnancy and represents a severe threat to foetal and maternal survival. A rapid differential diagnosis between liver disease related or unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. This report summarizes the recommendation of an expert panel established by the Italian Association for the Study of the Liver (AISF) on the management of liver disease during pregnancy. The article provides an overview of liver disease occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and an assessment of the available treatment options. The report contains in three sections: (1) specific liver diseases of pregnancy; (2) liver disease occurring during pregnancy; and (3) pregnancy in patients with pre-existing chronic liver disease. Each topic is discussed considering the most relevant data available in literature; the final statements are formulated according to both scientific evidence and clinical expertise of the involved physicians, and the AISF expert panel recommendations are reported.

A review of differences in cirrhosis between men and women and characteristics of cirrhosis in females

There are differences in the disease susceptibility, natural history of liver disease, complications and treatment response between females and males with cirrhosis. Pre-menopausal status for female patients is protective against viral hepatitis C, non-alcoholic steatohepatitis and primary biliary cirrhosis. Smoking accompanied with drinking is a strong risk factor for cirrhosis and malignancies in women with chronic liver disease. Pregnancy increases the incidence of variceal hemorrhage and hepatic encephalopathy in patients with cirrhosis. The choice of contraceptive measures between patients with liver cirrhosis and normal people is the same. The selection of drugs and surgical treatment in female patients with liver cirrhosis before and after pregnancy complications have obvious differences. The organ distribution of model for end-stage liver disease (MELD) scoring system is detrimental to female patients, but the introduction of new drugs for viral hepatitis C is expected to change this difference.

Review article: the management of cirrhosis in women

BACKGROUND

There are differences in the predisposition, natural history of liver disease, complications and treatment response between men and women.

AIM

To review clinical differences in cirrhosis between men and women and to address unique management issues of fertility, pregnancy and contraception in this patient population.

METHODS

PubMed and MEDLINE were searched using the terms 'cirrhosis' and 'chronic liver disease', each cross-referenced with specific liver diseases, as well as terms such as 'cancer', 'hepatocellular carcinoma', 'smoking', 'liver transplantation', 'metabolic bone disease', 'fertility',' pregnancy' and 'contraception'.

RESULTS

Pre-menopausal status is protective in viral hepatitis C and non-alcoholic steatohepatitis. However, smoking, especially in combination with alcohol, is a stronger risk factor for cirrhosis and malignancies in women with chronic liver disease compared to men, although they are less likely than men to develop hepatocellular carcinoma. Women with cirrhosis have more osteopenic bone disease than men and require active management. Successful pregnancy is possible in well-compensated cirrhosis or with mild portal hypertension, although the maternal and foetal mortality and morbidity are higher than in the general population. The maternal risk correlates with liver disease severity and derives mostly from variceal bleeding. The choices for contraception in compensated cirrhosis are generally the same as for the general population. Women with cirrhosis are disadvantaged by the current MELD system of organ allocation, at least in part due to body size.

CONCLUSION

The management of women with chronic liver disease is unique in regards to counselling, screening for complications, fertility and pregnancy.