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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: 2] [Impact Index Per Article: 2.0] [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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Pregnancy Outcomes After Liver Transplantation: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2021; 116:491-504. [PMID: 33657039 DOI: 10.14309/ajg.0000000000001105] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/13/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Liver transplantation (LT) remains the gold standard for treatment of end-stage liver disease. Given the increasing number of liver transplantation in females of reproductive age, our aim was to conduct a systematic review and meta-analysis evaluating pregnancy outcomes after LT. METHODS MEDLINE, Embase, and Scopus databases were searched for relevant studies. Study selection, quality assessment, and data extraction were conducted independently by 2 reviewers. Estimates of pregnancy-related outcomes in LT recipients were generated and pooled across studies using the random-effects model. RESULTS A comprehensive search identified 1,430 potential studies. Thirty-eight studies with 1,131 pregnancies among 838 LT recipients were included in the analysis. Mean maternal age at pregnancy was 27.8 years, with a mean interval from LT to pregnancy of 59.7 months. The live birth rate was 80.4%, with a mean gestational age of 36.5 weeks. The rate of miscarriages (16.7%) was similar to the general population (10%-20%). The rates of preterm birth, preeclampsia, and cesarean delivery (32.1%, 12.5%, and 42.2%, respectively) among LT recipients were all higher than the rates for the general US population (9.9%, 4%, and 32%, respectively). Most analyses were associated with substantial heterogeneity. DISCUSSION Pregnancy outcomes after LT are favorable, but the risk of maternal and fetal complications is increased. Large studies along with consistent reporting to national registries are necessary for appropriate patient counseling and to guide clinical management of LT recipients during pregnancy.
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Ziogas IA, Hayat MH, Tsoulfas G. Obstetrical and gynecologic challenges in the liver transplant patient. World J Transplant 2020; 10:320-329. [PMID: 33312893 PMCID: PMC7708880 DOI: 10.5500/wjt.v10.i11.320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
An increasing number of childbearing agewomen undergo liver transplantation (LT) in the United States. Transplantation in this patient subgroup poses a significant challenge regarding the plans for future fertility, particularly in terms of immunosuppression and optimal timing of conception. Intrapartum LT is only rarely performed as the outcome is commonly dismal for the mother or more commonly the fetus. On the other hand, the outcomes of pregnancy in LT recipients are favorable, and children born to LT recipients are relatively healthy. Counseling on pregnancy should start before LT and continue after LT up until pregnancy, while all pregnant LT recipients must be managed by amultidisciplinary team, including both an obstetrician and a transplant hepatologist. Additionally, an interval of at least 1-2 years after successful LT is recommended before considering pregnancy. Pregnancy-induced hypertension, pre-eclampsia, and gestational diabetes mellitus are reported more commonly during the pregnancies of LT recipients than in the pregnancies of non-transplant patients. As adverse fetal outcomes, such asmiscarriage, abortion, stillbirth, or ectopic pregnancy, may occur more often than in the non-transplant population, early planning or delivery either through a planned induction of labor or cesarean section is critical to minimize the risk of complications. No significant long-term physical or phycological abnormalities have been reported in children born to LT recipients.
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Affiliation(s)
- Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Muhammad H Hayat
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Georgios Tsoulfas
- Department of Surgery, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Thessaloniki 54622, Greece
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Evaluation of Lipid Profile in Children Born to Female Transplant Recipients. Transplant Proc 2020; 52:1977-1981. [DOI: 10.1016/j.transproceed.2020.02.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/05/2020] [Indexed: 11/21/2022]
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Ally A, Powell I, Ally MM, Chaitoff K, Nauli SM. Role of neuronal nitric oxide synthase on cardiovascular functions in physiological and pathophysiological states. Nitric Oxide 2020; 102:52-73. [PMID: 32590118 DOI: 10.1016/j.niox.2020.06.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/15/2020] [Accepted: 06/15/2020] [Indexed: 12/16/2022]
Abstract
This review describes and summarizes the role of neuronal nitric oxide synthase (nNOS) on the central nervous system, particularly on brain regions such as the ventrolateral medulla (VLM) and the periaqueductal gray matter (PAG), and on blood vessels and the heart that are involved in the regulation and control of the cardiovascular system (CVS). Furthermore, we shall also review the functional aspects of nNOS during several physiological, pathophysiological, and clinical conditions such as exercise, pain, cerebral vascular accidents or stroke and hypertension. For example, during stroke, a cascade of molecular, neurochemical, and cellular changes occur that affect the nervous system as elicited by generation of free radicals and nitric oxide (NO) from vulnerable neurons, peroxide formation, superoxides, apoptosis, and the differential activation of three isoforms of nitric oxide synthases (NOSs), and can exert profound effects on the CVS. Neuronal NOS is one of the three isoforms of NOSs, the others being endothelial (eNOS) and inducible (iNOS) enzymes. Neuronal NOS is a critical homeostatic component of the CVS and plays an important role in regulation of different systems and disease process including nociception. The functional and physiological roles of NO and nNOS are described at the beginning of this review. We also elaborate the structure, gene, domain, and regulation of the nNOS protein. Both inhibitory and excitatory role of nNOS on the sympathetic autonomic nervous system (SANS) and parasympathetic autonomic nervous system (PANS) as mediated via different neurotransmitters/signal transduction processes will be explored, particularly its effects on the CVS. Because the VLM plays a crucial function in cardiovascular homeostatic mechanisms, the neuroanatomy and cardiovascular regulation of the VLM will be discussed in conjunction with the actions of nNOS. Thereafter, we shall discuss the up-to-date developments that are related to the interaction between nNOS and cardiovascular diseases such as hypertension and stroke. Finally, we shall focus on the role of nNOS, particularly within the PAG in cardiovascular regulation and neurotransmission during different types of pain stimulus. Overall, this review focuses on our current understanding of the nNOS protein, and provides further insights on how nNOS modulates, regulates, and controls cardiovascular function during both physiological activity such as exercise, and pathophysiological conditions such as stroke and hypertension.
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Affiliation(s)
- Ahmmed Ally
- Arkansas College of Osteopathic Medicine, Fort Smith, AR, USA.
| | - Isabella Powell
- All American Institute of Medical Sciences, Black River, Jamaica
| | | | - Kevin Chaitoff
- Interventional Rehabilitation of South Florida, West Palm Beach, FL, USA
| | - Surya M Nauli
- Chapman University and University of California, Irvine, CA, USA.
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Rahim MN, Long L, Penna L, Williamson C, Kametas NA, Nicolaides KH, Heneghan MA. Pregnancy in Liver Transplantation. Liver Transpl 2020; 26:564-581. [PMID: 31950556 DOI: 10.1002/lt.25717] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/26/2019] [Indexed: 02/06/2023]
Abstract
Pregnancy after liver transplantation (LT) is increasingly common and is a frequent scenario that transplant physicians, obstetricians, and midwives encounter. This review summarizes the key issues surrounding preconception, pregnancy-related outcomes, immunosuppression, and breastfeeding in female LT recipients. Prepregnancy counseling in these patients should include recommendations to delay conception for at least 1-2 years after LT and discussions about effective methods of contraception. Female LT recipients are generally recommended to continue immunosuppression during pregnancy to prevent allograft rejection; however, individual regimens may need to be altered. Although pregnancy outcomes are overall favorable, there is an increased risk of maternal and fetal complications. Pregnancy in this cohort remains high risk and should be managed vigilantly in a multidisciplinary setting. We aim to review the available evidence from national registries, population-based studies, and case series and to provide recommendations for attending clinicians.
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Affiliation(s)
- Mussarat N Rahim
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Lisa Long
- Department of Obstetrics, King's College Hospital, London, United Kingdom
| | - Leonie Penna
- Department of Obstetrics, King's College Hospital, London, United Kingdom
| | | | - Nikos A Kametas
- Fetal Medicine Research Unit, King's College Hospital, London, United Kingdom
| | - Kypros H Nicolaides
- Fetal Medicine Research Unit, 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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Zullo F, Saccone G, Donnarumma L, Marino I, Guida M, Berghella V. Pregnancy after liver transplantation: a case series and review of the literature. J Matern Fetal Neonatal Med 2019; 34:3269-3276. [PMID: 31635500 DOI: 10.1080/14767058.2019.1680632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate maternal and perinatal outcomes in pregnant women after liver transplantation with a case series and literature systematic review. METHODS This was a single-center case-series study performed at University of Naples Federico II. All consecutive women with liver transplantation who reported pregnancy at our institution were included in a dedicated database. In addition, a systematic literature review was performed, including case series, population-based studies, and national registries, including maternal and perinatal outcomes of pregnant women with liver transplant. Studies with fewer than 10 cases and surveys were excluded. The primary outcome was perinatal death, defined as either stillbirth (defined as intrauterine fetal death after 20 weeks of gestation) or neonatal death (death of a live-born infant within the first 28 d of life). RESULTS During the study period, two women who underwent liver transplantation had a pregnancy in our Institution. Both of them underwent liver transplantation for biliary atresia at 1 year of age. One of them received cyclosporin as immunosuppressive regime during pregnancy, while the other one received tacrolimus. Both of them had a pregnancy with no major complications and delivered by cesarean section at term a baby with normal weight. One of them developed thrombocytopenia. Seventeen articles were included in this systematic review. Preterm birth at less than 37 weeks of gestations occurred in 279 women (33.6%). One-hundred women (14.9%) experienced preeclampsia, and 206 women (49.2%) delivered by cesarean delivery. Graft rejection related to pregnancy occurred in 73 women (8.3%). 117 women (12.9%) experienced miscarriage, and 22 (2.3%) IUFD. Fifty-two women (9.52%) underwent elective I-TOP. 195 fetuses (33.4%) were LBW. Eight neonatal deaths were recorded (1.3%). CONCLUSION The maternal and perinatal outcome is usually favorable, but with an increased risk of preeclampsia, preterm birth, and perinatal morbidity and mortality. However, appropriate counseling about risks and complications is essential but women shouldn't be advised against pregnancy.
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Affiliation(s)
- Fabrizio Zullo
- Department of Clinical and Experimental Medicine, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Laura Donnarumma
- Department of Clinical and Experimental Medicine, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Ignazio Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurizio Guida
- Department of Clinical and Experimental Medicine, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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Thornton AT, Huang Y, Mourad MJ, Wright JD, D'Alton ME, Friedman AM. Obstetric outcomes among women with a liver transplant. J Matern Fetal Neonatal Med 2019; 34:2932-2937. [PMID: 31564182 DOI: 10.1080/14767058.2019.1674804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Women with liver transplants may be at increased risk for adverse outcomes. OBJECTIVE The objectives of this study were to evaluate trends and provide recent data on outcomes for women with a liver transplant. STUDY DESIGN The National (Nationwide) Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project from 1998 to 2014 was used for this repeated cross-sectional analysis. Women aged between 15 and 54 years, with a history of liver transplant who underwent delivery, antepartum, or postpartum hospitalizations were identified. Temporal trends in deliveries of women with liver transplants were analyzed. The risk for severe maternal morbidity (SMM) excluding transfusion based on criteria from the Centers for Disease Control and Prevention (CDC), as well as for individual outcomes including hypertensive diseases of pregnancy, postpartum hemorrhage, placental abruption, liver rejection, cesarean delivery, preterm delivery, and coagulopathy during delivery hospitalizations were analyzed. Risks of SMM during antepartum and postpartum hospitalizations were also analyzed. An adjusted log-linear regression model for SMM during delivery hospitalizations including demographic factors, hospital characteristics, and underlying comorbidity was performed. The chi-squared or Fisher's exact test was used for comparisons. Temporal trends were analyzed with the Cochran-Armitage trend test. Population weights were applied to create national estimates. RESULTS From 1998 to 2014, an estimated 1165 births occurred by women with a liver transplant. The number of births occurring by women with liver transplants increased over the study period from 1.0 per 100,000 in 1998-2000 to 2.8 per 100,000 in 2012-2014 (p < .01). The risk for CDC SMM excluding transfusion was significantly higher during delivery hospitalizations among women with compared to without liver transplant (8.0 versus 0.5%, p < .01, unadjusted risk ratio 15.4, 95% CI 12.7-18.6). Women with liver transplant were also at significantly higher risk for abruption (2.5 versus 1.0%, p = .03), hypertensive diseases of pregnancy (27.8 versus 6.9%, p < .01), postpartum hemorrhage (8.0 versus 2.8%, p = .01), cesarean delivery (51.7 versus 29.5%, p < .01), preterm delivery (27.5 versus 7.0%, p < .01), and coagulopathy (3.1 versus 0.3%, p < .01). A diagnosis of liver rejection was present during 4.1% of delivery hospitalizations for women with liver transplant. In the adjusted analysis for severe morbidity excluding transfusion risk was retained with liver transplant associated with increased likelihood of this adverse outcome (aRR 8.49, 95% CI 5.59-12.87). Women with liver transplants were at significantly higher likelihood of undergoing antepartum and postpartum admissions, and of experiencing SMM during these hospitalizations. CONCLUSION In this analysis of antepartum, delivery, and postpartum hospitalizations, women with liver transplant were at significantly higher risk for both SMM during all hospitalizations and for a range of adverse outcomes including placental abruption, hypertensive diseases of pregnancy, postpartum hemorrhage, cesarean delivery, and coagulopathy delivery during delivery hospitalizations. While deliveries to women with liver transplant were rare, these births became more frequent over the study period.
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Affiliation(s)
- Andrew T Thornton
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Mirella J Mourad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
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AISF position paper on liver transplantation and pregnancy: Women in Hepatology Group, Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2016; 48:860-8. [PMID: 27267817 DOI: 10.1016/j.dld.2016.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/11/2016] [Indexed: 12/11/2022]
Abstract
After the first successful pregnancy in a liver transplant recipient in 1978, much evidence has accumulated on the course, outcomes and management strategies of pregnancy following liver transplantation. Generally, liver transplantation restores sexual function and fertility as early as a few months after transplant. Considering that one third of all liver transplant recipients are women, that approximately one-third of them are of reproductive age (18-49 years), and that 15% of female liver transplant recipients are paediatric patients who have a >70% probability of reaching reproductive age, the issue of pregnancy after liver transplantation is rather relevant, and obstetricians, paediatricians, and transplant hepatologists ever more frequently encounter such patients. Pregnancy outcomes for both the mother and infant in liver transplant recipients are generally good, but there is an increased incidence of preterm delivery, hypertension/preeclampsia, foetal growth restriction, and gestational diabetes, which, by definition, render pregnancy in liver transplant recipients a high-risk one. In contrast, the risk of congenital anomalies and the live birth rate are comparable to those of the general population. Currently there are still no robust guidelines on the management of pregnancies after liver transplantation. The aim of this position paper is to review the available evidence on pregnancy in liver transplant recipients and to provide national Italian recommendations for clinicians caring for these patients.
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Pregnancy following liver transplantation: review of outcomes and recommendations for management. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 26:621-6. [PMID: 22993734 DOI: 10.1155/2012/137129] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Liver transplantation is considered to be the treatment of choice for end-stage liver disease and its success has led to an increase in the number of female liver transplant recipients who are of childbearing age. Several key issues that are noted when counselling patients who are considering pregnancy following liver transplantation include the optimal timing of pregnancy, optimal contraception methods and the management of immunosuppression during pregnancy. The present review summarizes the most recent literature so that the clinician may address these issues with their patient and enable them to make informed decisions about pregnancy planning. The authors review recent studies examining maternal and fetal outcomes, and the rates of complications including risk of graft rejection. Subsequently, the authors provide recommendations for counselling prospective mothers and the management of the pregnant liver transplant recipient.
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Abstract
Liver transplantation has become a universally accepted treatment for numerous congenital and acquired hepatic disorders that cause liver failure. Without liver transplantation, patients in their reproductive years are afflicted with oligospermia or azoospermia in men and amenorrhea in women, with infertility being a consequence in both sexes. The aim of this study is to describe our experiences concerning the parenthood of pediatric individuals who are successful recipients of liver transplantations coming into the reproductive years of life. We retrospectively analyzed data of 207 pediatric liver transplanted patients (96 women, 111 men). Among them, three women conceived and delivered four babies, and two men admitted to paternity of two children after they all had been recipients of liver transplants. All female transplant recipients had received tacrolimus-based immunosuppression. Preterm delivery was the most clinically important complication among these patients. Only one of the female patients experienced hypercalcemia during the pregnancy. None had any other complications such as hypertension, preeclampsia, cholestasis, or diabetes. There was no graft insufficiency, rejection, or birth defect. We concluded that maternity and paternity in liver transplant patients show normal outcomes even though this procedure occurs in childhood, and pregnancy did not seem to impair graft function in patients receiving immunosuppressive drugs.
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Affiliation(s)
- Çiğdem Ecevit
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Ege University, Izmir, Turkey.
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Goarin AC, Homer L. [Liver transplantation and pregnancy]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2010; 39:529-36. [PMID: 20144511 DOI: 10.1016/j.jgyn.2010.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 12/31/2009] [Accepted: 01/12/2010] [Indexed: 11/27/2022]
Abstract
Management during their sexual life of patients with a liver transplantation is a more or less common situation depending centers. Based on literature review, a focus on management of recipient women was conducted, from contraception to pregnancy, describing the complications related to the status of transplant recipient, but also those that may be related to immunosuppressive agents. If fertility and access to contraception are only slightly modified by graft, complications related to graft or immunosuppressive drugs can affect the pregnancy. On the maternal side, hypertension and preeclampsia are more common, as well as renal dysfunction, iatrogenic diabetes and bacterial or viral infections, acute rejection and graft loss do not appear to be influenced by pregnancy. The fetus is also exposed to risks such as induced prematurity and IUGR. Pregnancy in recipients of hepatic grafts therefore requires joint follow-up by transplant specialist and perinatologist, which leads in most cases to successful outcome for mother and child.
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Affiliation(s)
- A-C Goarin
- Service de gynécologie obstétrique et médecine de la reproduction, hôpital Morvan, CHU de Brest, 2, avenue Foch, 29609 Brest, France
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Parolin MB, Coelho JCU, Urbanetz AA, Pampuch M. [Contraception and pregnancy after liver transplantation: an update overview]. ARQUIVOS DE GASTROENTEROLOGIA 2009; 46:154-8. [PMID: 19578619 DOI: 10.1590/s0004-28032009000200015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 10/01/2008] [Indexed: 11/22/2022]
Abstract
CONTEXT Successful liver transplantation not only treats the underlying liver disease but also restores libido and fertility in female recipients. Although reports of successful pregnancy after liver transplantation continue to increase, these pregnancies are considered of high-risk because they are associated with increase maternofetal morbidity. EVIDENCE ACQUISITION A MEDLINE search (1978-2007) was conducted using the terms 'liver transplantation', 'pregnancy', 'immunosuppressive agents', 'sexual function'. Reviews, retrospective series, long-term clinical follow-up of case series and original articles containing basic scientific observations were included. RESULTS Although no formal guidelines have been established there are some 'golden rules' to improve the probability of favorable maternal and fetal outcome. Most transplant centers recommend to delay pregnancy for at least 1-year after transplantation. The recipient should be on a stable immunosuppression regimen, with good graft function and no evidence of renal dysfunction or uncontrolled arterial hypertension. Considering the increased incidence of prematurity, low birth weight, hypertension and preeclampsia reported during pregnancy post-LT, these high-risk patients should be managed by a multidisciplinary team, including an obstetrician specialized in high-risk pregnancies. Carefully monitoring of immunosuppressive drugs serum level is prudent to avoid graft rejection episodes and drugs with teratogenic potential should be discontinued. Breastfeeding is usually not recommended. CONCLUSIONS Successful pregnancies are the rule after liver transplantation. A carefully monitoring by an experience multidisciplinary team increases the chances of favorable maternofetal outcome.
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Affiliation(s)
- Mônica Beatriz Parolin
- Serviço de Transplante Hepático, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR.
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Follow-up of pregnant women with autoimmune hepatitis: the disease behavior along with maternal and fetal outcomes. J Clin Gastroenterol 2009; 43:350-6. [PMID: 19077726 DOI: 10.1097/mcg.0b013e318176b8c5] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOALS To assess maternal and fetal outcomes and clinical management of pregnancy in patients with autoimmune hepatitis (AIH). BACKGROUND There is a paucity of information about maternal and fetal outcomes, and AIH activity during pregnancy and in the postpartum period. There is no consensus about the administration of azathioprine during pregnancy and breastfeeding. STUDY Retrospective analysis of 54 pregnancies (3 still in progress) in 39 AIH patients. RESULTS The median age at conception was 24 years, and 68.4% of women had liver cirrhosis. Before conception and in early pregnancy, azathioprine and prednisone were administered in 48.1%, but treatment regimen was usually changed further to 20 mg/d prednisone; and 20.4% were off treatment. There were 36 livebirths, and fetal loss rates were 29.4% (13 miscarriages, 1 stillbirth, and 1 ectopic pregnancy). Preterm birth rate was 11.8%. In 2 cases, there was acute fetal distress; and in 2 others congenital malformations (3.9%). The rate of serious maternal complication was 7.8%, with no deaths. There were no flares in 41.2% pregnancies, but aminotransferase elevations occurred in 54.9%, 31.4% of which were true AIH relapses, only registered in the postpartum period. CONCLUSIONS Despite the high fetal miscarriage rate, pregnancy in AIH was safe. Patients needed careful monitoring, especially in the postpartum period because of relapses. There was no evidence of a cause and effect relationship among azathioprine administration and premature births and congenital abnormalities, but more studies are necessary. Higher doses of prednisone may be an alternative option for those who prefer azathioprine withdrawal during pregnancy.
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Gauthier T, Hardeman S, Piver P, Aubard Y. [Uterine transplantation: animal and human studies]. ACTA ACUST UNITED AC 2008; 36:1218-23. [PMID: 19026586 DOI: 10.1016/j.gyobfe.2008.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 09/22/2008] [Indexed: 11/25/2022]
Abstract
Many cases of not life saving transplanted organs were described with the aim of improving quality of life. Uterus graft could be an alternative solution to adoption or surrogacy for women who have uterine factor infertility. Different animals' studies with mouse, sheep or monkey showed feasibility of the surgical technique with large vessels patch. One case of human uterine transplant has been reported but failed. Cold storage of the uterus in protective solution has been explored with mouse, sheep and human. Only pregnancy after uterus graft by syngenic mouse has been published. Results about pregnancy after allograft with sheep or monkey are necessary before pregnancy after human uterus graft becomes a reality.
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Affiliation(s)
- T Gauthier
- Service de gynécologie-obstétrique, hôpital de la Mère et de l'Enfant, CHU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France.
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Heneghan MA, Selzner M, Yoshida EM, Mullhaupt B. Pregnancy and sexual function in liver transplantation. J Hepatol 2008; 49:507-19. [PMID: 18715668 DOI: 10.1016/j.jhep.2008.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
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Langagergaard V, Pedersen L, Gislum M, Nørgard B, Sørensen HT. Birth outcome in women treated with azathioprine or mercaptopurine during pregnancy: A Danish nationwide cohort study. Aliment Pharmacol Ther 2007; 25:73-81. [PMID: 17229222 DOI: 10.1111/j.1365-2036.2006.03162.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Data on birth outcome after exposure to azathioprine or mercaptopurine during pregnancy is sparse. AIM To examine the risk of adverse birth outcome among newborns of women exposed to azathioprine or mercaptopurine during pregnancy. METHODS Data on drug use and births were obtained from Danish population registries. We included 76 exposed pregnancies in 69 women. Of these, we used 64 pregnancies exposed 30 days before conception or during the first trimester to examine the risk of congenital abnormalities, and 65 pregnancies exposed during the entire pregnancy to examine preterm birth and low birth weight at term. Their birth outcomes were compared with outcomes among women who did not fill prescriptions for azathioprine or mercaptopurine during pregnancy. RESULTS Azathioprine- or mercaptopurine-exposed women had a higher risk of adverse birth outcomes than unexposed controls. However, when the comparison was limited to newborns of women with the same types of underlying disease, relative risks for spontaneous and induced preterm birth, low birth weight at term, and congenital abnormalities were 1.1 (95% CI: 0.5-2.4), 4.0 (95% CI: 1.5-10.8), 1.7 (95% CI: 0.3-8.7) and 1.1 (95% CI: 0.5-2.9), respectively. CONCLUSION Our results suggest that adverse birth outcomes were caused by the underlying disease rather than by use of azathioprine or mercaptopurine.
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Affiliation(s)
- V Langagergaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus C, Denmark.
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21
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Dei Malatesta MF, Rossi M, Rocca B, Iappelli M, Giorno MP, Berloco P, Cortesini R. Pregnancy after liver transplantation: report of 8 new cases and review of the literature. Transpl Immunol 2006; 15:297-302. [PMID: 16635752 DOI: 10.1016/j.trim.2006.01.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Accepted: 01/13/2006] [Indexed: 01/01/2023]
Abstract
Improved survival and quality of life following liver transplantation are associated with an increased frequency of pregnancies in liver-transplanted women. We investigated the outcome, complications, and management of those pregnancies. We have reviewed the literature and report 8 pregnancies in 6 transplant recipients. Seven pregnancies were completed at 38+/-2 (mean+/-standard deviation) weeks. One miscarriage occurred at week 12. Newborns' weight averaged 2938+/-156 g. Main complications were preeclampsia (n=1) and reversible cholestasis (n=1). Among 285 pregnancies reported in literature, 78+/-20% were successful and the main complications were: preeclampsia (26+/-19%), hypertension (28+/-19%), reversible liver dysfunction (27+/-21%), cesarean delivery (23+/-10%), preterm birth (31+/-28%), small for gestational age infants (23+/-10%), rejection (10+/-7%). Gestational weeks were 36.7+/-1.3, perinatal mortality was 4+/-10%, malformation rate 3%. The rates of both abortions and complications (preeclampsia and/or hypertension) were inversely related to the time interval between transplantation and conception (p<0.05). Abortions occurred more often in recipients whose underlying disease was autoimmune cirrhosis than in recipients with inherited disorders. Rejection rate was approx. 10%, which appears higher than reported in a non-pregnant population after a comparable time interval from transplant (2-3%). Up to 28 months after delivery, maternal death was 5.5+/-7%. We conclude that: the time intervals between transplantation and conception as well as the original cause of liver failure influence the outcome and complications of pregnancies in liver recipients. However, neonatal survival is high, while malformations are relatively rare.
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Sanfey H. Gender-Specific Issues in Liver and Kidney Failure and Transplantation: A Review. J Womens Health (Larchmt) 2005; 14:617-26. [PMID: 16181018 DOI: 10.1089/jwh.2005.14.617] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Historically, research has been performed in male animals and extrapolated to the care of females regardless of biological differences. Men and women differ, however, with regard to severity and pathogenesis of disease and healthcare needs and this uniform approach, regardless of gender, is not always in the best interests of the patient. The relationship between sex hormones and immunological processes has been extensively documented but is not yet well understood and these differences will be discussed as they relate to liver and kidney failure and transplantation. DISCUSSION Certain forms of organ failure are more common in either men or women and the physiological changes associated with pregnancy present unique challenges to the transplant physician since pregnancy may adversely affect graft function and immunosuppression presents a risk for opportunistic infection in the mother or fetal injury. Donor and recipient gender affect graft and patient survival after transplantation and there is clearly some gender bias in organ donation and transplantation. CONCLUSIONS We need to be mindful of these differences in relation to gender-specific diseases, hormonal and immunological differences in designing clinical protocols and treatment pathways in order to improve outcomes in transplantation. Unfortunately, this is difficult in an environment where our practice is largely restricted by a shortage of donor organs and the need to decrease waiting list mortality.
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Affiliation(s)
- Hilary Sanfey
- Department of Surgery and Transplant Division, University of Virginia Health Systems, PO Box 800709, Charlottesville, VA 22908-8709, USA.
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23
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Abstract
OBJECTIVE To study pregnancy outcome before and after organ transplantation. DESIGN Registry study. SETTING Swedish Health Registers. POPULATION All births in Sweden 1973-2002. METHODS Women who had organ transplantation were identified from the Hospital Discharge Register and their deliveries before and after the transplantation were identified from the Medical Birth Register. Abortions requiring hospitalisation were identified from the Hospital Discharge Register. Outcomes were compared with those in the total population. Adjustments were made for maternal age, parity and smoking habits. MAIN OUTCOME MEASURES Miscarriage, preterm delivery, low birthweight, small for gestational age, congenital malformations, infant death, pre-eclampsia and placental abruption. RESULTS A total of 980 infants born before and 152 born after transplantation were identified. A high frequency of pre-eclampsia (22%), preterm birth (46%), low birthweight (41%), small for gestational age (16%) and infant death (5% before the age of one) were found for deliveries after transplantation but similar frequencies were found also among deliveries a few years before transplantation. No significant increase in congenital malformation rate was seen. Among 15 infants born after liver transplantation, 2 were malformed. CONCLUSIONS Pregnancies after organ transplantation have an increased risk of complications but this is similar to pregnancies occurring before the transplantation.
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McKay DB, Josephson MA, Armenti VT, August P, Coscia LA, Davis CL, Davison JM, Easterling T, Friedman JE, Hou S, Karlix J, Lake KD, Lindheimer M, Matas AJ, Moritz MJ, Riely CA, Ross LF, Scott JR, Wagoner LE, Wrenshall L, Adams PL, Bumgardner GL, Fine RN, Goral S, Krams SM, Martinez OM, Tolkoff-Rubin N, Pavlakis M, Scantlebury V. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005; 5:1592-9. [PMID: 15943616 DOI: 10.1111/j.1600-6143.2005.00969.x] [Citation(s) in RCA: 287] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
It has been almost 50 years since the first child was born to a female transplant recipient. Since that time pregnancy has become common after transplantation, but physicians have been left to rely on case reports, small series and data from voluntary registries to guide the care of their patients. Many uncertainties exist including the risks that pregnancy presents to the graft, the patient herself, and the long-term risks to the fetus. It is also unclear how to best modify immunosuppressive agents or treat rejection during pregnancy, especially in light of newer agents available where pregnancy safety has not been established. To begin to address uncertainties and define clinical practice guidelines for the transplant physician and obstetrical caregivers, a consensus conference was held in Bethesda, Md. The conferees summarized both what is known and important gaps in our knowledge. They also identified key areas of agreement, and posed a number of critical questions, the resolution of which is necessary in order to establish evidence-based guidelines. The manuscript summarizes the deliberations and conclusions of the conference as well as specific recommendations based on current knowledge in the field.
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Affiliation(s)
- Dianne B McKay
- Transplantation Medicine, The Scripps Clinic/Scripps Green Hospital, The Scripps Research Institute, La Jolla, California, USA.
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26
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Abstract
This article from the National Transplantation Pregnancy Registry (NTPR) describes the pregnancy outcomes of female transplant recipients who received a solid organ transplant when younger than 21 years old. The analysis includes kidney, liver, liver-kidney, heart, and lung recipients. No recipients in the registry received a pancreas-kidney or heart-lung transplant before age 21. To date, the NTPR has not received report of a pregnancy in a small bowel recipient. This article also reviews immunosuppressive medications with regard to pregnancy safety.
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Affiliation(s)
- Vincent T Armenti
- Division of Transplantation, Department of Surgery, Thomas Jefferson University, 1025 Walnut Street, 605 College Building, Philadelphia, PA 19107, USA.
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27
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Nørgård B, Pedersen L, Fonager K, Rasmussen SN, Sørensen HT. Azathioprine, mercaptopurine and birth outcome: a population-based cohort study. Aliment Pharmacol Ther 2003; 17:827-34. [PMID: 12641505 DOI: 10.1046/j.1365-2036.2003.01537.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data on the safety of azathioprine and mercaptopurine during pregnancy are very sparse. AIM To examine the risk of adverse birth outcomes in women who took up prescriptions for azathioprine or mercaptopurine during pregnancy. METHODS This is a Danish cohort study based on data from a population-based prescription registry, the Danish Birth Registry and the Hospital Discharge Registry. To examine the risk of congenital malformations, we included nine pregnancies exposed 30 days before conception or during the first trimester. To examine perinatal mortality, pre-term birth and low birth weight, we included 10 pregnancies exposed during the entire pregnancy. Eleven different exposed women were included in the study. Outcomes were compared with those of 19 418 pregnancies in which no drugs were prescribed to the mothers. RESULTS Fifty-five per cent of the exposed women had inflammatory bowel disease and 45% other diseases. Adjusted odds ratios for congenital malformations, perinatal mortality, pre-term birth and low birth weight were 6.7 (95% confidence interval, 1.4-32.4), 20.0 (2.5-161.4), 6.6 (1.7-25.9) and 3.8 (0.4-33.3), respectively. CONCLUSIONS Our results suggest that there is an increased risk of congenital malformations, perinatal mortality and pre-term birth in children born to women treated with azathioprine or mercaptopurine during pregnancy. More data are needed to determine whether the associations are causal or occur through confounding.
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Affiliation(s)
- B Nørgård
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
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29
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Abstract
BACKGROUND Cyclosporine (CsA) therapy must often be continued during pregnancy to maintain maternal health in such conditions as organ transplantation and autoimmune disease. This meta-analysis was performed to determine whether CsA exposure during pregnancy is associated with an increased risk of congenital malformations, preterm delivery, or low birthweight. METHODS Various health science databases were searched to identify relevant articles. Articles selected for inclusion in the study were required to be free of any apparent selection bias and report outcomes in at least 10 newborns exposed to CsA in utero, specifically commenting on the presence or absence of congenital malformations. Article selection and data extraction were performed by two independent reviewers, with adjudication in cases of disagreement. To assess risks of CsA exposure, a summary odds ratio was calculated. Prevalence of malformations was calculated as a rate for all cyclosporine-exposed live births and for the subgroups identified. Ninety-five percent confidence intervals were constructed for both the odds ratio and prevalence rates. RESULTS Fifteen studies (6 with control groups of transplant without use of cyclosporine; total patients: 410) met the inclusion criteria for major malformations, 10 for preterm delivery (4 with control groups; total patients: 379) and 5 for low birth weight (1 with control groups; total number of patients: 314). The calculated odds ratio of 3.83 for malformations did not achieve statistical significance (CI 0.75-19.6). The overall prevalence of major malformations in the study population (4.1%) also did not vary substantially from that reported in the general population. OR for prematurity [1.52 (CI 1.00-2.32)] did not reach statistical significance although the overall prevalence rate was 56.3%. The OR for low birth weight [1.5 (CI 0.95-2.44 based on 1 study)]. CONCLUSIONS CsA does not appear to be a major human teratogen. It may be associated with increased rates of prematurity. More research is needed to evaluate whether cyclosporine increases teratogenic risk.
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Affiliation(s)
- B Bar Oz
- The Motherisk Program, Division of Clinical Pharmacology/Toxicology, The Hospital for Sick Children, Toronto, Ontario, Canada
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30
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Abstract
The issues relating to assisted reproduction in women with severe medical disease can be divided into the likely effect of pregnancy upon the medical condition, and how the medical condition may adversely affect pregnancy outcome. In addition, consideration of the hazards relating to the process of assisted conception, in particular the risk of ovarian hyperstimulation syndrome and multiple pregnancy, must be remembered. In some women, successful assisted reproduction may result in a life-threatening pregnancy. Clinicians advising women about assisted conception should be aware of the medical conditions that are absolute contra-indications to pregnancy. Some women with severe medical disease may have a significantly reduced life expectancy, in which case ethical issues regarding the future welfare of the child must be considered. Examples include sickle cell disease, cystic fibrosis and HIV. One of the biggest advantages of assisted reproduction for women with severe medical disorders is that the pregnancy is planned. Thus, there is an opportunity for the patient to be informed fully about any risks, both to herself and her fetus. This article reviews the general management of women with severe medical disorders who seek assisted reproduction and gives specific guidelines for the more common conditions.
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Affiliation(s)
- A M Neill
- West Suffolk Hospital, Bury St Edmund's, Suffolk IP33 2QZ, UK
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31
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Abstract
1. Forty percent of transplant centers expect the primary care physician to be the primary physician; 40% have both a primary care physician and a hepatologist manage the patient. 2. Transplant centers expect primary care physicians to provide general preventive medicine, physical examinations, vaccinations, and, rarely, management of hypertension, renal dysfunction, and diabetes. 3. A high percentage of primary care physicians feel comfortable caring and managing the overall health care of a long-term liver transplant patient. 4. Primary care physicians feel at most ease managing preventive care, annual physical examinations, hypertension, diabetes mellitus, hyperlipidemia, bone disease, and vaccinations. 5. Primary care physicians should be aware of the common medical conditions of the liver transplant patient of hypertension, diabetes, obesity, hyperlipidemia, and recurrent disease. 6. Common medical conditions for both the transplant centers and primary care physicians are hypertension, dyslipidemia, diabetes mellitus, malignancy, bone disease, pregnancy, vaccination, infectious prophylaxis, and headaches.
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Affiliation(s)
- T M McCashland
- Department of Internal Medicine, The University of Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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32
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Abstract
1. Libido returns promptly after liver transplantation; patients should be counseled on contraception and avoidance of sexually transmitted diseases. 2. Women after liver transplantation are at increased risk for cancer and should have regularly scheduled screening for cervical and breast cancer. 3. Immunosuppression during pregnancy is not teratogenic and does not lead to congenital anomalies. 4. Pregnancy after liver transplantation is often successful, but must be regarded as high risk, associated with an increased risk for hypertension and preeclampsia, intrauterine growth retardation, and prematurity. It is best delayed until 1 to 2 years after grafting. 5. Close monitoring of immunosuppressant levels in the blood is crucial during pregnancy to avoid inappropriately low levels of immunosuppression.
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Affiliation(s)
- C A Riely
- Gastroenterology Division, University of Tennessee Health Sciences Center, Memphis, TN 38163, USA.
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33
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Raakow R, Neuhaus R, Büscher U, Schmidt S, Rayes N, Glanemann M, Neuhaus P. Parenthood following liver transplantation. Transplant Proc 2001; 33:1450-2. [PMID: 11267369 DOI: 10.1016/s0041-1345(00)02549-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- R Raakow
- Department of Surgery, Charité, Campus Virchow Clinics, Humboldt University Berlin, Berlin, Germany
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34
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Abstract
The first known posttransplantation pregnancy was in 1958 in a renal transplant recipient who had received a kidney from her identical twin sister. The first known posttransplantation pregnancy in a liver transplant recipient was in 1978. Information available from female kidney transplant recipients helped in the decision making involved in the management of this case, as well as those that followed. Over the last 20 years, issues specific to liver transplantation and pregnancy have been identified. Similar to the kidney transplant recipient population, when prepregnancy recipient graft function is stable and adequate, pregnancy appears to be well tolerated. Also similar to kidney transplant recipients, there has been no evidence of a specific malformation pattern among the children, and although prematurity and low birth weight occur, overall newborn outcomes have been favorable. Pregnancy in the setting of recurrent liver disease, such as recurrent hepatitis C, poses a potential problem among liver transplant recipients, as well as the possible adverse effects of immunosuppression on maternal kidney function. Also of significance, peripartum graft deterioration has more severe consequences in this transplant recipient population. Therefore, pregnancy must be considered carefully in this transplant recipient group. Since 1991, the National Transplantation Pregnancy Registry (NTPR) has studied the safety of pregnancy outcomes in solid-organ transplant recipients. The purpose of this review is to catalog studies in the literature, as well as to present current data from the registry with management guidelines.
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Affiliation(s)
- V T Armenti
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
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35
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Carr DB, Larson AM, Schmucker BC, Brateng DA, Carithers RL, Easterling TR. Maternal hemodynamics and pregnancy outcome in women with prior orthotopic liver transplantation. Liver Transpl 2000; 6:213-21. [PMID: 10719023 DOI: 10.1002/lt.500060223] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study is to evaluate the hemodynamics and pregnancy outcome of women with prior orthotopic liver transplantation. Hemodynamic measurements by Doppler technique were performed on pregnant subjects with prior orthotopic liver transplantation. Maternal characteristics, renal function, pregnancy complications, delivery indications, delivery mode, and neonatal outcomes were evaluated. Six pregnancies occurred in 5 women after orthotopic liver transplantation at the University of Washington Medical Center (Seattle, WA) between 1991 and 1999. Four of the 6 pregnancies were complicated by chronic hypertension, fetal growth restriction, and preterm delivery. Two pregnancies had worsening hypertension characterized by vasoconstriction in the second trimester despite antihypertensive therapy. These 2 subjects were administered cyclosporine for maintenance immunosuppression and had greater mean arterial pressures preconception and in the first trimester than the other subjects. One of these pregnancies resulted in fetal demise at 25 weeks' gestation. The other subject was delivered at 28 weeks' gestation for nonreassuring fetal status and superimposed preeclampsia. All pregnancies were complicated by renal insufficiency; however, the 2 subjects with poor obstetric outcome had preconception serum creatinine levels greater than 1.5 mg/dL and creatinine clearances less than 40 mL/min. Pregnancies complicated by second-trimester vasoconstriction and moderate renal insufficiency are at risk for preeclamspia, fetal growth restriction, and fetal demise. Good obstetric outcome can occur in women with mild renal insufficiency and well-controlled chronic hypertension. Improved hypertensive control preconception may decrease the risk for preeclampsia and poor obstetric outcome.
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Affiliation(s)
- D B Carr
- Department of Obstetrics and Gynecology and Medicine, Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA 98195-6460, USA
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36
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Parolin MB, Coelho JC, Balbi E, Wiederkehr JC, Anghinoni M, Nassif AE. [Normalization of menstrual cycles and pregnancy after liver transplantation]. ARQUIVOS DE GASTROENTEROLOGIA 2000; 37:3-6. [PMID: 10962620 DOI: 10.1590/s0004-28032000000100002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective of the present study is to evaluate the effects of successful liver transplantation on menstrual cycles abnormalities and on reproductive function of women with chronic liver disease. Twelve women with age between 17 and 54 years who underwent liver transplantation were evaluated. The following variables were analyzed: age, etiology of chronic liver disease, pattern of menstrual function and period of amenorrhea before and after transplantation, and occurrence of pregnancy after transplantation. The mean age of patients was 36 +/- 12.6 years. Patients with primary biliary cirrhosis did not have menstrual abnormalities before transplantation. The other patients presented amenorrhea for 3 months to 11 years before the transplantation. Rapid recovery of menstrual function was observed in all patients after the transplantation (3.1 +/- 1.2 months). Two patients became pregnant one and three years after the transplantation. It is concluded from this study that most women who present amenorrhea secondary to chronic liver disease have normal menstrual cycles in approximately three months following liver transplantation and they may become pregnant.
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Affiliation(s)
- M B Parolin
- Serviço de Transplante Hepático, Hospital de Clínicas, Universidade Federal do Paraná
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37
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Zetterman RK. Caring for the liver transplant recipient. Curr Gastroenterol Rep 1999; 1:175-6. [PMID: 10980946 DOI: 10.1007/s11894-999-0029-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- R K Zetterman
- University of Nebraska Medical Center, Department of Internal Medicine, 983332 Nebraska Medical Center, Omaha, NE 68198-3332, USA
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38
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Abstract
Childbearing is important to women with renal disease, but pregnancy has generally been regarded as very high risk in these women. In this review, an attempt is made to clarify the nature and severity of those risks in the settings of chronic renal insufficiency and end-stage renal disease, including dialysis patients and transplant recipients. Hypertension is the most common life-threatening problem in all three groups. A wide range of antihypertensive medications have been used, with angiotensin-converting enzyme inhibitors the only drugs absolutely contraindicated because of their association with neonatal anuria, pulmonary hypoplasia, and neonatal death. Women with serum creatinine levels of 1.4 mg/dL or greater are at risk for accelerated loss of renal function compared with women who don't become pregnant. Transplant recipients have a risk for loss of renal function similar to controls as long as renal function is well preserved. The frequency of conception is decreased in women with renal insufficiency and markedly decreased in dialysis patients (0.5% per year). Return of fertility is the rule in transplant recipients. Exposure to immunosuppressive drugs, including prednisone, azathioprine, cyclosporine, and tacrolimus, has not been associated with an increase in congenital anomalies. These drugs, particularly cyclosporine, have been associated with small-for-gestational-age babies. Transplant recipients are at risk for infections that have implications for the fetus, including cytomegalovirus, herpes simplex, and toxoplasmosis. All groups have an increased risk for prematurity and intrauterine growth restriction. The percentage of pregnancies resulting in surviving infants in women with renal insufficiency and transplant recipients ranges from 70% to 100%. For women who conceive after starting dialysis, the likelihood of a surviving infant is approximately 50%.
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MESH Headings
- Delivery, Obstetric
- Diagnosis, Differential
- Female
- Humans
- Hypertension, Renovascular/diagnosis
- Hypertension, Renovascular/therapy
- Immunosuppressive Agents/therapeutic use
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/therapy
- Kidney Transplantation
- Labor, Obstetric
- Nutritional Physiological Phenomena
- Pregnancy
- Pregnancy Complications/diagnosis
- Pregnancy Complications/therapy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Pregnancy Complications, Infectious/diagnosis
- Pregnancy Complications, Infectious/therapy
- Renal Dialysis
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Affiliation(s)
- S Hou
- Department of Medicine, Rush Medical College, Chicago, IL, USA.
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39
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Pruvot FR, Noel C. Comment on "Pregnancy after liver transplantation under tacrolimus" by Jain et al. Transplantation 1998; 65:1415-6. [PMID: 9625033 DOI: 10.1097/00007890-199805270-00027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
This article reviews the reported experience with pregnancy after liver transplantation and describes obstetric risks and medical issues that the maternal fetal medicine specialist has a reference for managing these pregnancies and for providing appropriate preconception counseling. Women who undergo liver transplantations have a higher risk of preeclampsia, worsening hypertension, preterm premature rupture of membranes, anemia, small for gestational age, preterm delivery, and cesarean section than the normal obstetric population. Women with preconceptional renal dysfunction appear to be at greatest risk for pregnancy complications. Women who conceived within 6 months of transplant had a high risk of rejection. Reproductive-aged recipients of liver allograft should receive contraception and preconception counseling. In an appropriately timed and planned pregnancy, women who undergo liver transplantations can have successful pregnancies with little risk to their allograft function.
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Affiliation(s)
- H L Casele
- Division of Maternal Fetal Medicine, Northwestern University Medical School, Evanston Hospital, IL 60201, USA
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41
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Casele HL, Laifer SA. Association of pregnancy complications and choice of immunosuppressant in liver transplant patients. Transplantation 1998; 65:581-3. [PMID: 9500638 DOI: 10.1097/00007890-199802270-00023] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The purpose of this study was to identify factors associated with antenatal complications for an ongoing series of pregnant women who have undergone orthotopic liver transplantation. METHODS We reviewed Magee-Womens Hospital records from 14 pregnancies in 13 women in whom a liver had been transplanted before pregnancy. We collected and analyzed data regarding the primary liver disease, allograft status, liver function at conception and during pregnancy, immunosuppressive medications, associated medical conditions, time from transplant to conception, cytomegalovirus serostatus, and maternal and fetal outcome. RESULTS Seven patients had evidence of renal dysfunction (creatinine, 1.3-2.0 mg/dl), five of whom also were hypertensive at their first prenatal visit. The complications of preeclampsia, worsening hypertension, and small for gestational age occurred only in women with renal dysfunction at conception. Renal dysfunction was more often associated with cyclosporine than tacrolimus use. CONCLUSIONS Renal dysfunction is the primary determinant of adverse pregnancy outcome in liver transplant recipients. Immunosuppression with cyclosporine during pregnancy was more often associated with antenatal complications than with the use of tacrolimus.
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Affiliation(s)
- H L Casele
- University of Pittsburgh Health Sciences Center, Department of Obstetrics, Gynecology and Reproductive Sciences, Pennsylvania 15213, USA
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42
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Davison JM, Redman CW. Pregnancy post-transplant: the establishment of a UK registry. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1997; 104:1106-7. [PMID: 9332984 DOI: 10.1111/j.1471-0528.1997.tb10930.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- J M Davison
- Royal Victoria Infirmary, Newcastle upon Tyne
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43
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Pruvot FR, Declerck N, Valat-Rigot AS, Gambiez L, Canva V, Labalette M, Noël C, Gottrand F, Puech F, Paris JC. Pregnancy after liver transplantation: focusing on risks to the mother. Transplant Proc 1997; 29:2470-1. [PMID: 9270813 DOI: 10.1016/s0041-1345(97)00452-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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44
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Abstract
Successful pregnancy outcomes are possible after liver transplantation. Although there are risks to the mother and fetus, there has not been an increased incidence of malformations noted in the newborn of liver recipients. Close, coordinated care involving the hepatologist, surgeon, and high-risk obstetrician is essential to ensure a favorable outcome. Immunosuppression peripartum should be maintained at appropriate levels. Of note, a small subset of recipients may suffer worsened graft function during pregnancy. Recurrent liver disease, especially viral hepatitis, and CMV infection appear to pose significant risks to mother and offspring, respectively, although the magnitude of the risks is unknown. It therefore would seem prudent to consider pregnancy only in female liver recipients who have passed at least 1 year with stable graft function. In addition, new immunosuppressive regimens further add to the lack of information regarding pregnancy safety. The NTPR is an ongoing database to collect information and pregnancy outcomes. That information should be helpful in counseling recipients and in pregnancy management.
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Affiliation(s)
- V T Armenti
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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45
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Albengres E, Le Louet H, Tillement JP. Immunosuppressive drugs and pregnancy: experimental and clinical data. Transplant Proc 1997; 29:2461-6. [PMID: 9270811 DOI: 10.1016/s0041-1345(97)00450-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- E Albengres
- Service Hospitalo-Universitaire de Pharmacologie, Faculté de Médecine de Paris XII, Créteil, France
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Pruvot FR, Noel C, Declerck N, Valat-Rigot AS, Roumilhac D, Hazzan M, Puech F, Lelièvre G. Consecutive successful pregnancies in a combined liver and kidney transplant recipient with type 1 primary hyperoxaluria. Transplantation 1997; 63:615-6. [PMID: 9047162 DOI: 10.1097/00007890-199702270-00024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pregnancy is now a common, but high-risk event, in young women who have received transplants. Consequences to the fetus are known, but pregnancy may also interfere with graft function. We report the outcome of two successive and successful pregnancies in a 29-year-old woman with type 1 hyperoxaluria, who received a combined liver and kidney transplant. Two healthy children were born at 35 and 37 weeks of gestation, with low birth weight. Liver function remained normal before, during, and after pregnancies up to 52 months after transplantation. Renal function was impaired before the first conception, worsened during both pregnancies, and returned to the previous level in both immediate postpartum periods. However, renal function has declined 17 months after the last delivery. This report shows the feasibility of successive pregnancies in multiple organ transplant recipients, but raises the question of long-term maternal kidney graft survival.
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Affiliation(s)
- F R Pruvot
- Unite de Transplantation, Hopital Calmette, CHU, Lille, France
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Avraamides EJ, Craen RA, Gelb AW. Anaesthetic management of a pregnant, post liver transplant patient for dental surgery. Anaesth Intensive Care 1997; 25:68-70. [PMID: 9075517 DOI: 10.1177/0310057x9702500112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- E J Avraamides
- Department of Anaesthesia, London Health Sciences Centre, University of Western Ontario, Canada
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Patapis P, Irani S, Mirza DF, Gunson BK, Lupo L, Mayer AD, Buckels JA, Pirenne J, McMaster P. Outcome of graft function and pregnancy following liver transplantation. Transplant Proc 1997; 29:1565-6. [PMID: 9123426 DOI: 10.1016/s0041-1345(96)00676-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- P Patapis
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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49
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Affiliation(s)
- C Roll
- Department of Paediatrics, University Hospital, Essen, Germany
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50
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Mass K, Quint EH, Punch MR, Merion RM. Gynecological and reproductive function after liver transplantation. Transplantation 1996; 62:476-9. [PMID: 8781613 DOI: 10.1097/00007890-199608270-00009] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Women of reproductive age who underwent orthotopic liver transplantation were surveyed to determine timing and pattern of menstruation, sexual activity, contraception, and incidence of pregnancy and gynecological disorders. Eighty two female recipients of liver transplantation at the University of Michigan between August 1985 and January 1992 were surveyed about menstrual function and gynecological and obstetrical histories before and after transplantation. Additional information was retrieved from medical records regarding their liver disease and details of pregnancies and gynecological care. In the year before transplantation, 27 women (42%) reported regular menstrual cycles, 18 (28%) irregular and unpredictable bleeding, and 19 (30%) amenorrhea. After transplantation, 30 women (48%) experienced regular menses, 16 (26%) irregular bleeding, and 16 (26%) amenorrhea. In women less than 46 years old, 27 (53%) had regular menses before and after transplant. Most women with acute liver disease had regular periods before (82%) and after transplant (73%). A total of 95% of women under the age of 46 had return of menstrual bleeding within the first year after transplantation. Of these women 49% had normal liver function tests at the time of survey, 33% mildly abnormal, and 18% severely abnormal. Liver function was not correlated with menstrual patterns. A total of 72% of women were sexually active after transplantation. Of 24 women under age 46 who had not undergone sterilization or hysterectomy, six women conceived seven pregnancies. Seven women reported abnormal cervical cytology results after transplantation. Six underwent colposcopy and 4 required some form of destructive therapy for cervical dysplasia. In women with liver disease, menstrual patterns may change after orthotopic liver transplantation. This is more common in women with chronic liver disease than in those with acute liver disease. There was no correlation between liver function and menstrual regularity after transplant. Return to sexual activity can be expected and pregnancies are not rare in a population of young women after liver transplantation. Regular cervical cytology is critical due to a recognized increase in cervical neoplasia in immunocompromised patients.
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Affiliation(s)
- K Mass
- Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor 48109-0718, USA
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