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Kosian P, Jansen C, Chang J, Praktiknjo M, Ayub TH, Gembruch U, Merz WM. Maternal and Perinatal Outcome in a Contemporary Cohort of Patients with Portal Hypertension: A Single-Center Experience. J Clin Med 2023; 12:jcm12093088. [PMID: 37176528 PMCID: PMC10179582 DOI: 10.3390/jcm12093088] [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: 02/08/2023] [Revised: 03/17/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Portal hypertension in pregnancy is characterized by an increased perinatal and maternal complication rate. The purpose of this study was to evaluate the perinatal and maternal outcomes of these high-risk pregnancies at our tertiary center. METHODS We identified pregnancies with portal hypertension in our departmental database for the years 2013 to 2021. The medical history and perinatal and maternal data were extracted from medical records. RESULTS Eleven cases were identified. In pregnancy, delivery and postpartum, complications occurred in 72.7% of cases and included among others ascites, subclavian thrombosis, variceal-ligation-induced ulcer bleeding and postoperative hemorrhage. The cesarean delivery rate was 72.7% (n = 8); five of these were done for obstetric or fetal indications. The rate of preterm birth and admissions to neonatal intensive care unit were high (54.5% and 45.5%, respectively). CONCLUSIONS Our case series substantiates the high maternal and perinatal complication rates seen in portal hypertension. The prevention of thromboembolic and bleeding complications was the main challenge. Care by an interdisciplinary team of experts is crucial for a successful perinatal and maternal outcome.
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Affiliation(s)
- Philipp Kosian
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Tiyasha Hosne Ayub
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Waltraut M Merz
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
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2
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Eletreby R, Abdelaziz R, Shousha HI, Hammam Z, Hany A, Sabry D, Elawady B, Zayed N, Yosry A, Alem SA. Screening for maternal cytomegalovirus infection during pregnancy and pregnancy outcome in patients with liver disease: an observational study. BMC Infect Dis 2023; 23:210. [PMID: 37024831 PMCID: PMC10080798 DOI: 10.1186/s12879-023-08144-9] [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: 12/30/2022] [Accepted: 03/09/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection among pregnant females could induce CMV hepatitis with possible changes in liver stiffness measurement (LSM) which could be reversibly increased during normal pregnancies, particularly in the third trimester. This study aimed to detect the prevalence of CMV infection among pregnant females with and without chronic liver disease and to evaluate the effects of CMV infection on LSM and pregnancy outcomes in comparison to non-CMV-infected pregnant females. METHODS This is an observational prospective study that included 201 pregnant ladies presented to the liver disease with pregnancy clinic, Cairo University from March 2018 to April 2019. We assessed the laboratory results, abdominal ultrasonography, LSM using ARFI elastography, and pregnancy outcomes. RESULTS Two hundred and one pregnant ladies were divided into ; group 1: pregnant ladies with normal pregnancy (n = 128), group 2: pregnant ladies with chronic liver diseases not related to pregnancy (n = 35), and group 3: pregnant ladies with pregnancy-related liver diseases (n = 38). Positive CMV serology (either/or, +ve CMV-IgM, IgG) was detected in 106/201 patients (52.74%), and fifteen of them had an active infection (IgG +, IgM+, PCR+). Pregnant females with chronic liver diseases not related to pregnancy had significantly higher serum levels of CMV IgM, IgG, and PCR. Moreover, LSM had a significant correlation with CMV IgG and CM_PCR in normal pregnant ladies. Maternal mortality occurred only in pregnant females with chronic liver diseases in 5.7% (2/35). CONCLUSION Maternal CMV infection carries a significant risk to pregnant females with chronic liver disease. Routine CMV screening for women planning to be pregnant, especially those with chronic liver disease could help to avoid bad maternal and fetal outcomes.
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Affiliation(s)
- Rasha Eletreby
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rasha Abdelaziz
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hend Ibrahim Shousha
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Zeinab Hammam
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ayman Hany
- Gynecology and Obstetrics Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dina Sabry
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Basma Elawady
- Medical Microbiology and Immunology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Naglaa Zayed
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ayman Yosry
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Shereen Abdel Alem
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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3
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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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4
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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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5
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Hansen JD, Perri RE, Riess ML. Liver and Biliary Disease of Pregnancy and Anesthetic Implications: A Review. Anesth Analg 2021; 133:80-92. [PMID: 33687174 DOI: 10.1213/ane.0000000000005433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Liver and biliary disease complicates pregnancy in varying degrees of severity to the mother and fetus, and anesthesiologists may be asked to assist in caring for these patients before, during, and after birth of the fetus. Therefore, it is important to be familiar with how different liver diseases impact the pregnancy state. In addition, knowing symptoms, signs, and laboratory markers in the context of a pregnant patient will lead to faster diagnosis and treatment of such patients. This review article discusses changes in physiology of parturients, patients with liver disease, and parturients with liver disease. Next, general treatment of parturients with acute and chronic liver dysfunction is presented. The article progresses to specific liver diseases with treatments as they relate to pregnancy. And finally, important aspects to consider when anesthetizing parturients with liver disease are discussed.
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Affiliation(s)
- Jennette D Hansen
- From the Department of Anesthesiology, North Kansas City Hospital, North Kansas City, Missouri
| | - Roman E Perri
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthias L Riess
- From the Department of Anesthesiology, North Kansas City Hospital, North Kansas City, Missouri.,Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
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6
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Sirilert S, Tongsong T. Hepatitis B Virus Infection in Pregnancy: Immunological Response, Natural Course and Pregnancy Outcomes. J Clin Med 2021; 10:jcm10132926. [PMID: 34210105 PMCID: PMC8267880 DOI: 10.3390/jcm10132926] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 01/02/2023] Open
Abstract
This review aimed to provide an update on the impact of pregnancy on the natural course of hepatitis B virus (HBV) infection and also on the impact of HBV infection on adverse pregnancy outcomes, including mother-to-child transmission (MTCT). For the literature review, original research articles, review articles, and guidelines were narratively reviewed and comprehensively validated. The databases of PubMed, EMBASE, and CINAHL were carefully searched for articles in English on topics related to HBV infection, pregnancy, and vertical transmission from 1960 to May 2021. Immunological changes during pregnancy such as suppression of Th1 response and induction of Th2 immunity lead to an impaired immune reaction to HBV and stimulate viral activity along with the reduction of CD8 T cells to escape immune detection. The impact of pregnancy on the natural course of chronic HBV infection seems to be minimal, while pregnancy can increase morbidity and mortality in the case of advanced HBV hepatitis or cirrhosis. Importantly, hepatitis flare or alanine aminotransferase (ALT) flare can occur during pregnancy and is more common during the postpartum period due to the interaction between HBV and the immune response. Interestingly, the impact of HBV infection on adverse pregnancy outcomes is more serious than ever thought. Updated evidence indicates that pregnancies with chronic HBV infection increase the risk of preterm birth and gestational diabetes, especially in cases of positive hepatitis e antigen (HBeAg).
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7
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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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8
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Zhang Y, Meng Z, Li Z, Wang L, Qiu S, Xu C. A pregnant woman with congenital hepatic fibrosis delivers a healthy neonate. Liver Int 2021; 41:128-132. [PMID: 33012093 DOI: 10.1111/liv.14683] [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: 05/09/2020] [Revised: 09/09/2020] [Accepted: 09/24/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS Congenital hepatic fibrosis (CHF) is a rare disease associated with polycystic kidney gene mutation and is characterized by liver fibrosis and portal hypertension. The pathology of CHF has common characteristics with hepatitis B cirrhosis. Currently, little is known about the clinical course of CHF during pregnancy or its effect on maternal and fetal outcomes. METHODS Whole exome sequencing (WES), and laboratory and histopathological findings of the patient were documented. RESULTS We report the case of a 30-year-old Chinese woman who had been diagnosed with hepatitis B cirrhosis 17 years before and whose diagnosis was revised to CHF based on confirmation by liver biopsy and WES. She conceived naturally and delivered a healthy live infant. CONCLUSIONS The diagnostic methods for CHF are liver biopsy and WES. In pregnant patients with CHF, prenatal monitoring is mainly performed to monitor liver function, platelet and clotting function, portal hypertension and degree of esophageal and gastric varices. Precise guidelines for screening and management of patients with CHF need to be better defined.
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Affiliation(s)
- Yiwen Zhang
- Department of Obstetrics, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhanao Meng
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhe Li
- Department of Obstetrics, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Wang
- Department of Obstetrics, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Suli Qiu
- Department of Obstetrics, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chengfang Xu
- Department of Obstetrics, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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9
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Park C, Patel YA, Suhocki P, Dorsey C, Kapila N, Tang L, Gilner J. High-risk third trimester pregnancy with decompensated cirrhosis safely delivered following emergent preoperative interventional radiology for mitigation of variceal bleeding. Clin Imaging 2020; 68:143-147. [PMID: 32615516 DOI: 10.1016/j.clinimag.2020.06.032] [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: 05/03/2020] [Revised: 06/11/2020] [Accepted: 06/16/2020] [Indexed: 11/26/2022]
Abstract
Coagulopathy coupled with severe portal hypertension in the setting of cirrhosis increases the risk of mortality from variceal bleeding in pregnant women. Studies suggest transjugular intrahepatic portosystemic shunt (TIPS) creation to be a safe procedure during pregnancy in preventing variceal bleeding complications; however, it is not typically employed in severely decompensated cirrhosis. This case report of a pregnant woman presenting at 34.7 weeks' gestation demonstrates successful variceal mapping, emergent TIPS creation and variceal embolization to allow safe cesarean delivery despite severe hypofibrinogenemia and decompensated alcoholic cirrhosis. With careful medical optimization, angiographic imaging and vascular interventional radiology may be employed outside of usual indications to achieve safe pregnancy delivery and postpartum recovery.
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Affiliation(s)
- Christine Park
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Yuval A Patel
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
| | - Paul Suhocki
- Department of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
| | - Claire Dorsey
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
| | - Nikhil Kapila
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, USA
| | - Linnan Tang
- Department of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
| | - Jennifer Gilner
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA.
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10
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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: 20] [Impact Index Per Article: 5.0] [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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11
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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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12
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Kotzev AI, Tanchev LS, Pavlov CS, Tanchev SY. [Unsolved issues of pregnancy in liver cirrhosis]. TERAPEVT ARKH 2019; 91:114-117. [PMID: 32598689 DOI: 10.26442/00403660.2019.04.000145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 01/16/2023]
Abstract
Pregnancy in patients with liver cirrhosis and portal hypertension occurs very rare, because of their significantly derailed reproductive functions. Тhe risks for the mother and the fetus are connected with worsening of the portal hypertension, progression of decompensated liver cirrhosis and development of its complications: liver failure, ascites, hepatorenal syndrome, hepatic encephalopathy and variceal hemorrhage, and with increased incidence of spontaneous abortions and abnormal uterine bleeding. The decision for continuation of the pregnancy in cirrhotic patients must be based on individual approach and a multidisciplinary team consisting of obstetricians, hepatologists, anesthesiologists, surgeons and hematologists must participate in the therapy. We are presenting a clinical case with 34 years old pregnant woman with Child-Pugh class C cirrhosis and untreated chronic viral hepatitis C. The patient was admitted in emergency with abortus imminens, vaginal bleeding, anemia, thrombocytopenia and impaired hemostasis. The pregnancy was interrupted in the Department of obstetrics and gynecology due to the high risk for mother's life. Later the patient developed severe disseminated intravascular coagulation (DIC) syndrome with life-threatening uterine bleeding. The DIC syndrome and the bleeding were resolved after therapy in intensive care unit and the patient was discharged from the hospital with stable vital signs.
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Affiliation(s)
- A I Kotzev
- Clinic of Gastroenterology, University Hospital "Alexandrovska", Medical University
| | | | - C S Pavlov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of Russian Federation (Sechenov University)
| | - S Y Tanchev
- Obstetric Clinic, University Hospital "Dr. Georgi Stranski", Department of obstetrics and gynecology, Medical University
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13
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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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14
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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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15
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Shukla A, Sadalage A, Gupta D, Gupte A, Mahapatra A, Mazumder D, Shah C, Modi T, Meshram M, Dhore P, Bhatia S. Pregnancy outcomes in women with Budd Chiari Syndrome before onset of symptoms and after treatment. Liver Int 2018; 38:754-759. [PMID: 28834123 DOI: 10.1111/liv.13552] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 08/14/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Pregnancy is known to have poor outcomes in women with Budd Chiari syndrome. There are no data on fertility and pregnancy outcomes prior to onset of symptoms or the effect of therapy on these parameters. We therefore evaluated reproductive profile of women with Budd Chiari Syndrome before the onset of symptoms and after therapy. PATIENTS AND METHODS Eighty women with Budd Chiari Syndrome (29 years [20-45]) were enrolled over 8 years. Baseline demographic characteristics, disease severity, thrombophilic disorders and treatment were reviewed. Their obstetric history before symptoms and after therapy was noted and compared. RESULTS Sixty women conceived at least once (150 pregnancies) before symptom onset and 20 had primary infertility. Eighty-one pregnancies resulted in live births and remaining 69 pregnancies had adverse pregnancy outcomes. Post-intervention, 28 women (15 with primary infertility) attempted conception. Thirteen patients conceived 15 times. More women had live births after successful therapy as compared to presymptomatic period (0/28 vs 5/28 P = .000, Odds ratio5.6; 95% CI: 2.16-14.5). In women with primary infertility, conception (0/15 vs 3/15 P = .007, Odds ratio 5, 95% CI: 1.44-17.27) and proportion of live births (0/15 vs 2/15 P = .002, Odds ratio 7.5, 95% CI: 1.71-32.79) was higher as compared to presymptomatic period. CONCLUSION Primary infertility is common and pregnancy outcomes are poor before the onset of symptoms in women with Budd-Chiari syndrome. Effective therapy of Budd-Chiari syndrome may improve fertility and pregnancy outcomes.
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Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Abhishek Sadalage
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Deepak Gupta
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Amit Gupte
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Anupam Mahapatra
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Dipendu Mazumder
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Chirag Shah
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Tejas Modi
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Megha Meshram
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Prashant Dhore
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Deleterious impact of maternal hepatitis-C viral infection on maternal and fetal outcome: a 5-year prospective study. Arch Gynecol Obstet 2017; 296:1097-1102. [PMID: 28956137 DOI: 10.1007/s00404-017-4550-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/20/2017] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To assess prospectively the maternal and fetal outcome among pregnant women with chronic Hepatitis-C virus (HCV) infection compared to normal control group. METHODS A prospective observational study conducted on 342 pregnant women with HCV who were divided into two groups according to polymerase chain reaction (PCR) result, group 1 (n = 184, HCV-PCR negative) and group 2 (n = 154, HCV-PCR positive) with a third group of normal pregnant women (n = 170). Obstetric outcome was recorded. RESULTS Patients with positive HCV-PCR have more elevated liver enzymes (p < 0.05) and lower prothrombin INR (p < 0.001) than those with negative HCV-PCR testing. Fewer patients with HCV received previous medical treatment (16/342, 4.6%). More women in the HCV groups delivered by vacuum or cesarean section (p < 0.05), experienced higher rates of antepartum hemorrhage, postpartum hemorrhage, anemia, development of GDM, premature rupture of membranes, repeated hospital admissions, blood transfusions, admission to ICU and maternal mortality (p < 0.001) compared to the control group. Fetuses of women with HCV infections were more prone to IUFD with higher rates of low birth weight, prematurity, low Apgar scores at 5 min, admission to NICU, need for ventilation, and acquisition of HCV (p < 0.001) as well as neonatal mortality (p < 0.05) compared to the control group. CONCLUSION Patients with HCV infection even those without viremia suffered poor maternal and fetal outcome. Multidisciplinary management of the affected patients should be implemented to improve their obstetric outcome.
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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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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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Hepatitis B During Pregnancy in Endemic Areas: Screening, Treatment, and Prevention of Mother-to-Child Transmission. Paediatr Drugs 2017; 19:173-181. [PMID: 28434087 DOI: 10.1007/s40272-017-0229-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The proper management of pregnant women infected with hepatitis B virus (HBV) is necessary to prevent maternal and fetal morbidity and mortality and to protect the baby from HBV infection. In the majority of cases, vertical transmission can be prevented with a universal screening program, HBV vaccine immunoprophylaxis, and administration of hepatitis B immunoglobulin (HBIg) for babies born to mothers with HBV. However, in mothers with a high viral load (>200,000 or >1,000,000 IU/ml, depending on the guideline), the chance of immunoprophylaxis failure remains high. The standard recommendation is to give an antiviral agent during the third trimester in these patients. US FDA pregnancy category B agents such as tenofovir and telbivudine are allowed through all trimesters of pregnancy. Breastfeeding for patients who receive antiviral agents can be allowed after a risk-benefit discussion with the patient.
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Fagiuoli S, Bruno R, Debernardi Venon W, Schepis F, Vizzutti F, Toniutto P, Senzolo M, Caraceni P, Salerno F, Angeli P, Cioni R, Vitale A, Grosso M, De Gasperi A, D'Amico G, Marzano A. Consensus conference on TIPS management: Techniques, indications, contraindications. Dig Liver Dis 2017; 49:121-137. [PMID: 27884494 DOI: 10.1016/j.dld.2016.10.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/27/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022]
Abstract
The trans jugular intrahepatic Porto systemic shunt (TIPS) is no longer viewed as a salvage therapy or a bridge to liver transplantation and is currently indicated for a number of conditions related to portal hypertension with positive results in survival. Moreover, the availability of self-expandable polytetrafluoroethylene (PTFE)-covered endoprostheses has dramatically improved the long-term patency of TIPS. However, since the last updated International guidelines have been published (year 2009) new evidence have come, which have open the field to new indications and solved areas of uncertainty. On this basis, the Italian Association of the Study of the Liver (AISF), the Italian College of Interventional Radiology-Italian Society of Medical Radiology (ICIR-SIRM), and the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI) promoted a Consensus Conference on TIPS. Under the auspices of the three scientific societies, the consensus process started with the review of the literature by a scientific board of experts and ended with a formal consensus meeting in Bergamo on June 4th and 5th, 2015. The final statements presented here were graded according to quality of evidence and strength of recommendations and were approved by an independent jury. By highlighting strengths and weaknesses of current indications to TIPS, the recommendations of AISF-ICIR-SIRM-SIAARTI may represent the starting point for further studies.
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Affiliation(s)
- Stefano Fagiuoli
- Gastroenterologia Epatologia e Trapiantologia, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Raffaele Bruno
- Dept. of Infectious Diseases, Hepatology Outpatients Unit, University of Pavia-Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Wilma Debernardi Venon
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
| | - Filippo Schepis
- Department of Gastroenterology University of Modena and Reggio Emilia, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Pierluigi Toniutto
- Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, Internal Medicine, University of Udine, Italy
| | - Marco Senzolo
- Unità di Trapianto Multiviscerale, Gastroenterologia, Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Università-Ospedale di Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Italy
| | - Paolo Angeli
- Internal Medicine and Hepatology Department of Medicine (DIMED), University of Padova, Italy
| | - Roberto Cioni
- Dipartimento di Radiologia Diagnostica e Interventistica, UO di Radiologia Interventistica, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alessandro Vitale
- U.O.C. di Chirurgia Epatobiliare e del Trapianto Epatico, Azienda Ospedaliera Università di Padova, Italy
| | - Maurizio Grosso
- Department of Radiology S. Croce and Carle Hospital Cuneo, Italy
| | - Andrea De Gasperi
- 2° Servizio Anestesia e Rianimazione-Ospedale Niguarda Ca Granda, Milan, Italy
| | | | - Alfredo Marzano
- Gastroepatologia, AOU Città della Salute e della Scienza, Molinette Hospital, Torino, Italy
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Solanke D, Rathi C, Pandey V, Patil M, Phadke A, Sawant P. Etiology, clinical profile, and outcome of liver disease in pregnancy with predictors of maternal mortality: A prospective study from Western India. Indian J Gastroenterol 2016; 35:450-458. [PMID: 27796940 DOI: 10.1007/s12664-016-0704-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 10/02/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study is to study the etiology, clinical profile, and prognostic factors related to maternal and fetal health in pregnant patients with liver disease in Western India. METHODS This study included 103 consecutive pregnant patients with liver dysfunction from August 2013 to July 2015, who underwent regular biochemical tests, viral markers, ultrasound of abdomen, etc. and were followed up for 6 weeks postpartum or until death. RESULTS Pregnancy-specific causes of liver dysfunction were found in 39 % (40/103) patients. Liver diseases were most frequent in third trimester 69.9 % (72/103). Etiologies in third trimester were viral hepatitis 36.1 % (26/72), pregnancy induced hypertension (PIH) 30.5 % (22/72), intrahepatic cholestasis of pregnancy 11.1 % (8/72), acute fatty liver of pregnancy (2/72), etc. Hepatitis E was the commonest agent among viral hepatitis 71.8 % (28/39). Causes of maternal mortality (n = 25) were hepatitis E 40 % (10/25), PIH 32 % (8/25), and tropical diseases 20 % (5/25). Fetal mortality (n = 31) was 38.7 % (12/31) in hepatitis E. Maternal mortality was significantly associated with presence of jaundice, fever, abdominal pain, oliguria, anemia, leukocytosis, and coagulopathy. Model for end-stage liver disease (MELD) score >21 predicted maternal mortality with 80 % sensitivity and 91 % specificity (area under the receiver operating characteristic curve = 0.878 and p < 0.001). CONCLUSIONS Liver disease was most common in the third trimester of pregnancy. Hepatitis E was the most common cause of liver disease in pregnant women in western India with significant maternal mortality, predicted by high MELD score.
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Affiliation(s)
- Dattatray Solanke
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, 400 022, India.
| | - Chetan Rathi
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, 400 022, India
| | - Vikas Pandey
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, 400 022, India
| | - Mallanagoud Patil
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, 400 022, India
| | - Aniruddha Phadke
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, 400 022, India
| | - Prabha Sawant
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, 400 022, India
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Tran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol 2016; 111:176-94; quiz 196. [PMID: 26832651 DOI: 10.1038/ajg.2015.430] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/01/2015] [Indexed: 12/11/2022]
Abstract
Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women.
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Affiliation(s)
- Tram T Tran
- Department of Medicine, Liver Transplant, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Ahn
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nancy S Reau
- Department of Medicine, Rush University, Chicago, Illinois, USA
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24
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Shekhar S, Diddi G. Liver disease in pregnancy. Taiwan J Obstet Gynecol 2015; 54:475-82. [DOI: 10.1016/j.tjog.2015.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 12/17/2022] Open
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Licata A, Ingrassia D, Serruto A, Soresi M, Giannitrapani L, Montalto G, Craxì A, Almasio PL. Clinical course and management of acute and chronic viral hepatitis during pregnancy. J Viral Hepat 2015; 22:515-23. [PMID: 25288051 DOI: 10.1111/jvh.12335] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pregnancy is a para-physiologic condition, which usually evolves without any complications in the majority of women, even if in some circumstances moderate or severe clinical problems can also occur. Among complications occurring during the second and the third trimester very important are those considered as concurrent to pregnancy such as hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, HELLP syndrome and acute fatty liver of pregnancy. The liver diseases concurrent to pregnancy typically occur at specific times during the gestation and they may lead to significant maternal and foetal morbidity and mortality. Commonly, delivery of the foetus, even preterm, usually terminates the progression of these disorders. All chronic liver diseases, such as chronic viral hepatitis, autoimmune hepatitis, Wilson's disease, and cirrhosis of different aetiologies may cause liver damage, independently from pregnancy. In this review we will also comment the clinical implications of pregnancies occurring in women who received a orthotopic liver transplantation (OLT) Therefore, the management of immunosuppressive therapy before and after the delivery in women who received liver transplant is becoming a relevant clinical issue. Finally, we will focus on acute and chronic viral hepatitis occurring during pregnancy, on management of advanced liver disease and we will review the literature on the challenging issue regarding pregnancy and OLT.
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MESH Headings
- Acute Disease
- Chronic Disease
- Disease Management
- Female
- Hepatitis, Viral, Human/complications
- Hepatitis, Viral, Human/diagnosis
- Hepatitis, Viral, Human/pathology
- Hepatitis, Viral, Human/therapy
- Hepatitis, Viral, Human/virology
- Humans
- Liver Transplantation
- Pregnancy
- Pregnancy Complications, Infectious
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Affiliation(s)
- A Licata
- Sezione di Gastroenterologia & Epatologia, Sezione di Medicina Interna, Di.Bi.M.I.S., Università di Palermo, Palermo, Italy
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Li DL, Liu BR. A review of differences in cirrhosis between men and women and characteristics of cirrhosis in females. Shijie Huaren Xiaohua Zazhi 2015; 23:1763-1769. [DOI: 10.11569/wcjd.v23.i11.1763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Geenes V, Williamson C. Liver disease in pregnancy. Best Pract Res Clin Obstet Gynaecol 2015; 29:612-24. [PMID: 25982587 DOI: 10.1016/j.bpobgyn.2015.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 04/06/2015] [Indexed: 12/18/2022]
Abstract
Liver disease in pregnancy, either pre-existing or pregnancy specific, can be associated with a significant risk of maternal and fetal morbidity and mortality. Here, we review the presentation, management and perinatal outcomes of common causes of liver disease.
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Affiliation(s)
- Victoria Geenes
- Women's Health Academic Centre, King's College London, London, UK
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Ellington SR, Flowers L, Legardy-Williams JK, Jamieson DJ, Kourtis AP. Recent trends in hepatic diseases during pregnancy in the United States, 2002-2010. Am J Obstet Gynecol 2015; 212:524.e1-7. [PMID: 25448511 DOI: 10.1016/j.ajog.2014.10.1093] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/03/2014] [Accepted: 10/28/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE While pregnancy-related severe liver disorders are rare, when they occur morbidity and mortality rates are increased for mothers and infants. The objective of this study was to examine the prevalence and trends of hepatic diseases during pregnancy hospitalizations from 2002 through 2010 in the United States. STUDY DESIGN Hospital discharge data were obtained from the Nationwide Inpatient Sample, the largest all-payer hospital inpatient care database in the United States that provides nationally representative estimates. Pregnancy hospitalizations with the following diagnoses were identified: hepatitis B, hepatitis C, gallbladder disease/cholelithiasis, liver disorders of pregnancy, chronic/alcohol-related liver disease, biliary tract disease, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. Age, insurance status, hospital location, and hospital region were compared among women with and without hepatic diseases using a χ(2) test. Trends in rates of pregnancy hospitalizations and mean charges were analyzed using multivariable logistic and linear regression, respectively. RESULTS From 2002 through 2010 there were an estimated 41,479,358 pregnancy hospitalizations in the United States. Gallbladder disease and liver disorders of pregnancy were the most common hepatic diseases (rates = 7.18 and 4.65/1000 pregnancy hospitalizations, respectively). Adjusted rates and mean charges significantly increased for all hepatic diseases during pregnancy over the study period. All hepatic diseases were associated with significantly higher charges compared to all pregnancy hospitalizations. HELLP syndrome was associated with the highest mean charges. CONCLUSION This large study among a representative sample of the US population provides valuable information that can aid policy planning and management of these hepatic diseases during pregnancy in the United States.
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Puljic A, Salati J, Doss A, Caughey AB. Outcomes of pregnancies complicated by liver cirrhosis, portal hypertension, or esophageal varices. J Matern Fetal Neonatal Med 2015; 29:506-9. [DOI: 10.3109/14767058.2015.1009438] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Transjugular Intrahepatic Portosystemic Shunt Placement During Pregnancy: A Case Series of Five Patients. Cardiovasc Intervent Radiol 2015; 38:1205-10. [DOI: 10.1007/s00270-015-1053-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 12/25/2014] [Indexed: 12/19/2022]
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Savas N. Gastrointestinal endoscopy in pregnancy. World J Gastroenterol 2014; 20:15241-15252. [PMID: 25386072 PMCID: PMC4223257 DOI: 10.3748/wjg.v20.i41.15241] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 05/25/2014] [Accepted: 07/30/2014] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal endoscopy has a major diagnostic and therapeutic role in most gastrointestinal disorders; however, limited information is available about clinical efficacy and safety in pregnant patients. The major risks of endoscopy during pregnancy include potential harm to the fetus because of hypoxia, premature labor, trauma and teratogenesis. In some cases, endoscopic procedures may be postponed until after delivery. When emergency or urgent indications are present, endoscopic procedures may be considered with some precautions. United States Food and Drug Administration category B drugs may be used in low doses. Endoscopic procedures during pregnancy may include upper gastrointestinal endoscopy, percutaneous endoscopic gastrostomy, sigmoidoscopy, colonoscopy, enteroscopy of the small bowel or video capsule endoscopy, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. All gastrointestinal endoscopic procedures in pregnant patients should be performed in hospitals by expert endoscopists and an obstetrician should be informed about all endoscopic procedures. The endoscopy and flexible sigmoidoscopy may be safe for the fetus and pregnant patient, and may be performed during pregnancy when strong indications are present. Colonoscopy for pregnant patients may be considered for strong indications during the second trimester. Although therapeutic endoscopic retrograde cholangiopancreatography may be considered during pregnancy, this procedure should be performed only for strong indications and attempts should be made to minimize radiation exposure.
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Allen AM, Hay JE. Review article: the management of cirrhosis in women. Aliment Pharmacol Ther 2014; 40:1146-54. [PMID: 25263269 DOI: 10.1111/apt.12974] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 07/21/2014] [Accepted: 09/09/2014] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- A M Allen
- Hepatology and Liver Transplantation, Mayo Clinic, Rochester, MN, USA
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Agrawal S, Dhiman RK. Hepatobiliary quiz 11 (2014). J Clin Exp Hepatol 2014; 4:271-5. [PMID: 25755572 PMCID: PMC4284207 DOI: 10.1016/j.jceh.2014.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Abstract
In the majority of patients with chronic gastrointestinal and liver diseases, maintenance therapy is required during pregnancy to control the disease, and disease follow-up or disease control might necessitate endoscopy. Evidence on the safety of drugs and imaging techniques during pregnancy is scarce and sometimes difficult to interpret. In this review we summarise existing literature with the aim of optimising counselling of patients with common chronic gastrointestinal and liver diseases who want to conceive.
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Aggarwal N, Negi N, Aggarwal A, Bodh V, Dhiman RK. Pregnancy with portal hypertension. J Clin Exp Hepatol 2014; 4:163-71. [PMID: 25755552 PMCID: PMC4116711 DOI: 10.1016/j.jceh.2014.05.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/28/2014] [Indexed: 12/12/2022] Open
Abstract
Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of non-cirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes.
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Key Words
- ACOG, American College of Obstetrics and Gynecology
- EHPVO, extrahepatic portal vein obstruction
- EST, endoscopic sclerotherapy
- EVL, endoscopic variceal ligation
- FDA, Food & Drug Association of America
- HVPG, hepatic vein pressure gradient
- NCPF, non-cirrhotic portal fibrosis
- NCPH, non-cirrhotic portal hypertension
- PPH, postpartum hemorrhage
- PVT, portal vein thrombosis
- Portal vein thrombosis
- cirrhosis
- non-cirrhotic portal fibrosis
- portal hypertension
- pregnancy
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Affiliation(s)
- Neelam Aggarwal
- Department of Obstetrics & Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India,Address for correspondence: Neelam Aggarwal, Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Neha Negi
- Department of Obstetrics & Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Aakash Aggarwal
- Department Of Internal Medicine, State University of New York (Suny) Upstate Syracuse, NY, USA
| | - Vijay Bodh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Farshchi A, Stohl HE, Lee RH. Placental abruption in an adolescent with liver cirrhosis and severe thrombocytopenia. CASE REPORTS IN PERINATAL MEDICINE 2014. [DOI: 10.1515/crpm-2012-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Pregnancy in patients with cirrhosis of the liver poses significant risks to both the mother and her fetus. Little is known about the occurrence of thrombocytopenia or placental abruption in pregnant women with cirrhosis. We present an 18-year-old primigravida who was diagnosed with cirrhosis of the liver during evaluation of severe thrombocytopenia at 20 weeks’ gestation. Esophagogastroduodenoscopy confirmed large esophageal varices, and β-blocker therapy was initiated for primary prophylaxis of esophageal bleeding. She delivered via emergent cesarean section at 24 and 6/7 weeks for fetal heart rate decelerations and placental abruption. This case demonstrates how cirrhosis of the liver, especially in association with thrombocytopenia, may be associated with an increased risk for placental abruption. Hypersplenism should be considered in a pregnant woman with thrombocytopenia and leukopenia.
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Affiliation(s)
- Annahita Farshchi
- Department of Ob/Gyn, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Hindi E. Stohl
- Department of Ob/Gyn, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Richard H. Lee
- Department of Ob/Gyn, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
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Pregnancies after transjugular intrahepatic portosystemic shunt for noncirrhotic portal hypertension. Eur J Gastroenterol Hepatol 2014; 26:488-90. [PMID: 24526236 DOI: 10.1097/meg.0000000000000048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
With the growing role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension complications, a number of women of childbearing age are now being treated with TIPS. However, if pregnancy is unusual in patients with cirrhosis, it can occur in the case of noncirrhotic portal hypertension. To our knowledge, there are no data on pregnancy safety after TIPS insertion. We report the first case of a patient with noncirrhotic portal hypertension treated by TIPS who had two successful pregnancies. She presented with HIV-associated obliterative portopathy with recurrent variceal bleeding treated by TIPS. Pregnancies occurred later and progressed normally without maternal or fetal morbidity. There was no effect on TIPS patency, but only a moderate increase in the flow velocity in the portal vein, the stent, and the hepatic artery. Thus, TIPS does not seem to impair progression of pregnancy.
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Pillai AK, Joseph AM, Reddick M, Toomay S, Kalva S. Intravascular US–Guided Transjugular Intrahepatic Portosystemic Shunt Creation in a Second-Trimester Pregnancy to Prophylactically Decompress Abdominal Wall Varices before Cesarean Section. J Vasc Interv Radiol 2014; 25:481-3. [DOI: 10.1016/j.jvir.2013.11.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 11/22/2013] [Accepted: 11/24/2013] [Indexed: 11/24/2022] Open
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Sobral M, Granja C, Sampaio M, Guerreiro F. Bleeding from oesophageal varices in pregnancy. BMJ Case Rep 2013; 2013:bcr-2013-009653. [PMID: 23893272 DOI: 10.1136/bcr-2013-009653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Bleeding from oesophageal varices is the most fearful event in pregnant women with cirrhosis and is the main cause of death in this group. Its approach and treatment are controversial, with ligation, sclerosis and β-blockers as possible choices. Follow-up must be multidisciplinary and delivery programmed because of the high risk of bleeding. Delivery route is also controversial. We present a case of a pregnant woman, with alcoholic cirrhosis and upper tract bleeding during the second trimester of pregnancy. She was submitted to an oesophagogastroduodenoscopy (OGD), which revealed varices grade II/III in the lower third of the oesophagus. She was transfused and was haemodynamically stable. It was decided not to start β-blockers. The pregnancy went well, with regular follow-up in obstetrics and hepatology. A deficiency of α-1 antitrypsin was detected. Delivery was programmed at 39 weeks of gestation, and a caesarean section was performed, with good maternal and fetal outcome.
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Affiliation(s)
- Marta Sobral
- Department of Serviço de Ginecologia, Hospital de Faro, EPE, Faro, Portugal.
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40
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Prognosis and determinants of pregnancy outcome among patients with post-hepatitis liver cirrhosis. Int J Gynaecol Obstet 2013; 121:247-51. [PMID: 23518137 DOI: 10.1016/j.ijgo.2012.12.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/13/2012] [Accepted: 02/20/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate maternal, fetal, and neonatal outcomes and their associated risk factors among pregnant women with liver cirrhosis (LC). METHODS A prospective cohort study was conducted at Sohag University Hospital, Egypt, between May 1, 2009, and April 1, 2012. Participants included 129 pregnant women with LC (study group), 647 pregnant women without LC (control group 1), and 853 non-pregnant women with LC (control group 2). Univariate and multivariate analyses were performed. RESULTS Maternal, fetal, and neonatal complication rates were significantly higher in the study group than in control group 1 (P=0.001 for all complications). The rate of hepatic decompensation (HD) was higher in the study group than in control group 2 (63.6% vs 13.6%; P=0.001). Maternal mortality was higher in the study group (7.8%) than in either control group 1 (0.2%) or control group 2 (2.5%; P=0.001). Variceal bleeding during vaginal delivery was the most frequent cause of maternal mortality. Vaginal delivery and increasing gestational age were the key variables affecting the rate of HD (P=0.001 for both). CONCLUSION The presence of LC during pregnancy was associated with high rates of maternal and neonatal complications. Increasing gestational age and vaginal delivery were the most important risk factors for HD.
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Hyperammonemia: A Report of Maternal Biliary Cirrhosis and Neonatal Outcome. Case Rep Crit Care 2013; 2013:507169. [PMID: 24829827 PMCID: PMC4010006 DOI: 10.1155/2013/507169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/13/2013] [Indexed: 11/23/2022] Open
Abstract
Although uncommon during pregnancy, cirrhosis results in multiple medical complications impacting both mother and fetus. Previous reports suggest liver dysfunction in pregnancy causes accumulation of neurotoxins within the maternal compartment that increases neonatal morbidity through placental transfer. We present a case of a 36-year-old G2P1 female with history of biliary cirrhosis presenting at 32-weeks' gestation with hepatic congestion progressing to hepatic encephalopathy prompting delivery. Umbilical cord sampling and postnatal infant testing demonstrated elevated ammonia levels which resolved by 12 hours of life without intervention. At discharge, the infant did not demonstrate evidence of neurologic deficit. We conclude that acute maternal hepatic encephalopathy and hyperammonemia due to chronic liver disease do not portend adverse neonatal outcomes, notably encephalopathy.
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Borgia G, Carleo MA, Gaeta GB, Gentile I. Hepatitis B in pregnancy. World J Gastroenterol 2012; 18:4677-83. [PMID: 23002336 PMCID: PMC3442205 DOI: 10.3748/wjg.v18.i34.4677] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 12/05/2011] [Accepted: 03/28/2012] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis B virus (HBV) infection affects about 350 million individuals worldwide. Management of HBV infection in pregnancy is difficult because of several peculiar and somewhat controversial aspects. The aim of the present review is to provide a tool that may help physicians to correctly manage HBV infection in pregnancy. This review focuses on (1) the effect of pregnancy on HBV infection and of HBV infection on pregnancy; (2) the potential viral transmission from mother to newborn despite at-birth prophylaxis with immunoglobulin and vaccine; (3) possible prevention of mother-to-child transmission through antiviral drugs, the type of antiviral drug to use considering their efficacy and potential teratogenic effect, and the timing of their administration and discontinuation; and (4) the evidence for the use of elective caesarean section vs vaginal delivery and the possibility of breastfeeding.
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Chaudhuri K, Tan EK, Biswas A. Successful pregnancy in a woman with liver cirrhosis complicated by recurrent variceal bleeding. J OBSTET GYNAECOL 2012; 32:490-1. [DOI: 10.3109/01443615.2012.683215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
Changes in the liver biochemical profile are normal in pregnancy. However, up to 3% to 5% of all pregnancies are complicated by liver dysfunction. It is important that liver disease during pregnancy is recognized because early diagnosis may improve maternal and fetal outcomes, with resultant decreased morbidity and mortality. Liver diseases that occur in pregnancy can be divided into 3 different groups: liver diseases that are unique to pregnancy, liver diseases that are not unique to pregnancy but can be revealed or exacerbated by pregnancy, and liver diseases that are unrelated to but occur coincidentally during pregnancy.
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Affiliation(s)
- Arjmand R Mufti
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medical Center, IL 60637, USA
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45
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Kumar A. Hepatitis B virus infection and pregnancy: a practical approach. Indian J Gastroenterol 2012; 31:43-54. [PMID: 22528342 DOI: 10.1007/s12664-012-0174-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 03/12/2012] [Indexed: 02/04/2023]
Abstract
Hepatitis B virus (HBV) infection is a global problem and the world has 350 million carriers of chronic hepatitis B. Over 50 % of these have acquired their infection vertically from their mothers (mother-to-child transmission [MTCT]). Majority (>90 %) of vertically-acquired infection results into chronic infection, due to induction of an immune-tolerant state. Hence, management of chronic HBV during pregnancy and strategies to prevent MTCT would go a long way in global control of HBV infection and the morbidity and mortality associated with it. However, chronic HBV infection in pregnancy presents a unique challenge, because of existence of a complex relationship between the physiological changes of pregnancy and the pathophysiological response of body to HBV. This relationship may lead to a varied presentation of the patient to the doctor depending on the period of her pregnancy and stage of her liver disease. Each of these modes of presentation raises issues that need to be addressed for successful maternal and fetal outcome, including prevention of MTCT of HBV. This review will try to give a practical approach in addressing these issues.
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Affiliation(s)
- Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi 110 060, India.
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Westbrook RH, Yeoman AD, O'Grady JG, Harrison PM, Devlin J, Heneghan MA. Model for end-stage liver disease score predicts outcome in cirrhotic patients during pregnancy. Clin Gastroenterol Hepatol 2011; 9:694-9. [PMID: 21570482 DOI: 10.1016/j.cgh.2011.03.036] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 03/02/2011] [Accepted: 03/30/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pregnancy is rare among patients with cirrhosis, and data about complications and outcomes are sparse. We evaluated the utility of prognostic models of severity of cirrhosis in determining outcomes in pregnant women with cirrhosis. METHODS We evaluated all cirrhotic patients who self-reported pregnancy at our center and correlated prognostic scores at the time of conception with outcomes. RESULTS Sixty-two pregnancies occurred in 29 women. The median model for end-stage liver disease (MELD) score at conception was 7 (range, 6-17), the median MELD sodium score was 9 (range, 6-17), the median United Kingdom end-stage liver disease (UKELD) score was 44 (range, 36-53), and the median Child-Pugh score was 5 (range, 5-8). The live birth rate was 58%; the median gestational age was 36 weeks. Higher MELD (P = .01), MELD sodium (P = .01), UKELD (P = .01), and Child-Pugh (P = .03) scores were associated with gestation <37 weeks. Maternal complications (ascites, encephalopathy, or variceal hemorrhage) occurred in 10% of patients and were associated with higher MELD (P = .01) and UKELD (P = .02) scores. Receiver operator curve analysis demonstrated that a MELD score ≥10 predicted, with 83% sensitivity and 83% specificity, which patients were likely to have significant, liver-related complications (area under curve, 0.8); a UKELD score ≥47 had 83% sensitivity and 79% specificity (area under curve, 0.8). No patient who had a MELD score ≤6 or a UKELD score ≤42 developed any significant hepatologic complications. CONCLUSIONS MELD and UKELD scores at the time of conception can be used to predict specific clinical outcomes in pregnant women with cirrhosis.
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Affiliation(s)
- Rachel H Westbrook
- Institute of Liver Studies, King's College Hospital, NHS Foundation Trust, Denmark Hill, London, United Kingdom
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47
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Abstract
This article briefly discusses gestational physiologic changes and thereafter reviews liver diseases during pregnancy, which are divided into 3 main categories. The first category includes conditions that are unique to pregnancy and generally resolve with the termination of pregnancy, the second category includes liver diseases that are not unique to the pregnant population but occur commonly or are severely affected by pregnancy, and the third category includes diseases that occur coincidentally with pregnancy and in patients with underlying chronic liver disease, with cirrhosis, or after liver transplant who become pregnant.
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Affiliation(s)
- Ayaz Matin
- Division of Gastroenterology and Hepatology, Drexel University College of Medicine, 12th Floor New College Building, 245 North 15th Street, Suite 12324, Philadelphia, PA 19102, USA
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48
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Collyer T, Holbrook S, Lyons G. Anaesthetic management of the pregnant patient with liver disease. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2011. [DOI: 10.1016/j.tacc.2011.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Aggarwal N, Chopra S, Raveendran A, Suri V, Dhiman RK, Chawla YK. Extra hepatic portal vein obstruction and pregnancy outcome: largest reported experience. J Obstet Gynaecol Res 2011; 37:575-80. [PMID: 21375674 DOI: 10.1111/j.1447-0756.2010.01407.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Evaluate pregnancy outcome in women with extra hepatic portal vein obstruction (EHPVO). MATERIAL & METHODS A total of 26 pregnancies in 14 women with EHPVO were evaluated for maternal and perinatal outcomes in a tertiary centre of Northern India. Fourteen pregnancies were evaluated prospectively while the details of 12 previous pregnancies in the same women were studied retrospectively. RESULTS Mean age of pregnant women with EHPVO was 24.5 years and approximately one-third were primigravidae. Only one patient was diagnosed as EHPVO in the index pregnancy. The presenting event was hematemesis in 71% of the patients; others presented with thrombosis, pain abdomen and jaundice or incidental splenomegaly. The incidence of abortion, preterm deliveries and still births was 20%, 15.4% and 7.7%, respectively. Underlying hypercoagulable and prothrombotic state was diagnosed in around one-fifth of the patients. Half of these women required platelet transfusion in the intrapartum period due to hypersplenism resulting in thrombocytopenia. Anemia was seen in 40% of the patients; however, no other major complications were seen as a result of EHPVO. The vaginal delivery rate and obstetrical outcome were similar as in general population. CONCLUSION Pregnancy outcome is expected to be successful in women with EHPVO if disease is adequately controlled prior to pregnancy.
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Affiliation(s)
- Neelam Aggarwal
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Abstract
Severe liver disease in pregnancy is rare. Pregnancy-related liver disease is the most frequent cause of liver dysfunction in pregnancy and provides a real threat to fetal and maternal survival. A rapid diagnosis differentiating between liver disease related and unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. Research has improved our understanding of the pathogenesis of pregnancy-related liver disease, which has translated into improved maternal and fetal outcomes. Here, we provide an overview of liver diseases that occur in pregnancy, an update on the key mechanisms involved in their pathogenesis, and assessment of available treatment options.
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Affiliation(s)
- Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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