Immunosuppressive effect of pregnancy on autoimmune hepatitis: a case report and review of literature

Systematic review with meta-analysis: outcomes of pregnancy in patients with autoimmune hepatitis

BACKGROUND

Autoimmune hepatitis (AIH) is common in females of childbearing age. Although some studies have provided information about the outcomes of pregnancy, there remains uncertainty regarding conclusions.

AIM

To comprehensively explore the interactions between pregnancy and AIH.

METHODS

Databases including PubMed, Embase, Cochrane Library and Science Citation Index Expanded were searched to collect available studies in relation to pregnancy in AIH patients (from inception to 28 August 2021). Pooled data were calculated using a random effects model with standardised mean difference (SMD), or risk ratio (RR), and 95% confidence intervals (CI).

RESULTS

Twelve studies were considered eligible for meta-analysis. Data from 26 case reports/series were extracted for systematic review. AST level in AIH patients was significantly lower during pregnancy (SMD = -0.41, 95% CI = [-0.70, -0.12]; SMD = -1.60, 95% CI = [-2.76, -0.44]) and loss of biochemical remission occurred more frequently in post-partum (RR = 0.31, 95% CI = [0.19, 0.52]). Patients with portal hypertension or without established remission before conception presented as high-risk subgroups and the incidence of pre-term delivery was higher in these groups compared to other AIH patients (RR = 9, 95% CI = [1.22, 51.1]; RR = 0.05, 95% CI = [0.004, 0.38]). In population-based comparison, pre-term birth (RR = 2.45, 95% CI = [1.66, 3.62]) also occurred more often in AIH patients compared with the general population.

CONCLUSIONS

Successful pregnancy is a reasonable expectation in AIH. However, hepatic biochemistry should be monitored closely in both the puerperium and the post-partum period. Though some patients may present higher risk, with carefully selected therapeutic manipulation and multi-disciplinary care, the majority of mothers and infants should achieve uneventful outcomes.

Prior pregnancy and antenatal rubella sero-negativity-evidence of persistent maternal immunologic alteration?

PROBLEM

It is unclear if the immunologic alterations induced by pregnancy could persist.

METHOD OF STUDY

Antenatal rubella sero-negativity was correlated with gravidity, abortions and parity in 112 083 gravidae managed during 1997-2015, with further analysis stratified for factors known to influence rubella serology.

RESULTS

The 10.2% sero-negative gravidae had different characteristics, and the incidence showed significant difference and positive trend (P<.001 for both) with gravidity, abortions and parity. The pattern remained consistent when analysis was stratified for advanced age, high body mass index and medical history, but was negated by hepatitis B virus infection except for abortions, and by high body mass index for parity. For gravidity 2-4, no difference in rubella sero-negativity was found between gravidae with all previous pregnancies ended in abortion vs delivery.

CONCLUSION

Prior pregnancies diminished rubella immunity in a dose-dependent manner, which may be a reflection of the cumulative effect of pregnancy-associated maternal immunologic alteration.

Management of patients with difficult autoimmune hepatitis

Autoimmune hepatitis (AIH) is characterized by a T-cell rich infiltrate associated with lobular and interface hepatitis, hypergammaglobulinemia and production of autoantibodies. Genetic risk is linked to the HLA particularly DRB1*0301 and DRB1*0401 alleles in North American and European Caucasian populations. It has recently been suggested that functional deficiencies in CD4(+)CD25(+)CD127(low)FOXP3(+) regulatory T cells contribute to the breakdown of immune tolerance that results in AIH. Most patients respond to immunosuppressive therapy with corticosteroids and can be maintained in remission by low-dose corticosteroid treatment and/or azathioprine. For those who progress to end-stage disease liver transplantation is an effective treatment although it is associated with recurrence. In the future it is likely that biological therapies will allow more targeted therapy designed to switch the balance to immune regulation and thereby restore immune homeostasis. Although treatment for many cases is relatively straightforward and successful problems are encountered in those who fail to respond to standard treatment, are unable to tolerate it or relapse. In such cases alternative therapies should be considered. In addition treatment is complicated in some patients by comorbidity and special care is required during and after pregnancy. We will discuss the current and future therapeutic options for patients with difficult to treat AIH.

[Autoimmune hepatitis and pregnancy: about a patient's three consecutive pregnancies]

Spontaneous evolution of autoimmune hepatitis during pregnancy is not well known, nor are its consequences on pregnancy evolution. Immunosuppressive treatment during pregnancy is sometimes necessary but the long- and short-term consequences are unrecognized. We relate a patient's disease with autoimmune hepatitis and cirrhosis and three consecutive pregnancies with different obstetrical and medical complications.

Autoimmune hepatitis among fertile women: strategies during pregnancy and breastfeeding?

OBJECTIVE

In published studies there is a lack of data about the risks, management and how women with autoimmune hepatitis (AIH) decide on and are advised about pregnancy. The aim of this study was to investigate how women with AIH consider pregnancies, are advised and pharmacologically treated, as well as the outcome.

MATERIAL AND METHODS

A questionnaire was mailed to 128 women with AIH diagnosed during their fertile period and data from the Swedish National Birth Register was also used for matched controls.

RESULTS

There was an 83% response rate to the questionnaires. Sixty-three pregnancies were reported by 35 women. 48% did not consult their doctors before getting pregnant. More than half of the women reduced or stopped the immune suppression during pregnancy or breastfeeding. Some women were advised to abstain from pregnancy or even to have an abortion. Caesarean sections were performed more frequently in the AIH group (16% compared with 6.5% in the control group p<0.01). There were no significant differences in the number of stillborn infants or infants with malformations. However, 30% of the patients experienced flare-up after delivery.

CONCLUSIONS

In general, the outcome of pregnancy in women with AIH seems to be good. Current pharmacological treatment appears to be safe, including azathioprine during pregnancy and lactation. After delivery an active preparedness to increase pharmacotherapy should be considered.

Autoimmune hepatitis and pregnancy: a rheumatologist's dilemma

OBJECTIVES

To review the course, predisposing risk factors, treatment employed, and complications of autoimmune hepatitis (AIH) during pregnancy. Maternal and fetal outcomes will be discussed.

METHODS

We reviewed the literature from February 1966 to January 2004 using MEDLINE and the key words autoimmune hepatitis, chronic active hepatitis, lupoid hepatitis, and pregnancy. An additional case of ours was included as she had AIH since childhood with worsening of liver disease during pregnancy.

RESULTS

Including the present case, 58 pregnant women with AIH were reported in 17 case reports and series. In the 101 pregnancies documented in these cases, there were 47 flare-ups, 5 clinical improvements, 45 stabilizations of the disease during pregnancy, and 4 cases in which the disease course was not reported. Two maternal deaths occurred. A perinatal mortality of 4% and 19 fetal deaths were described. Most women were treated with prednisone alone; however azathioprine was used in a number of patients.

CONCLUSIONS

Pregnancy course in patients with AIH is unpredictable. AIH exacerbates in some patients and is associated with a high rate of fetal complications including prematurity and death. Low-dose prednisone seems to be the preferred treatment. The use of azathioprine must be individualized and further studies are needed to better define its role and safety during pregnancy in patients with AIH.

RELEVANCE

A better understanding of the course of pregnancy in patients with AIH should help design appropriate therapeutic schemes to improve pregnancy outcomes for both mother and fetus.

Autoimmune hepatitis

Autoimmune hepatitis (AIH) is an intermittently progressive liver disease characterized by hypergammaglobulinemia, autoantibodies, predominately periportal hepatitis, and a favorable response to corticosteroid therapy in most cases. There are no pathognomonic markers of autoimmune liver disease; rather, the diagnosis must be based on the presence of a constellation of characteristic clinical, laboratory, and histologic features in patients without other causes of such liver pathology. Although prednisone or prednisolone are the mainstays in initial therapy of AIH, azathioprine or other drugs with similar immunosuppressive mechanisms are of benefit for steroid-sparing effects or for use as monotherapy to maintain long-term remission. A fraction of patients meeting diagnostic criteria for AIH remains in long-term remission following withdrawal of immunosuppressive therapies, but in most patients, this disease represents a chronic condition requiring life-long monitoring and therapy.

Severe autoimmune hepatitis first presenting in the early post partum period

BACKGROUND & AIMS

Autoimmune hepatitis (AIH) may run an aggressive clinical course if untreated. The influence of pregnancy on AIH is variable. Both flares in disease activity and remissions, often followed by a post partum flare, are well recognized. In contrast, definite AIH first presenting in the early post partum period has not been reported.

METHODS

We discuss a case series of 5 patients who developed severe AIH within 4 months post partum.

RESULTS

The diagnosis of AIH was definite based on internationally accepted criteria. Liver injury responded to conventional immunosuppressive therapy in all patients. Immune reactivation in the early post partum period may contribute to this entity.

CONCLUSIONS

AIH should be considered in the differential diagnosis of liver dysfunction first presenting in the early post partum period.

Liver emergencies during pregnancy

Liver disease is an uncommon complication of pregnancy, although one that must be recognized early because of its potential for grave consequences for mother and child. Because of increased awareness and rapid triage of patients, maternal and fetal outcomes have improved significantly over the last 30 years.

Relation Between Post-partum Liver Dysfunction and Anti-cytochrome 2D6 Antibodies

PROBLEM

Autoimmune thyroid disease frequently aggravates or develops after delivery through the immune rebound mechanism. However, little is known about the post-partum development of autoimmune hepatitis (AIH).

METHOD OF STUDY

We examined 18 patients who developed liver dysfunction after delivery or abortion. Serial examinations were performed in 10 of these cases. Anti-cytochrome 2D6(CYP2D6) antibodies, which are liver-specific autoantibodies, were measured using a sensitive radioligand assay.

RESULTS

Liver dysfunction developed between 1 and 5 months after delivery and was mild and transient except in one case. One patient developed liver dysfunction after abortion. Eight of 10 patients who underwent serial serologic examinations were positive for anti-nuclear antibodies, but anti-smooth muscle antibodies were positive in only three patients, and were present only at low titer. None of the patients had anti-mitochondrial antibodies. Nine of these 10 cases were diagnosed as definite or probable AIH according to the international scoring system of AIH. Nine of these 10 patients were positive for anti-CYP2D6 antibodies. The increase of anti-CYP2D6 antibodies was slightly delayed compared to increase of aminotransferase. Of the 18 patients who developed liver dysfunction, 15 cases (83.3%) were positive for anti-CYP2D6 antibodies. Of the 77 post-partum control subjects only three (3.9%) had positive antibodies.

CONCLUSIONS

Autoimmune hepatitis developed after delivery, similarly to the development of post-partum autoimmune thyroid disease. Measurement of anti-CYP2D6 antibodies by a sensitive radioligand assay could provide information important for the detection of post-partum AIH.

Development of liver dysfunction after delivery is possibly due to postpartum autoimmune hepatitis. A report of three cases

Autoimmune diseases, especially autoimmune thyroid disease, frequently develop after delivery due to the immune rebound mechanism. Most cases involve transient dysfunction of affected organs. We examined three patients who developed liver dysfunction after delivery. They were all diagnosed with definite or probable autoimmune hepatitis using the scoring system of the International Autoimmune Hepatitis Group. Moreover, all of them had anti-CYP2D6 antibodies detected by a sensitive radioligand assay. Our findings strongly suggest that liver dysfunction is induced by postpartum autoimmune hepatitis, and clinicians should be aware of this disease.