Pregnancy and its outcome in patients with noncirrhotic portal hypertension

Maternal and fetal outcomes in pregnant patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis

Background

Concerned studies with respect to the outcome of pregnant patients with non-cirrhotic portal hypertension are limited. Thus, a systematic review and meta-analysis of the available literature was conducted.

Methods

A literature search was conducted from 1999 to December 2021 for studies evaluating pregnancy outcomes in patients with non-cirrhotic portal hypertension.

Results

Twelve studies were included in the meta-analysis. The pooled rate of variceal bleeding, ascites and severe anemia requiring blood transfusion were 9.6%, 2.3%, and 14.9%, respectively. The pooled rate of spontaneous miscarriage, gestational hypertension, delivery by cesarean section, and postpartum hemorrhage were 11.9%, 4.5%, 36.7%, and 4.7%, respectively. The pooled stillbirth rate was 2.5% and among the live births, the pooled rates of preterm birth, low birth weight, intensive care unit admission, and neonatal mortality were 21.6%, 18.7%, 15.5%, and 1.8%, respectively.

Conclusion

Pregnancy in patients with non-cirrhotic portal hypertension is associated with increased maternal & fetal morbidity but mortality remains low.

Maternal and Perinatal Outcome in a Contemporary Cohort of Patients with Portal Hypertension: A Single-Center Experience

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.

Maternal and perinatal outcome in pregnancies complicated with portal hypertension: a systematic review and meta-analysis

BACKGROUND

Portal hypertension is secondary to either cirrhotic or non-cirrhotic causes, and complicating pregnancy poses a challenge to the treating team. A systematic review was performed to determine maternal and perinatal outcomes in women with portal hypertension. Outcomes were compared among those with cirrhotic (CPH) with non-cirrhotic portal hypertension (NCPH) as well as non-cirrhotic portal fibrosis (NCPF) with extra-hepatic portal vein obstruction (EHPVO).

METHODS

Medline and EMBASE databases were searched for studies reporting outcomes among pregnant women with portal hypertension. Reference lists from relevant papers and reviews were hand-searched for appropriate citations. Data were extracted to describe maternal complications, obstetric and neonatal outcomes. A random-effects model was used to derive pooled estimates of various outcomes, and final estimates were reported as percentages with a 95% confidence interval (CI). Cumulative, sequential and sensitivity analysis was studied to assess the temporal trends of outcomes over the period.

RESULTS

Information on 895 pregnancies among 581 patients with portal hypertension was included from 26 studies. Portal hypertension was diagnosed during pregnancy in 10% (95% CI 4-24%). There were 22 maternal deaths (0%, 95% CI 0-1%), mostly following complications from variceal bleeding or hepatic decompensation. Variceal bleeding complicated in 14% (95% CI 9-20%), and endoscopic interventions were performed in 12% (95% CI 8-17%) during pregnancy. Decompensation of liver function occurred in 7% (95% CI 3-12%). Thrombocytopenia was the most common complication (41%, 95% CI 23-60%). Miscarriages occurred in 14% (95% CI 8-20%), preterm birth in 27% (95% CI 19-37%), and low birth weights in 22% (95% CI 15-30%). Risk of postpartum hemorrhage was higher (RR 5.09, 95% CI 1.84-14.12), and variceal bleeding was lower (RR 0.51, 95% CI 0.30-0.86) among those with CPH compared to NCPH. Risk of various outcomes was comparable between NCPF and EHPVO.

CONCLUSION

One in ten pregnancies complicated with portal hypertension is diagnosed during pregnancy, and thrombocytopenia is the most common complication. Hepatic decompensation and variceal bleeding remain the most common cause of maternal deaths, with reduced rates of bleeding and its complications reported following the introduction of endoscopic procedures during pregnancy. CPH increases the risk of postpartum hemorrhage, whereas variceal bleeding is higher among NCPH.

Vascular liver diseases: A sex-oriented analysis of the literature

Vascular liver diseases are an heterogenous group of diseases that collectively represent an important health issue in the field of liver diseases. This narrative review was elaborated by the Special Interest Group (SIG) "Gender in Hepatology" of the Italian Association for the Study of the Liver (AISF). We aimed to review the current knowledge regarding the potential role of biological sex in patients with vascular liver diseases such as splanchnic vein thrombosis, hepatic vein thrombosis, porto-sinusoidal vascular disorder, and hereditary hemorrhagic telangiectasia. As vascular liver diseases commonly affect young individuals, including women in childbearing age, we also included a specific section on the management of pregnancy in these challenging patients.

Pregnancy in Patients with Non-cirrhotic Portal Hypertension: A Literature Review

Pregnancy in non-cirrhotic portal hypertension (NCPH) is an uncommon condition. Its management is challenging both to the obstetricians as well as to the gastroenterologists due to the lack of more extensive studies and standard clinical practice guidelines. These patients are at increased risk of portal hypertension (PTH) complications, especially variceal bleeding, and with an increased incidence of adverse maternal and fetal outcomes. Hence, a multidisciplinary approach is required for management of pregnancy in NCPH. This short review describes the different aspects of pregnancy with NCPH, emphasizing specific strategies for preventing and managing PTH from the preconceptional period to postpartum.

Endoscopy in Pregnancy: A Systematic Review

Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy.

Methods A systematic literature search was performed using PubMed. All original research articles with sample size > 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021.

Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (>95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (> 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy.

Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.

Chronic Liver Disease in the Obstetric Patient

Chronic liver disease in pregnancy is rare. Historically, many chronic liver diseases were considered contraindications to pregnancy; however, with current monitoring and treatment strategies, pregnancy may be considered in many cases. Preconception and initial antepartum consultation should focus on disease activity, medication safety, risks of pregnancy, as well as the need for additional monitoring during pregnancy. In most cases, a multidisciplinary approach is necessary to ensure optimal maternal and fetal outcomes. Despite improving outcomes, pregnancy in women with the chronic liver disease remains high risk.

Review article: chronic liver disease and pregnancy

BACKGROUND

The prevalence of chronic liver disease in women of child bearing age is increasing, leading to a higher incidence of pregnancy in this cohort. Chronic medical conditions have a significant adverse effect on maternal morbidity and mortality. To date, reviews on this topic have been written either from a hepatology or obstetrics viewpoint, and no specific guidelines are available solely for the management of chronic liver disease in pregnancy.

AIMS

To produce a comprehensive review on the clinical management of women with chronic liver disease during pregnancy, addressing the risks of pregnancy to mother and child, how these risks can be ameliorated, and what additional considerations are required for management of chronic liver disease in pregnancy.

METHODS

Data were collected up to May 2020 from the biomedical database PubMed, national and international guidelines in gastroenterology and hepatology.

RESULTS

During pregnancy, women with cirrhosis are more likely to develop decompensated disease, worsening of portal hypertension, and to deliver premature infants.

CONCLUSIONS

The risks associated with pregnancy can be ameliorated by advanced planning, assessing risk using the model for end stage liver disease score and risk reduction through varices screening. A multidisciplinary approach is paramount in order to minimise complications and maximise the chance of a safe pregnancy and birth for mother and baby.

Maternal-fetal outcome in pregnancies complicated with non-cirrhotic portal hypertension: experience from a Tertiary Centre in South India

OBJECTIVE

To assess the maternal and perinatal outcomes of pregnant women with non-cirrhotic portal hypertension (NCPH).

METHODS

This was an observational study done by retrieving the records of pregnant women with non-cirrhotic portal hypertension admitted to a tertiary hospital in South India, over a 9-year study period. Data regarding the clinical course, complications during pregnancy, labor, and delivery details were reviewed. We also compared the outcomes among women with non-cirrhotic portal fibrosis (NCPF) with extrahepatic portal vein obstruction (EHPVO).

RESULTS

During the study period, portal hypertension was noted in 0.07%(n = 108) of the pregnancies and 74.1% of them had NCPH. The diagnosis was made for the first time in 54.7% of them when presented with pancytopenia or splenomegaly. Variceal bleeding complicated 25% of the pregnancies in women with NCPH pregnancies, with three among them having a massive bleed. Eighteen among them underwent endoscopy following bleeding; variceal banding procedure was performed in nine of them without any complications. Preterm birth was the most common (20.6%) obstetric complication. There was one maternal death from severe sepsis, acute kidney injury, and disseminated intravascular coagulation, following a massive variceal bleed. Obstetric outcomes and medical complications were similar in women with NCPF and EHPVO. Perinatal loss was comparable in both the groups (14.3% vs. 9.6%, p = 0.417) CONCLUSION: Multidisciplinary team approach, with optimal and timely intervention with intensive monitoring, can reduce the morbidity and help achieve an optimal maternal-perinatal outcome in pregnancies complicated with portal hypertension.

Safety of Endoscopy and Its Outcome in Pregnancy

Objective: Gastrointestinal (GI) endoscopy is an important tool for diagnosis and treatment of GI diseases. However, when endoscopy is indicated during pregnancy, concerns about its safety for mother and fetus often arise. Our objective was to evaluate the safety and efficacy of endoscopic procedures in pregnant patients along with maternal and fetal outcomes.

Methods: This study was conducted at the Aga Khan University Hospital after Ethics review committee approval. It was a retrospective study and medical records of all pregnant patients who underwent endoscopy during pregnancy from January 2000 to January 2014 were analyzed. Data regarding the indications and type of endoscopic procedure, use of sedation and radiation were noted; data on any complications during or after pregnancy were recorded as well.

Results: A total of 48 pregnant women underwent endoscopic procedures. Procedures that were performed included gastroscopy, sigmoidoscopy, colonoscopy, and endoscopic retrograde cholangio-pancreaticography (ERCP) in 28, 15, 1, and 4 patients, respectively. The major indication for gastroscopy was hematemesis in 16 procedures (57.14%) and screening for esophageal varices was done in 10 (21.42%). The indications of ERCP were choledocholithiasis and cholangitis. However, bleeding per rectum was the main indication for sigmoidoscopy and colonoscopy. Some 34 (70.83%) procedures were diagnostic and the rest were therapeutic. Only one patient had a miscarriage in second trimester.

Conclusions: Endoscopic procedures are safe to be performed in pregnant patients in the presence of strong indications without posing major risk to the mother or the fetus. However, further prospective multicenter research studies are strongly recommended.

Pregnancy in a Woman with Latent Myeloproliferative Neoplasm Induced Chronic Portal Vein Thrombosis, Portal Cavernoma, and Gastric Varices

Extra-hepatic portal vein thrombosis (EHPVO) represents the obstruction of the portal vein outside the liver and is not related to chronic liver disease or neoplasia. In chronic EHPVO, collateral veins and portal hypertension develop, resulting in splenomegaly and variceal formation. Myeloproliferative neoplasms (MPN) are the most frequent acquired etiology of EHPVO. These conditions put pregnant women at increased risk of vascular complications, including venous thrombosis, occlusion of the placental circulation, and variceal bleeding. In this report, we present a 36-year-old pregnant woman with chronic, anticoagulated EHPVO secondary to latent MPN who developed severe intrauterine growth restriction and had cesarean section at 32+1 weeks for increased umbilical doppler resistance and breech presentation. The article will emphasize outcome and management of pregnancies complicated by chronic EHPVO, portal hypertension, and MPN.

Pregnancy in idiopathic non-cirrhotic portal hypertension: A multicentric study on maternal and fetal management and outcome

BACKGROUND & AIMS

A total of 15% of patients with idiopathic non-cirrhotic portal hypertension (INCPH) are women of childbearing age. We aimed to determine maternal and fetal outcome of pregnancies occurring in women with INCPH.

METHODS

We retrospectively analyzed the charts of women with INCPH followed in the centers of the VALDIG network, having had ≥1 pregnancy during the follow-up of their liver disease. Data are represented as median (interquartile range).

RESULTS

A total of 24 pregnancies occurred in 16 women within 24 (5-66) months after INCPH diagnosis. Four women had associated partial portal vein thrombosis before pregnancy. At conception, 2 out of the 16 women had detectable ascites and others were asymptomatic. Out of these 24 pregnancies, there were four miscarriages, one ectopic pregnancy, and one medical termination of pregnancy at 20 weeks of gestation. Out of the 18 other pregnancies reaching 20 weeks of gestation (in 14 patients), there were nine preterm and nine term deliveries. All infants were healthy at delivery, but one died at day 1 of unknown cause and one at day 22 of infectious meningitis; both were preterm. Concerning mothers, two had worsening of ascites, two had variceal bleeding despite non-selective betablockers during pregnancy and one developed a main portal vein thrombosis in early postpartum. Genital bleeding occurred in three patients, including two receiving anticoagulation. All 16 women were alive and asymptomatic after a median follow-up of 27 (9-93) months after last delivery.

CONCLUSION

The overall outcome of women with INCPH who become pregnant is favorable despite a significant incidence of complications related to portal hypertension. Fetal outcome is favorable in most pregnancies reaching 20 weeks of gestation.

LAY SUMMARY

About 15% of patients with idiopathic non-cirrhotic portal hypertension are women of childbearing age, who can become pregnant. As available reports on pregnancy in these women are scarce and heterogeneous, it is unclear whether or not pregnancy should be contraindicated in this setting. We provide detailed data showing that, regardless of the associated conditions, the overall outcome of women with idiopathic non-cirrhotic portal hypertension becoming pregnant is good despite a significant incidence of complications related to portal hypertension, and that fetal outcome is favorable in most pregnancies reaching 20 weeks of gestation.

Extrahepatic portal-vein obstruction in pregnancy

BACKGROUND

Extrahepatic portal-vein obstruction (EHPVO) is a common cause of portal hypertension in developing countries. The main risk in pregnant women with this condition is variceal bleeding, which may be life-threatening. The objective of our study was to assess the outcome of pregnancy in women with EHPVO.

MATERIALS AND METHODS

A retrospective analysis of 21 pregnancies in 12 women with EHPVO was carried out at a tertiary hospital in India.

RESULTS

The mean age of pregnant women with EHPVO was 25.3 years, and the mean duration of disease since diagnosis was 6.1 ± 1.2 years. All the patients had chronic EHPVO, and two patients were diagnosed in the index pregnancy. The incidence of abortion, preterm deliveries, and small for gestational age fetus was 23.8%, 18.7%, and 12.5%, respectively. Thrombocytopenia was found to complicate 61.9% of the pregnancies, while anemia was detected in 40% of the pregnancies. Variceal bleeding occurred in one woman, who was diagnosed during pregnancy and was managed successfully with endoscopic sclerotherapy. None of the patients who were diagnosed prenatally had variceal bleeding during pregnancy. The outcome in nine pregnancies, in which prenatal endoscopic variceal ligation was done, was compared with eight pregnancies, in which endoscopic sclerotherapy was done. No significant difference between the two groups in terms of pregnancy outcome and complications was found. There were no stillbirths or maternal mortality.

CONCLUSION

Women with EHPVO who have been diagnosed and treated prenatally have a good pregnancy outcome. They should be managed in a tertiary care center with a multidisciplinary approach.

AISF position paper on liver disease and pregnancy

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

Liver disease in pregnancy

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.

Pregnancy and vascular liver disease

Vascular disorders of the liver frequently affect women of childbearing age. Pregnancy and the postpartum are prothrombotic states. Pregnancy seems to be a trigger for Budd-Chiari syndrome in patients with an underlying prothrombotic disorder. Whether pregnancy is a risk factor for other vascular liver disorders is unknown. In women with a known vascular liver disorder and a desire for pregnancy, stabilisation of the liver disease, including the use of a portal decompressive procedure when indicated, should be reached prior to conception. The presence of esophageal varices should be screened and adequate prophylaxis of bleeding applied in a manner similar to what is recommended for patients with cirrhosis. Most women likely benefit from anticoagulation during pregnancy and the postpartum. Labor and delivery are best managed by a multidisciplinary team with experience in this situation. Assisted vaginal delivery is the preferred mode of delivery. Although the risk of miscarriage and premature birth is heightened, current management of these diseases makes it very likely to see the birth of a live baby when pregnancy reaches 20 weeks of gestation.

Gastrointestinal endoscopy in pregnancy

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.

Pregnancy with portal hypertension

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.

Pregnancy in the Setting of Asymptomatic Non-Cirrhotic Chronic Portal Vein Thrombosis Complicated by Pre-Eclampsia

Portal vein thrombosis (PVT) can be chronic or acute in nature; it is characterized by a thrombus formation in the main portal vein and/or its right or left branches. Herein, we present a 36-year-old woman with asymptomatic noncirrhotic chronic PVT who developed preeclampsia in the later stage of pregnancy. This report will emphasize the clinical differential diagnosis, outcome, and management of pregnancies complicated by noncirrhotic PVT.

Pregnancy in women with portal vein thrombosis: results of a multicentric European study on maternal and fetal management and outcome

BACKGROUND & AIMS

Women of childbearing age account for approximately 25% of patients with non-cirrhotic portal vein thrombosis (PVT). We aimed at assessing maternal and fetal outcome in pregnant women with known PVT.

METHODS

We performed a retrospective analysis of the files of women with chronic PVT in three European referral centers between 1986 and 2010.

RESULTS

Forty-five pregnancies, 28 (62%) treated with low molecular weight heparin, occurred in 24 women. Nine (20%) were lost before gestation week 20. Preterm birth occurred in 38% of deliveries: there were 3 births at week 24-25, 7 at week 32-36, and 26 after week 37. A term birth with a healthy infant occurred in 58% of pregnancies. Cesarean section was used in 53% of deliveries. Two women developed HELLP syndrome. A favorable outcome happened in 64% of pregnancies. Pregnancies with an unfavorable outcome were associated with a higher platelet count at diagnosis. Bleeding from esophageal varices occurred in 3 patients during pregnancy, all without adequate primary prophylaxis. Genital or parietal bleeding occurred postpartum in 4 patients, only one being on anticoagulation therapy. Thrombotic events occurred in 2 patients, none related to lower limbs or mesenteric veins. There were no maternal deaths.

CONCLUSIONS

In pregnant PVT patients treated with anticoagulation on an individual basis, the rate of miscarriage and preterm birth appears to be increased. However, fetal and maternal outcomes are favorable for most pregnancies reaching gestation week 20. High platelet counts appear to increase the risk for unfavorable outcome. Pregnancy should not be contraindicated in stable PVT patients.

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.

Extra hepatic portal vein obstruction and pregnancy outcome: largest reported experience

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.

Impact of cirrhosis and liver transplant on maternal health during labor and delivery

BACKGROUND & AIMS

The impact of cirrhosis or prior liver transplant on maternal health during pregnancy has not been studied. We sought to characterize outcomes during labor and delivery among pregnant women with these 2 conditions.

METHODS

A population-based cohort study of women admitted for labor and delivery to US hospitals between 1998 and 2005 was conducted using the Nationwide Inpatient Sample database. We compared health outcomes between pregnant women with cirrhosis or liver transplant with those without known liver disease, adjusting for potential confounders.

RESULTS

The rates of cesarean section were higher among pregnant women with cirrhosis (n = 187; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.7-3.4) and those with prior liver transplant (n = 86; aOR, 1.8; 95% CI, 1.0-3.2), compared with general obstetrical patients (n = 662,408), as were the rates of preterm labor, peripartum infection, and hypertension. The rates of death (aOR, 42.5; 95% CI, 8.5-214), venous thromboembolism (aOR, 12.3; 95% CI, 4.9-31.0), and protein-calorie malnutrition (aOR, 67.4; 95% CI, 7.5-603), as well as the rates of placental abruption and peripartum blood transfusion, were specifically higher in cirrhotic women. Women with clinically apparent decompensated cirrhosis had higher rates of cesarean delivery, preterm labor, placenta previa, and peripartum blood transfusion than women with compensated cirrhosis.

CONCLUSIONS

Pregnant women with cirrhosis or prior liver transplant are at higher risk of developing numerous adverse health problems than pregnant women without these conditions. Further prospective studies are warranted to assess the benefit of aggressive preventative measures and involvement of multidisciplinary health care teams.

Massive bleeding from ectopic varices in the postpartum period: rare but serious complication in women with portal hypertension

Portal hypertension (PHT) often leads to collateralization of blood flow through variceal vessels that shunt blood from the portal to the systemic circulation. Life-threatening bleeding from esophageal and ectopic varices often complicates severe PHT. Increase in PHT occurs during the last stages of the second trimester of pregnancy and is associated with increased risk of PHT bleeding in the later stages of pregnancy. In this report, we present two rare cases of pregnant women with PHT, who had postpartum bleeding from very uncommon sites. The first had a rupture of an intra-abdominal varix and the second had two episodes of bleeding from abdominal wall varices, after two emergent cesarean sections, in two consecutive pregnancies. On the basis of a literature review, we constructed an algorithm that includes instructions on how to handle women with PHT during the various stages of pregnancy and labor.

Hepatic and mesenteric sarcoidosis without thoracic involvement: a case of severe noncirrhotic portal hypertension and successful pregnancy

Here we report a case of a 25-year-old woman with mesenteric and hepatic sarcoidosis without lung involvement complicated by severe noncirrhotic portal hypertension. In 1992, at the clinical presentation, she had abdominal pain, asthenia, and weight loss. Splenomegaly, signs of flogosis, sideropenic anemia, and cholestasis were observed. Laparoscopic abdominal exploration and histological analysis demonstrated noncaseating granulomas of the liver, abdominal lymph nodes, and mesenteric connective tissue. The clinical course was severe with episodic remissions and recrudescences characterized by ascites (mild or moderate), elevation of bilirubin levels (mean: 1.1 mg/dl; range: 0.9-3.5 mg/dl), reduction of albumin levels (mean: 4 g/dl; range: 3.4-4.2 g/dl), and prolongation of elevated international normalized ratio (mean: 1; range: 0.9-1.4). In 1997, the patient had variceal bleeding. Complete hemostasis was obtained with band ligation. Liver function was preserved, and until 2000 the disease remained stable. In 2001, the patient became pregnant. At the 36th week of gestation, the patient delivered a healthy female infant and afterwards remained in clinical remission. This report stresses that sarcoidosis can have a hepatic and mesenteric involvement in absence of thoracic lymphadenopathy. Portal hypertension may be severe, and in absence of cirrhosis it may be associated with portal thrombosis. Finally, portal hypertension in patients with hepatic sarcoidosis and preserved liver function should not be considered as an absolute contraindication to pregnancy.

Hepatic disorders mildly to moderately affected by pregnancy: medical and obstetric management

Hepatic, biliary, and pancreatic disorders are often complex and clinically challenging during pregnancy. Hepatic disorders can affect the pregnancy and vice versa. The differential diagnosis of hepatic diseases is particularly broad during pregnancy because it includes disorders related to, and unrelated to, pregnancy. This article discusses the physiologic effects of pregnancy on liver function; the differential diagnosis of hepatic findings during pregnancy; modifications of abdominal imaging and hepatobiliary endoscopic procedures during pregnancy; and the medical and obstetric management of hepatic, biliary, and pancreatic diseases that are mildly to moderately affected by pregnancy.

[Portal hypertension and pregnancy]

Pregnancy in patients with portal hypertension is rare but worrying for the clinician. Although the effects of portal hypertension during pregnancy have not been fully elucidated, there is an evident increase in morbidity, especially associated with cirrhosis, which justifies the idea of at-risk pregnancy and requires management by a multidisciplinary team. The prevention and treatment of gastrointestinal haemorrhage is quite similar to that in nonpregnant patients. Investigation and management of portal hypertension before and at the beginning of pregnancy can reduce the risks of foetal loss, restricted intra-uterine growth, premature birth and maternal mortality, which are closely related to gastrointestinal haemorrhage. The risks related to the underlying disease, such as liver failure with cirrhosis and thromboembolic risk with vascular diseases associated with thrombophilia must be taken into consideration. Generally, vaginal delivery with early analgesics for the mother assisted by an extraction device should be preferred to caesarean section, which must be reserved for obstetrical indications.

Pregnancy and liver disease

Liver disease has an impact on women's health during pregnancy because of the complex interactions between the physiologic changes induced by pregnancy and the pathophysiologic changes of liver disease. In particular, liver diseases that predominantly afflict females, such as primary biliary cirrhosis and autoimmune hepatitis, pose a special problem for conception and management of pregnancy. Pregnancy, moreover, specifically is associated with several potentially life-threatening liver diseases. This article reviews comprehensively the impact of liver diseases on pregnancy and of pregnancy on liver function and liver disease.

The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.

Review article: current endoscopic therapeutic options in the management of variceal bleeding

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate in those who survive. Therefore, many studies and randomized clinical trials have focused on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control haemorrhage during the acute bleeding episode (emergency treatment), and to prevent re-bleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This review concentrates on the clinical aspects of the endoscopic modalities used to treat oesophageal variceal haemorrhage, including variceal injection sclerotherapy, variceal band ligation, and the use of tissue adhesives (glue) and their substitutes. We also draw conclusions from the available literature regarding the use of endoscopic modalities in primary prophylaxis, emergency treatment, and secondary prophylaxis of variceal re-bleeding. The management of gastric varices and variceal bleeding during pregnancy is also addressed.