Liver disease in pregnancy

The Spectrum of Hepatic Critical Care During Pregnancy: A Clinical Review

Hepatic disease during pregnancy can result in the development of critical illness requiring special attention from a multidisciplinary team with a low threshold for tertiary care transfer to provide access to liver transplantation. Management of this population requires taking into consideration the benefit and risks of both mother and fetus. A myriad of diseases has been recognized, some being unique to pregnancy while others are common to the general population. We present a review of the literature on the diagnosis, management, and prognosis of these diseases to aid in the optimization of care in this special population.

Approach to the patient with cholestasis and jaundice syndrome. Joint AMH, AMG, and AMEG scientific position statement

The term cholestasis refers to bile acid retention, whether within the hepatocyte or in the bile ducts of any caliber. Biochemically, it is defined by a level of alkaline phosphatase that is 1.67-times higher than the upper limit of normal. Cholestatic diseases can be associated with an inflammatory process of the liver that destroys hepatocytes (hepatitis), withjaundice (yellowing of the skin and mucus membranes, associated with elevated serum bilirubin levels), or with both, albeit the three concepts should not be considered synonymous. Cholestatic diseases can be classified as intrahepatic or extrahepatic, depending on their etiology. Knowing the cause of the condition is important for choosing the adequate diagnostic studies and appropriate treatment in each case. A complete medical history, together with a thorough physical examination and basic initial studies, such as liver ultrasound and liver function tests, aid the clinician in deciding which path to follow, when managing the patient with cholestasis. In a joint effort, the Asociación Mexicana de Hepatología (AMH), the Asociación Mexicana de Gastroenterología (AMG) and the Asociación Mexicana de Endoscopia Gastrointestinal (AMEG) developed the first Mexican scientific position statement on said theme.

Management of pregnancy in women with cirrhosis

Although pregnancy is rare in women with cirrhosis, it is increasingly prevalent in an era of modern assisted conception techniques and improved awareness, monitoring and management of underlying liver disease. After overcoming the difficulties of subfertility and becoming pregnant, women undergo a 'high-risk' pregnancy which can be complicated by variceal haemorrhage (≤50%) and hepatic decompensation (≤25%). Management of these complications are similar to non-pregnant individuals. However, there are a few caveats to consider. These pregnancies are associated with adverse maternal and foetal outcomes, such as mortality (0%-8%) and prematurity (19%-67%) in the newborn, and mortality (0%-14%), pregnancy-induced hypertension (5%-22%) and post-partum haemorrhage (5%-45%) in the mother. Pre-pregnancy counselling, use of predictive scores and appropriate variceal screening during pregnancy can stratify patients and improve outcomes. This review focusses on the complications that can occur during pregnancy in women with cirrhosis.

Preeclampsia and HELLP syndrome, the role of the liver

Preeclampsia is a multisystemic disorder which accounts for the high prevalence of maternal and perinatal morbidity and mortality, especially in middle and low-income countries. Currently, the primary intervention is the urgent delivery of the fetus, hence it would be advantageous to identify those who are likely to develop preeclampsia and the maternal and fetal outcomes. However, an array of risk factors makes these challenging. This review explores the potentials of liver biomarkers in predicting the occurrence and outcome of preeclampsia, which could be beneficial in reducing the burden of the disease. Liver dysfunction in preeclampsia results in a severe condition, hence liver function tests are specific predictors of outcome.

Clinical characteristics of acute fatty liver of pregnancy in a tertiary Indonesian hospital

Acute fatty liver of pregnancy (AFLP) is a rare, often autosomal recessive disorder with a major risk for maternal and perinatal mortality and morbidity. In order to achieve a more favorable outcome, awareness of its clinical signs and symptoms and early recognition are of pivotal importance. Over a 5-year period 18 patients were diagnosed with AFLP (one twin, 19 babies). The most common sign and symptoms were jaundice, hypoglycemia, nausea and vomiting, encephalopathy, and hypertension. Abnormal laboratory test results included: elevated total/ conjugated (direct) bilirubin, AST, ALT, PT, APTT, creatinine, leukocyte count, and hypoalbuminemia. Maternal and fetal mortality rate was high: 66.7% resulted in a maternal death and 57.9% in an intrauterine fetal demise (IUFD). The number of complications was found to correlate with maternal death (p = 0.042). Surviving AFLP patients had ≤ 3 complications, while patients with > 3 complications on presentation had a high risk of maternal death (OR = 5.0; 95% CI: 0.55-45.4). The presence of hypertension significantly increased the risk of maternal death (OR: 24.5; 95% CI: 1.1-542.8; p = 0.01). The risk of IUFD was primarily related to gestational age at delivery and birth weight. The high rate of jaundice as presenting symptom of AFLP suggests that Indonesian primary maternity care providers may often miss its important earlier signs and symptoms, in particular de-novo onset of nausea and vomiting in late pregnancy.

Obstetric Outcome in Women with Chronic Liver Disease

AIM

This study determines the prevalence, causes and outcome of pregnancy in women with chronic liver diseases in a tertiary level teaching institute in Southern India.

METHODS

Retrospective analysis of case records was carried out between December 2010 and May 2015 in the departments of Obstetrics and Gynecology and Gastroenterology including pregnant women diagnosed to have chronic liver diseases prenatally or during pregnancy.

RESULTS

The frequency of chronic liver disease in pregnancy was 50 among 10,823 deliveries (0.4%). Twenty-six women with chronic liver disease had 50 pregnancies during the study period. Fifty percent of the women had cirrhosis. Maternal complications occurred in 22% of the study group. Variceal hemorrhage occurred in 4%, and hepatic decompensation occurred in 16%. There were two maternal deaths (4%). Obstetric complication such as preeclampsia, postpartum hemorrhage and puerperal infection occurred in 18, 14 and 18%, respectively. Abortion occurred in 34%, 55% in cirrhotic and 4.8% in non-cirrhotic. Live birth rate of 76% was significantly higher (p < 0.014) in the non-cirrhotic group compared to cirrhotic group.

CONCLUSION

Pregnancies in chronic liver disease are associated with high rate of abortions. Live birth rates are better and complications such as variceal bleeding or decompensation of liver disease are less common than previously reported.

Anesthetic considerations for liver diseases unique to pregnancy

Liver diseases that are most unique to pregnancy consist of hyperemesis gravidarum, acute fatty liver of pregnancy, intrahepatic cholestasis of pregnancy, and hemolysis, elevated liver enzymes and low platelets syndrome. In this review, risk factors, etiology, symptoms, diagnosis, prognosis and treatment of each entity followed by principles of anesthetic management based on the case reports or retrospective records will be addressed.

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.

Successful pregnancy with autoimmune cirrhosis

Pregnancy with liver cirrhosis is a rare and dangerous event that exposes mother and fetus to potentially lethal risks. During pregnancy, hepatic decompensation could suffice and the development of hepatic failure and encephalopathy could occur. The incidence of obstetric complications is also increased with a high rate of pre-eclampsia, postpartum bleeding, preterm delivery and stillbirth. We report a case of a 27-year-old woman with autoimmune hepatitis and liver cirrhosis complicated by splenomegaly, oesophageal varices and severe thrombocytopaenia. During pregnancy, close clinical and analytical surveillance was performed. She was medicated with corticosteroids, azathioprine and propranolol. At the 25th week of gestation, an upper gastrointestinal endoscopy was performed to control oesophageal varices. This patient had an uneventful pregnancy until 37 weeks. At 37th week of gestation, after spontaneous rupture of membranes, signs of acute fetal distress were observed, and an urgent caesarean was performed. Good neonatal and maternal outcomes were achieved.

Management of gastrointestinal and liver diseases during pregnancy

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.

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.

Prognosis and determinants of pregnancy outcome among patients with post-hepatitis liver cirrhosis

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.

Liver disease in pregnancy

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.

Successful pregnancy outcome in decompensated chronic liver disease with portal vein thrombosis: case report and review of literature

Pregnancy is rare in women with decompensated chronic liver disease. In this case report, we describe a case of a young woman who presented with hepatitis B-related decompensated chronic liver disease with portal vein thrombosis having successful full-term uneventful pregnancy.

Liver disease in pregnancy

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.

What is expected from the pathologist in the diagnosis of viral hepatitis?

The clinician expects from the pathologist a clinically relevant diagnosis on the basis of liver biopsy interpretation. Today, a liver biopsy, as invasive procedure, is only justified when a significant benefit for the patient can be expected particularly with respect to the clinical management. Consequently, liver biopsy is usually not required in uncomplicated acute viral hepatitis. It is, however, an important diagnostic tool in chronic hepatitis and in transplanted liver to confirm the clinical diagnosis and to assess stage and grade of necroinflammation, treatment efficiency, and concurrent diseases. The diagnosis of liver disease is based on teamwork between clinician and pathologist. Evaluation of the biopsy in the clinical context requires clinical information and appropriate size and handling of the biopsy specimen. Aim of this review is the discussion of morphologic features of acute and chronic viral hepatitis with regard to their clinical relevance.

The outcomes of pregnancy in patients with cirrhosis: a population-based study

BACKGROUND

The outcomes of pregnancy in patients with cirrhosis are poorly described. Our objective was to assess obstetric outcomes in cirrhotic women and their infants from a population-based perspective.

METHODS

We analysed the 1993-2005 US Nationwide Inpatient Sample database to identify obstetric hospitalizations among patients with cirrhosis (n=339) and controls matched on age, hospital and year (n=6625). The effect of cirrhosis on maternal and fetal outcomes was evaluated using regression models with adjustment for patient and hospital factors.

RESULTS

Between 1993 and 2005, 114 antepartum and 225 delivery admissions in cirrhotic patients were identified. The estimated mean number of deliveries nationwide increased from 68 to 106 annually between 1993 and 1999 and 2000 and 2005 (P=0.0004). Patients with cirrhosis were more likely to deliver by caesarean [42 vs. 28%; adjusted odds ratio (OR) 1.41; 95% confidence interval (CI) 1.06-1.88]. Maternal (1.8 vs. 0%; P<0.0001) and fetal mortality (5.2 vs. 2.1%; P<0.0001), antepartum admission (OR 2.97; 95% CI 2.24-3.96), and maternal (OR 2.03; 95% CI 1.60-2.57) and fetal complications (OR 3.66; 95% CI 2.74-4.88) were greater among cirrhotic patients than controls. Gestational hypertension, placental abruption and uterovaginal haemorrhage were more common in patients with cirrhosis; their infants had higher rates of prematurity and growth restriction. Hepatic decompensation occurred in 15%, including ascites in 11% and variceal haemorrhage in 5%. In women with decompensation, maternal and fetal mortality were 6 and 12% respectively.

CONCLUSIONS

Although rare, pregnancies among women with cirrhosis are increasing. Cirrhotic patients and their infants have an increased risk of obstetric complications, emphasizing the importance of close maternal-fetal monitoring during pregnancy.

Follow-up of pregnant women with autoimmune hepatitis: the disease behavior along with maternal and fetal outcomes

GOALS

To assess maternal and fetal outcomes and clinical management of pregnancy in patients with autoimmune hepatitis (AIH).

BACKGROUND

There is a paucity of information about maternal and fetal outcomes, and AIH activity during pregnancy and in the postpartum period. There is no consensus about the administration of azathioprine during pregnancy and breastfeeding.

STUDY

Retrospective analysis of 54 pregnancies (3 still in progress) in 39 AIH patients.

RESULTS

The median age at conception was 24 years, and 68.4% of women had liver cirrhosis. Before conception and in early pregnancy, azathioprine and prednisone were administered in 48.1%, but treatment regimen was usually changed further to 20 mg/d prednisone; and 20.4% were off treatment. There were 36 livebirths, and fetal loss rates were 29.4% (13 miscarriages, 1 stillbirth, and 1 ectopic pregnancy). Preterm birth rate was 11.8%. In 2 cases, there was acute fetal distress; and in 2 others congenital malformations (3.9%). The rate of serious maternal complication was 7.8%, with no deaths. There were no flares in 41.2% pregnancies, but aminotransferase elevations occurred in 54.9%, 31.4% of which were true AIH relapses, only registered in the postpartum period.

CONCLUSIONS

Despite the high fetal miscarriage rate, pregnancy in AIH was safe. Patients needed careful monitoring, especially in the postpartum period because of relapses. There was no evidence of a cause and effect relationship among azathioprine administration and premature births and congenital abnormalities, but more studies are necessary. Higher doses of prednisone may be an alternative option for those who prefer azathioprine withdrawal during pregnancy.

Pregnancy and cirrhosis

As the treatment of cirrhosis improves, pregnancy in patients with cirrhosis is likely to become more common. Although maternal and fetal mortality is expected to similarly improve, pregnant patients with cirrhosis face unique risks. These include higher rates of spontaneous abortion and prematurity and a potential for life-threatening variceal hemorrhage, hepatic decompensation, splenic artery aneurysm rupture, and postpartum hemorrhage. Pregnancy outcome may be influenced by the underlying etiology of liver disease, as in viral and autoimmune hepatitis. Medications also impact the course of pregnancy, and must be tailored appropriately during this time.

Hepatic disorders severely affected by pregnancy: medical and obstetric management

Hepatic disorders severely affected by pregnancy include choledochal cysts that can be compressed by the gravid uterus and potentially rupture; hepatic adenomas that exhibit accelerated growth because of hyperestrogenemia during pregnancy; acute intermittent porphyria that is exacerbated by increased female sex hormones during pregnancy; splenic artery aneurysms that can rupture during pregnancy because of compression by the gravid uterus; Budd-Chiari syndrome that is promoted by hyperestrogenemia; and hepatitis E and herpes simplex hepatitis that are particularly severe during pregnancy. Hepatic disorders unique to pregnancy include intrahepatic cholestasis of pregnancy; acute fatty liver of pregnancy; preeclampsia and eclampsia; and hemolysis, elevated liver function tests, and low platelet count (HELLP) syndrome. Most disorders uniquely related to pregnancy are treated by prompt fetal delivery as soon as the fetus is sufficiently mature.

Liver diseases unique to pregnancy

Liver injury and dysfunction in a pregnant woman may be caused by intrinsic features of the pregnancy itself, disorders that are coincidental with pregnancy or pre-existing liver disease that is exacerbated by pregnancy. The clinical setting, gestational age and standard liver biochemistry testing are useful tools in helping to establish a diagnosis. Prompt recognition of the signs of liver disease in pregnant patients leads to timely management and may save the life of both mother and baby. This review summarises the incidence, risk factors, pathogenesis, clinical presentation, diagnosis, treatment and outcome of those liver diseases unique to pregnancy.