Pregnancy after liver transplant: maternal and perinatal outcomes

Hypogonadism and nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD), recently proposed to be renamed to metabolic dysfunction-associated steatotic liver disease (MASLD), is a major global public health concern, affecting approximately 25-30% of the adult population and possibly leading to cirrhosis, hepatocellular carcinoma, and liver transplantation. The liver is involved in the actions of sex steroids via their hepatic metabolism and production of the sex hormone-binding globulin (SHBG). Liver disease, including NAFLD, is associated with reproductive dysfunction in men and women, and the prevalence of NAFLD in patients with hypogonadism is considerable. A wide spectrum of possible pathophysiological mechanisms linking NAFLD and male/female hypogonadism has been investigated. As therapies targeting NAFLD may impact hypogonadism in men and women, and vice versa, treatments of the latter may affect NAFLD, and an insight into their pathophysiological pathways is imperative. This paper aims to elucidate the complex association between NAFLD and hypogonadism in men and women and discuss the therapeutic options and their impact on both conditions.

Successful full-term pregnancy after preterm event in a liver transplant patient: a case report

BACKGROUND

Pregnancy after liver transplantation poses a significant challenge to both the patient and the transplant team.

CASE PRESENTATION

We present the case of a 19-year-old European patient who underwent liver transplantation 5 years previously owing to autoimmune hepatitis. Poor compliance with immunosuppressive therapy and missed follow-up visits during the patient's first pregnancy likely contributed to her liver function deterioration, hospitalization, and failed pregnancy. Owing to the patient's complex medical history, combined immunosuppressive treatment, and risks to the fetus, her second pregnancy was high risk. However, close outpatient monitoring and adherence to treatment led to a successful, uneventful, full-term pregnancy and healthy delivery.

CONCLUSION

Liver transplant recipients who desire to become pregnant require careful planning and management to ensure optimal outcomes for both the mother and the fetus. A personalized strategy is necessary to balance the potential benefits of childbirth with the risks involved in pregnancy after liver transplantation.

Outcomes With Belatacept Exposure During Pregnancy in Kidney Transplant Recipients: A Case Series

BACKGROUND

Posttransplant fertility returns quickly, and female recipients of child-bearing age may conceive while on immunosuppression. However, pregnancy after transplantation confers risks to the recipient, transplant, and fetus, including gestational hypertension, preeclampsia, gestational diabetes, transplant dysfunction, preterm labor, and low birthweight infants. Additionally, mycophenolic acid (MPA) products are teratogenic. Literature evidence regarding belatacept, a selective T-cell costimulation blocker, during pregnancy and while breastfeeding is extremely limited. When female transplant recipients on a belatacept-based regimen are desirous of pregnancy or at the time of conception, transplant providers manage the immunosuppression regimen in 1 of 2 ways: (1) switch both belatacept and MPA to a calcineurin inhibitor-based regimen with or without azathioprine, which is the more common practice but requires several modifications, having potential negative outcomes; or (2) only switch MPA to azathioprine while continuing belatacept.

METHODS

This case series includes 16 pregnancies in 12 recipients with exposure to belatacept throughout pregnancy and while breastfeeding. Patient information was obtained from several sources, including Transplant Pregnancy Registry International, providers at Emory University, and Columbia University, as well as literature review.

RESULTS

Pregnancy outcomes included 13 live births and 3 miscarriages. No birth defects or fetal deaths were reported in any of the live births. Seven infants were breastfed while their mothers continued belatacept. Outcomes appear comparable to those documented with the administration of calcineurin inhibitors.

CONCLUSIONS

This case series provides data supporting the continued administration of belatacept during pregnancy. Additional research will assist in developing better guidelines to counsel female transplant recipients on belatacept desiring to pursue pregnancy.

Overview of pregnancy in solid-organ transplantation

PURPOSE OF REVIEW

Pregnancy in solid organ transplantation (SOT) is a very complex part of transplant medicine wherein there is scarce information available in the literature. Solid organ transplant recipients often have comorbidities, such as hypertension and diabetes, which add additional risk to a pregnancy.

RECENT FINDINGS

We present this review article on the various aspects of different types of immunosuppressant medications used in pregnancy with added inputs on contraception and fertility after transplant. We described the antepartum and postpartum considerations and discussed the adverse effects of the immunosuppressive medications. Maternal and fetal complications of each SOT have been also discussed in this article.

SUMMARY

This article will serve as the primary review articles for the use of immunosuppressive medications during pregnancy with consideration during pregnancy after SOT.

Perinatal Outcomes after Liver Transplantation: Is There a Role for Aspirin Treatment?

BACKGROUND

We aimed to describe perinatal outcomes and evaluate aspirin treatment effects in liver-transplanted pregnant women.

METHODS

A retrospective study examining perinatal outcomes in liver transplant recipients at a single center (2016-2022). The effect of low-dose aspirin treatment on the risk of developing hypertensive disease in these patients was evaluated.

RESULTS

Fourteen deliveries in 11 pregnant liver transplant recipients were identified. Primary liver disease was Wilson's in 50% of pregnancies. The median age was 23 years at transplant and 30 at conception. Tacrolimus was administered in all, steroids in 10 (71.43%), and aspirin (100 mg daily) in 7 (50.0%). Overall, two women (14.28%) developed preeclampsia, and one (7.14%) developed gestational hypertension. Median gestational age at delivery was 37 weeks (31-39 weeks), with six preterm births (between 31-36 weeks) and a median birthweight of 3004 g(range 1450-4100 g). None of those receiving aspirin developed hypertensive disease or suffered excessive bleeding during pregnancy, compared to two (28.57%) with pre-eclampsia in the non-aspirin group.

CONCLUSION

Liver-transplanted pregnant women comprise a unique and complex patient population with overall favorable pregnancy outcomes. Based on our single-center experience and due to its safety profile and potential benefit, we recommend low-dose aspirin in all liver transplanted patients during pregnancy for preeclampsia prevention. Further large prospective studies are needed to corroborate our findings.

Importance of complete response for outcomes of pregnancy in patients with autoimmune hepatitis

BACKGROUND AND AIMS

While some articles describe outcome of pregnancy in autoimmune hepatitis (AIH), there are less data evaluating influence of AIH control on maternal and perinatal outcomes. This study analysed outcomes of pregnancy and related possible risk factors in AIH.

METHOD

A retrospective multicentre cohort study on pregnancy in AIH was performed in 11 hospitals in the Netherlands. Maternal and neonatal outcomes were collected from records and completed by interview. Risk factors-including incomplete response, relapse and cirrhosis-for adverse outcomes were identified using logistic regression analysis.

RESULTS

Ninety-seven pregnancies in 50 women resulted in 70 deliveries (72%) with a live birth rate of 98.5%. AIH relapse occurred in 6% during pregnancy, and in 27% of post-partum episodes. Absence of complete biochemical response at conception was identified as risk factor for the occurrence of gestational and post-partum relapses. Relapse of AIH in the year before conception was a risk factor for the occurrence of both gestational relapses and post-partum relapses. No complete biochemical response increased the risk for hypertensive disorders during pregnancy and intrahepatic cholestasis of pregnancy (ICP). Cirrhosis was found to be a risk factor for miscarriages, but not for other outcomes.

CONCLUSION

Pregnancy in AIH is related to an increased incidence of maternal and fetal/neonatal complications; in most cases, outcome is good. Incomplete biochemical response at conception or relapse in the year before conception are risk factors for gestational and post-partum relapses, for hypertensive disorders and for ICP. Cirrhosis was a risk factor for miscarriages.

Does Intrauterine Exposure of the Foetus to Immunosuppressive Drugs Used by the Mother—The Organ Recipient—Affect the Development of Post-Vaccination Immunity against Selected Viral Diseases in Children of These Mothers in Postnatal Life?

Background: Pregnancy in women who are organ recipients has long been a controversial issue due to the lack of data on the safety of immunosuppressive drugs for the developing foetus. Scientific data show that the effect of immunosuppressants on the foetus causes an impairment of T and B lymphocyte function and a reduction in their total number. For this reason, some authors recommend delaying the obligatory immunization of infants. The aim of the study is to analyse the impact of chronic immunosuppressive therapy used during pregnancy by women after organ transplantation on the effectiveness of anti-viral vaccinations in the children of these women. Methods: Concentrations of post-vaccination IgG antibodies (measles, HBV, polio) in 18 children of post-transplant mothers (9KTRs; 9LTRs) were determined using the ELISA method. The results were compared with the control group (n = 21). The incidence of vaccination AEs was also analysed. Results: There were no significant differences between the analysed groups in the concentrations of antibodies against HBV, measles and polio (p > 0.05). Conclusions: No difference was observed in the immunogenicity of HBV, polio and measles vaccinations between children of post-transplant mothers and the general population. The immunization of children of post-transplant mothers is safe, and the percentage of adverse post-vaccination events does not differ from the general population. The obtained study results do not indicate the necessity for modifying the vaccination program for HBV, measles, and polio in this group of patients.

Domino liver transplant from a donor with maple syrup urine disease into a recipient with phenylketonuria

Classical phenylketonuria (PKU) presents a unique challenge for women of child-bearing age. In the context of pregnancy, poorly controlled hyperphenylalaninemia can result in a devastating constellation of outcomes for the baby referred to as the maternal PKU Syndrome. We present the case of a woman with classical PKU unable to maintain a restricted diet and refractory to pharmacological therapies. She elected to undergo a domino liver transplant, receiving an organ from a donor with classical branched chain ketoacid dehydrogenase deficiency (maple syrup urine disease). Plasma phenylalanine concentrations normalized within a few days after transplant and remained so on an unrestricted diet during the first year of follow-up. The patient reports subjective improvements in mood, energy level, and overall quality of life. In the appropriate clinical setting, liver transplant should be considered to provide metabolic stability for PKU patients, particularly women of childbearing age.

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This article describes thenovel use of liver transplantation to prevent maternal PKU in a planned pregnancy.

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Utilization of a domino liver allograft from a patient who was being transplanted for Maple Syrup Urine Disease.

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Provides a systematic review of the available literature supporting the procedure and discussing the current outcome after transplant.