Lupine Publishers| Current Trends in Gastroenterology and Hepatology
Introduction
In 1978, Walcott and coworkers documented the first
pregnancy in a liver transplant recipient [1]. The recipient’s
immunosuppressive regimen included prednisone and
azathioprine. Her pregnancy was uncomplicated, and she delivered
a healthy male, weighing 2400 g, at term. Since Walcott’s report,
there have been hundreds of pregnancies reported worldwide in
liver transplant recipients. Whether the transplant could take in
an adverse effect of the pregnancy or whether the pregnancy could
potentiate liver transplant it is not settled [2].
Liver Transplant and Timing of Pregnancy
a) Women should wait at least 1 year after receiving a solidorgan
transplant before attempting to get significant, and then
should do so but when earned by the transplant team and
obstetrician, with close monitoring [3].
b) The best contraceptive method, at least early after liver
transplantation, is a barrier method. Later, when the patient is
stabilized, hormonal methods may be considered. Sterilization
is an option for patients who have completed their family [4].
c) Liver transplant recipients considering pregnancy should
have preconception counseling with a maternal–fetal medicine
specialist and their transplant physician. There are no specific
guidelines for liver transplant recipients to decide whether an
allograft is functioning sufficiently well for pregnancy as there
is for kidney transplant recipients. Nevertheless, a general
assessment of graft function and the status of comorbidities,
such as high blood pressure, should be done before conception.
The preconceptional visit also provides an opportunity to
look back with the patient outcomes of pregnancies with liver
transplants, potential effects of immunosuppressive agents on
the pregnancy and fetus, and the plan of management for the
gestation.
Pregnancy outcome after liver transplantation
Despite advances in immunosuppressive therapy, pregnancies
in liver transplant recipients are still more risky than in the general
population for both the mother and the fetus. Pregnancies in liver
transplant recipients should be followed up more cautiously by a
multidisciplinary team because [5,6]:
a) Overall, 78% of pregnancies were successful.
b) Many recipients of solid-organ transplants, including liver
transplants, develop high blood pressure and renal dysfunction.
It is easily grounded in the obstetrical literature that these
conditions are independently linked with adverse pregnancy
events. The most common obstetric complications were high
blood pressure (28%), preeclampsia (12%), and reversible
liver dysfunction (27%) [7].
c) The rate of acute rejection was 10% [8].
d) The incidence of perinatal and neonatal death was about
4%.
e) Thither was a 3% incidence of congenital malformations,
after exclusion of an infant with the presumed fetal alcohol
syndrome and an infant with an autosomal dominant genetic
disorder inherited from the female parent.
f) The maternal death rate was 5.5%, over a 2-year period
following delivery [9].
g) Additionally, it seems that the danger of infection
during gestation is also significantly increased after liver
transplant; this finding may be a consequence of chronic
immunosuppressive therapy [1].
h) Liver transplantation does not significantly modify pretransplant
diabetes mellitus. Diabetes mellitus frequently
develops de novo after liver transplantation, although this
complication is usually short-lived and likely linked to
immunosuppressive drug administration. The prognosis of
patients with post-transplant diabetes mellitus is worse than
that of those without this complication [10].
i) The incidence of preterm delivery is 24% [8].
j) The rate of cesarean delivery for liver transplant recipients
is higher (20% -100%) than the national average [11].
k) The rate of newborn complications was also high, at 29%.
l) Subjective hearing impairment is frequent in patients
after OLT and contributes to post-OLT morbidity. Calcineurin
inhibitor-related neurotoxicity appears as a potential
mechanism. Further prospective investigations with objective
hearing tests are necessary to substantiate these results and to
assess the use of immunosuppression [12].
Management Recommendations
a) Patients with liver transplants considering pregnancy
should receive preconception counseling. The preconceptional
evaluation will require an appraisal of the current graft status
and episodes of rejection.
b) Preconceptional counseling should be provided to both
the patient and her spouse. For patients who bear a genetic
disorder underlying their liver disease, genetic counseling
should also be provided. These will include patients with
alpha-1antitrypsin deficiency and hemochromatosis, as well
as less common disorders such as Alagille syndrome and Caroli
syndrome. Prenatal testing may be usable for certain disorders.
c) Ideally, immunosuppressive medications are at stable
doses, and no episodes of rejection have occurred in the old yr.
An assessment of renal, cardiovascular, and pulmonary status
should be performed.
d) Comorbidities such as diabetes and hypertension should
be addressed and ideally should be easily-controlled before
conception.
e) The status of hepatitis B and C infections as easily as
the CMV status should be known and the possible impact
on pregnancy discussed. Patients should have up-to-date
vaccinations for influenza, pneumococcus, tetanus, and
hepatitis B if indicated. In summation, a discussion of pregnancy
results in transplant recipients should take place, concentrating
especially on the potential for and long-term outcomes of
preterm parturition.
f) Pregnancies in patients with liver transplants should be
done in an interdisciplinary fashion between a maternal–fetal
medicine specialist, a transplant physician, and other specialists
as indicated.
g) Transplant recipients will require frequent prenatal visits
throughout the class of their pregnancies.
h) Close monitoring of line pressure, proteinuria, and
laboratory studies throughout the pregnancy are all-important.
i) Patients on chronic prednisone should have early
screening for gestational diabetes. Although the frequency of congenital birth defects does not appear to be increased
with immunosuppressive agents in studies thus far, a genetic
sonogram is indicated for transplant patients to boot out the
presence of congenital abnormalities.
j) Serial growth scans should be done throughout pregnancy
to monitor for fetal growth restriction.
k) In the third trimester, antenatal testing may be done,
although the benefit of testing in this population has not been
established.
l) Cesarean delivery should be performed for standard
obstetrical indications.
m) Stress-dose steroids are shown at the time of delivery
for patients who have been taking corticosteroids during
pregnancy.
n) An increase in baseline liver function needs an
aggressive evaluation in these pregnancies. On that point is no
contraindication to liver biopsy in these patients to evaluate for
graft rejection.
o) Several other complications of pregnancy, such as
preeclampsia, HELLP syndrome, and cholestasis of pregnancy,
may result in elevations of liver enzymes. Some small reports
have demonstrated an increase in the rate of cholestasis of
pregnancy in liver transplant recipients, but this has not been
measured in larger works. It may be rather challenging to
identify these complications of pregnancy from graft rejection
or exacerbation of the underlying liver disease, such as hepatitis
C.
p) The goal of managing these pregnancies is to optimize
maternal health, including graft function and co morbidities,
to find and manage complications of pregnancy such as
preeclampsia and infection, and to downplay the complications
of preterm birth whenever possible.
q) From the literature, it appears that many liver transplant
recipients can look at safe gestation and neonatal outcomes.
However, at that place is a big deal of research needed to clarify
the optimal management of these pregnancies.
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