Pregnancy after liver transplantation

Pregnancy after liver transplantation: a case series and review of the literature

OBJECTIVE

To evaluate maternal and perinatal outcomes in pregnant women after liver transplantation with a case series and literature systematic review.

METHODS

This was a single-center case-series study performed at University of Naples Federico II. All consecutive women with liver transplantation who reported pregnancy at our institution were included in a dedicated database. In addition, a systematic literature review was performed, including case series, population-based studies, and national registries, including maternal and perinatal outcomes of pregnant women with liver transplant. Studies with fewer than 10 cases and surveys were excluded. The primary outcome was perinatal death, defined as either stillbirth (defined as intrauterine fetal death after 20 weeks of gestation) or neonatal death (death of a live-born infant within the first 28 d of life).

RESULTS

During the study period, two women who underwent liver transplantation had a pregnancy in our Institution. Both of them underwent liver transplantation for biliary atresia at 1 year of age. One of them received cyclosporin as immunosuppressive regime during pregnancy, while the other one received tacrolimus. Both of them had a pregnancy with no major complications and delivered by cesarean section at term a baby with normal weight. One of them developed thrombocytopenia. Seventeen articles were included in this systematic review. Preterm birth at less than 37 weeks of gestations occurred in 279 women (33.6%). One-hundred women (14.9%) experienced preeclampsia, and 206 women (49.2%) delivered by cesarean delivery. Graft rejection related to pregnancy occurred in 73 women (8.3%). 117 women (12.9%) experienced miscarriage, and 22 (2.3%) IUFD. Fifty-two women (9.52%) underwent elective I-TOP. 195 fetuses (33.4%) were LBW. Eight neonatal deaths were recorded (1.3%).

CONCLUSION

The maternal and perinatal outcome is usually favorable, but with an increased risk of preeclampsia, preterm birth, and perinatal morbidity and mortality. However, appropriate counseling about risks and complications is essential but women shouldn't be advised against pregnancy.

Pregnancy after liver transplantation

The first known posttransplantation pregnancy was in 1958 in a renal transplant recipient who had received a kidney from her identical twin sister. The first known posttransplantation pregnancy in a liver transplant recipient was in 1978. Information available from female kidney transplant recipients helped in the decision making involved in the management of this case, as well as those that followed. Over the last 20 years, issues specific to liver transplantation and pregnancy have been identified. Similar to the kidney transplant recipient population, when prepregnancy recipient graft function is stable and adequate, pregnancy appears to be well tolerated. Also similar to kidney transplant recipients, there has been no evidence of a specific malformation pattern among the children, and although prematurity and low birth weight occur, overall newborn outcomes have been favorable. Pregnancy in the setting of recurrent liver disease, such as recurrent hepatitis C, poses a potential problem among liver transplant recipients, as well as the possible adverse effects of immunosuppression on maternal kidney function. Also of significance, peripartum graft deterioration has more severe consequences in this transplant recipient population. Therefore, pregnancy must be considered carefully in this transplant recipient group. Since 1991, the National Transplantation Pregnancy Registry (NTPR) has studied the safety of pregnancy outcomes in solid-organ transplant recipients. The purpose of this review is to catalog studies in the literature, as well as to present current data from the registry with management guidelines.

[Normalization of menstrual cycles and pregnancy after liver transplantation]

The objective of the present study is to evaluate the effects of successful liver transplantation on menstrual cycles abnormalities and on reproductive function of women with chronic liver disease. Twelve women with age between 17 and 54 years who underwent liver transplantation were evaluated. The following variables were analyzed: age, etiology of chronic liver disease, pattern of menstrual function and period of amenorrhea before and after transplantation, and occurrence of pregnancy after transplantation. The mean age of patients was 36 +/- 12.6 years. Patients with primary biliary cirrhosis did not have menstrual abnormalities before transplantation. The other patients presented amenorrhea for 3 months to 11 years before the transplantation. Rapid recovery of menstrual function was observed in all patients after the transplantation (3.1 +/- 1.2 months). Two patients became pregnant one and three years after the transplantation. It is concluded from this study that most women who present amenorrhea secondary to chronic liver disease have normal menstrual cycles in approximately three months following liver transplantation and they may become pregnant.

Pregnancy after liver transplantation

This article reviews the reported experience with pregnancy after liver transplantation and describes obstetric risks and medical issues that the maternal fetal medicine specialist has a reference for managing these pregnancies and for providing appropriate preconception counseling. Women who undergo liver transplantations have a higher risk of preeclampsia, worsening hypertension, preterm premature rupture of membranes, anemia, small for gestational age, preterm delivery, and cesarean section than the normal obstetric population. Women with preconceptional renal dysfunction appear to be at greatest risk for pregnancy complications. Women who conceived within 6 months of transplant had a high risk of rejection. Reproductive-aged recipients of liver allograft should receive contraception and preconception counseling. In an appropriately timed and planned pregnancy, women who undergo liver transplantations can have successful pregnancies with little risk to their allograft function.

Reproductive function after liver transplantation

Successful pregnancy outcomes are possible after liver transplantation. Although there are risks to the mother and fetus, there has not been an increased incidence of malformations noted in the newborn of liver recipients. Close, coordinated care involving the hepatologist, surgeon, and high-risk obstetrician is essential to ensure a favorable outcome. Immunosuppression peripartum should be maintained at appropriate levels. Of note, a small subset of recipients may suffer worsened graft function during pregnancy. Recurrent liver disease, especially viral hepatitis, and CMV infection appear to pose significant risks to mother and offspring, respectively, although the magnitude of the risks is unknown. It therefore would seem prudent to consider pregnancy only in female liver recipients who have passed at least 1 year with stable graft function. In addition, new immunosuppressive regimens further add to the lack of information regarding pregnancy safety. The NTPR is an ongoing database to collect information and pregnancy outcomes. That information should be helpful in counseling recipients and in pregnancy management.

National Transplantation Pregnancy Registry: analysis of pregnancy outcomes in female liver transplant recipients

Outcomes from 48 pregnancies in 34 female liver transplant recipients were analyzed. Data were collected via interviews, questionnaires, and hospital records. All recipients were treated with cyclosporine-based immunosuppression except 2 patients treated with FK506 and 2 treated with no immunosuppression. The age at conception was 26.1 +/- 5.9 years (mean +/- SD) with a transplant interval (time from transplantation to conception) of 2.9 +/- 2.5 years. There were 49 outcomes (1 set of twins): miscarriage 9 (18%), therapeutic abortion 4 (8%), and live birth 36 (74%). No stillbirths or ectopic pregnancies were reported. Of the 36 live births, the gestational age was 36.9 +/- 3.5 weeks, the birthweight was 2,604 +/- 698 grams, 39% were premature (< 37 weeks), and 31% had low birthweight (< 2,500 grams). No birth defects or neonatal deaths (< 28 days) were reported. The newborn complication rate was 17% (n = 6), 5% in premature infants. The incidence of drug-treated hypertension was 46%; pre-eclampsia 21%; infectious complications 26%; and Caesarean section 47%. Recipients with hypertension had a higher proportion of premature infants (71%) than normotensive patients (38%) (P = .04 by Fisher's exact test). Acute rejection was diagnosed in 6 pregnancies, 2 of which were ended by therapeutic abortion. Four recipients who continued their pregnancies were treated with increased immunosuppression for rejection, and all delivered livebirths. There were two grafts lost within 6 months of pregnancy. The only maternal death occurred in a patient who required retransplantation for recurrent C hepatitis 3 months afte therapeutic abortion and died 6 months later. The other recipient with graft loss was successfully retransplanted for chronic rejection 6 months after delivery. We draw the following conclusions: (1) female liver transplant recipients can safely undergo pregnancy, although there is a high rate of premature and low birthweight infants; (2) pregnancies in this population should be considered high-risk and require close monitoring of liver function; and (3) altered graft function during pregnancy should be thoroughly investigated.

Reproductive function and outcome of pregnancy after liver transplantation in women

OBJECTIVE

To discuss menstrual function before and after liver transplantation, immunosuppression during pregnancy, outcome and management of pregnancy, and use of contraception in women after liver transplantation.

MATERIAL AND METHODS

We review the relevant medical literature and describe our clinical experience in the management of gynecologic and obstetric issues in recipients of liver transplants.

RESULTS

Menstrual abnormalities, such as amenorrhea, oligomenorrhea, irregular bleeding, and metrorrhagia, are common in women with liver disease and may often be the first clinical indication of liver dysfunction. Normal menstrual function is frequently restored after transplantation. Successful pregnancies have occurred in recipients of liver transplants, but such pregnancies are often complicated by preterm delivery, preeclampsia, and infection. Use of immunosuppressive medications should be maintained during pregnancy, and drug concentrations should be carefully monitored; none has been found to be teratogenic. Pregnancy does not seem to accelerate graft rejection. Barrier contraception or sterilization, if appropriate, seems to be the safest option for these patients.

CONCLUSION

Because liver transplantation leads to restoration of normal menstruation, female patients of reproductive age must be counseled about the possibility of pregnancy and the use of contraception. Pregnancy should be avoided for at least the first 6 months after transplantation. With specialized care and attention, pregnancies are generally associated with good outcomes.

[Liver transplantation and pregnancy: 1994 perspectives]

The authors report a case of pregnancy in a 24-year-old, gravida-3, para-1 patient who had previously undergone liver transplantation for alveolar echinococcosis. Pregnancy and delivery were uneventful with no obstetrical or liver complications. Pregnancy seems to have little effect on liver transplants and rejection is seldom observed. Primary maternal complications are hypertension, preeclampsia, anemia and hyperbilirubinemia. Primary fetal complications include premature delivery and growth retardation. The mode of delivery depends on the obstetrical situation. Cyclosporin may be used during pregnancy. The risk of breastfeeding has not been clearly established. Pregnancy after liver transplantation is possible after 9 to 12 months but requires strict multidisciplinary surveillance. Barrier methods remain the preferred method of contraception for liver transplant patients.