1
|
Porrello G, Cannella R, Bernuau J, Agman A, Brancatelli G, Dioguardi Burgio M, Vilgrain V. Liver imaging and pregnancy: what to expect when your patient is expecting. Insights Imaging 2024; 15:66. [PMID: 38411871 PMCID: PMC10899155 DOI: 10.1186/s13244-024-01622-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/07/2024] [Indexed: 02/28/2024] Open
Abstract
Liver diseases in pregnancy can be specific to gestation or only coincidental. In the latter case, the diagnosis can be difficult. Rapid diagnosis of maternal-fetal emergencies and situations requiring specialized interventions are crucial to preserve the maternal liver and guarantee materno-fetal survival. While detailed questioning of the patient and a clinical examination are highly important, imaging is often essential to reach a diagnosis of these liver diseases and lesions. Three groups of liver diseases may be observed during pregnancy: (1) diseases related to pregnancy: intrahepatic cholestasis of pregnancy, pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, and acute fatty liver of pregnancy; (2) liver diseases that are more frequent during or exacerbated by pregnancy: acute herpes simplex hepatitis, Budd-Chiari syndrome, hemorrhagic hereditary telangiectasia, hepatocellular adenoma, portal vein thrombosis, and cholelithiasis; (3) coincidental conditions, including acute hepatitis, incidental focal liver lesions, metabolic dysfunction-associated steatotic liver disease, cirrhosis, hepatocellular carcinoma, liver abscesses and parasitosis, and liver transplantation. Specific knowledge of the main imaging findings is required to reach an early diagnosis, for adequate follow-up, and to avoid adverse consequences in both the mother and the fetus.Critical relevance statement Pregnancy-related liver diseases are the most important cause of liver dysfunction in pregnant patients and, in pregnancy, even common liver conditions can have an unexpected turn. Fear of radiations should never delay necessary imaging studies in pregnancy.Key points• Pregnancy-related liver diseases are the most frequent cause of liver dysfunction during gestation.• Fear of radiation should never delay necessary imaging studies.• Liver imaging is important to assess liver emergencies and for the diagnosis and follow-up of any other liver diseases.• Common liver conditions and lesions may take an unexpected turn during pregnancy.• Pregnancy-specific diseases such as pre-eclampsia and HELLP syndrome must be rapidly identified. However, imaging should never delay delivery when it is considered to be urgent for maternal-fetal survival.
Collapse
Affiliation(s)
- Giorgia Porrello
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France.
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy.
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy
| | - Jacques Bernuau
- AP-HP Nord, Hôpital Beaujon, Service d'Hépatologie, Paris, Clichy, France
| | - Antoine Agman
- Service de Gynécologie obstétrique maternité, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
| | - Giuseppe Brancatelli
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University Hospital "Paolo Giaccone", Palermo, Italy
| | - Marco Dioguardi Burgio
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018, Paris, France
| | - Valérie Vilgrain
- Service de Radiologie, AP-HP Nord, Hôpital Beaujon, Paris, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, F-75018, Paris, France
| |
Collapse
|
2
|
Shukla A, Singh A, Saxena A, Panda S, Mane P, Khan N, Harindranath S, Vaidya A, Kuruthukulangara M, Mayadeo N. Navigating portal hypertension: Unlocking safe passage to healthy pregnancy in EHPVO. Liver Int 2024; 44:454-459. [PMID: 38010991 DOI: 10.1111/liv.15785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/03/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS Pregnancy is associated with hyperdynamic circulatory state and increased risk of portal hypertension related complications in patients with extra-hepatic portal vein obstruction (EHPVO). We aim to study the impact of EHPVO on pregnancy-related outcomes with focus on subset of patients with UGIB (upper GI bleed). METHODS Retrospective analysis of obstetric, maternal and neonatal outcomes of patients with EHPVO registered between January 2006 and December 2022. Forty-five patients were included. Forty-five healthy females with low-risk pregnancies formed the control group. RESULTS Adverse obstetric and neonatal outcomes were comparable between EHPVO and control group (22% vs. 28.6%; p > .05; low birth weight/ small for gestational age 17.8% vs. 36%, p = .0918 and 14.2% vs. 10%, p = .5698 respectively). Adverse outcomes were similar in patients with and without history of UGIB (26.3% vs. 19.4%, p = .0814; 17.8% vs. 36%, p = .0918; 14.2% vs. 10%, p = .5698). There was no maternal mortality in both the groups. A total of 7% pregnancies in EHPVO patients were complicated by ascites. CONCLUSIONS EHPVO pregnancies have successful obstetric and neonatal outcomes with adequate management of portal hypertension.
Collapse
Affiliation(s)
- Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Ankita Singh
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Akriti Saxena
- Department of Obstetrics and Gynaecology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Saurav Panda
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Prajakta Mane
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Nagma Khan
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Arun Vaidya
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | - Niranjan Mayadeo
- Department of Obstetrics and Gynaecology, Seth GS Medical College and KEM Hospital, Mumbai, India
| |
Collapse
|
3
|
Conthe A, Ibáñez-Samaniego L, Muñoz MF, Ortega V, Yunquera AF, Romero M, Yllana F, Catalina MV, Larroca SGT, Bañares R. Pregnancy outcomes in patients with portal cavernoma: A case series study. Int J Gynaecol Obstet 2023; 163:277-281. [PMID: 37128972 DOI: 10.1002/ijgo.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Non-cirrhotic portal vein cavernoma (PVC) is a cause of portal hypertension (PH) frequently affecting women of childbearing age. Cavernous transformation of the portal vein is frequently associated with prothrombotic disorders and often entails multiple hemodynamic changes, porto-collateral shunt development and thrombopenia, all of which can affect the course of pregnancy. Our aim was to evaluate the risk of PH-related complications and pregnancy outcomes in patients with PVC. METHODS Retrospective case series study of patients with PVC undergoing pregnancy in a tertiary care hospital. RESULTS Eight pregnancies fulfilled the eligibility criteria. All patients had a predisposing factor for PVC. One episode of variceal bleeding was reported at week 28. Six cesarean sections were scheduled to avoid labor while two urgent surgeries were indicated due to fetal distress and intrauterine growth restriction (IUGR). In all but one case, anticoagulation was prescribed after delivery. No hemorrhagic or thrombotic complications were reported. There were four cases of IUGR with no case of miscarriage or stillbirth. CONCLUSION Pregnancy in patients with PVC has an overall favorable outcome albeit a higher risk of PH-derived complications, and IUGR may be expected. Hence, PVC must not be considered a contraindication for pregnancy although larger prospective studies are necessary.
Collapse
Affiliation(s)
- Andrés Conthe
- Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Luis Ibáñez-Samaniego
- Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - María Fernández Muñoz
- Department of Gynecology & Obstetrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Virginia Ortega
- Department of Gynecology & Obstetrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ainhoa Fernández Yunquera
- Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Mario Romero
- Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Fátima Yllana
- Department of Gynecology & Obstetrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Maria Vega Catalina
- Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Rafael Bañares
- Department of Gastroenterology & Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| |
Collapse
|
4
|
Giri S, Sahoo S, Sundaram S, Shukla A. Maternal and fetal outcomes in pregnant patients with non-cirrhotic portal hypertension: A systematic review and meta-analysis. Obstet Med 2023; 16:170-177. [PMID: 37719996 PMCID: PMC10504878 DOI: 10.1177/1753495x221143864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/21/2022] [Indexed: 09/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Nizam's Institute of Medical Science, Hyderabad, Telangana, India
| | - Shradhanjali Sahoo
- Maternal and Fetal Medicine, Fernandez Hospital, Hyderabad, Telangana, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, TATA Memorial Hospital, Mumbai, Maharashtra, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
5
|
Williamson C, Nana M, Poon L, Kupcinskas L, Painter R, Taliani G, Heneghan M, Marschall HU, Beuers U. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol 2023; 79:768-828. [PMID: 37394016 DOI: 10.1016/j.jhep.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 07/04/2023]
Abstract
Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.
Collapse
|
6
|
Elkrief L, Payancé A, Plessier A, d’Alteroche L, Ronot M, Paradis V, Valla D, Rautou PE. Management of splanchnic vein thrombosis. JHEP Rep 2023; 5:100667. [PMID: 36941824 PMCID: PMC10023986 DOI: 10.1016/j.jhepr.2022.100667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/11/2022] [Accepted: 12/23/2022] [Indexed: 01/04/2023] Open
Abstract
The expression splanchnic vein thrombosis encompasses Budd-Chiari syndrome and portal vein thrombosis. These disorders have common characteristics: they are both rare diseases which can cause portal hypertension and its complications. Budd-Chiari syndrome and portal vein thrombosis in the absence of underlying liver disease share many risk factors, among which myeloproliferative neoplasms represent the most common; a rapid comprehensive work-up for risk factors of thrombosis is needed in these patients. Long-term anticoagulation is indicated in most patients. Portal vein thrombosis can also develop in patients with cirrhosis and in those with porto-sinusoidal vascular liver disease. The presence and nature of underlying liver disease impacts the management of portal vein thrombosis. Indications for anticoagulation in patients with cirrhosis are growing, while transjugular intrahepatic portosystemic shunt is now a second-line option. Due to the rarity of these diseases, studies yielding high-grade evidence are scarce. However, collaborative studies have provided new insight into the management of these patients. This article focuses on the causes, diagnosis, and management of patients with Budd-Chiari syndrome, portal vein thrombosis without underlying liver disease, or cirrhosis with non-malignant portal vein thrombosis.
Collapse
Key Words
- BCS, Budd-Chiari syndrome
- CALR, calreticulin
- Cavernoma
- DOACs, direct-acting oral anticoagulants
- Direct oral anticoagulants
- EHPVO, extrahepatic portal vein obstruction
- GFR, glomerular filtration rate
- JAK2, Janus kinase 2
- LMWH, low-molecular-weight heparin
- MPN, myeloproliferative neoplasm
- MTHFR, methylene-tetrahydrofolate reductase
- PNH, paroxysmal nocturnal hemoglobinuria
- PVT, portal vein thrombosis
- Portal biliopathy
- Portal vein recanalisation
- SVT, splanchnic vein thrombosis
- TIPS, transjugular intrahepatic portosystemic shunt
- VKAs, vitamin K antagonists
- Vascular liver diseases
Collapse
Affiliation(s)
- Laure Elkrief
- Service d’Hépato-Gastroentérologie CHU de Tours, France
| | - Audrey Payancé
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Aurélie Plessier
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | | | - Maxime Ronot
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service de radiologie, Hôpital Beaujon APHP.Nord, Clichy, France
| | - Valérie Paradis
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d’anatomie et cytologie pathologique, Hôpital Beaujon APHP.Nord, Clichy, France
| | - Dominique Valla
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Corresponding author. Address: Service d’Hépatologie, Hôpital Beaujon, 100 boulevard du Général Leclerc, 92110, Clichy, France; Tel.: +331 40 87 50 91, fax +331 40 87 44 35
| |
Collapse
|
7
|
Maternal and perinatal outcome in pregnancies complicated with portal hypertension: a systematic review and meta-analysis. Hepatol Int 2023; 17:170-179. [PMID: 35802227 DOI: 10.1007/s12072-022-10385-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023]
Abstract
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.
Collapse
|
8
|
Zanetto A, Cossiga V, Shalaby S, Guarino M, Invernizzi F, Lapenna L, Becchetti C, Morisco F, Morelli MC, Merli M, Toniutto P, Burra P. Vascular liver diseases: A sex-oriented analysis of the literature. Dig Liver Dis 2023; 55:178-186. [PMID: 35906168 DOI: 10.1016/j.dld.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 02/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Valentina Cossiga
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Sarah Shalaby
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Maria Guarino
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | - Federica Invernizzi
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, University of Rome Sapienza, Rome, Italy
| | - Chiara Becchetti
- Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Filomena Morisco
- Department of Clinical Medicine and Surgery, Gastroenterology and Hepatology Unit, University of Naples "Federico II", Naples, Italy
| | | | - Manuela Merli
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Academic Hospital, University of Udine, Udine, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy.
| | | |
Collapse
|
9
|
Giri S, Sahoo S. Pregnancy in Patients with Non-cirrhotic Portal Hypertension: A Literature Review. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:609-613. [PMID: 35760363 PMCID: PMC9948258 DOI: 10.1055/s-0042-1748973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shradhanjali Sahoo
- Department of Maternal and Fetal Medicine, Fernandez Hospital, Hyderabad, Telangana, India
| |
Collapse
|
10
|
Sant'Antonio E, Borsani O, Camerini C, Botta C, Santoro M, Allegra A, Siragusa S. Philadelphia chromosome-negative myeloproliferative neoplasms in younger adults: A critical discussion of unmet medical needs, with a focus on pregnancy. Blood Rev 2021; 52:100903. [PMID: 34742614 DOI: 10.1016/j.blre.2021.100903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 11/02/2022]
Abstract
Myeloproliferative neoplasms (MPN) are traditionally regarded as a disease of older adults, though a not negligible fraction of cases occurs at a younger age, including women of childbearing potential. MPN in younger patients, indeed, offer several challenges for the clinical hematologist, that goes from difficulties in reaching a timely and accurate diagnosis to a peculiar thrombotic risk, with a relatively high incidence of thromboses in unusual sites (as the splanchnic veins or the cerebral ones). Moreover, the issue of pregnancy is recently gaining more attention as maternal age is rising and molecular screening are widely implemented, leading to a better recognition of these cases, both before and during pregnancy. In the present work we aim at discussing four clinical topic that we identified as areas of uncertainty or true unmet medical needs in the management of younger patients with MPN, with a particular focus on the topic of pregnancy. For each of these topics, we critically reviewed the available evidence that support treatment decisions, though acknowledging that recommendations in this field are mostly based on expert opinion or derived from guidelines of other clinical conditions that share with MPN a high vascular risk, as antiphospholipid syndrome. Taking into consideration both the lack of evidence-based data and the clinical heterogeneity of MPN, we support an individualized strategy of counseling and management for both young patients and for expectant mother with MPN.
Collapse
Affiliation(s)
| | - Oscar Borsani
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Chiara Camerini
- Division of Hematology, Azienda USL Toscana Nord Ovest, Ospedale San Luca, Lucca, Italy
| | - Cirino Botta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Marco Santoro
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood "Gaetano Barresi", University of Messina, Messina, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| |
Collapse
|
11
|
Wiegers H, Hamulyák EN, Damhuis SE, van Duuren JR, Darwish Murad S, Scheres L, Gordijn SJ, Leentjens J, Duvekot JJ, Lauw MN, Hutten BA, Middeldorp S, Ganzevoort W. Pregnancy outcomes in women with Budd-Chiari syndrome or portal vein thrombosis - a multicentre retrospective cohort study. BJOG 2021; 129:608-617. [PMID: 34520620 PMCID: PMC9293458 DOI: 10.1111/1471-0528.16915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/25/2021] [Accepted: 08/29/2021] [Indexed: 11/29/2022]
Abstract
Objective To evaluate current practice and outcomes of pregnancy in women previously diagnosed with Budd–Chiari syndrome and/or portal vein thrombosis, with and without concomitant portal hypertension. Design and setting Multicentre retrospective cohort study between 2008 and 2021. Population Women who conceived in the predefined period after the diagnosis of Budd–Chiari syndrome and/or portal vein thrombosis. Methods and main outcome measures We collected data on diagnosis and clinical features. The primary outcomes were maternal mortality and live birth rate. Secondary outcomes included maternal, neonatal and obstetric complications. Results Forty‐five women (12 Budd–Chiari syndrome, 33 portal vein thrombosis; 76 pregnancies) were included. Underlying prothrombotic disorders were present in 23 of the 45 women (51%). Thirty‐eight women (84%) received low‐molecular‐weight heparin during pregnancy. Of 45 first pregnancies, 11 (24%) ended in pregnancy loss and 34 (76%) resulted in live birth of which 27 were at term (79% of live births and 60% of pregnancies). No maternal deaths were observed; one woman developed pulmonary embolism during pregnancy and two women (4%) had variceal bleeding requiring intervention. Conclusions The high number of term live births (79%) and lower than expected risk of pregnancy‐related maternal and neonatal morbidity in our cohort suggest that Budd–Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy. Individualised, nuanced counselling and a multidisciplinary pregnancy surveillance approach are essential in this patient population. Tweetable abstract Budd–Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy. Budd–Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy. Linked article This article is commented on by YY Chung & MA Heneghan pp. 618 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17002.
Collapse
Affiliation(s)
- Hmg Wiegers
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - E N Hamulyák
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - S E Damhuis
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J R van Duuren
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - S Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ljj Scheres
- Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J Leentjens
- Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M N Lauw
- Deparment of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B A Hutten
- Departmentof Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - S Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| |
Collapse
|
12
|
Verhagen H, Alonso-Andicoberry C, Assunção R, Cavaliere F, Eneroth H, Hoekstra J, Koulouris S, Kouroumalis A, Lorenzetti S, Mantovani A, Menozzi D, Nauta M, Poulsen M, Rubert J, Siani A, Sirot V, Spaggiari G, Thomsen ST, Trevisan M, Cozzini P. Risk-benefit in food safety and nutrition - Outcome of the 2019 Parma Summer School. Food Res Int 2021; 141:110073. [PMID: 33641961 DOI: 10.1016/j.foodres.2020.110073] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022]
Abstract
Risk-benefit assessment is the comparison of the risk of a situation to its related benefits, i.e. a comparison of scenarios estimating the overall health impact. The risk-benefit analysis paradigm mirrors the classical risk analysis one: risk-benefit assessment goes hand-in-hand with risk-benefit management and risk-benefit communication. The various health effects associated with food consumption, together with the increasing demand for advice on healthy and safe diets, have led to the development of different research disciplines in food safety and nutrition. In this sense, there is a clear need for a holistic approach, including and comparing all of the relevant health risks and benefits. The risk-benefit assessment of foods is a valuable approach to estimate the overall impact of food on health. It aims to assess together the negative and positive health effects associated with food intake by integrating chemical and microbiological risk assessment with risk and benefit assessment in food safety and nutrition. The 2019 Parma Summer School on risk-benefit in food safety and nutrition had the objective was to provide an opportunity to learn from experts in the field of risk-benefit approach in food safety and nutrition, including theory, case studies, and communication of risk-benefit assessments plus identify challenges for the future. It was evident that whereas tools and approaches have been developed, more and more case studies have been performed which can form an inherent validation of the risk-benefit approach. Executed risk-benefit assessment case studies apply the steps and characteristics developed: a problem formulation (with at least 2 scenarios), a tiered approach until a decision can be made, one common currency to describe both beneficial and adverse effects (DALYs in most instances). It was concluded that risk-benefit assessment in food safety and nutrition is gaining more and more momentum, while also many challenges remain for the future. Risk-benefit is on the verge of really enrolling into the risk assessment and risk analysis paradigm. The interaction between risk-benefit assessors and risk-benefit managers is pivotal in this, as is the interaction with risk-benefit communicators.
Collapse
Affiliation(s)
- Hans Verhagen
- University of Ulster, Northern Ireland, United Kingdom; European Food Safety Authority, Parma, Italy; Technical University of Denmark, Lyngby, Denmark.
| | | | - Ricardo Assunção
- National Institute of Health Dr. Ricardo Jorge, Lisbon, Portugal; CESAM, Centre for Environmental and Marine Studies, University of Aveiro, Aveiro, Portugal
| | | | | | - Jeljer Hoekstra
- National Institute for Public Health and the Environment (RIVM), the Netherlands
| | | | | | - Stefano Lorenzetti
- Istituto Superiore di Sanità - ISS, Dpt. of Food Safety, Nutrition and Veterinary Public Health, Rome, Italy
| | - Alberto Mantovani
- Istituto Superiore di Sanità - ISS, Dpt. of Food Safety, Nutrition and Veterinary Public Health, Rome, Italy
| | | | | | | | - Josep Rubert
- CIBIO, Department of Cellular, Computational and Integrative Biology, University of Trento, Via Sommarive 9, Povo 38123, Italy; Interdisciplinary Research Structure of Biotechnology and Biomedicine, Department of Biochemistry and Molecular Biology, Universitat de Valencia, 46100 Burjassot, València, Spain
| | | | | | | | | | - Marco Trevisan
- DiSTAS, Università Cattolica del Sacro Cuore, Piacenza Campus, Italy
| | - Pietro Cozzini
- University of Parma, Department of Food and Drug, Italy.
| |
Collapse
|
13
|
Barbosa OA, Andrade TG, de Almeida Sousa MD, Correia JW. Portal venous thrombosis associated with JAK 2 mutation in pregnancy - case report. J OBSTET GYNAECOL 2020; 41:659-661. [PMID: 33241956 DOI: 10.1080/01443615.2020.1824215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Orivaldo Alves Barbosa
- Department of Internal Medicine, Hospital Dr. César Cals, Fortaleza, Brazil.,Department of Clinical Medicine, Christus University Center (UNICHRISTUS), Fortaleza, Brazil
| | | | | | | |
Collapse
|
14
|
Payancé A, Ceccaldi PF, De Raucourt E, Valla D, Hillaire S, Dutheil D, Hernandez-Gea V, Bureau C, Plessier A. Pregnancy and vascular liver diseases: Vascular liver diseases: position papers from the francophone network for vascular liver diseases, the French Association for the Study of the Liver (AFEF), and ERN-rare liver. Clin Res Hepatol Gastroenterol 2020; 44:433-437. [PMID: 32278776 DOI: 10.1016/j.clinre.2020.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Audrey Payancé
- DHU Unity, Department of Hepatology, Beaujon Hospital, AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Hambourg Germany; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - Pierre François Ceccaldi
- Department of obstetrics and gynecology, Beaujon Hospital, AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Inserm 3PHM « Pathophysiology & Pharmacotoxicology of the Human Placenta, pre & postnatal Microbiota (3PHM)», Faculty of Pharmacy, University of Paris, Paris, France
| | - Emmanuelle De Raucourt
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of haematology, Beaujon Hospital, AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France
| | - Dominique Valla
- DHU Unity, Department of Hepatology, Beaujon Hospital, AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Hambourg Germany; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Sophie Hillaire
- Department of Internal Medicine, Foch Hospital, 40, rue Worth, 92150 Suresnes, France
| | - Danielle Dutheil
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Association of patients with vascular liver diseases (AMVF), Department of Hepatology, Beaujon Hospital, 100, boulevard du Général Leclerc, 92118 Clichy, France
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd). Health Care Provider of the European Reference Network onRare Liver Disorders (ERN-Liver), Spain
| | - Christophe Bureau
- French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France; Department of Gastroenterology and Hepatology, Rangueil Hospital, University Hospital of Toulouse, 1, avenue du Professeur Jean-Poulhès, 31400 Toulouse, France
| | - Aurélie Plessier
- DHU Unity, Department of Hepatology, Beaujon Hospital, AP-HP, 100, boulevard du Général Leclerc, 92118 Clichy, France; Reference center of vascular liver diseases, European Reference Network (ERN) "Rare-Liver", Hambourg Germany; French Network for Rare Liver Diseases FILFOIE, Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| |
Collapse
|
15
|
Abstract
Idiopathic portal hypertension (IPH) and extrahepatic portal venous obstruction (EHPVO) are prototype noncirrhotic causes of portal hypertension (PHT), characterized by normal hepatic venous pressure gradient, variceal bleeds, and moderate to massive splenomegaly with preserved liver synthetic functions. Infections, toxins, and immunologic, prothrombotic and genetic disorders are possible causes in IPH, whereas prothrombotic and local factors around the portal vein lead to EHPVO. Growth failure, portal biliopathy, and minimal hepatic encephalopathy are long-term concerns in EHPVO. Surgical shunts and transjugular intrahepatic portosystemic shunt resolve the complications secondary to PHT. Meso-Rex shunt is now the standard-of-care surgery in children with EHPVO.
Collapse
Affiliation(s)
- Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi 110 070, India.
| |
Collapse
|
16
|
Hernández-Gea V, De Gottardi A, Leebeek FWG, Rautou PE, Salem R, Garcia-Pagan JC. Current knowledge in pathophysiology and management of Budd-Chiari syndrome and non-cirrhotic non-tumoral splanchnic vein thrombosis. J Hepatol 2019; 71:175-199. [PMID: 30822449 DOI: 10.1016/j.jhep.2019.02.015] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Budd-Chiari syndrome and non-cirrhotic non-tumoral portal vein thrombosis are 2 rare disorders, with several similarities that are categorized under the term splanchnic vein thrombosis. Both disorders are frequently associated with an underlying prothrombotic disorder. They can cause severe portal hypertension and usually affect young patients, negatively influencing life expectancy when the diagnosis and treatment are not performed at an early stage. Yet, they have specific features that require individual consideration. The current review will focus on the available knowledge on pathophysiology, diagnosis and management of both entities.
Collapse
Affiliation(s)
- Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain
| | - Andrea De Gottardi
- Hepatology, University Clinic of Visceral Medicine and Surgery, Inselspital, and Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France; Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, European Reference Network for Rare Vascular Liver Diseases, Universitat de Barcelona, Spain.
| |
Collapse
|
17
|
Pregnancy in a Woman with Latent Myeloproliferative Neoplasm Induced Chronic Portal Vein Thrombosis, Portal Cavernoma, and Gastric Varices. Case Rep Obstet Gynecol 2019; 2019:5702983. [PMID: 31001438 PMCID: PMC6437724 DOI: 10.1155/2019/5702983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/21/2019] [Indexed: 11/18/2022] Open
Abstract
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.
Collapse
|
18
|
Andrade F, Shukla A, Bureau C, Senzolo M, D'Alteroche L, Heurgué A, Garcia-Pagan JC, Turon F, Oberti F, Tripathi D, Roux O, Ceccaldi PF, de Raucourt E, Payancé A, Valla D, Plessier A, Rautou PE. Pregnancy in idiopathic non-cirrhotic portal hypertension: A multicentric study on maternal and fetal management and outcome. J Hepatol 2018; 69:1242-1249. [PMID: 30138688 DOI: 10.1016/j.jhep.2018.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/25/2018] [Accepted: 08/02/2018] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Filipe Andrade
- Service d'Hépatologie, DHU Unity, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; Department of Medicine, Hospital Pedro Hispano, Matosinhos, Portugal
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | | | - Alexandra Heurgué
- Service d'Hépato-Gastro-entérologie, Hôpital Robert-Debré, Reims, France
| | - Juan-Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Lab and Liver Unit, Hospital Clinic-IDIBAPS and CIBERehd, University of Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Lab and Liver Unit, Hospital Clinic-IDIBAPS and CIBERehd, University of Barcelona, Spain
| | - Frédéric Oberti
- University Hospital of Angers, Department of Hepatology, Angers, France
| | - Dhiraj Tripathi
- Liver Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Olivier Roux
- Service d'Hépatologie, DHU Unity, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Pierre-François Ceccaldi
- Service de Gynécologie-Obstétrique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | | | - Audrey Payancé
- Service d'Hépatologie, DHU Unity, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Dominique Valla
- Service d'Hépatologie, DHU Unity, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; INSERM, UMR1149, Centre de Recherche sur l'Inflammation, Paris, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, 75018, Paris, France
| | - Aurélie Plessier
- Service d'Hépatologie, DHU Unity, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; INSERM, UMR1149, Centre de Recherche sur l'Inflammation, Paris, France
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, DHU Unity, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; INSERM, U970, Paris Cardiovascular Research Center - PARCC, Paris, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, 75018, Paris, France.
| |
Collapse
|
19
|
Hibi A, Mogi K. Portal vein thrombosis after cesarean section in a patient on prolonged bed rest due to threatened preterm labor. Clin Case Rep 2018; 6:531-536. [PMID: 29531735 PMCID: PMC5838291 DOI: 10.1002/ccr3.1405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/01/2017] [Accepted: 01/14/2018] [Indexed: 12/27/2022] Open
Abstract
Portal vein thrombosis is a rare but life-threatening complication during pregnancy and postpartum period. Color Doppler ultrasound is useful for prompt diagnosis. Although the risk of complications should be considered, successful pregnancy with comorbid portal vein thrombosis is possible with appropriate anticoagulation therapy and close monitoring.
Collapse
Affiliation(s)
- Arata Hibi
- Division of Nephrology and RheumatologyDepartment of Internal MedicineKariya Toyota General Hospital5‐15, Sumiyoshi‐choKariyaAichi 448‐8505Japan
| | - Kazumasa Mogi
- Department of Obstetrics and GynecologyKariya Toyota General Hospital5‐15, Sumiyoshi‐choKariyaAichi 448‐8505Japan
| |
Collapse
|
20
|
López Correa T, Sastre Rincón JA. Caesarean section in a patient with chronic portal vein thrombosis and thrombocytopenia: Case report. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
21
|
López Correa T, Sastre Rincón JA. Cesárea en paciente con trombosis portal crónica y trombocitopenia: reporte de caso. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
22
|
Caesarean section in a patient with chronic portal vein thrombosis and thrombocytopenia: Case report☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
23
|
Mhaske NC, Madhva Prasad S, Kharat D, Fonseca MN. Successful Pregnancy Outcome with Extra Hepatic Portal Venous Obstruction: Three Case Series. J Obstet Gynaecol India 2016; 66:694-697. [DOI: 10.1007/s13224-016-0911-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 05/07/2016] [Indexed: 10/21/2022] Open
|
24
|
AISF position paper on liver disease and pregnancy. Dig Liver Dis 2016; 48:120-37. [PMID: 26747754 DOI: 10.1016/j.dld.2015.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 10/29/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
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.
Collapse
|
25
|
Bissonnette J, Durand F, de Raucourt E, Ceccaldi PF, Plessier A, Valla D, Rautou PE. Pregnancy and vascular liver disease. J Clin Exp Hepatol 2015; 5:41-50. [PMID: 25941432 PMCID: PMC4415189 DOI: 10.1016/j.jceh.2014.12.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 12/30/2014] [Indexed: 12/12/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Julien Bissonnette
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - François Durand
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
| | - Emmanuelle de Raucourt
- Laboratoire d'hématologie biologique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Pierre-François Ceccaldi
- Service d'Obstétrique-Gynécologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Aurélie Plessier
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
| | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
- INSERM, U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Paris-Diderot-Paris 7, Hôpital Bichat, Paris, France
- INSERM, U970, Paris Cardiovascular Research Center—PARCC, and Université Paris Descartes, Sorbonne Paris Cité, UMR-S970, Paris, France
| |
Collapse
|
26
|
Abstract
Portal vein thrombosis is an important cause of portal hypertension. PVT occurs in association with cirrhosis or as a result of malignant invasion by hepatocellular carcinoma or even in the absence of associated liver disease. With the current research into its genesis, majority now have an underlying prothrombotic state detectable. Endothelial activation and stagnant portal blood flow also contribute to formation of the thrombus. Acute non-cirrhotic PVT, chronic PVT (EHPVO), and portal vein thrombosis in cirrhosis are the three main variants of portal vein thrombosis with varying etiological factors and variability in presentation and management. Procoagulant state should be actively investigated. Anticoagulation is the mainstay of therapy for acute non-cirrhotic PVT, with supporting evidence for its use in cirrhotic population as well. Chronic PVT (EHPVO) on the other hand requires the management of portal hypertension as such and with role for anticoagulation in the setting of underlying prothrombotic state, however data is awaited in those with no underlying prothrombotic states. TIPS and liver transplant may be feasible even in the setting of PVT however proper selection of candidates and type of surgery is warranted. Thrombolysis and thrombectomy have some role. TARE is a new modality for management of HCC with portal vein invasion.
Collapse
Key Words
- ACLA, anti-cardiolipin antibody
- AFP, alpha feto protein
- BCS, Budd-Chiari syndrome
- CDUS, color doppler ultrasonography
- CT, computed tomography
- CTP, Child Turcotte Pugh
- EHPVO, extra hepatic portal venous obstruction
- EST, endoscopic sclerotherapy
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- IGF-1, insulin like growth factor-1
- IGFBP-3, insulin like growth factor binding protein-3
- INR, international normalized ratio
- JAK-2, Janus kinase 2
- LA, lupus anticoagulant
- LMWH, low molecular weight heparin
- MELD, model for end stage liver disease
- MPD, myeloproliferative disorder
- MRI, magnetic resonance imaging
- MTHFR, methylenetetrahydrofolate reductase
- MVT, mesenteric vein thrombosis
- OCPs, oral contraceptive pills
- PAI-1 4G-4G, plasminogen activator inhibitor type 1- 4G/4G genotype
- PNH, paroxysmal nocturnal hemoglobinuria
- PV, portal vein
- PVT
- PVT, portal vein thrombosis
- PWUS, Pulsed Wave ultrasonography
- RFA, radio frequency ablation
- SMA, superior mesenteric artery
- SMV, superior mesenteric vein
- TAFI, thrombin activatable fibrinolysis inhibitor
- TARE, Trans arterial radioembolization
- TB, tuberculosis
- TIPS, transjugular intrahepatic portosystemic shunt
- UFH, unfractionated heparin
- acute and chronic
- anticoagulation
- imaging
- prothrombotic
- rtPA, recombinant tissue plasminogen activator
Collapse
Affiliation(s)
- Yogesh K. Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | | |
Collapse
|
27
|
Abstract
Portal vein thrombosis (PVT) is a rare event in the general medical setting that commonly complicates cirrhosis with portal hypertension, and can also occur with liver tumors. The diagnosis is often incidental when a thrombus is found in the portal vein on imaging tests. However, PVT may also present with clinical symptoms and can progress to life-threatening complications of ischemic hepatitis, liver failure, and/or small intestinal infarction. This article reviews the pathophysiology of this disorder, with a major focus on PVT in patients with cirrhosis, and presents detailed guidelines on optimal diagnostic and therapeutic strategies.
Collapse
Affiliation(s)
- Syed Abdul Basit
- Section of Gastroenterology and Hepatology, University of Nevada School of Medicine, 2040 West Charleston Boulevard, Suite 300, Las Vegas, NV 89102, USA
| | - Christian D Stone
- Section of Gastroenterology and Hepatology, University of Nevada School of Medicine, 2040 West Charleston Boulevard, Suite 300, Las Vegas, NV 89102, USA
| | - Robert Gish
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Alway Building, Room M211, 300 Pasteur Drive, MC: 5187 Stanford, CA 94305-5187, USA.
| |
Collapse
|
28
|
Guettrot-Imbert G, Plessier A, Hillaire S, Delluc C, Leroux G, Le Guern V, Costedoat-Chalumeau N. [Liver diseases and pregnancy]. Rev Med Interne 2015; 36:211-8. [PMID: 25591870 DOI: 10.1016/j.revmed.2014.10.355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/20/2014] [Indexed: 12/15/2022]
Abstract
Liver disease can be observed in pregnant women whether or not related to pregnancy. Liver disorders can be revealed by pruritus, vomiting, jaundice or abnormal liver blood tests during pregnancy. These liver manifestations can lead to the diagnosis of liver disease specifically associated to pregnancy as intrahepatic pregnancy, intrahepatic cholestasis of pregnancy, Hyperemesis gravidarum, acute fatty liver of pregnancy and preeclampsia-induced liver injury. Pregnancy may also be a risk factor for other liver diseases coincident with pregnancy as viral hepatitis, thrombosis, drug toxicity or gallstone. Finally, pre-existing liver disease must be taken into account given the risk of fœto-maternal transmission risk as well as the risk of decompensation of underlying cirrhosis secondary to the hemodynamic changes caused by pregnancy. The aim of this revue is to perform an update on the various situations that can be observed, the principles of management of these liver diseases, in order to reduce the risk of complications and to ensure the best maternal and fetal prognosis.
Collapse
Affiliation(s)
- G Guettrot-Imbert
- Service de médecine interne, hôpital Gabriel-Montpied, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex 1, France
| | - A Plessier
- Service d'hépatologie, institut national de la santé et de la recherche médicale U773, université Denis Diderot-Paris 7, hôpital Beaujon, AP-HP, 92210 Clichy, France
| | - S Hillaire
- Service d'hépatologie, institut national de la santé et de la recherche médicale U773, université Denis Diderot-Paris 7, hôpital Beaujon, AP-HP, 92210 Clichy, France; Service de médecine interne, hôpital Foch, 92150 Suresnes, France
| | - C Delluc
- EA 3878 (GETBO), université de Bretagne Occidentale, 29238 Brest, France
| | - G Leroux
- Service de médecine interne 1, AP-HP, groupe hospitalier Pitié-Salpêtrière, 75651 Paris, France
| | - V Le Guern
- Centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, université René-Descartes, pôle médecine, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
| | - N Costedoat-Chalumeau
- Centre de référence maladies auto-immunes et systémiques rares, service de médecine interne, université René-Descartes, pôle médecine, hôpital Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France.
| |
Collapse
|
29
|
Aggarwal N, Negi N, Aggarwal A, Bodh V, Dhiman RK. Pregnancy with portal hypertension. J Clin Exp Hepatol 2014; 4:163-71. [PMID: 25755552 PMCID: PMC4116711 DOI: 10.1016/j.jceh.2014.05.014] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 05/28/2014] [Indexed: 12/12/2022] Open
Abstract
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.
Collapse
Key Words
- ACOG, American College of Obstetrics and Gynecology
- EHPVO, extrahepatic portal vein obstruction
- EST, endoscopic sclerotherapy
- EVL, endoscopic variceal ligation
- FDA, Food & Drug Association of America
- HVPG, hepatic vein pressure gradient
- NCPF, non-cirrhotic portal fibrosis
- NCPH, non-cirrhotic portal hypertension
- PPH, postpartum hemorrhage
- PVT, portal vein thrombosis
- Portal vein thrombosis
- cirrhosis
- non-cirrhotic portal fibrosis
- portal hypertension
- pregnancy
Collapse
Affiliation(s)
- Neelam Aggarwal
- Department of Obstetrics & Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India,Address for correspondence: Neelam Aggarwal, Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Neha Negi
- Department of Obstetrics & Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Aakash Aggarwal
- Department Of Internal Medicine, State University of New York (Suny) Upstate Syracuse, NY, USA
| | - Vijay Bodh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| |
Collapse
|
30
|
Jabiry-Zieniewicz Z, Dabrowski FA, Suchońska B, Kowalczyk R, Nowacka E, Kociszewska-Najman B, Pietrzak B, Malkowski P, Wielgos M. Pregnancy and delivery in women with esophageal varices due to hepatic vein thrombosis. J Matern Fetal Neonatal Med 2014; 28:177-81. [DOI: 10.3109/14767058.2014.908846] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
31
|
Portal Cavernoma during Pregnancy. Case Rep Obstet Gynecol 2014; 2013:396083. [PMID: 24392231 PMCID: PMC3872388 DOI: 10.1155/2013/396083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 11/07/2013] [Indexed: 12/02/2022] Open
Abstract
Portal vein thrombosis (PVT) is characterized by the obstruction of the portal venous system. The venous obstruction can be partial or complete and it is caused by thrombogenic conditions (acquired or hereditary) or nonthrombotic factors. The acquired conditions include abdominal inflammation, infections, surgery, myeloproliferative disorders, obesity, oral contraceptive intake, pregnancy, and postpartum period. Occasionally, it is not possible to recognize any overt cause of PVT. During pregnancy there is an increased venous thromboembolism risk mainly in the systemic venous system and the PVT can occur, but there are no data about its exact prevalence, etiology, and outcome. The portal cavernoma is the cavernomatous transformation of the portal vein. It is a consequence of chronic PVT and occurs when myriads of collateral channels develop to bypass the occlusion. The clinical presentation includes hematemesis due to variceal bleeding, ascites or anaemia, and splenomegaly. The cavernous transformation of the portal vein is easily diagnosed by sonography. We report our case of a 32-year-old, gravida 3 para 2, pregnant woman admitted to our hospital at 13 weeks and 1 day of gestation, clinically asymptomatic. Laboratory test, ultrasound, and endoscopic evaluation were negative. After a detailed counseling, the patient decided on termination of pregnancy at 15 weeks and 1 day of gestation.
Collapse
|
32
|
Casini A, Fontana P, Lecompte TP. Thrombotic complications of myeloproliferative neoplasms: risk assessment and risk-guided management. J Thromb Haemost 2013; 11:1215-27. [PMID: 23601811 DOI: 10.1111/jth.12265] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Indexed: 12/29/2022]
Abstract
Philadelphia-negative myeloproliferative neoplasms are considered to be acquired thrombophilic states. Thromboses, both arterial and venous (not rarely in unusual sites), are often the initial events leading to the diagnosis. After diagnosis, the yearly incidence of thrombotic events is highly variable, and ranges from approximately 1% to 10%. The identification of patients at risk who may benefit from antithrombotic therapy remains a challenge, and it is currently based on age and history of thrombotic events. However, the predictive value of these clinical characteristics is rather limited. Few prospective studies and even fewer interventional randomized studies are available, and there are no studies designed to formally validate the use of risk stratification. The implementation of laboratory parameters such as leukocytosis and/or the JAK2 V617F mutation into a scoring system may be of interest. The mechanisms at work leading to thrombosis remain largely speculative, but are likely to be complex and multifactorial, with a prominent role of cell-cell interactions, mostly owing to qualitative changes. The long-term treatment options to prevent thrombosis are, schematically, aspirin alone as primary prevention for the low-risk patients, and cytoreduction combined with aspirin for the other patients. In very low-risk young essential thrombocythemia patients, abstention can even be considered. The optimal duration of anticoagulation after a thrombotic event is not established. All antithrombotic therapies should be balanced with the hemorrhagic risk, which can also be increased in these patients.
Collapse
Affiliation(s)
- A Casini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | | | | |
Collapse
|
33
|
Pregnancy in the Setting of Asymptomatic Non-Cirrhotic Chronic Portal Vein Thrombosis Complicated by Pre-Eclampsia. Case Rep Obstet Gynecol 2013; 2013:984271. [PMID: 23781362 PMCID: PMC3679696 DOI: 10.1155/2013/984271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 05/15/2013] [Indexed: 11/18/2022] Open
Abstract
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.
Collapse
|