Pregnancy outcomes after liver transplantation in Finland

Outcomes of Pregnancies in Liver Transplant Recipients: Experience of a Single Center in Turkey

BACKGROUND

Liver transplantation is the ultimate treatment for end-stage liver failure. As organ donation systems improve, more reproductive-age women are expected to undergo liver transplantation. Current studies indicate increased risk of some perinatal and maternal complications; however, the available data is still scarce. Therefore, we aimed to evaluate the maternal and fetal outcomes of pregnancies in liver transplant recipients.

METHODS

We retrospectively evaluated liver transplantations performed between 2011 and 2020 in a tertiary center. Perinatal, maternal, fetal outcomes and transplant status were assessed among pregnancies conceived after liver transplantation.

RESULTS

Among 1137 patients, 82 (7.2%) were reproductive-age females. Ten pregnancies in nine patients were identified after liver transplantation. The mean age of patients was 29.3±6.1 at transplantation, and 32.5±5.4 at conception. The mean interval between conception and transplantation was 30.3±11.7 months. There were eight live births (80%), one miscarriage (10%) and one termination (10%). Three patients delivered<37th gestational week (37.5%). The median gestational age at birth was 38.5 (IQR: 5.21) weeks. The mean birth weight of infants was 2669.3±831 g. Two patients were diagnosed with preeclampsia (25%) and acute graft rejection episode was observed in one patient (10%) during pregnancy.

CONCLUSION

Although the incidence of some perinatal complications, such as hypertensive disorders and preterm delivery, is increased in liver transplant recipients, pregnancy after liver transplantation appears to have favorable outcomes for the mother, fetus and transplant with close monitoring by a multidisciplinary team.

Uterine Transplantation: Review of Livebirths and Reproductive Implications

Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.

Effects of liver transplantation on sexual function and quality of life

This descriptive study aimed to determine patients' sexual dysfunction and quality of life before and after liver transplantation. The study was conducted with 64 patients who underwent liver transplantation at a university hospital between January 2015 and 2017. The patients were aged 18 or over, able to answer relevant questions and volunteered to participate in the study. The population of the study included patients who underwent liver transplantation on the specified dates and agreed to participate in the study. Descriptive Characteristics Form, Short Form-36 (SF-36), Female Sexual Function Index (FSFI) and International Index of Erectile Function (IIEF) were used for data collection. A significant increase was found in all subscale scores of males on the IIEF scale after transplantation (p = 0.000). The total FSFI score of the females was 24.27 ± 18.60 before transplantation and 29.62 ± 25.19 after transplantation. The results were not statistically significant (p = 0.072). After transplantation, a highly significant increase was observed in the Physical Component Summary and Mental Component Summary subscale scores of the SF-36 both in males and females (p = 0.000). An increase was observed in the sexual functions of males and females after transplantation. A statistically significant increase was found in the mean scores of both males and females on the quality of life after transplantation (p = 0.000). This study concluded that sexual functions of male (p < 0.05) and female (p > 0.05) patients improved after transplantation.

Pregnancy Outcomes After Liver Transplantation: A Systematic Review and Meta-Analysis

INTRODUCTION

Liver transplantation (LT) remains the gold standard for treatment of end-stage liver disease. Given the increasing number of liver transplantation in females of reproductive age, our aim was to conduct a systematic review and meta-analysis evaluating pregnancy outcomes after LT.

METHODS

MEDLINE, Embase, and Scopus databases were searched for relevant studies. Study selection, quality assessment, and data extraction were conducted independently by 2 reviewers. Estimates of pregnancy-related outcomes in LT recipients were generated and pooled across studies using the random-effects model.

RESULTS

A comprehensive search identified 1,430 potential studies. Thirty-eight studies with 1,131 pregnancies among 838 LT recipients were included in the analysis. Mean maternal age at pregnancy was 27.8 years, with a mean interval from LT to pregnancy of 59.7 months. The live birth rate was 80.4%, with a mean gestational age of 36.5 weeks. The rate of miscarriages (16.7%) was similar to the general population (10%-20%). The rates of preterm birth, preeclampsia, and cesarean delivery (32.1%, 12.5%, and 42.2%, respectively) among LT recipients were all higher than the rates for the general US population (9.9%, 4%, and 32%, respectively). Most analyses were associated with substantial heterogeneity.

DISCUSSION

Pregnancy outcomes after LT are favorable, but the risk of maternal and fetal complications is increased. Large studies along with consistent reporting to national registries are necessary for appropriate patient counseling and to guide clinical management of LT recipients during pregnancy.

Pregnancy outcomes in women with liver transplants: systematic review and meta-analysis

BACKGROUND

Despite increasing reports of pregnancy in liver transplant recipients, questions remain about the impact of transplantation in pregnancy.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 26th December 2019 for studies reporting pregnancy with liver transplant. A meta-analysis was conducted with the use of random-effects modelling and prospectively registered with the PROSPERO database.

RESULTS

Of 1239 unique studies, 28 met inclusion criteria, representing 1496 pregnancies in 1073 liver transplant recipients. The live-birth rate was 85.6% (CI95%: 80.5%-90.7%). The rate of other pregnancy outcomes was as follows: induced abortions (5.7%), miscarriages (7.8%) and stillbirths (3.3%). Pooled rates of obstetric complications were hypertension (18.2%), pre-eclampsia (12.8%) and gestational diabetes (7.0%). Pooled rates of delivery outcomes for caesarean section (C-section) and pre-term birth were 42.2% and 27.8%, respectively.

CONCLUSION

In conclusion, live birth outcomes are good among liver transplant recipients and this favourable trend is consistent at an international level. However, special attention should be given to obstetric complications such as hypertension, pre-eclampsia, and preterm delivery. The high incidence of these complications supports the high-risk classification of post-liver transplant pregnancies and it is necessary for a multidisciplinary team to be involved in the monitoring and counselling of liver transplant recipients both before and during pregnancy. Whilst majority data originate from institutions from high-income countries, data from low-middle income countries (LMIC) are needed owing to rising rates of liver transplantation in LMIC.

Pregnancy in Liver Transplantation

Pregnancy after liver transplantation (LT) is increasingly common and is a frequent scenario that transplant physicians, obstetricians, and midwives encounter. This review summarizes the key issues surrounding preconception, pregnancy-related outcomes, immunosuppression, and breastfeeding in female LT recipients. Prepregnancy counseling in these patients should include recommendations to delay conception for at least 1-2 years after LT and discussions about effective methods of contraception. Female LT recipients are generally recommended to continue immunosuppression during pregnancy to prevent allograft rejection; however, individual regimens may need to be altered. Although pregnancy outcomes are overall favorable, there is an increased risk of maternal and fetal complications. Pregnancy in this cohort remains high risk and should be managed vigilantly in a multidisciplinary setting. We aim to review the available evidence from national registries, population-based studies, and case series and to provide recommendations for attending clinicians.

Obstetric outcomes among women with a liver transplant

BACKGROUND

Women with liver transplants may be at increased risk for adverse outcomes.

OBJECTIVE

The objectives of this study were to evaluate trends and provide recent data on outcomes for women with a liver transplant.

STUDY DESIGN

The National (Nationwide) Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project from 1998 to 2014 was used for this repeated cross-sectional analysis. Women aged between 15 and 54 years, with a history of liver transplant who underwent delivery, antepartum, or postpartum hospitalizations were identified. Temporal trends in deliveries of women with liver transplants were analyzed. The risk for severe maternal morbidity (SMM) excluding transfusion based on criteria from the Centers for Disease Control and Prevention (CDC), as well as for individual outcomes including hypertensive diseases of pregnancy, postpartum hemorrhage, placental abruption, liver rejection, cesarean delivery, preterm delivery, and coagulopathy during delivery hospitalizations were analyzed. Risks of SMM during antepartum and postpartum hospitalizations were also analyzed. An adjusted log-linear regression model for SMM during delivery hospitalizations including demographic factors, hospital characteristics, and underlying comorbidity was performed. The chi-squared or Fisher's exact test was used for comparisons. Temporal trends were analyzed with the Cochran-Armitage trend test. Population weights were applied to create national estimates.

RESULTS

From 1998 to 2014, an estimated 1165 births occurred by women with a liver transplant. The number of births occurring by women with liver transplants increased over the study period from 1.0 per 100,000 in 1998-2000 to 2.8 per 100,000 in 2012-2014 (p < .01). The risk for CDC SMM excluding transfusion was significantly higher during delivery hospitalizations among women with compared to without liver transplant (8.0 versus 0.5%, p < .01, unadjusted risk ratio 15.4, 95% CI 12.7-18.6). Women with liver transplant were also at significantly higher risk for abruption (2.5 versus 1.0%, p = .03), hypertensive diseases of pregnancy (27.8 versus 6.9%, p < .01), postpartum hemorrhage (8.0 versus 2.8%, p = .01), cesarean delivery (51.7 versus 29.5%, p < .01), preterm delivery (27.5 versus 7.0%, p < .01), and coagulopathy (3.1 versus 0.3%, p < .01). A diagnosis of liver rejection was present during 4.1% of delivery hospitalizations for women with liver transplant. In the adjusted analysis for severe morbidity excluding transfusion risk was retained with liver transplant associated with increased likelihood of this adverse outcome (aRR 8.49, 95% CI 5.59-12.87). Women with liver transplants were at significantly higher likelihood of undergoing antepartum and postpartum admissions, and of experiencing SMM during these hospitalizations.

CONCLUSION

In this analysis of antepartum, delivery, and postpartum hospitalizations, women with liver transplant were at significantly higher risk for both SMM during all hospitalizations and for a range of adverse outcomes including placental abruption, hypertensive diseases of pregnancy, postpartum hemorrhage, cesarean delivery, and coagulopathy delivery during delivery hospitalizations. While deliveries to women with liver transplant were rare, these births became more frequent over the study period.

Deficiencies in reproductive health counseling in liver transplant recipients

BACKGROUND

In liver transplant (LT) recipients of childbearing age, there is often rapid return of fertility post-transplant. Our aim was to determine whether healthcare providers are documenting reproductive health counseling in LT recipients.

METHODS

We performed a review of 365 LT recipients (164 female, 201 male) of childbearing age transplanted between 1994 and 2015 at a single center. We evaluated documentation of reproductive health counseling, content of the counseling and its provider.

RESULTS

Reproductive health counseling was documented in 7% of LT recipients (14% of females, 0.5% of males). The transplant team provided the counseling in 56%, obstetrics/gynecology in 35%, and primary care in 9%. Twenty-four post-LT pregnancies occurred; these were unplanned in 13%. Miscarriage/stillbirth occurred in 7/24 pregnancies (29%). Mycophenolic acid was used by 20% of female recipients at conception. Only age at transplant (P = 0.001) and post-LT pregnancy was associated with documentation of reproductive health counseling in female recipients (P = 0.0001).

CONCLUSION

Despite rapid return of fertility in reproductive-aged LT recipients, documentation of reproductive health counseling in this population is rare in men and women. This increases the potential for adverse maternal and fetal outcomes in this high-risk population.

Effects of intrahepatic cholestasis of pregnancy on hepatic function, changes of inflammatory cytokines and fetal outcomes

The effects of intrahepatic cholestasis of pregnancy (ICP) on hepatic function, changes of inflammatory cytokines and fetal outcomes were studied. In total, 663 pregnant women admitted to Daqing Longnan Hospital from July 2016 to December 2017 were selected. There were, 40 cases with ICP enrolled in the observation group, and 40 normal pregnant women were recruited in the normal group. They were also grouped according to hepatic function and inflammatory cytokines, with 40 cases in each group. Neonatal Apgar scores were recorded. The correlations of serum cholylglycine (CG) in pregnant women with umbilical artery systolic-to-diastolic (S/D) ratio in the third trimester of pregnancy, the alanine aminotransferase level, the high-sensitivity C-reactive protein (hs-CRP) level, neonatal Apgar score and gestational week were analyzed. The birth weight in the observation group was lighter than that in the normal group (P<0.05); the gestational week at birth was earlier than that in the normal group (P<0.05); Apgar score at birth was lower than that in the normal group (P<0.05), and the levels of inflammatory cytokines were higher than those in the control group (P<0.05). Apgar scores of newborns at birth and at 1 and 5 min after birth in the normal hepatic function and normal inflammatory cytokine groups were higher than those in the abnormal hepatic function group (P<0.05). The serum CG level in pregnant women was positively correlated with umbilical artery S/D ratio, the alanine aminotransferase level and the hs-CRP level in the third trimester of pregnancy, but negatively correlated with neonatal Apgar score and gestational week. Among patients with ICP, the higher the GG level in the body is, the higher the alanine aminotransferase, inflammatory cytokine and umbilical artery S/D ratio will be, which may cause lower neonatal Apgar score, neonatal asphyxia and premature delivery.