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PREGNANCY

  • More than 30% of patients undergoing liver transplantation are women

    • Approximately 75% are of reproductive age and desire future fertility

    • Five percent are pediatric females who will mostly survive into adulthood and consider pregnancy

    • The number of successful liver recipients is increasing worldwide

  • Pregnancy associated with an increase in portal pressure

    • Hypervolemic state of pregnancy leads to an increase in portal flow and elevation of portal venous pressure transmitted to collateral veins

    • Increased pressure leads to increased risk of esophageal variceal bleeding

  • All pregnancies following transplantation are considered to be high risk

    • Maternal and fetal mortality much higher than general population

      • Maternal mortality compared with general population: 1.8% vs. 0%

      • Fetal mortality compared with general population: 5.2% vs. 2.1%

    • Need multidisciplinary care during all aspects of pregnancy with transplant hepatologist, maternal fetal medicine specialist, neonatologist, anesthesiologist, and other specialists

  • Goals of pregnancy

    • Maintain maternal health and graft function with stable immunosuppression dosing

    • Minimize pregnancy complications such as preterm delivery, hypertensive disorders, and fetal growth restriction

  • Preconception counseling

    • Ideally should occur during pretransplant evaluation process and continue through post-transplant process

    • Counsel on optimal timing of pregnancy, mode of delivery, and risks of immunosuppressive therapy

      • Suggested optimal timing of pregnancy: 1 to 2 years after transplantation, 1 year at minimum

      • At this time, patient should be on maintenance immunosuppression

      • Minimizes fetal exposure to high doses of immunosuppressants

    • The better optimized the graft function, the greater the likelihood of successful maternal and fetal outcomes

    • American Society of Transplantation (AST) consensus summary recommends that pregnancy is allowable if there has been

      • No rejection within the past year

      • Adequate and stable graft function

      • No acute infections that may affect fetal growth and well-being

      • Maintenance immunosuppression at stable dosing

    • Women need to be prepared to potentially care for a disabled child

      • Also need to consider who will take care of a child in case of parental disability or death due to unexpected illnesses and/or graft dysfunction

  • National Transplantation Pregnancy Registry (NTPR)

    • Active voluntary registry established in 1991 evaluating pregnancy outcomes in transplant recipients in North America

    • Rates of preeclampsia, cesarean delivery, and preterm birth higher than rates of the general population (last reported in 2013)

      • Preeclampsia rates: 21.9% vs. 3.8%

      • Cesarean delivery rates: 44.6% vs. 31.9%

      • Preterm birth rates: 39.4% vs. 12.5%

  • National Inpatient Sample (NIS)

    • All-payer inpatient database in the United States containing sample of approximately 20% of all hospitalizations

    • Rates of major maternal morbidity, hypertensive disorders, coagulopathy, preterm delivery, cesarean delivery, and postpartum hemorrhage higher than rates of general population (database from 1998 to 2014)

      • Major maternal morbidity rates: 8.0% vs. 0.5%

      • Hypertensive disorder rates: 27.8% vs. 6.9%

      • Coagulopathy rates: 3.1% vs. 0.3%

      • Preterm delivery rates: 27.5% vs. 7.0%

      • Cesarean delivery rates: 51.7% vs. 29.0%

      • Postpartum hemorrhage rates: 8.0% vs. 2.8%

    • Liver graft rejection affected 4.1% of delivery hospitalizations

  • Cesarean delivery

    • History of liver transplantation is not an indication for cesarean delivery. Should only be performed for obstetric reasons.

    • Cesarean section increases risk of maternal ...

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