Chapter 33: Obstetrics and Gynecologic Care after Liver Transplantation

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 ...