RT Book, Section A1 Lee, Jessica A1 Dos Santos, Lisa A. A1 Menzin, Andrew W. A1 Trye, Sudhi A2 Molmenti, Ernesto Pompeo A2 SantibaƱes, Martin de A2 SantibaƱes, Eduardo de SR Print(0) ID 1180108280 T1 Obstetrics and Gynecologic Care after Liver Transplantation T2 Liver Transplantation: Operative Techniques and Medical Management YR 2021 FD 2021 PB McGraw Hill PP New York, NY SN 9781260462517 LK accesssurgery.mhmedical.com/content.aspx?aid=1180108280 RD 2024/03/28 AB More than 30% of patients undergoing liver transplantation are womenApproximately 75% are of reproductive age and desire future fertilityFive percent are pediatric females who will mostly survive into adulthood and consider pregnancyThe number of successful liver recipients is increasing worldwidePregnancy associated with an increase in portal pressureHypervolemic state of pregnancy leads to an increase in portal flow and elevation of portal venous pressure transmitted to collateral veinsIncreased pressure leads to increased risk of esophageal variceal bleedingAll pregnancies following transplantation are considered to be high riskMaternal and fetal mortality much higher than general populationMaternal 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 specialistsGoals of pregnancyMaintain maternal health and graft function with stable immunosuppression dosingMinimize pregnancy complications such as preterm delivery, hypertensive disorders, and fetal growth restrictionPreconception counselingIdeally should occur during pretransplant evaluation process and continue through post-transplant processCounsel on optimal timing of pregnancy, mode of delivery, and risks of immunosuppressive therapySuggested optimal timing of pregnancy: 1 to 2 years after transplantation, 1 year at minimumAt this time, patient should be on maintenance immunosuppressionMinimizes fetal exposure to high doses of immunosuppressantsThe better optimized the graft function, the greater the likelihood of successful maternal and fetal outcomesAmerican Society of Transplantation (AST) consensus summary recommends that pregnancy is allowable if there has beenNo rejection within the past yearAdequate and stable graft functionNo acute infections that may affect fetal growth and well-beingMaintenance immunosuppression at stable dosingWomen need to be prepared to potentially care for a disabled childAlso need to consider who will take care of a child in case of parental disability or death due to unexpected illnesses and/or graft dysfunctionNational Transplantation Pregnancy Registry (NTPR)Active voluntary registry established in 1991 evaluating pregnancy outcomes in transplant recipients in North AmericaRates 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 hospitalizationsRates 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 hospitalizationsCesarean deliveryHistory of liver transplantation is not an indication for cesarean delivery. Should only be performed for obstetric reasons.Cesarean section increases risk of maternal infection in the presence of significant immunosuppression and of postpartum hemorrhage.AnemiaDecreased hemoglobin synthesis due to bone marrow suppression by immunosuppressantsRecommend hemoglobin level of 10 to 12 g/dL as therapeutic goalIncreased risk of postpartum hemorrhage due to:Increased rates of cesarean deliveryThrombocytopenia due to immunosuppressantsCoagulation defects due to hypertensive disordersInfectionImmunosuppression makes women more susceptible to infections from various pathogens, including ...