How are liver diseases managed during pregnancy?

Management of Liver Diseases in Pregnancy

All pregnant women with liver disease require pre-pregnancy counseling with risk stratification, continuation of most chronic liver disease medications (except teratogens), and a multidisciplinary approach prioritizing maternal and fetal outcomes through disease-specific protocols. 1

Pre-Pregnancy Planning and Risk Assessment

Pre-pregnancy counseling is mandatory for all women with known liver disease, with calculation of risk scores to characterize complication likelihood before conception. 1

• For liver transplant recipients, delay pregnancy for at least 1 year post-transplant to optimize maternal and fetal outcomes 1
• Screen for liver fibrosis in women with metabolic dysfunction-associated steatotic liver disease (MASLD) using non-invasive tests before conception 1
• Women with cirrhosis or portal hypertension must undergo screening endoscopy within 1 year prior to conception to assess for varices and institute primary prophylaxis 1

Medication Management During Pregnancy

Continue These Medications

Most immunosuppressive and liver disease medications should be continued throughout pregnancy, as stopping them risks maternal clinical deterioration and worse outcomes. 1

• Azathioprine, cyclosporine, tacrolimus, and prednisolone must not be stopped in pregnant women 1
• Prednis(ol)one, budesonide, and thiopurines should be continued for autoimmune hepatitis (AIH), including de novo AIH diagnosed during pregnancy 1
• Wilson's disease therapy with zinc, D-penicillamine, and trientine should continue, with dose reduction of chelators in the second and third trimesters 1
• Beta-blockers should be initiated or continued for primary or secondary prophylaxis of variceal bleeding (unless contraindicated) 1

Stop Before Conception

Mycophenolate mofetil is teratogenic and must be stopped at least 12 weeks before conception 1

Disease-Specific Management

Autoimmune Hepatitis (AIH)

• Continue immunosuppressive therapy throughout pregnancy and postpartum, with consideration for dose increase postpartum due to flare risk 1
• Women with AIH have increased rates of gestational diabetes, hypertensive disorders, preterm birth, and fetal growth restriction requiring close obstetric surveillance 1

Portal Hypertension and Cirrhosis

• Perform endoscopic band ligation for high-risk varices during pregnancy 1
• Delivery should be performed for obstetric indications, considering the severity and distribution of portal hypertension including size/severity of esophageal, gastric, and pelvic varices 1

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

• Optimize metabolic comorbidities before conception and implement treatment during pregnancy 1
• Lifestyle modifications including dietary advice should be advised as for non-pregnant populations 1
• Manage as high-risk for gestational diabetes and hypertensive disease with appropriate screening protocols and liver function monitoring 1
• Breastfeeding is encouraged 1

Viral Hepatitis

Hepatitis A

• Caesarean section is not recommended unless there is an obstetric indication 1, 2
• Breastfeeding should not be discouraged 1, 2
• Active or passive immunization of newborns is not routinely suggested 1

Hepatitis B

• Caesarean section is not recommended to reduce mother-to-child transmission in HBsAg-positive women 1
• Exception: Consider caesarean section only in Asian HBeAg-positive women with high HBV DNA titre (>7 log10 copies/ml; 6.14 log10 IU/ml) who have not received antiviral therapy 1
• Breastfeeding should not be discouraged unless mothers with detectable HBV DNA have cracked nipples and/or the infant has oral ulcers 1

Hepatitis C

• HCV testing is recommended as part of routine antenatal care 1
• Caesarean section should not be recommended to reduce mother-to-child transmission in women with isolated HCV infection 1

Liver Transplant Recipients

• Check blood markers of rejection regularly during pregnancy and titrate immunosuppression appropriately 1
• Increase frequency of review as these women are at risk for gestational hypertension, preeclampsia, gestational diabetes, cholestasis, and acute kidney injury 1
• Initiate low-dose aspirin in the first trimester for preeclampsia prophylaxis 1
• Ensure increased surveillance for preterm birth and fetal growth restriction 1

Hepatocellular Carcinoma and Liver Masses

• Maintain ultrasound surveillance for hepatocellular carcinoma in patients with cirrhosis according to standard screening protocols 1
• Women with hepatocellular carcinoma should be advised that spontaneous and induced vaginal delivery are not contraindicated 1
• Haemangiomas, even giant ones, do not preclude pregnancy, but imaging is recommended each trimester for large or exophytic lesions at higher rupture risk 1
• Focal nodular hyperplasia does not contraindicate pregnancy and vaginal delivery is not associated with increased risks 1

Monitoring During Pregnancy

Immunosuppression-Specific Monitoring

• Women taking cyclosporine and tacrolimus require close monitoring for hypertension and preeclampsia throughout pregnancy 1
• Women taking glucocorticoid treatment should be screened for gestational diabetes 1
• Women taking >5 mg prednisolone daily for >3 weeks are at increased risk of adrenal suppression; consider increased glucocorticoid dose at delivery and with intercurrent infection, vomiting, or hyperemesis gravidarum 1

Critical Pitfalls to Avoid

• Never stop azathioprine, cyclosporine, tacrolimus, or prednisolone during pregnancy - the risk of disease flare outweighs theoretical fetal risks 1
• Do not assume caesarean section reduces viral transmission for hepatitis A, B (in most cases), or C 1, 2
• Do not forget that AIH may deteriorate postpartum - continue and potentially increase immunosuppression after delivery 1
• Do not overlook the need for endoscopic variceal screening before conception in women with cirrhosis 1