What are the indications for treatment in autoimmune hepatitis (AIH) during pregnancy?

Treatment Indications for Autoimmune Hepatitis in Pregnancy

All pregnant women with autoimmune hepatitis—whether pre-existing or newly diagnosed—should receive immunosuppressive treatment with glucocorticoids and/or azathioprine, as treatment significantly reduces maternal complications and improves fetal outcomes compared to untreated disease. 1

Core Treatment Principles

Continue existing immunosuppression throughout pregnancy. The most critical indication for treatment is the presence of AIH itself, regardless of pregnancy status. 1 The evidence is unequivocal: flares occur primarily in patients who are not on therapy or who have not achieved remission prior to conception, and these flares drive the 38% maternal complication rate and contribute to the 27% fetal loss rate. 1

Specific Clinical Scenarios Requiring Treatment:

Pre-existing AIH on maintenance therapy:

• Continue maintenance doses of glucocorticoids and/or azathioprine without interruption 1
• The goal is preventing disease flares, which occur 3 times more commonly postpartum than during pregnancy 1
• Discontinuing therapy based on outdated teratogenicity concerns poses greater maternal and fetal risks than continued medication 2

New-onset AIH diagnosed during pregnancy:

• Initiate treatment immediately using the same approach as non-pregnant patients 1
• Start prednisolone 0.5-1 mg/kg/day as induction therapy 1
• For severe presentations (acute liver failure or acute severe AIH), use intravenous corticosteroids with parallel assessment for liver transplantation 1

Patients not in remission prior to conception:

• These patients have the highest risk of flares and require aggressive treatment optimization 1
• Flares during pregnancy are primarily due to inadequate disease control, not pregnancy itself 1

Treatment Regimens

First-line therapy:

• Prednisolone/prednisone: 5-20 mg daily for maintenance, or 0.5-1 mg/kg/day for induction 1, 2
• Azathioprine: 50-150 mg daily (US dosing) or 1-2 mg/kg daily (European dosing) can be continued or added 1
• Budesonide is also acceptable per EASL guidelines 1

Safety data supporting azathioprine use:

• A systematic review of 3,000 pregnant patients with inflammatory bowel disease found no increase in low birth weight or birth defects 1
• The live birth rate is 73% in mothers with AIH on treatment, with no specific birth defects associated with azathioprine 1
• Large observational studies show no apparent relationship between azathioprine use and adverse fetal outcomes beyond baseline population rates 2

Critical Monitoring Requirements

Postpartum period demands intensified surveillance:

• Monitor serum AST/ALT at 3-week intervals for at least 3 months postpartum 2
• Flares occur in 52% of patients postpartum, making this the highest-risk period 2
• Consider increasing immunosuppression doses postpartum prophylactically 1

During pregnancy:

• Regular monitoring of liver enzymes (AST/ALT), bilirubin, and immunoglobulin levels 2
• Disease activity is unpredictable, with flares occurring in 21-33% of pregnancies despite treatment 2

Special Populations

Patients with cirrhosis:

• Screen for varices by endoscopy either prior to conception or during the second trimester 1
• Treat varices with band ligation as indicated 1
• Serious maternal complications (death, transplant need, hepatic decompensation) occur in approximately 11% of pregnancies, significantly higher in women with established cirrhosis 2

Variant syndromes (AIH-PBC or AIH-PSC overlap):

• Add ursodeoxycholic acid to improve pruritus and cholestatic biochemistry 1
• Continue standard AIH immunosuppression 1

Absolute Contraindications

Mycophenolate mofetil (MMF) must be discontinued:

• MMF is contraindicated during pregnancy 1
• Women should be counseled about adverse effects prior to initiating MMF treatment 1
• Switch to azathioprine or increase glucocorticoid doses before conception 1

Common Pitfalls to Avoid

The most dangerous error is discontinuing immunosuppression during pregnancy based on outdated concerns about azathioprine teratogenicity—disease flares pose greater maternal and fetal risks than continued medication. 2 Inadequate postpartum monitoring is the second major pitfall, as over half of disease flares occur in the 3 months following delivery when surveillance may inadvertently decrease. 2

Failure to achieve remission before conception increases complications substantially. The ideal approach includes achieving biochemical remission for 1 year prior to conception. 1