Keywords:
Chronic liver diseases, cirrhosis in pregnancy, Budd Chiari Syndrome,
splenomegaly in pregnancy, jaundice in pregnancy
Dear Dr. Papageorghiou,
Recently, obstetricians have come across more pregnancies complicated by
chronic liver diseases (CLD) due to an advancement in the diagnosis of
non-communicable diseases. CLD in pregnancy is associated with adverse
feto-maternal outcome. This study addressed the pattern of liver
diseases in the obstetric population with special attention to
feto-maternal outcome.
It was prospective cohort study over a period of three years.
Institutional ethics committee approval was obtained prior to its
commencement. Written informed consents were taken from all
participants. Pregnant women with diagnosed liver disorders and
delivering in the labour wards were included. Women not willing to
participate or those delivering outside and being referred in the
postpartum period were excluded. Data was collected after a detailed
interview of patients and their relatives. Hospital records were
reviewed and prospectively followed till discharge. More than two months
of treatment or at least five antenatal visits was considered as booked.
Data relating to obstetric parameters like age, parity, presence of
previous stillbirth and complications specific to pregnancy was
collected. In the postpartum period, data was collected pertaining to
gestation at delivery, mode of delivery, birth weight and congenital
malformations. Post partum mothers were monitored for any complications
till discharge.
Extra hepatic portal venous obstruction (EHPVO) with associated varices
and splenomegaly had the highest prevalence (28.9%). Next common was
non-alcoholic steato-hepatitis (26.3%) followed by chronic Hepatitis-C
infection (23.6%). The prevalence of liver cirrhosis, Budd-Chiari
Syndrome, Gilbert Syndrome and non-cirrhotic portal fibrosis (NCPF) were
6.6%, 5.2%, 5.2% and 3.9% respectively (Table-1). Most pregnancies
were booked (72.4%). Majority of women were in the age group of 25-29
years (39.5%). In 77.6% women, disease activity was diagnosed before
pregnancy.
Among pregnancy specific complications, obstetric cholestasis was the
most common. In the study population, 23.6% and 63.2% had preterm and
term deliveries, while 51.3% and 31.6% patients had vaginal and
caesarean delivery respectively. There were no cases of maternal near
miss and mortality. Analyzing the fetal outcome, there were 13.2%
abortions, 84.2% live births, 2.6% stillbirths and 28.2% fetal growth
restriction with no neonatal death. No babies had any gross congenital
malformations. Low birth weight, very low birth weight and extremely low
birth weight was observed in 30.3 %, 2.6 % and 3.9 % babies
respectively. There was no clinical macrosomia.
Maternal immune tolerance involving immunological shift is the key of
successful pregnancy. The main risk in EHPVO is variceal bleeding, which
may be life threatening [1]. Pregnancy outcome is successful if the
disease is adequately controlled prior to pregnancy [1]. Pregnancy
with Hepatitis-C and liver cirrhosis is a high risk combination for
mother and foetus and is associated with worsening of liver
decompensation and progression to portal hypertension, ascites,
hepatorenal syndrome, hepatic encephalopathy and variceal hemorrhage
[3,4]. The overall outcome in patients with NCPF is favorable
despite a significant increase in incidence of complications related to
portal hypertension [5].
Hepatic diseases in pregnancy have to be managed with multidiscipilinary
expertise. The key to successful management includes preconception
counselling and meticulous antepartum, intrapartum and postpartum care.