Liver Disease and Pregnancy

Publication Date: February 1, 2016

Recommendations

EVALUATION

A pregnant patient presenting with abnormal liver tests should undergo standard workup as with any non-pregnant individual. (Strong  “We recommend”Very low)
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IMAGING

Ultrasound is safe and the preferred imaging modality used in assessment of abnormal liver tests suggestive of biliary tract disease. (Strong  “We recommend”Low)
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Magnetic resonance imaging (MRI) without gadolinium can be used in the second and third trimester. (Conditional (weak)  “We suggest”Low)
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Computed tomography (CT) scans carry a risk of teratogenesis and childhood hematologic malignancies but may be used judiciously with minimized radiation protocols (2–5 rads). (Conditional (weak)  “We suggest”Very low)
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ENDOSCOPY

Endoscopy is safe in pregnancy but should be deferred until the second trimester if possible. (Strong  “We recommend”Low)
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Meperidine and propofol can be used for endoscopic sedation. (Strong  “We recommend”Moderate)
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BILIARY DISEASE

ERCP can be performed when indicated for pregnant women presenting with biliary disease that strongly necessitates intervention such as biliary pancreatitis, symptomatic choledocholithiasis, and/or cholangitis. Minimizing fetal exposure to fluoroscopy is imperative. (Strong  “We recommend”Low)
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Symptomatic cholecystitis should be managed with early surgical intervention with laparoscopic cholecystectomy. (Strong  “We recommend”Low)
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LIVER MASSES

Asymptomatic hemangioma and focal nodular hyperplasia do not need routine imaging or surveillance during pregnancy. (Strong  “We recommend”Very low)
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Hepatic adenomas should be monitored with ultrasound during pregnancy for growth. Patients with large adenomas (>5 cm) should be referred for resection before pregnancy. (Strong  “We recommend”Low)
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LIVER DISEASES UNIQUE TO PREGNANCY

The treatment of hyperemesis gravidarum (HG) is supportive and may require hospitalization. (Strong  “We recommend”Very low)
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Because of increased risk of fetal complications with intrahepatic cholestasis of pregnancy (IHCP), early delivery at 37 weeks is recommended. (Strong  “We recommend”Very low)
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Ursodeoxycholic acid (UDCA) should be given at 10–15 mg/kg to women with IHCP for symptomatic improvement. (Strong  “We recommend”Moderate)
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Preeclampsia with hepatic involvement elevates the diagnosis to severe preeclampsia. After 36 weeks, women with severe preeclampsia should be delivered promptly to limit maternal and fetal complications. (Strong  “We recommend”Very low)
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Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome should be managed by prompt delivery, especially after 34 weeks gestation. (Strong  “We recommend”Very low)
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Platelet transfusion to 40,000–50,000 cells/μl should be considered before delivery, especially if cesarean section is likely. (Conditional (weak)  “We suggest”Very low)
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Women with acute fatty liver disease of pregnancy (AFLP) should be delivered promptly; expectant management is not appropriate. (Strong  “We recommend”Very low)
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All women with AFLP and their children should have molecular testing for long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD). (Conditional (weak)  “We suggest”Moderate)
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The offspring of mothers affected by AFLP should be monitored carefully for manifestations of deficiency of LCHAD including hypoketotic hypoglycemia and fatty liver. (Conditional (weak)  “We suggest”Very low)
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COINCIDENT LIVER DISEASE

Pregnant women presenting with acute hepatitis should be tested for common etiologies of acute liver injury including viral hepatitis, hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis E virus (HEV), and herpes simplex virus (HSV). (Strong  “We recommend”Very low)
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Pregnant women with acute hepatitis suspected from HSV should be initiated on acyclovir. (Strong  “We recommend”Very low)
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CHRONIC LIVER DISEASES, CIRRHOSIS, AND LIVER TRANSPLANTATION

Hepatitis B

Active–passive immunoprophylaxis with hepatitis B immune globulin and the HBV vaccination series should be administered to all infants born to HBV-infected mothers to prevent perinatal transmission. (Strong  “We recommend”Low)
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Women chronically infected with HBV and high viral load (>200,000 U/ml or >106 log copies/ml and higher) should be offered antiviral medication with tenofovir or telbivudine in the third trimester to reduce perinatal transmission of HBV. (Strong  “We recommend”Low)
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C-section should not be performed electively in HBV-positive mothers to prevent fetal infection. (Strong  “We recommend”Very low)
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Women chronically infected with HBV should be allowed to breastfeed as recommended for infant health. (Strong  “We recommend”Very low)
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Hepatitis C

All pregnant women with risk factors for HCV should be screened with anti-HCV antibody. Screening should not be performed in women without risk factors for HCV acquisition. (Strong  “We recommend”Low)
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Invasive procedures (e.g., amniocentesis, invasive fetal monitoring) should be minimized in infected mothers and their fetus to prevent vertical transmission of hepatitis C. (Strong  “We recommend”Very low)
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C-section should not be performed electively in HCV-positive mothers to prevent fetal infection. (Strong  “We recommend”Very low)
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Women chronically infected with HCV should be allowed to breastfeed as indicated for infant health. (Strong  “We recommend”Very low)
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Hepatitis C therapy should not be offered to pregnant women to either treat HCV or decrease the risk for vertical transmission. (Strong  “We recommend”Very low)
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Pregnant women with autoimmune hepatitis (AIH) should be continued on their treatment with corticosteroids and/or azathioprine (AZA). (Strong  “We recommend”Very low)
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Pregnant women with primary biliary cirrhosis (PBC) should be continued on their treatment with UDCA. (Strong  “We recommend”Very low)
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Pregnant women with Wilson’s disease (WD) should be continued, with dose reduction if possible, on their treatment with penicillamine, trientine, or zinc. (Strong  “We recommend”Very low)
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Pregnant women with suspected portal hypertension should undergo screening with upper endoscopy for esophageal varices in the second trimester. (Strong  “We recommend”Low)
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Pregnant women who are found to have large esophageal varices should be treated with beta-blockers and/or band ligation. (Conditional (weak)  “We suggest”Very low)
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Pregnant women with a history of liver transplantation should continue their immunosuppression except for mycophenolic acid. (Strong  “We recommend”Moderate)
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Recommendation Grading

Disclaimer

Overview

Title

Liver Disease and Pregnancy

Authoring Organization

Publication Month/Year

February 1, 2016

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women

Target Patient Population

Pregnant women with liver disease

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Keywords

pregnancy, liver disease, Radiology

Source Citation

Tran, Tram T MD, FACG, FAASLD; Ahn, Joseph MD, MS, FACG; Reau, Nancy S MD, FAASLD, FAGA. ACG Clinical Guideline: Liver Disease and Pregnancy, American Journal of Gastroenterology: February 2016 - Volume 111 - Issue 2 - p 176-194 doi: 10.1038/ajg.2015.430

Supplemental Methodology Resources

Data Supplement