Reproductive Health and Liver Disease
Sexual Function Across Age in Patients with Chronic Liver Disease
Evaluation and Management of Sexual Dysfunction in Chronic Liver Disease
Pregnancy Planning in Adolescents and Adults With Liver Conditions
Assisted Reproduction and Liver Disease
Menopause, Andropause, and Hormone Therapy
Evaluation of Liver Disease in Pregnancy
Initial Evaluation of a Pregnant Patient With Liver Disease
Liver Biochemistry Changes During Normal Pregnancy
Abdominal Imaging in Pregnancy
Management of Chronic Liver Diseases During Pregnancy and Lactation
HBsAg‐positive pregnant women:
In women with WD:
- Preconception counseling should include genetic counseling and discussion of medication safety in pregnancy.
- Use of zinc is safe in pregnancy and delaying conception until the patient is on zinc monotherapy should be encouraged.
- Chelating agents should be continued during pregnancy due to the high risk of spontaneous abortion if withdrawn. Dose reductions in the second and third trimesters are required.
- Breastfeeding is associated with infant risks, as all WD drugs are excreted in breast milk, and there is risk for copper deficiency in the infant.
In women with AIH:
- Preconception counseling should include discussion of medication safety in pregnancy and potential for disease exacerbation, including decompensation. Delaying conception until liver disease is well controlled on stable doses of immunosuppressants for at least 1 year is suggested.
- Counseling regarding the potential risks of azathioprine and 6‐mercaptopurine (6‐MP) is recommended, although these drugs are considered safe in pregnancy and lactation.
- Prednisone and budesonide are considered low risk in pregnancy and lactation.
- MPA products are contraindicated in pregnancy and lactation.
Chronic Cholestatic Liver Diseases
Primary Biliary Cholangitis and Primary Sclerosing Cholangitis
In women with PBC and PSC:
- Measurement of total serum bile acids may be considered in the first trimester to aid in excluding ICP in the setting of new‐onset or worsening pruritus during pregnancy.
- UDCA is safe in pregnancy and lactation, although no data support a therapeutic benefit in primary sclerosing cholangitis.
- Obeticholic acid and fibrate use cannot be recommended in pregnancy or lactation in women with PBC due to lack of safety data.
- Clinically significant pruritus typically requires a multifaceted approach with cholestyramine (4‐16 g daily, divided dose and separated from other medications by at least 2 hours), rifampin (300‐600 mg daily), SAMe (1,000‐1,200 mg daily), and antihistamines considered, although evidence is low.
- Vitamin K deficiency related to cholestasis should be corrected, and regular monitoring of PT is recommended.
Nonalcoholic Fatty Liver Disease
In reproductive‐aged patients with NAFLD:
- Evaluation for symptoms associated with polycystic ovary syndrome is recommended.
- Preconception counseling should include review of maternal and fetal risks associated with obesity and diabetes and the benefits of optimizing weight and metabolic comorbidities before conception.
In pregnant patients with NAFLD:
Alcohol‐Associated Liver Disease
Liver Conditions Requiring Special Management in Pregnancy
Benign Hepatic Lesions in Pregnancy
- US monitoring of HCAs during each trimester of pregnancy and up to 3 months postpartum is reasonable.
- Pregnancy in women with HCAs less than 5 cm in diameter is not contraindicated.
- For HCAs greater than 5 cm in diameter, prophylactic treatment with embolization or resection should be considered before conception to reduce the risk of rupture during pregnancy.
Focal Nodular Hyperplasia
Gallstone Disease in Pregnancy
Acute Viral Hepatitis
Pregnancy in the Patient With Cirrhosis
Management of portal hypertension (PHT) in Pregnancy
Liver Diseases Unique to Pregnancy and Their Management
Intrahepatic Cholestasis of Pregnancy
Hypertensive Diseases of Pregnancy
Acute Fatty Liver of Pregnancy
Reproductive Health and Pregnancy in Transplant Recipients
Reproductive Health and Liver Disease
September 18, 2020
Supplemental Implementation Tools
External Publication Status
Country of Publication
This first Practice Guidance on Reproductive Health from the American Association for the Study of Liver Diseases (AASLD) is intended to be a comprehensive reference on adolescents and adults with chronic liver disease. The Guidance specifically (1) addresses management of reproductive health in women and men from puberty to senescence and (2) summarizes the natural history, risk factors, evaluation, and optimal management of liver diseases during pregnancy and after birth.
Female, Male, Adolescent, Adult
Health Care Settings
Nurse, nurse practitioner, physician, physician assistant
Assessment and screening, Management
D008107 - Liver Diseases, D060728 - Reproductive Health, D016031 - Liver Transplantation
Reproductive Health, liver disease
Sarkar M, Brady CW, Fleckenstein J, Forde KA, Khungar V, Molleston JP, Afshar Y, Terrault NA. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2020 Sep 18. doi: 10.1002/hep.31559. Epub ahead of print. PMID: 32946672.