With rates of liver disease increasing among adolescents and young adults, hepatologists are thinking more carefully about screening and treating women of childbearing age, according to a Duke hepatologist and liver transplant specialist. Because of the need to consider both maternal and fetal health, there are special considerations for managing liver disease that occurs in pregnancy.
Carla W. Brady, MD, MHS, specializes in helping women with liver disease-related issues, especially those who are pregnant or seeking to become pregnant and have chronic liver disease. She is the author of a review published in Hepatology Communications in January 2020 on the pathogenesis and expression of liver diseases in pregnancy. She is also a co-author of the first practice guidance on reproductive health and liver disease published by the American Association for Study of Liver Diseases in its journal Hepatology in September 2020.
Although overall pregnancy outcomes for women with hepatitis C infection are generally favorable, with low rates of maternal-fetal transmission, Brady notes that recent studies suggest a possible association between infection in pregnancy and gestational diabetes, low birth weight, preterm delivery, and intrahepatic cholestasis, making screening particularly important for women of childbearing age.
“We don’t treat hepatitis C during pregnancy, so screening is very important because this disease often exists silently,” says Brady. “If we identify and treat it before pregnancy, we can mitigate significant chronic liver disease—cirrhosis, liver failure, cancer—which are potential complications. For pregnant patients who have hepatitis C, I strongly encourage them to come back in the early postpartum stage so we can actively discuss treatment to eradicate the virus while they still have a well-functioning liver.”
Brady stresses that pregnant women with autoimmune hepatitis must have a hepatologist involved in their care in addition to their obstetrician. “We treat this disorder with immunosuppression, so a specialist is needed to ensure compatibility of various immunosuppressive drugs in pregnancy and ensure a patient’s liver function is stable throughout pregnancy. A great degree of vigilance is also required early postpartum because a patient’s immune system shifts back to baseline, resulting in up to a 30% to 50% chance of flares of autoimmune hepatitis.”
Less frequent than liver disease—but equally important—is managing pregnancy in patients who have had a liver transplant. “Pregnancy in a post-transplant setting can occur safely, but hepatologists must understand the compatibility of immunosuppressive drugs with pregnancy and monitor allograft function closely during pregnancy and postpartum,” says Brady.
Cirrhosis, Portal Hypertension
The management of potential complications is also complex in pregnant women who have cirrhosis and portal hypertension. “Pregnancy is less likely to occur in a woman with cirrhosis due to an increased likelihood of amenorrhea and anovulation, but when it does occur, there are implications on liver-related health,” Brady explains. “It’s very important that these women are closely monitored for complications.”
Brady notes that another important factor in the care of pregnant women with liver disease is the collaboration between hepatologists and obstetricians.
Jennifer B. Gilner, MD, PhD, is a Duke maternal-fetal medicine specialist who has advanced training in the medical and surgical care of women with pregnancies affected by medical conditions or pregnancy-related complications. She often collaborates with Brady in the care of pregnant patients with liver disease and those who have undergone liver transplantation.
“Dr. Brady is a wonderfully thoughtful and informative consultant, with the ability to frame hepatology care within the complex adaptations that pregnancy demands of the mother’s body,” says Gilner. “We have coordinated the care of many patients with high-risk comorbidities in pregnancy over our years of working together, helping our patients realize their family goals even when living with complex liver conditions.”
Gilner says the collaboration is invaluable when planning the necessary vigilant monitoring of symptoms and labs throughout a patient’s pregnancy and postpartum period, particularly when a clinical scenario requires a short timeline for action.
For pregnant women with any type of liver disease, Brady believes that education is a critical factor in their care. Gilner and Brady recently collaborated on an editorial that was published in Liver Transplantation in August 2020 about the importance of reproductive counseling in liver transplant care.
“I always talk with patients about the effects of their condition on pregnancy outcomes and maternal-fetal health, and facts about the safety of breastfeeding,” says Brady. “Before and during pregnancy is an opportune time to educate women about maternal outcomes of hepatitis and other liver conditions because they’re usually very actively engaged in their own health care during this time in their lives.”
“Dr. Brady promotes the importance of family planning that begins well before conception to give the mother and infant the best chances of happy, healthy outcomes,” says Gilner.