The Management of Pregnancy in Patients with Advanced Liver Disease Before and After Liver Transplantation

Pregnancy in cirrhotic women carries a significant risk of morbidity and mortality to both mother and fetus. Fetal complications include higher rates of spontaneous abortion, prematurity, and perinatal death. Maternal complications in a patient with established cirrhosis include portal hypertension, potentially life-threatening variceal hemorrhage, hepatic decompensation, postpartum hemorrhage, and splenic artery aneurysm rupture. Most of these adverse outcomes are associated with the severity of liver disease; however, physiologic hypervolemiain pregnancy leads to an additional increase in portal hypertension. Preconception liver transplantation mitigates some of these complications but also introduces added risks of hypertension/preeclampsia, gestational diabetes, and fetal growth restriction. Delaying conception by at least 1 year after transplantation minimizes fetal exposure to high doses of immunosuppressant medication and allows demonstration of good graft function prior to pregnancy. Thus, contraception counseling shortly after the transplant is imperative. Long-acting reversible contraception, which includes intrauterine devices and contraceptive implants, provides the most effective contraception for this population. Once pregnancy is planned and achieved, women need to maintain stable immunosuppression to prevent allograft rejection. Given the complexity of these patients, a multidisciplinary approach and close monitoring are essential to achieving successful outcomes. © Springer Science+Business Media New York 2016.