Liver Disease and Pregnancy
Official guideline from the American College of Gastroenterology.
summary by Russell Rosenblatt, MD Robert S. Brown, MD
Diagnosis and Workup
Initial Evaluation
Pregnant patients with abnormal liver tests should undergo standard work-up; same as non-pregnant.
Strong recommendation
Very low quality evidence
Imaging
Sono is safe and preferred for suspected biliary disease.
Strong recommendation
Low quality evidence
MRI without gadolinium can be used in 2nd and 3rd tri.
Conditional recommendation
Low quality evidence
CT can be used judiciously with minimized radiation protocols (2-5 rads).
Conditional recommendation
Very low quality evidence
Endoscopy
Safe in pregnancy but should be deferred to 2nd tri if possible.
Strong recommendation
Low quality evidence
Can use meperidine and propofol for sedation.
Strong recommendation
Moderate quality evidence
Biliary Disease, Liver Mass, CLD
Biliary Disease
ERCP okay if strongly indicated, e.g. biliary pancreatitis, choledocho, cholangitis.
Strong recommendation
Low quality evidence
Lap chole should be done early if symptomatic cholelithiasis - 10-60% fetal demise if progresses to biliary pancreatitis.
Strong recommendation
Low quality evidence
Liver Masses
Asymptomatic hemangioma and focal nodular hyperplasia do not need surveillance in pregnancy.
Strong recommendation
Very low quality evidence
Should monitor hepatic adenoma during pregnancy w/US. If nonpregnant and adenoma >5cm, should refer for surgery before pregnancy.
Strong recommendation
Low quality evidence
Other Chronic Liver Disease
Continue AIH treatment with steroids or AZA.
Strong recommendation
Very low quality evidence
Continue UDCA for PBC.
Strong recommendation
Very low quality evidence
Continue/reduce Wilson’s disease therapy
Strong recommendation
Very low quality evidence
If suspect portal hypertension, screen for varices in 2nd tri.
Strong recommendation
Low quality evidence
Treat large varices with band ligation or NSBB.
Conditional recommendation
Very low quality evidence
If s/p liver transplant, continue all meds except mycophenolic acid.
Strong recommendation
Moderate quality evidence
Infectious
Hepatitis B
HBIG and HBV vaccine for children with HBV-infected mothers.
Strong recommendation
Low quality evidence
Should offer tenofovir in 3rd tri if chronic HBV and viral load >10⁶ log copies/mL (200,000 IU/mL).
Strong recommendation
Low quality evidence
C-section not recommended.
Strong recommendation
Very low quality evidence
Breastfeeding should be allowed.
Strong recommendation
Very low quality evidence
Hepatitis C
Screen with anti-HCV Ab if risk factors; should not screen if no risk factors.
Strong recommendation
Low quality evidence
Should minimize invasive procedures e.g. amniocentesis, invasive fetal monitoring.
Strong recommendation
Very low quality evidence
Elective C-section not recommended.
Strong recommendation
Very low quality evidence
Breastfeeding should be allowed.
Strong recommendation
Very low quality evidence
Treatment should not be offered during pregnancy.
Strong recommendation
Very low quality evidence
Hepatitis A and E, HSV
Test for HAV, HBV, HEV, HSV if acute hepatitis.
Strong recommendation
Very low quality evidence
If suspect HSV hepatitis, should start empiric acyclovir.
Strong recommendation
Very low quality evidence
Pregnancy-specific
Hyperemesis Gravidarum
Treatment is supportive, may require hospitalization.
Strong recommendation
Very low quality evidence
Intrahepatic Cholestasis of Pregnancy
Recommend early delivery at 37 weeks due to increased risk of fetal complications.
Strong recommendation
Very low quality evidence
Should give UDCA 10-15 mg/kg for symptoms.
Strong recommendation
Moderate quality evidence
Preeclampsia, Eclampsia
Preeclampsia + liver involvement = severe preeclampsia; should deliver after 36 weeks.
Strong recommendation
Very low quality evidence
HELLP Syndrome
Prompt delivery, especially after 35 weeks.
Strong recommendation
Very low quality evidence
Consider platelet transfusion if 40-50,000.
Conditional recommendation
Very low quality evidence
Acute Fatty Liver Disease of Pregnancy
Should manage with prompt delivery; expectant mgmt not appropriate.
Strong recommendation
Very low quality evidence
Test mother and children for LCHAD.
Conditional recommendation
Moderate quality evidence
Monitor children of AFLP mothers for LCHAD deficiency - hypoglycemia, fatty liver.
Conditional recommendation
Very low quality evidence
What do the icons mean?
How strong is the ACG's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Moderate recommendation
Further research likely to impact confidence in estimate of effect.
Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.Weak recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.
High quality evidence
Further research unlikely to change guideline authors' confidence in estimate of effect.
Moderate-high quality evidence
Between high and moderate levels of evidence.
Moderate quality evidence
Further research likely to impact confidence in estimate of effect.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Very low quality evidence
Effect is very uncertain.Literature
