MDCalc

Liver Disease and Pregnancy

Official guideline from the American College of Gastroenterology.

Diagnosis and Workup

Initial Evaluation
Strong recommendation
Very low quality evidence
Pregnant patients with abnormal liver tests should undergo standard work-up; same as non-pregnant.
Imaging
Strong recommendation
Low quality evidence
Sono is safe and preferred for suspected biliary disease.
Conditional recommendation
Low quality evidence
MRI without gadolinium can be used in 2nd and 3rd tri.
Conditional recommendation
Very low quality evidence
CT can be used judiciously with minimized radiation protocols (2-5 rads).
Endoscopy
Strong recommendation
Low quality evidence
Safe in pregnancy but should be deferred to 2nd tri if possible.
Strong recommendation
Moderate quality evidence
Can use meperidine and propofol for sedation.

Biliary Disease, Liver Mass, CLD

Biliary Disease
Strong recommendation
Low quality evidence
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.
Liver Masses
Strong recommendation
Very low quality evidence
Asymptomatic hemangioma and focal nodular hyperplasia do not need surveillance in pregnancy.
Strong recommendation
Low quality evidence
Should monitor hepatic adenoma during pregnancy w/US. If nonpregnant and adenoma >5cm, should refer for surgery before pregnancy.
Other Chronic Liver Disease
Strong recommendation
Very low quality evidence
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
Low quality evidence
If suspect portal hypertension, screen for varices in 2nd tri.
Conditional recommendation
Very low quality evidence
Treat large varices with band ligation or NSBB.
Strong recommendation
Moderate quality evidence
If s/p liver transplant, continue all meds except mycophenolic acid.

Infectious

Hepatitis B
Strong recommendation
Low quality evidence
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
Very low quality evidence
C-section not recommended.
Strong recommendation
Very low quality evidence
Breastfeeding should be allowed.
Hepatitis C
Strong recommendation
Low quality evidence
Screen with anti-HCV Ab if risk factors; should not screen if no risk factors.
Strong recommendation
Very 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.
Hepatitis A and E, HSV
Strong recommendation
Very low quality evidence
Test for HAV, HBV, HEV, HSV if acute hepatitis.
Strong recommendation
Very low quality evidence
If suspect HSV hepatitis, should start empiric acyclovir.

Pregnancy-specific

Hyperemesis Gravidarum
Strong recommendation
Very low quality evidence
Treatment is supportive, may require hospitalization.
Intrahepatic Cholestasis of Pregnancy
Strong recommendation
Very low quality evidence
Recommend early delivery at 37 weeks due to increased risk of fetal complications.
Strong recommendation
Moderate quality evidence
Should give UDCA 10-15 mg/kg for symptoms.
Preeclampsia, Eclampsia
Strong recommendation
Very low quality evidence
Preeclampsia + liver involvement = severe preeclampsia; should deliver after 36 weeks.
HELLP Syndrome
Strong recommendation
Very low quality evidence
Prompt delivery, especially after 35 weeks.
Conditional recommendation
Very low quality evidence
Consider platelet transfusion if 40-50,000.
Acute Fatty Liver Disease of Pregnancy
Strong recommendation
Very low quality evidence
Should manage with prompt delivery; expectant mgmt not appropriate.
Conditional recommendation
Moderate quality evidence
Test mother and children for LCHAD.
Conditional recommendation
Very low quality evidence
Monitor children of AFLP mothers for LCHAD deficiency - hypoglycemia, fatty liver.
Literature
Original/Primary Reference
Research PaperTran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016;111(2):176-94.