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    Liver Disease and Pregnancy (beta)

    Official guideline from the American College of Gastroenterology.

    Summary by Russell Rosenblatt, MD & Robert S. Brown, MD
    Strong recommendation
    Moderate recommendation
    Conditional recommendation
    Weak recommendation
    High quality evidence
    Moderate-high quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Diagnosis and Workup

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

    Biliary Disease, Liver Mass, CLD

    Biliary Disease
    1. ERCP okay if strongly indicated, e.g. biliary pancreatitis, choledocho, cholangitis.
    2. Lap chole should be done early if symptomatic cholelithiasis - 10-60% fetal demise if progresses to biliary pancreatitis.
    Liver Masses
    1. Asymptomatic hemangioma and focal nodular hyperplasia do not need surveillance in pregnancy.
    2. Should monitor hepatic adenoma during pregnancy w/US. If nonpregnant and adenoma >5cm, should refer for surgery before pregnancy.
    Other Chronic Liver Disease
    1. Continue AIH treatment with steroids or AZA.
    2. Continue UDCA for PBC.
    3. Continue/reduce Wilson’s disease therapy
    4. If suspect portal hypertension, screen for varices in 2nd tri.
    5. Treat large varices with band ligation or NSBB.
    6. If s/p liver transplant, continue all meds except mycophenolic acid.


    Hepatitis B
    1. HBIG and HBV vaccine for children with HBV-infected mothers.
    2. Should offer tenofovir in 3rd tri if chronic HBV and viral load >10⁶ log copies/mL (200,000 IU/mL).
    3. C-section not recommended.
    4. Breastfeeding should be allowed.
    Hepatitis C
    1. Screen with anti-HCV Ab if risk factors; should not screen if no risk factors.
    2. Should minimize invasive procedures e.g. amniocentesis, invasive fetal monitoring.
    3. Elective C-section not recommended.
    4. Breastfeeding should be allowed.
    5. Treatment should not be offered during pregnancy.
    Hepatitis A and E, HSV
    1. Test for HAV, HBV, HEV, HSV if acute hepatitis.
    2. If suspect HSV hepatitis, should start empiric acyclovir.


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