Obstetrical and gynecologic challenges in the liver transplant patient

Table 1 Causes of severe liver dysfunction during pregnancy

Provoked by pregnancy1	Pre-existing disorders	Coincidental conditions2
Acute fatty liver of pregnancy	Alcoholic liver disease	Acute viral hepatitis A and E
Eclampsia-related liver disease	Non-alcoholic steatosis hepatitis	Herpes simplex viruses
Hemolysis, elevated liver enzymes, low platelet count(HELLP) syndrome	Human immunodeficiency and hepatitis B and C viruses	Drug toxicities
Intrahepatic cholestasis of pregnancy	Coagulation disorders	Budd-Chiari syndrome

¹Mostly in last trimester.

²Impact non-pregnant patients as well, but are associated with higher mortality and morbidity when coexisting with pregnancy.

Table 2 Potential adverse maternal and fetal outcomes of immunosuppressive medication in pregnant liver transplant recipients

Immunosuppressive medication	Adverse outcome	FDA pregnancy category
Calcineurin inhibitors, e.g. cyclosporine, tacrolimus	Maternal diabetes; Hypertension; Pre-eclampsia; Renal dysfunction; Fetal perinatal hyperkalemia	C
Azathioprine	Fetal anemia, thrombocytopenia, leukopenia; Decreased fetal immunoglobulin levels; Neonatal infection and sepsis; Pre-term delivery; Low birth weight	D
Corticosteroids	Gestational hypertension; Gestational diabetes; Fetal adrenal insufficiency; Fetal cleft lip and palate	B
Mycophenolate mofetil	Increased first trimester pregnancy loss; Fetal cleft lip and palate; Microtia; Absence of auditory canals	D

FDA: Food and Drug Administration.

Table 3 National Transplantation Pregnancy Registry maternal and neonatal outcome data according to transplanted organ type[76]

	Kidney, %	Liver, %	Kidney/Pancreas, %	Heart, %	Lung, %
Maternal complications
Hypertension	53-64	17-40	41-95	28-51	52
Preeclampsia	30-32	20-24	22-32	10-25	5
Diabetes	5-12	2-13	0-5	0-4	26
Rejection	1-2	2-11	0-14	3-21	16
Graft loss within 2 yr	6-9	2-8	10-17	0-4	14
Pregnancy outcomes
Spontaneous abortion	12-25	15-20	8-31	19-44	27
Live birth	71-77	72-82	64-79	48-70	58
Prematurity, < 37 wk	52-53	30-48	65-84	8-54	63
Mean gestational age in wk	35.3-35.9	36-37.3	33.7-34.8	36.1-37.8	33.9
Cesarean delivery	43-57	29-45	61-69	30-57	32