Liver disease, pregnancy, and infertility

There is increasing prevalence of liver disorders in women of childbearing age, as well as more women with severe liver disease becoming pregnant, a leading expert and researcher in liver disease told the Irish Society of Gastroenterology’s (ISG) Winter Meeting, held in Killiney, Co Dublin, last month.

Prof Michael Heneghan, Consultant Hepatologist, King’s College Hospital, London, UK, gave a comprehensive presentation on management of liver disease in pregnancy. Increasing obesity rates and associated diabetes have contributed to a rise in liver disease in women of childbearing age. The rate of autoimmune hepatitis among women of reproductive age is also increasing, he noted.

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and foetal morbidity and mortality, outlined Prof Heneghan.

In 2023 the European Association for the Study of Liver Disease (EASL) published evidence-based clinical practice guidelines on the management of liver diseases in pregnancy, to which Prof Heneghan contributed. He outlined the key recommendations to the ISG meeting.

For female patients with liver disease considering a pregnancy, pre-conception counselling and multidisciplinary collaboration are important, he said. “Folic acid supplementation is essential”, and low-dose aspirin prophylaxis is recommended in women at high risk of pre-eclampsia.

Gestational liver disorders affect 3 per cent of the pregnant population and include pre-eclampsia and HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome; acute fatty liver of pregnancy; hyperemesis gravidarum; and intrahepatic cholestasis of pregnancy. These disorders require prompt investigation and management in order to reduce maternal and foetal morbidity and mortality.

When investigating liver disease in pregnancy, Prof Heneghan cautioned that one should be aware of the normal physiological and hormonal changes of pregnancy that can mimic those seen in women with chronic liver disease. Discussing diagnostics, he said Fibroscan is safe to use in pregnancy, as is ultrasound, magnetic resonance cholangiopancreatography (MRCP), and  endoscopic-retrograde-cholangiopancreatography (ERCP) as per the EASL guidelines.

In severe liver disease, a liver transplant can rapidly restore fertility in women (within a month) therefore patients need to be informed of this and counselled on contraception if necessary, he noted.

Prof Heneghan also discussed the management of patients with liver disease undergoing IVF, and those with hepatitis B, hepatitis C, and cirrhosis, as per the EASL guidelines.

In addition, where breastfeeding is possible, he stressed the health benefits to the mother (reduced risk of diabetes, etc) and the baby.