This podcast discusses the effect of cirrhosis on pregnancy. While women that have cirrhosis get pregnant less often, when women with cirrhosis do become pregnanct, there are added concerns and dangers. Complications include and increased risk of bleeding esophageal varicies, worsening hepatic function, internal bleeding, and hepatic encephalopathy.
Details from the article are posted below.
Esophageal Varicies
Esophageal variceal bleeding has been reported in 18% to 32% of pregnant women with cirrhosis and in up to 50% of those with known portal hypertension. Among those with preexisting varices, up to 78% will have gastrointestinal bleeding during pregnancy, with a mortality rate of 18% to 50%. In contrast, pregnant patients with noncirrhotic portal hypertension fare much better. Their mortality rate from variceal bleeding is between 2% to 6%] This disparity may be related to the severity of their underlying liver disease, with patients with cirrhosis more likely to be coagulopathic.
Variceal bleeding most commonly occurs during the second and third trimesters when maternal blood volume is maximally expanded and the larger fetus causes increased compression of the inferior vena cava and collateral vasculature.
As in nonpregnant patients with cirrhosis, endoscopic band ligation remains the mainstay of therapy for acute episodes of hemorrhage. The first case of successful band ligation in a pregnant patient with acute bleeding was reported in 1998 by Starkel et al., but no prospective randomized trials for this treatment currently exist. As in the nongravid population, sclerotherapy was previously looked to as a potential alternative, but it has largely been replaced by band ligation. Experts argue that band ligation should be preferred during pregnancy because it avoids any potential risk from chemical instillation.
Upper endoscopy in general appears to be safe during pregnancy, with the main risk being fetal hypoxia from sedative drugs or positioning. No cases of premature labor or fetal malformations have been reported in patients who have undergone endoscopy during pregnancy.
Octreotide, designated as pregnancy category B by the Food and Drug Administration, is often used to treat acute variceal bleeding, although its safety has not been well studied in pregnant patients. Given its similarity to vasopressin, however, possible concerns include arteriolar vasospasm, which can result in decreased placental perfusion and an increased risk of placental abruption, myocardial infarction, peripheral ischemia, and hypertension.
Hepatic Decompensation
Up to 24% of pregnant patients with cirrhosis will also experience hepatic decompensation, which can lead to rapid clinical deterioration. This has been described in all stages of pregnancy, but often occurs after episodes of variceal bleeding.
When fulminant hepatic failure occurs, the only treatment available may be emergent liver transplantation. This has been performed during pregnancy in a small number of cases, with successful outcomes for both mother and fetus. Reported complications remain high, however, and have included an increased risk of fetal ischemia, pregnancy-induced hypertension, anemia, caesarian section, and preterm delivery. Moreover, these case reports largely involved women without underlying cirrhosis, and it is unclear how underlying liver disease would change the outcome.