Pregnancy & Liver Diseases

Vol. 30, Issue 1 (March 2025)

Yiğit Berk Şahin, MD
Hacettepe University Department of Internal Medicine
Ankara, Türkiye

 

Burcu Gürbüz, MD
Hacettepe University Department of Internal Medicine,
Gastroenterology and Hepatology
Ankara, Türkiye

 

Hatice Yasemin Balaban, MD
Hacettepe University Department of Internal Medicine,
Gastroenterology and Hepatology
Ankara, Türkiye

 

Pregnancy causes significant physiological adaptations in hepatic function, which can predispose women to various liver related pathological conditions and metabolic alterations. Although the prevalence of elevated liver enzymes during pregnancy is reported to be 3%–5% in the literature,¹ with the growing knowledge about chronic liver diseases and emerging management strategies, the importance of understanding liver diseases specific to pregnancy and those preexisting has increased, especially in the context of the global pandemic of steatotic liver disease (SLD), which affects almost one in three people worldwide.²

Indeed, contraceptive counseling is an essential but usually ignored issue in women with liver diseases. Most of the contraceptive methods have safe profiles
with varying effectiveness. Contraceptive methods containing progesterone pose minimal risk of liver disease exacerbations. However, combined hormonal preparations carry higher risks because of the estrogen component increasing the risks for thromboembolism and hepatic adenoma growth. They are contraindicated in women with prior venous thromboembolism hepatic adenomas, Budd-Chiari syndrome, decompensated cirrhosis due to impaired estrogen metabolism, or after liver transplantation (LT) due to insufficient safety data.³

Although antenatal counseling before conception is recommended for all women, this is especially important for women with known liver diseases. Chronic liver disease, cirrhosis, and post-liver transplantation processes have a potential for negative impact risk on reproductive health by causing sexual dysfunction and infertility through various physiological mechanisms. Additionally, the course of liver disease may also worsen during or after pregnancy, and so may adversely affect maternal and fetal outcomes. Thus, it is crucial for women to undergo a detailed evaluation of their medical condition before making a decision about pregnancy. Women with liver diseases should be counseled about pregnancy-specific risks, such as the worsening of underlying liver disease, obstetric and perinatal complications for both mother and baby during or after pregnancy, and potential effects and safety concerns on drugs used for liver diseases during pregnancy and breastfeeding.^{4, 5}

Liver diseases in pregnancy are categorized into three groups:

1. Pregnancy-specific liver diseases:
   Intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, preeclampsia/eclampsia/HELLP syndrome, hyperemesis gravidarum
2. Pre-existing liver diseases exacerbated by pregnancy:
   Viral hepatitis, metabolic or autoimmune liver diseases, liver transplantation
3. Coincidental liver diseases occurring during pregnancy

Since the evaluation of coincidental liver diseases occurring during pregnancy is similar to that of non-pregnant patients, this brief review includes the management tips for pregnancy-related liver issues in two sections focusing on preexisting and pregnancy-specific liver diseases in accordance with clinical practice guidelines of American and European hepatology societies.^{6, 7}

I. Preexisting Liver Diseases

Hepatitis A (HAV)
Hepatitis A is one of the most common causes of acute viral hepatitis; it does not cause chronic liver disease, yet is rarely reported during pregnancy. While it is generally associated with favorable outcomes, it may lead to preterm delivery, especially when it occurs in the second or third trimester. In addition to preterm delivery, it has also been associated with other gestational complications such as abruptio placentae. However, reports of adverse outcomes in pregnancy remain scarce.⁸ The treatment is supportive, similar to non-pregnant cases. It generally does not affect normal vaginal delivery and does not contraindicate breastfeeding. The newborn can be protected through the administration of immunoglobulin and/ or vaccination. Due to transmission route, transmission of infections while breastfeeding can be prevented by good hand hygiene and other hygiene practices.⁹

Hepatitis B (HBV)
Hepatitis B in pregnancy is particularly significant due to mother-to-child transmission risks. Current management recommendations are as follows.^{6, 7}

i. Screening and assessment:

• Universal prenatal HBsAg screening is recommended for all pregnant women.
• HBV DNA levels should be measured for HBsAg-positive mothers.
• Active immunization by HBV vaccination should not be delayed and be given to all pregnant women without immunity.

ii. Prevention of transmission:

• Transmission prevention strategies include administering hepatitis B immunoglobulin G (HBIG) within 12 hours of birth and vaccination at 0, 1 to
  2, and 6 months that provides high effectiveness (85%) in preventing HBV infection in newborns.
• The maternal viral load is another critical factor. Thus, HBV DNA <200,000 correlates with a low vertical transmission rate while others must be treated with tenofovir disoproxil fumarate (TDF) from 24–28w of gestation and continue up to 12 weeks after delivery.
• Another high-risk indicator is HBeAg positivity. If HBVDNA or HBeAg measurement cannot be made, WHO suggests that every HBsAg-positive woman must be treated with TDF.¹⁰ According to a recent study, Pan et al. found that vaccination and early initiation of TDF (16w of gestation) combination is a non-inferior strategy than standard care regimen (HBIG + vaccine + 28w starting TDF) for high risk mother-to-child transmission conditions in geographic areas where HBIG is not available.¹¹

iii. Antiviral therapy:

• Treatment with TDF is recommended for both newly diagnosed or pre-existing hepatitis B patients, regardless of fibrosis level.
• Antiviral therapy reduces the risk of hepatic flares compared to untreated patients.
• Among antiviral treatments, TDF is the preferred treatment option, but tenofovir alafenamide fumarate (TAF) also has established safety data.
• Treatment should begin as early as possible and continue through guideline indications.

iv. Delivery and postpartum care:

• Vaginal delivery and breastfeeding are recommended.
• Caesarean delivery is recommended for untreated Asian women who are HBeAg positive with high viral loads (HBV DNA >7 log10 copies/mL) according to the EASL guidelines.

Hepatitis C (HCV)
All pregnant women should be screened with anti-HCV Ig total serology. Currently, the safety of direct acting antiviral agents (DAAs) used for HCV treatment remains unestablished in pregnancy, and routine treatment is not recommended. Pregnant women with high HCV-RNA viral loads, particularly those co-infected with HIV, carry an increased risk of vertical transmission.¹² The invasive procedures (e.g., amniocentesis) should be avoided in anti-HCV positive women because of the increase in vertical transmission risk. Since antibodies are transferred to the infant, anti-HCV positivity may persist postpartum until 18 months, so testing of newborns for HCV infection should be delayed beyond 18 months to ensure accurate diagnosis.¹³ Vaginal delivery and breastfeeding are safe and recommended.

Hepatitis E
Hepatitis E infection typically follows a mild, asymptomatic course in the general population, while it can manifest with severe, potentially fatal complications in pregnant women. Treatment options are significantly limited during pregnancy since conventional antiviral therapies for HEV infection, including ribavirin and interferon-alpha, are contraindicated during gestation. In the absence of safe antiviral options, the management primarily focuses on supportive care to maintain maternal and fetal health.¹⁴

Herpes Simplex Virus (HSV)
Herpes hepatitis is a rare cause of acute hepatitis, but the risk for disseminated infection is increased during pregnancy.¹⁵ Acyclovir is considered safe for use during pregnancy, and therefore early recognition and immediate initiation of acyclovir are critical components of successful HSV infection management in pregnant women.¹⁶

Cholestatic Diseases: Primary biliary cholangitis (PBC) and Primary sclerosing cholangitis (PSC)
The fertility is often unaffected in cholestatic diseases.¹⁷ On the other hand, the worsening may not be prudent in stable PBC patients under UDCA treatment, 60% may experience deterioration. Similarly, PSC patients develop de novo pruritus and jaundice at high rates during pregnency,¹⁸ and one-third may experience postpartum enzyme elevation. 

Autoimmune Liver Diseases (AILD)
The continuation of immunosuppressive therapy is recommended during pregnancy. There is higher postpartum flare-ups in patients having disease activity before gestation or having insufficient immunosuppression during pregnancy. Corticosteroids and azathioprine are considered safe during pregnancy,¹⁹ in spite of an increased risk for gestational diabetes and hypertensive disorders of pregnancy (HELLP syndrome, gestational hypertension, preeclampsia, eclampsia).²⁰

Wilson’s Disease (WD)
Women with Wilson’s disease must be informed about potential risks of infertility and miscarriages, athough they can often conceive. Treatment of WD include zinc, D-penicillamine, and trientine, which is safe for both mother and baby.²¹ According to AASLD and EASL guidelines, zinc can be continued without dose reduction, while D-penicillamine and trientine doses should be reduced in the second and third trimesters because of their adverse effects on tissue healing.

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)
Similar to the non-pregnant population, lifestyle modifications including dietary and exercise should be advised to pregnant women with MASLD. These women face increased risks about maternal and fetal complications. Breastfeeding should be encouraged. ⁶

Hepatic Adenomas
Hepatic adenomas require preconceptional evaluation due to potential risks of growth and rupture associated with pregnancy-related hormonal changes. Adenomas larger than 5 cm are classified high-risk adenomas, requiring either close surveillance throughout pregnancy or surgical management prior to pregnancy (Figure 1).

Figure 1. Hepatic adenoma management in pregnancy. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy, 2023.

Cirrhosis
The successful pregnancy outcomes are possible in cirrhotic women without decompensation. Studies have shown favorable maternal and fetal outcomes in pregnant women with MELD scores <6. A MELD score of 10 is considered the threshold for refraining from pregnancy. MELD scores ≥10 carry a high risk of decompensation, warranting multidisciplinary preconception counseling.22 Portal hypertension with or without cirrhotic requires specific attention as recommend in AASLD’s clinical practice guideline. Esophagogastroduodenoscopy (EGD) within one year prior to pregnancy or in the second trimester should be done for screening of esophageal varices (Figure 2). If medium or large varices are detected, non-selective beta blockers (NSBB) or endoscopic variceal ligation (EVL) should be initiated.

Figure 2. Variceal screening for pregnancy management. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases, 2021.

Liver Transplantion (LT)
The menstrual functions return as early as one month after successful LT with up to 95% of recipients, and complete normalization occurs within the first year.²³ After LT, it is recommended to delay pregnancy for at least one year and ensure six months of stable liver function for a sucessful and safe gestation. The immunosuppressive regimen must be carefully reconsidered before planned pregnancy. Mycophenolic acid (MMF) products are contraindicated during pregnancy and breastfeeding, and so contraception is necessary in patients on MMF treatment. Cyclosporine, tacrolimus, corticosteroids, and azathioprine/6-MP can be safely continued during both pregnancy and lactation. Tacrolimus is a calcineurin inhibitor and requires more frequent drug level monitoring than non-pregnant individuals in every 2–4 weeks.7 mTOR inhibitors, namely sirolimus and everolimus, are not recommended in pregnant women due to insufficient safety data.

II. Pregnancy-Related Liver Diseases

During pregnancy, increases in placental-derived alkaline phosphatase (ALP) and liver-derived alpha-fetoprotein (AFP) are observed, as well as mild hypoalbuminemia across all three trimesters. Notably, not elevations but dilutional decrease in liver transaminases, gamma-glutamyl transferase, bilirubin, and total serum bile acid levels are typically seen in pregnancy. Timing of pregnancy-specific liver diseases is as shown in Figure 3.

Figure 3. Timing of pregnancy-specific liver diseases. Reproductive Health and Liver Diseases: Practice Guidance by the American Association for the Study of Liver Diseases, 2021.

Hyperemesis Gravidarum
Hyperemesis gravidarum is seen in 0.35%–2.0% of pregnancies, typically during the first trimester. It is characterized by persistent vomiting, leading to weight loss exceeding 5% of prepregnancy body weight, dehydration, and ketonuria.²⁴ Liver enzyme abnormalities may also occur as a result of persistent vomiting. However, with rehydration, micronutrient supplementation, and antiemetic treatments, improvements are generally observed. If liver enzyme elevations persist, underlying other etiologies should be investigated.

Intrahepatıc Cholestasıs of Pregnancy (ICP)
Intrahepatic cholestasis of pregnancy (ICP) represents a common pregnancy- related liver disease affecting 0.4%–10% of pregnancies, with prevalence varying across geographical regions and between ethnic groups.²⁵ Classical symptoms include generalized pruritus, particularly affecting the palms and soles, without rash, accompanied by elevated transaminases. While 80% of cases occur after 30 weeks of gestation, onset is typically during the second or third trimester. Diagnosis is based on clinical findings and confirmed by measurement of postprandial total serum bile acid concentrations, with levels >10 μmol/L being diagnostic.

While maternal complications are generally mild, ICP carries significant risk for adverse fetal outcomes, including preterm delivery, meconium-stained amniotic fluid, asphyxia, and intrauterine growth restriction. Severe elevations in bile acid concentrations (>100 μmol/L) have been linked to increased postpartum risks of gallstones, progressive liver disease, cholangitis, and even hepatic malignancy.^{26, 27}

The standard of care is ursodeoxycholic acid (UDCA), which is completely safe during pregnancy. Weekly postprandial serum bile acid monitoring is recommended during follow-up. Delivery timing is strategically determined based on serum bile acid thresholds (>10 μmol, >40 μmol, >100 μmol) and the gestational week of diagnosis. The various obstetric and gynecological guidelines recommend early-term (37-39 weeks) or preterm (34-37 weeks) delivery depending on disease severity.²⁸

Hypertensive Disorders of Pregnancy

Preeclampsia/Eclampsia/HELLP Syndrome
Preeclampsia is a condition characterized by de novo hypertension occurring after the 20th week of gestation, accompanied by multi-organ complications (renal, hepatic, neurological, or hematological/DIC). Eclampsia is defined by the addition of seizures to these symptoms, and is a more severe form of hypertensive disorders of pregnancy. HELLP syndrome is defined by Hemolysis, Elevated Liver enzymes, and Low Platelet count. HELLP syndrome is a severe variant of preeclampsia that can occasionally present without hypertension.²⁹ Patients may be asymptomatic, but commonly present with symptoms such as jaundice, abdominal pain, weight gain, nausea, and vomiting.

Management involves antihypertensive treatments to achieve normal blood pressure during pregnancy, close monitoring of coagulation parameters, liver enzymes, and proteinuria. Severe cases may require IV magnesium sulfate for seizure prophylaxis, corticosteroids for lung maturity, and delivery based on disease severity. Delivery timing is based on disease severity: recommended respectively at 34 to 37 weeks for mild to severe forms of preeclampsia, and immediate delivery for eclampsia. Platelet counts should exceed 100,000 to minimize delivery complications.³⁰ Abdominal imaging is recommended if symptoms such as abdominal pain, shoulder pain, or hypotension is present, and may indicate maternal complications like hepatic adenoma rupture or
hepatic hemorrhage (with incidences as high as 45%). The definitive treatment is delivery after stabilizing the patient.

Acute Fatty Liver of Pregnancy (AFLP)
Acute fatty liver of pregnancy (AFLP) is an obstetric emergency with significant perinatal and maternal mortality risks. It is associated with fetal mitochondrial long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency. Postpartum genetic counseling is necessary to prevent adverse outcomes in next pregnancy.^{31, 32}

Patients may initially present with non-specific symptoms such as nausea, vomiting, abdominal pain, and fatigue. The disease can progress and lead to multiple complications, including coagulopathy (52%), ascites (48%), acute liver failure (47.3%), acute renal failure (80%), encephalopathy (18%), hepatorenal syndrome (4%), pancreatitis (16%), and multiorgan failure (2%). Diabetes insipidus may also develop. Up to 60% of affected women require intensive care, with a maternal mortality rate of 2%–18% and fetal/infant mortality rate of 7%–11%.^{33, 34} Therefore, early recognition of AFLP is crucial. Diagnosis of AFLP is clinical and based on the Swansea criteria, which require at least six unexplained findings (Table 1).

Table 1: Swansea Criteria of AFLP

Vomiting

Abdominal pain

Polydipsia/Polyuria

Encephalopathy

Bilirubin >0.8 mg/dl (14 μmol/L)

Hypoglycaemia <72 mg/dl (<4 μmol/L)

Uric acid >5.7 mg/dl (>340 μmol/L)

Leukocytosis (>11×10⁶/L), ascites or bright liver on sonogram

ALT or AST >42 IU/L

Ammonia >27.5 mg/dl (>47 μmol/L)

Creatinine >1.7 mg/dl (>150 μmol/L)

Coagulopathy (prothrombin time >14s or activated partial thromboplastin time >34s)

Microvesicular steatosis on liver biopsy

According to meta-analysis data of 149 patients,34 plasmapheresis may be beneficial. However, the only recommended treatment is delivery after stabilizing coagulopathy, hypoglycemia, and metabolic acidosis.35 The critical period extends beyond delivery, with persistent high maternal and fetal mortality risks that necessitates intensive care monitoring. In severe cases unresponsive to conventional management, liver transplantation may be required as a life-saving intervention.

Special Conditions: Delivery and Breastfeeding
The AASLD and EASL guidelines consistently support vaginal delivery for nearly all liver conditions. 

However, breastfeeding recommendations show divergence, especially for Wilson’s disease. AASLD advises against breastfeeding due to concerns about ATP7B expression in mammary tissue and potential infant copper deficiency, while EASL supports breastfeeding during treatment, citing prospective studies showing comparable copper and zinc levels in breast milk between treated patients and control groups.³⁶

In conclusion, antenatal counseling, diagnosis, and managment of liver diseases in pregnant women pose challenges, and so require a multidisciplinary approach, involving both gynecologists and hepatologists who should carefully consider maternal and fetal well-being. These conditions are complex and demand further research to understand their pathophysiology and management in order to improve maternal and fetal outcomes.

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