Extremely Severe Maternal Morbidity due to liver disease
Dear Editor
Motivated by the interesting publication of the authors Afra Jiwa, fourth year medical student, Adam D Jakes and Anita Banerjee in BMJ on altered liver function during pregnancy, we wish to share our modest experience in the care of pregnant patients with Extremely Severe Maternal Morbidity (ESMM) with acute liver disease.
When caring for pregnant women with liver dysfunction, we recognize that the prevalence of liver diseases in pregnancy is not negligible and among the many causes are physiological changes in pregnancy; Pre-existing liver disease, the most common being cholestatic diseases (primary biliary cholangitis and primary sclerosing cholangitis), autoimmune hepatitis, Wilson's disease, chronic viral hepatitis, established cirrhosis of any etiology, and a patient with a history of liver transplantation; liver disease acquired during pregnancy, the main ones being viral hepatitis, drug-induced toxicity, and hepatolithiasis; pregnancy-related liver disease, in which five main entities are found: hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, preeclampsia, HELLP syndrome, and fatty liver of pregnancy. The severity of these entities has a wide range of presentations, from the patient who is completely asymptomatic, to acute liver failure and even death. The severity of the condition is associated with significant morbidity and mortality for both the mother and the fetus, which makes a rapid evaluation, accurate diagnosis, and appropriate management by a multidisciplinary team (including high-risk obstetrics, hepatology, gastroenterology, and radiology) interventionist), in a service that has the possibility of offering liver transplantation, are essential to obtain good outcomes.
All women, regardless of age, are at risk of suffering some type of liver disease, be it acute or chronic, being of vital importance optimal management when these pathologies affect women in pregnancy, not only because of the adverse effects themselves, but also by maternal and fetal outcomes. The presence of acute or chronic liver disease in pregnant women requires changes in gynecological care, contraception, pregnancy planning, cervical cancer screening, papilloma vaccine, and postmenopausal hormone replacement therapy.
Liver dysfunction in pregnancy may be due to pregnancy-associated liver diseases, exacerbation of pre-existing liver diseases, or conditions not related to pregnancy.
References
1. Eguchi S, Yanaga K, Fujita F, Okudaira S, Furui J, Miyamoto M, et al. Living-related right lobe liver transplantation for a patient with fulminant hepatic failure during the second trimester of pregnancy: Report of a Case. Transplantation, 73 (2002), pp. 1970-1.
2. Lai M, Wolf J. The liver in pregnancy. Handbook of Liver Disease. Elsevier. 2018. p. 308-23. Doi: https://doi.org/10.1016/B978-0-323-47874-8.00023-7
3. Kroumpouzos G. Intrahepatic cholestasis of pregnancy: what's new. J Eur Acad Dermatol Venereol, 16 (2002), pp. 316-8.
4. Westbrook R, Dusheiko G, Williamson C. Pregnancy and liver disease. J Hepatol. 2016;64(4):933-45. doi: https://doi.org/10.1016/j.jhep.2015.11.030.
5. London V, Grube S, Sherer D, Abulafia O. Hyperemesis gravida-rum: a review of recent literature. Pharmacology. 2017;100(3-4):161-71. doi: https://doi.org/10.1159/000477853.
6. Ch'ng CL, Morgan M, Hainsworth I, Kingham JGC. Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut, 51 (2002), pp. 876-80.
7. Khuroo MS, Kamili S. Aetiology, clinical course and outcome of sporadic acute viral hepatitis in pregnancy. Journal of Viral Hepatitis, 10 (2003), pp. 61-9.
8. Westbrook R , Yeoman A, O’Grady J, Harrison P, Devlin J, Heneghan M. Model for end-stage liver disease score pre-dicts outcome in cirrhotic patients during pregnancy. Clin Gastroenterol Hepatol. 2011;9(8):694-9. doi: https://doi.org/10.1016/j.cgh.2011.03.036.
9. Geenes V, Williamson C. Gastrointestinal and liver disease in pregnancy. Obstet Gynaecol Reprod Med. 2017;27(3):91-8. doi: https://doi.org/10.1016/j.ogrm.2017.01.005.
10. Geenes V, Williamson C. Liver disease in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2015;29(5):612-24. doi: https://doi.org/10.1016/j.bpobgyn.2015.04.003.15.
11. Ditisheim A, Sibai B. Diagnosis and management of HELLP syndrome complicated by liver hematoma. Clin Obstet Gynecol. 2017;60(1):190-7. doi: https://doi.org/10.1097/GRF.0000000000000253.
12. Schmeltzer P, Russo M. Clinical narrative: autoimmune hepatitis. Am J Gastroenterol. 2018;113(7):951-8. doi: https://doi.org/10.1038/s41395-018-0058-z.
13. Dionne-Odom J, Tita A, Silverman N. Hepatitis B in preg-nancy screening, treatment, and prevention of vertical trans-mission. Am J Obstet Gynecol. 2016;214(6-14).
14. Patton H, Tran T. Management of hepatitis B during preg-nancy. Nat Rev Gastroenterol Hepatol. 2014;11(7):402-9. doi: https://doi.org/10.1038/nrgastro.2014.30.
15. Rac M, Sheffield J. Prevention and management of viral hepa-titis in pregnancy. Obstet Gynecol Clin N Am. 2014;41:573-92. doi: https://doi.org/10.1016/j.ogc.2014.08.004.
16. Castillo E, Murphy K, van Schalkwyk J. Hepatitis B and preg-nancy. J Obstet Gynaecol Can JOGC J. 2017;39(3):181-90. doi: https://doi.org/10.1016/j.jogc.2016.11.001.
17. Liu CP, Zeng YL, Zhou M, Chen LL, Hu R , Wang L, et al. Factors associated with mother-to-child transmission of hepatitis B virus despite immunoprophylaxis. Intern Med Tokyo Jpn. 2015;54(7):711-6. doi: https://doi.org/10.2169/internalmedicine.54.3514.
Competing interests:
No competing interests
01 April 2021
Masleidy Valladares-Valle
Specialist in Imaging Profesor Master of Science Head of the Imaging Department
Santos-Peña Moises A, Ojed-Treto Yoani, Rocha-Hernandez Juan F., Pujol-Enseñat Yeneys, Perez-Garcia Roberto M.
Dr. Gustavo Aldereguia University General Hospital. WHO Collaborating Center
Ave 5 of September and 51-A street. Cienfuegos. Cuba 55100
Rapid Response:
Extremely Severe Maternal Morbidity due to liver disease
Dear Editor
Motivated by the interesting publication of the authors Afra Jiwa, fourth year medical student, Adam D Jakes and Anita Banerjee in BMJ on altered liver function during pregnancy, we wish to share our modest experience in the care of pregnant patients with Extremely Severe Maternal Morbidity (ESMM) with acute liver disease.
When caring for pregnant women with liver dysfunction, we recognize that the prevalence of liver diseases in pregnancy is not negligible and among the many causes are physiological changes in pregnancy; Pre-existing liver disease, the most common being cholestatic diseases (primary biliary cholangitis and primary sclerosing cholangitis), autoimmune hepatitis, Wilson's disease, chronic viral hepatitis, established cirrhosis of any etiology, and a patient with a history of liver transplantation; liver disease acquired during pregnancy, the main ones being viral hepatitis, drug-induced toxicity, and hepatolithiasis; pregnancy-related liver disease, in which five main entities are found: hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, preeclampsia, HELLP syndrome, and fatty liver of pregnancy. The severity of these entities has a wide range of presentations, from the patient who is completely asymptomatic, to acute liver failure and even death. The severity of the condition is associated with significant morbidity and mortality for both the mother and the fetus, which makes a rapid evaluation, accurate diagnosis, and appropriate management by a multidisciplinary team (including high-risk obstetrics, hepatology, gastroenterology, and radiology) interventionist), in a service that has the possibility of offering liver transplantation, are essential to obtain good outcomes.
All women, regardless of age, are at risk of suffering some type of liver disease, be it acute or chronic, being of vital importance optimal management when these pathologies affect women in pregnancy, not only because of the adverse effects themselves, but also by maternal and fetal outcomes. The presence of acute or chronic liver disease in pregnant women requires changes in gynecological care, contraception, pregnancy planning, cervical cancer screening, papilloma vaccine, and postmenopausal hormone replacement therapy.
Liver dysfunction in pregnancy may be due to pregnancy-associated liver diseases, exacerbation of pre-existing liver diseases, or conditions not related to pregnancy.
References
1. Eguchi S, Yanaga K, Fujita F, Okudaira S, Furui J, Miyamoto M, et al. Living-related right lobe liver transplantation for a patient with fulminant hepatic failure during the second trimester of pregnancy: Report of a Case. Transplantation, 73 (2002), pp. 1970-1.
2. Lai M, Wolf J. The liver in pregnancy. Handbook of Liver Disease. Elsevier. 2018. p. 308-23. Doi: https://doi.org/10.1016/B978-0-323-47874-8.00023-7
3. Kroumpouzos G. Intrahepatic cholestasis of pregnancy: what's new. J Eur Acad Dermatol Venereol, 16 (2002), pp. 316-8.
4. Westbrook R, Dusheiko G, Williamson C. Pregnancy and liver disease. J Hepatol. 2016;64(4):933-45. doi: https://doi.org/10.1016/j.jhep.2015.11.030.
5. London V, Grube S, Sherer D, Abulafia O. Hyperemesis gravida-rum: a review of recent literature. Pharmacology. 2017;100(3-4):161-71. doi: https://doi.org/10.1159/000477853.
6. Ch'ng CL, Morgan M, Hainsworth I, Kingham JGC. Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut, 51 (2002), pp. 876-80.
7. Khuroo MS, Kamili S. Aetiology, clinical course and outcome of sporadic acute viral hepatitis in pregnancy. Journal of Viral Hepatitis, 10 (2003), pp. 61-9.
8. Westbrook R , Yeoman A, O’Grady J, Harrison P, Devlin J, Heneghan M. Model for end-stage liver disease score pre-dicts outcome in cirrhotic patients during pregnancy. Clin Gastroenterol Hepatol. 2011;9(8):694-9. doi: https://doi.org/10.1016/j.cgh.2011.03.036.
9. Geenes V, Williamson C. Gastrointestinal and liver disease in pregnancy. Obstet Gynaecol Reprod Med. 2017;27(3):91-8. doi: https://doi.org/10.1016/j.ogrm.2017.01.005.
10. Geenes V, Williamson C. Liver disease in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2015;29(5):612-24. doi: https://doi.org/10.1016/j.bpobgyn.2015.04.003.15.
11. Ditisheim A, Sibai B. Diagnosis and management of HELLP syndrome complicated by liver hematoma. Clin Obstet Gynecol. 2017;60(1):190-7. doi: https://doi.org/10.1097/GRF.0000000000000253.
12. Schmeltzer P, Russo M. Clinical narrative: autoimmune hepatitis. Am J Gastroenterol. 2018;113(7):951-8. doi: https://doi.org/10.1038/s41395-018-0058-z.
13. Dionne-Odom J, Tita A, Silverman N. Hepatitis B in preg-nancy screening, treatment, and prevention of vertical trans-mission. Am J Obstet Gynecol. 2016;214(6-14).
14. Patton H, Tran T. Management of hepatitis B during preg-nancy. Nat Rev Gastroenterol Hepatol. 2014;11(7):402-9. doi: https://doi.org/10.1038/nrgastro.2014.30.
15. Rac M, Sheffield J. Prevention and management of viral hepa-titis in pregnancy. Obstet Gynecol Clin N Am. 2014;41:573-92. doi: https://doi.org/10.1016/j.ogc.2014.08.004.
16. Castillo E, Murphy K, van Schalkwyk J. Hepatitis B and preg-nancy. J Obstet Gynaecol Can JOGC J. 2017;39(3):181-90. doi: https://doi.org/10.1016/j.jogc.2016.11.001.
17. Liu CP, Zeng YL, Zhou M, Chen LL, Hu R , Wang L, et al. Factors associated with mother-to-child transmission of hepatitis B virus despite immunoprophylaxis. Intern Med Tokyo Jpn. 2015;54(7):711-6. doi: https://doi.org/10.2169/internalmedicine.54.3514.
Competing interests: No competing interests