ACG Clinical Guideline: Liver Disease and Pregnancy

Abstract

Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women. Am J Gastroenterol 2016; 111:176-194; doi: 10.1038/ajg.2015 Initial evaluation of pregnant patientA pregnant patient presenting with abnormal liver tests should undergo standard workup as with any non-pregnant individual (strong recommendation, very low level of evidence). Imaging in pregnancyUltrasound is safe and the preferred imaging modality used in assessment of abnormal liver tests suggestive of biliary tract disease (strong recommendation, low level of evidence).Magnetic resonance imaging without gadolinium can be used in the second and third trimester (conditional recommendation, low level of evidence).Computed tomography scans carry a risk of teratogenesis and childhood hematologic malignancies but may be used judiciously with minimized radiation protocols (2-5 rads; conditional recommendation, very low level of evidence). Endoscopy in pregnancyEndoscopy is safe in pregnancy but should be deferred until the second trimester if possible (strong recommendation, low level of evidence).Meperidine and propofol can be used for endoscopic sedation (strong recommendation, moderate level of evidence). Management of biliary disease in pregnancyERCP can be performed when indicated for pregnant women presenting with biliary disease that strongly necessitates intervention such as biliary pancreatitis, symptomatic choledocholithiasis, and/or cholangitis. Minimizing fetal exposure to fl uoroscopy is imperative (strong recommendation, low level of evidence).Symptomatic cholecystitis should be managed with early surgical intervention with laparoscopic cholecystectomy (strong recommendation, low level of evidence). Liver masses in pregnancyAsymptomatic hemangioma and focal nodular hyperplasia do not need routine imaging or surveillance during pregnancy (strong recommendation, very low level evidence).Hepatic adenomas should be monitored with ultrasound during pregnancy for growth. Patients with large adenomas (>5 cm) should be referred for resection prior to pregnancy (strong recommendation, low level of evidence). Hepatitis B in pregnancyActive-passive immunoprophylaxis with hepatitis B immunoglobulin and the HBV vaccination series should be administered to all infants born to HBV-infected mothers to prevent perinatal transmission (strong recommendation, low level of evidence).Women chronically infected with HBV and high viral load (>10 6 log copies/ml (200,000 IU/ml) and higher) should be offered antiviral medication with tenofovir or telbivudine in the third trimester to reduce perinatal transmission of HBV (strong recommendation, low level of evidence).C-section should not be performed electively in HBV-pos...

Jaundice and Pregnancy: Why Going Viral Is Out of Style

“…Among the total number of deliveries during the study (80,408), the rate of hyperbilirubinemia (0.5%) was consistent with data previously reported in the literature [1]. Greater than 75% of the maternal population in this study-both hyperbilirubinemic and control groups-was Hispanic.…”

“…The prevalence of abnormal liver function tests among expectant mothers is 0.3-3% [1]. For 70 years, acute viral hepatitis was thought to be the leading cause worldwide, based on epidemiologic studies conducted primarily outside of the USA [2,3], although one US study also reported that hepatitis B accounted for 40% of expectant mothers with symptoms and signs of acute hepatitis [4].…”

A cross sectional study of liver function tests in normal pregnancy during third trimester: a treasure from the past

“…15 However ACG 2016 guideline support that there is no significant rise in serum belirubin levels in pregnancy. 9 SGOT levels were normal in as many as 88 % of our study population (mean±SD; 20±15.2). Friedman et al and Santhagopalan et al obtained similar results (mean±SD; 23.8±5.4, 18±12; 9.46±3.78) respectively.…”

“…12 ACG 2016 guidelines support the same. 9 Serum bilirubin levels were normal in majority of the study population and were raised in as many of 20% of study population (mean±SD; 0.1-0.7±0.09). Long et al demonstrated a rise in serum bilirubin levels where as Wetstone et al failed to demonstrate any rise in serum bilirubin.…”

“…ACG 2016 guidelines support the same notion. 9 Serum protein was within normal limits in majority of study the population (88% of subjects; Mean±SD; 6.5±0.6). There was also no change in serum albumin and serum globulin levels (mean±SD; 4±0.5 and 2.4±0.01 respectively).…”