Autoimmune hepatitis in pregnancy: Pearls and pitfalls

Abstract

Autoimmune hepatitis (AIH) in pregnancy has many unique considerations.Evidence provided from single center studies with patient level data and nationwide population studies provide valuable insight into this complex situation. Because a planned pregnancy is a safer pregnancy, preconception counseling is a crucial opportunity to optimize care and risk stratify women with AIH. Women with chronic liver disease who receive preconception advice and counseling are more likely to achieve stable liver disease at conception and undergo appropriate variceal surveillance. Loss of biochemical response in pregnancy is associated with adverse outcomes in unstable disease. New onset AIH in pregnancy should be managed with classical treatment regimens. The continued use of immunosuppression in pregnancy, with the exception of mycophenolate mofetil, has not shown to adversely affect the rates of stillbirth or congenital malformation. Previously adopted immunosuppression withdrawal paradigms in pregnancy should no longer be considered advantageous, because remission loss postdelivery is likely (12%-86%). Population studies, report improved outcomes with preterm birth rates falling from 20% to 9%-13% in AIH pregnancies over a 20-year period.Newer data have also demonstrated an increased risk of gestational diabetes and hypertensive complications in AIH pregnancy, which has implications for management and preeclampsia prevention with aspirin use. This review aims to provide the framework to guide and manage pregnancy in AIH outlining pearls and pitfalls to ensure optimal outcomes for mother, baby and to reduce variation in practice.

The Spectrum of Hepatic Critical Care During Pregnancy: A Clinical Review

“…It is also important to recognize an increased incidence of pregnancy-associated liver disease in women with AIH, including gestational diabetes and hypertensive complications in pregnancy (gestational hypertension, eclampsia, pre-eclampsia, and HELLP syndrome) 18–20. Rates of pre-eclampsia are as high as 30% 20.…”

“…Biopsy is generally deferred until after the second trimester if possible. Upon diagnosis of AIH, evaluation for cirrhosis is of high importance as one-third will have established cirrhosis at the time of presentation 1,18. Treatment is also similar to steroid induction and the addition of azathioprine for steroid-sparing effects after 2 weeks.…”

“…Approximately 20% of patients with AIH will flare in pregnancy, and this is associated with both maternal and fetal complications 18. Flares of AIH can lead to hepatic compromise, which complicates up to 11% of pregnancies in women with known AIH 1.…”

“…Upon diagnosis of AIH, evaluation for cirrhosis is of high importance as onethird will have established cirrhosis at the time of presentation. 1,18 Treatment is also similar to steroid induction and the addition of azathioprine for steroid-sparing effects after 2 weeks. Those that present with acute severe AIH should be assessed for liver transplantation, especially if they do not respond rapidly to steroids.…”

“…Approximately 20% of patients with AIH will flare in pregnancy, and this is associated with both maternal and fetal complications. 18 Flares of AIH can lead to hepatic compromise, which complicates up to 11% of pregnancies in women with known AIH. 1 The risk of decompensation leading to LT or death is the highest in women with cirrhosis (21% vs 4% without cirrhosis).…”