Maternal hemodynamics and pregnancy outcome in women with prior orthotopic liver transplantation

Abstract

The aim of this study is to evaluate the hemodynamics and pregnancy outcome of women with prior orthotopic liver transplantation. Hemodynamic measurements by Doppler technique were performed on pregnant subjects with prior orthotopic liver transplantation. Maternal characteristics, renal function, pregnancy complications, delivery indications, delivery mode, and neonatal outcomes were evaluated. Six pregnancies occurred in 5 women after orthotopic liver transplantation at the University of Washington Medical Center (Seattle, WA) between 1991 and 1999. Four of the 6 pregnancies were complicated by chronic hypertension, fetal growth restriction, and preterm delivery. Two pregnancies had worsening hypertension characterized by vasoconstriction in the second trimester despite antihypertensive therapy. These 2 subjects were administered cyclosporine for maintenance immunosuppression and had greater mean arterial pressures preconception and in the first trimester than the other subjects. One of these pregnancies resulted in fetal demise at 25 weeks' gestation. The other subject was delivered at 28 weeks' gestation for nonreassuring fetal status and superimposed preeclampsia. All pregnancies were complicated by renal insufficiency; however, the 2 subjects with poor obstetric outcome had preconception serum creatinine levels greater than 1.5 mg/dL and creatinine clearances less than 40 mL/min. Pregnancies complicated by second-trimester vasoconstriction and moderate renal insufficiency are at risk for preeclamspia, fetal growth restriction, and fetal demise. Good obstetric outcome can occur in women with mild renal insufficiency and well-controlled chronic hypertension. Improved hypertensive control preconception may decrease the risk for preeclampsia and poor obstetric outcome. Copyright 2000 by the American Association for the Study of Liver DiseasesP regnancies in women with prior orthotopic liver transplantation are complicated by fetal growth restriction (9% to 20%), preterm delivery (40% to 86%), cesarean delivery (45% to 71%), and preeclampsia (20% to 71%). 1-5 Significant preeclampsia rates of 27% to 71% have been reported by several investigators who evaluated smaller series of patients. 1,3 However, larger studies 2,5 and registry data 4 report preeclampsia rates in the range of 13.6% to 21%. Most of the women included in these reports were administered cyclosporine, prednisone, and azathioprine as maintenance immunosuppression. Recently, pregnancy outcomes were published for women administered tacrolimus (FK506) for maintenance immunosuppression. These women had lower rates of preeclampsia (0% to 4%), severe chronic hypertension (0% to 11%), and fetal growth restriction (0% to 4%) and similar rates of cesarean delivery (44%) and preterm delivery (48%) as patients administered cyclosporine. 6,7 The increased rate of pregnancy complications is not surprising because both cyclosporine and FK506 are known to cause renal insufficiency and hypertension. [8][9][10][11] Our institution has previously described pregna...