Pregnancy with Portal Hypertension

Abstract

Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of noncirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes. ( J CLIN EXP HEPATOL 2014;4:163-171) P regnancy associated with liver diseases is an infrequent situation, but when seen together, presents a complicated clinical situation. Portal hypertension develops as a result of number of etiologies. In the west, cirrhosis is the commonest cause of portal hypertension. In the setting of cirrhotic portal hypertension, pregnancy is very rare due to hepatocellular damage leading to amenorrhea and infertility, the incidence of cirrhosis in pregnancy has been reported as 1 in 5950 pregnancies. 1 Cirrhosis may get exacerbated during pregnancy and has significant adverse effects on the mother and the baby. [2][3][4] In the developing countries, other causes like extrahepatic portal vein obstruction contribute significantly to noncirrhotic portal hypertension (NCPH). Mostly liver function is much better preserved in women with NCPH and pregnancy is spontaneous in these women. Portal hypertension associated with pregnancy is a high risk situation as both pregnancy and portal hypertension share some of the hemodynamic changes. The physiological changes, in adaptation to the pregnancy and fetal needs, worsen the portal hypertension resulting in potentially life-threatening variceal bleed and other complications. Pregnancy is a potential hazard for occurrence of recurrent variceal bleed due to its hyperdynamic state causing increase in flow to the collaterals. 5-7 Therefore management in pregnancy requires knowledge of both the effects of changes during pregnancy on portal hemodynamics and the effects of portal hypertension and its cause on both mother and fetus, hepatotoxic...

Consensus conference on TIPS management: Techniques, indications, contraindications

“…Complications of portal hypertension are associated with significant increases in both mortality and complications during pregnancy or in the post-partum period. Increase in portal hypertension occurs during the last stages of the second trimester of pregnancy and is associated with increased risk of portal hypertension related bleeding in the later stages of pregnancy [229][230][231]. The available literature suggest considering TIPS placement in pregnant patients who bleed or rebleed despite an optimal pharmacological and endoscopic treatment.…”

Pregnancy in a patient with portal hypertension secondary to liver cirrhosis

“…A population-based study reviewing the outcomes of pregnant women with liver cirrhosis found that gestational hypertension, placenta abruption and uterovaginal haemorrhage were more common in this population. The rate of spontaneous miscarriages was significantly higher,2 as was the risk of prematurity and perinatal death 3. Hepatic decompensation occurred in 15% of patients, including 11% with ascites and 5% with variceal bleed 2.…”

“…The rate of spontaneous miscarriages was significantly higher,2 as was the risk of prematurity and perinatal death 3. Hepatic decompensation occurred in 15% of patients, including 11% with ascites and 5% with variceal bleed 2. In women with hepatic decompensation, maternal and fetal mortality was 6% and 12%, respectively.…”

“…Oesophageal and gastric varices, hepatic decompensation and encephalopathy, spontaneous bacterial peritonitis and postpartum uterine haemorrhage are all potential maternal complications 2 3. Termination of pregnancy may be required in instances where the mother gets a variceal bleed or intrauterine growth restriction 2. Due to these potential complications, a multidisciplinary approach is generally recommended 1 2…”

Successful Pregnancy Outcome with Extra Hepatic Portal Venous Obstruction: Three Case Series

“…The liver function is much better preserved in non-cirrhotic portal hypertension than in those associated with cirrhosis. The exact incidence of non-cirrhotic portal hypertension in pregnancy is not known [1]. The management of such patients requires multidisciplinary approach, preferably in a tertiary care institution.…”