Guidelines

ACG releases guidelines for managing liver disease during pregnancy

The American College of Gastroenterology has released a clinical practice guideline for the diagnosis, treatment and management of various forms of liver disease among pregnant women.

“The purpose of this guideline is to provide a review of the diagnostic and treatment challenges of managing liver disease in pregnant women,” Nancy S. Reau, MD, FAASLD, FAGA, assistant professor of medicine at the University of Chicago, and HCV Next Editorial Board member, and colleagues wrote in The American Journal of Gastroenterology. “The evidence behind approaches to diagnosis and treatment of liver disease in pregnant women are assessed to provide management recommendations.”

Nancy S. Reau, MD

Nancy S. Reau

According to the guidelines, experts implemented the use of the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system for providing the best evidence to support the recommendations. Experts incorporated data from selected studies cited with strong evidence with the GRADE system. As a result, the experts comprised multiple recommendations for managing liver disease in pregnant women. A few of the recommendations include:

Evaluation

A pregnant woman who has abnormal liver tests should undergo the same workup as a nonpregnant person would.

“A complete history, physical exam and standard serological workup should be performed as indicated by the clinical presentation,” the researchers wrote.

Imaging

Ultrasound is safe for pregnant women and is the preferred imaging method for assessing abnormal liver tests of biliary tract disease. MRI without gadolinium can be used in the second and third trimesters without gadolinium. CT could be used “judiciously,” according to the guidelines, with only minimal radiation due to the fact this type of imaging carries risk for teratogenesis and childhood hematologic malignancies.

Endoscopy

The use of endoscopy in pregnancy is generally safe, but should be delayed until second trimester. Meperidine and propofol are recommended for endoscopic sedation.

Management of biliary disease and liver masses

Minimal fetal exposure to fluoroscopy is important, therefore endoscopic retrograde cholangiopancreatography can be used for women with indications for biliary pancreatitis, symptomatic choledocholithiasis or cholangitis. Women with asymptomatic hemangioma and focal nodular hyperplasia do not need to undergo routine imaging or surveillance during pregnancy. Patients with large adenomas should be referred to resection before pregnancy, according to the guidelines. 

HBV and HCV

Women with chronic HBV and high viral load should be offered antiviral medication with Viread (tenofovir disoproxil fumarate, Gilead Sciences) or Tyzeka (telbivudine, Novartis) in the third trimester to reduce transmission. HBV vaccination series and active-passive immunoprophylaxis with hepatitis B immunoglobulin should be administered to infants born to mothers with HBV. Cesarean section is not recommended in mothers with HBV and breastfeeding should be allowed.

All women showing risk factors for HCV should be screened with anti-HCV antibody and should not performed in women not presenting risk factors for the infection. Invasive procedures should be used minimally to prevent transmission. Breastfeeding is recommended for health reasons for the infant. A C-section and HCV therapy should not be offered to pregnant women.

HAV, HEV and herpes simple virus

Women with acute hepatitis should be tested for common etiologies of acute liver injury. Pregnant women with acute hepatitis from suspected herpes simple virus should begin treatment on acyclovir.

HELLP syndrome

This should be managed by prompt delivery, especially after 34 weeks gestation, according to the guidelines. Platelet transfusion to between 40,000 and 50,000 cells/µL should be considered before delivery, especially if C-section will occur.

Other chronic liver disease

Pregnant women with autoimmune hepatitis should continue treatment with corticosteroids and/or azathioprine; pregnant women with primary biliary cirrhosis should continue treatment with ursodeoxycholic acid; pregnant women with a history of liver transplantation should continue immunosuppression, but not with mycophenolic acid.

The researchers concluded: “Clinical evaluation of the pregnant women who presents with liver test abnormalities relies on the accurate determination of intrinsic liver disease or liver diseases related to specific pregnancy. Judicious and timely evidence-based management most often results in good maternal and fetal outcomes.”

See the full study for a complete list of clinical recommendations for the treatment of liver diseases in pregnancy. – by Melinda Stevens

Disclosure: Tran reports receiving research grants and consulting for Bristol-Myers Squibb and Gilead Sciences. Please see the full study for a list of all other authors’ relevant financial disclosures.

The American College of Gastroenterology has released a clinical practice guideline for the diagnosis, treatment and management of various forms of liver disease among pregnant women.

“The purpose of this guideline is to provide a review of the diagnostic and treatment challenges of managing liver disease in pregnant women,” Nancy S. Reau, MD, FAASLD, FAGA, assistant professor of medicine at the University of Chicago, and HCV Next Editorial Board member, and colleagues wrote in The American Journal of Gastroenterology. “The evidence behind approaches to diagnosis and treatment of liver disease in pregnant women are assessed to provide management recommendations.”

Nancy S. Reau, MD

Nancy S. Reau

According to the guidelines, experts implemented the use of the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system for providing the best evidence to support the recommendations. Experts incorporated data from selected studies cited with strong evidence with the GRADE system. As a result, the experts comprised multiple recommendations for managing liver disease in pregnant women. A few of the recommendations include:

Evaluation

A pregnant woman who has abnormal liver tests should undergo the same workup as a nonpregnant person would.

“A complete history, physical exam and standard serological workup should be performed as indicated by the clinical presentation,” the researchers wrote.

Imaging

Ultrasound is safe for pregnant women and is the preferred imaging method for assessing abnormal liver tests of biliary tract disease. MRI without gadolinium can be used in the second and third trimesters without gadolinium. CT could be used “judiciously,” according to the guidelines, with only minimal radiation due to the fact this type of imaging carries risk for teratogenesis and childhood hematologic malignancies.

Endoscopy

The use of endoscopy in pregnancy is generally safe, but should be delayed until second trimester. Meperidine and propofol are recommended for endoscopic sedation.

Management of biliary disease and liver masses

Minimal fetal exposure to fluoroscopy is important, therefore endoscopic retrograde cholangiopancreatography can be used for women with indications for biliary pancreatitis, symptomatic choledocholithiasis or cholangitis. Women with asymptomatic hemangioma and focal nodular hyperplasia do not need to undergo routine imaging or surveillance during pregnancy. Patients with large adenomas should be referred to resection before pregnancy, according to the guidelines. 

HBV and HCV

Women with chronic HBV and high viral load should be offered antiviral medication with Viread (tenofovir disoproxil fumarate, Gilead Sciences) or Tyzeka (telbivudine, Novartis) in the third trimester to reduce transmission. HBV vaccination series and active-passive immunoprophylaxis with hepatitis B immunoglobulin should be administered to infants born to mothers with HBV. Cesarean section is not recommended in mothers with HBV and breastfeeding should be allowed.

All women showing risk factors for HCV should be screened with anti-HCV antibody and should not performed in women not presenting risk factors for the infection. Invasive procedures should be used minimally to prevent transmission. Breastfeeding is recommended for health reasons for the infant. A C-section and HCV therapy should not be offered to pregnant women.

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HAV, HEV and herpes simple virus

Women with acute hepatitis should be tested for common etiologies of acute liver injury. Pregnant women with acute hepatitis from suspected herpes simple virus should begin treatment on acyclovir.

HELLP syndrome

This should be managed by prompt delivery, especially after 34 weeks gestation, according to the guidelines. Platelet transfusion to between 40,000 and 50,000 cells/µL should be considered before delivery, especially if C-section will occur.

Other chronic liver disease

Pregnant women with autoimmune hepatitis should continue treatment with corticosteroids and/or azathioprine; pregnant women with primary biliary cirrhosis should continue treatment with ursodeoxycholic acid; pregnant women with a history of liver transplantation should continue immunosuppression, but not with mycophenolic acid.

The researchers concluded: “Clinical evaluation of the pregnant women who presents with liver test abnormalities relies on the accurate determination of intrinsic liver disease or liver diseases related to specific pregnancy. Judicious and timely evidence-based management most often results in good maternal and fetal outcomes.”

See the full study for a complete list of clinical recommendations for the treatment of liver diseases in pregnancy. – by Melinda Stevens

Disclosure: Tran reports receiving research grants and consulting for Bristol-Myers Squibb and Gilead Sciences. Please see the full study for a list of all other authors’ relevant financial disclosures.