Pregnancy and vascular
liver diseases
J B Dilawari, Chandigarh, India
Pierre-Emmanuel Rautou, Clichy, France
Outline
• Introduction
• Is pregnancy a risk factor for vascular liver
disease?
• What are the outcomes of pregnancy in women
with vascular liver disorders ?
• Management of pregnancy and delivery
Outline
• Introduction
• Is pregnancy a risk factor for vascular liver
disease?
• What are the outcomes of pregnancy in women
with vascular liver disorders ?
• Management of pregnancy and delivery
Pregnancy and liver disorders
1. Pre-existing chronic liver disease:
2. Unique to pregnancy:
3. Developing during with pregnancy:
Hyperemesis gravidarum
Acute fatty liver of pregnancy
HELLP, preeclampsia
Intrahepatic cholestasis of pregnancy
Viral hepatitis
Drug induced liver injury
Vascular liver disease
Cirrhosis
Viral hepatitis
Cholestastic liver disease
Benign liver nodules
Wilson’s disease
Vascular liver diseases
IVC
PV HA
HVHV
• Affect either IVC, HV, PV
• Frequent during pregnancy
Pregnancy and vascular liver disorders
Hemodynamic changes in pregnancy
- Vasodilatation, arterial BP
- Cardiac out put , Blood Volume
- Portal blood flow , P.V. diameter
- Venous return in IVC due to Gravid uterus
(blood flows from lower part to azygous system)
Changes reminiscent of those of cirrhosis
Munnell, JCI 1947. Mustafa, J Pregnancy 2012; Bissonnette, JCEH 2015
Procoagulant
state
Anticoagulant
state
Pregnancy
Von Willebrand factor
Fibrinogen
Factors II, VII, VIII and X
Protein S
Resistance to activated protein C
Plasminogen activator inhibitor-1
Pregnancy
-
Battaglioli, Curr Opin Hematol 2007; Marik, NEJM 2008
Coagulation changes in pregnancy
Outline
• Introduction
• Is pregnancy a risk factor for vascular liver
disease?
• What are the outcomes of pregnancy in women
with vascular liver disorders ?
• Management of pregnancy and delivery
• A 29 year old female
• History of 2 miscarriages
• Day 10 post-partum (baby born at 32 weeks):
– Acute onset of right upper quadrant abdo. pain
– Ascites and jaundice
– T Bili: 5.6 mg/dL; AST/ALT: 205/418 IU/L; INR: 2.6
– Doppler U/S: localized thrombosis right HV, Coma
shaped collaterals
CASE 1
Is that a fortuitous association?
Is pregnancy a risk factor for Budd-Chiari
syndrome?
Mohanti, Hepatology 2001; Dilawari, Medicine 1994; Rautou, Gut 2009
• Temporal association between the 2 conditions
• Prevalence of pregnancy/postpartum in women
aged 15-45 in France between 1995 and 2005:
Yes(likely, and other risk factors frequently associated)
Among women
presenting with BCS:
16% (7/43)
In the general French
population:
7–8%
Pregnancy
Budd-Chiari syndrome Yes (likely)
Portal vein thrombosis Rare reports
Sinusoidal obstruction syndrome No report
Liver hemangioma Exceptional
Obliterative portal veinopathy No report
Is pregnancy a risk factor for vascular liver
diseases?
Bissonnette, JCEH 2015
Outline
• Introduction
• Is pregnancy a risk factor for vascular liver
disease?
• What are the outcomes of pregnancy in women
with vascular liver disorders ?
• Management of pregnancy and delivery
CASE 2
• A 29 year old woman with BCS due to
myeloproliferative disease desires a pregnancy
• Treatment: vitamin K antagonists; hydroxyurea
• Physical examination: no symptom
• Blood test: INR 1,1; serum bilirubin normal
- Is pregnancy contraindicated?
- What is the expected risk for the baby, for her?
Pregnancy and BCS: Maternal outcome
0
10
20
30
40
50
60
% o
f m
ate
rnalde
ath
Khuroo
1963-78
Dilawari
1967-91
Rautou
1985-2005
N=16 N=38
Khan,
2001-15
N=16N=24
Shukla
2012-15
N=15Number of
pregnancies
No treatment
0% 0% 0%
Anticoagulation angioplasty/TIPS
56 pregnancies
GI Bleeding 0
Genital, parietal bleeding33 pts with anticoagulation
7
Thrombotic event 0
Liver relatedascites, pulmonary artery hypertension
4
Related to pregnancycholestasis, placenta praevia, preeclampsia
13
Rautou, J Hepatol 2009; Khan, World J Hepatol 2017;
Shukla, Liv Int 2017; Aggarwal Arch Gynecol Obstet 2013
Pregnancy and BCS: Maternal outcome
Pregnancy and BCS: Fetal outcome
Rautou, J Hepatol 2009; Khan, World J Hepatol 2017
Num
be
r o
f p
reg
na
ncie
s
13
3
16
8
0
2
4
6
8
10
12
14
16
18
< 20 20-31 32-36 > 36
Weeks of gestation
40 pregnancies
26 alive
No sequelae
1 stillbirth
Miscarriage/
ectopic
pregnancy
Early
preterm
Preterm
Term
CASE 3
• 34 year old female
• INCPH revealed 1 year ago:
• Splenomegaly, no varices
• Liver blood tests abnormalities
• Liver biopsy: no cirrhosis, nodular regenerative hyperplasia
• Sicca syndrome
• Desires pregnancy (1 daughter, 5 year-old)
- Is fertility preserved?
- Is pregnancy contraindicated?
- What is the expected risk for the baby, for her?
0,00%
0,05%
0,10%
0,15%
0,20%
0,25%
Kochhar R Dig Dis Sci. 1999
INCPH and fertility
Controls
(N=44)
Before diagnosis After diagnosis
Fe
rtili
tyra
te
of noncirrhotic portal hypertension (n=55)
No difference
INCPH and pregnancy24 pregnancies (16 women)
Diagnosis 1st pregnancy
controlled
Anticoagulation (n=6)
Antiplatelet (n=1)
No treatment (n=19)
• 7 w/o prophylaxis of GI bleeding
• 5 with portal vein thrombosis
• 4 TIPS
Median: 38 months
Andrade, revised
24 pregnancies
Maternal death 0
Esophageal varices1 w/o appropriate prophylaxis
2
Ascites 3
Porto-pulmonary hypertension 1
Genital-parietal bleeding 2
Thrombotic event 1
INCPH: maternal outcome
Andrade, revised
24 pregnancies in 16 women with INCPH
Num
ber
of pre
gnancie
s
5
2
8
9
0
2
4
6
8
10
< 20 20-31 32-36 > 36
Weeks of gestation
Miscarriage/
ectopic
pregnancy
18 alive
No sequelae
2 death
Andrade, revised; similar or better results in: Kochhar R Dig Dis Sci. 1999
INCPH: fetal outcome
• 27 yr-old female
• Acute portal vein thrombosis in 2009 – Superior mesenteric and splenic veins
– Mesenteric intestinal ischemia
• Associated conditions – Pernicious anemia (vit B12 supplementation)
– Hyperhomocysteinemia
CASE 3
• Anticoagulation therapy– By 3 months: portal cavernoma development
– Maintained long term
• Esophageal varices → Nonselective β-block.
• 2015: Routine work-up – Normal liver blood tests
– Unchanged esophageal varices
– Desire for pregnancy
CASE 3
What is your answer to patient’s
concern about pregnancy outcome?
1.The probability of a term birth of a healthy
child is below 50%.
2.The rate of miscarriage is increased.
3.The probability of preterm birth is
increased.
4.The probability of congenital malformation
is increased.
5.Perinatal mortality rate is about 25 %.
1.The probability of a term birth of a healthy
child is below 50%.
2.The rate of miscarriage is increased.
3.The probability of preterm birth is
increased.
4.The probability of congenital malformation
is increased.
5.Perinatal mortality rate is about 25 %.
What is your answer to patient’s
concern about pregnancy outcome?
PVT: fetal outcome
Mandal, Singapore Med J 2012. Hoekstra, J Hepatol 2012.
Aggarwal, J Obstet Gynaecol Res 2011
PVT General population
Miscarriages 14% 15%
Stillbirths 2% 0.5%
Live birth 83% 85%
Preterm births 14% 6-10%
Perinatal death 1% -
in 104 pregnancies with known PVT
Bissonnette et al., J Clin Exp Hepatol 2015
A gestation reaching the 20th week
is very likely to end with a live newborn
PVT: fetal outcome
1. Portal hypertension worsens
2. Risk of variceal bleeding is about 30%
3. Risk of deep vein thrombosis/pulmonary
embolism is about 30%
4. Risk of complications of anticoagulation
therapy is about 30%
5. Risk of maternal death is not increased
What is your answer to patient’s concern about maternal outcome?
1. Portal hypertension worsens
2. Risk of variceal bleeding is about 30%
3. Risk of deep vein thrombosis/pulmonary
embolism is about 30%
4. Risk of complications of anticoagulation
therapy is about 30%
5. Risk of maternal death is not increased
What is your answer to patient’s concern about maternal outcome?
PVT: Maternal outcome
PVTN = 104
CirrhosisN = 129
Maternal death 0% 8%
Variceal bleeding3 pts without adequate prophylaxis
5% 6%
Genital/parietal bleeding 1 pt on anticoagulation therapy
6% 16%
Thrombotic events 2% 1%
Mandal, Singapore Med J 2012. Hoekstra, J Hepatol 2012.
Aggarwal J Obstet Gynaecol Res 2011.
PVTN = 104
CirrhosisN = 129
Maternal death 0% 8%
Variceal bleeding3 pts without adequate prophylaxis
5% 6%
Genital/parietal bleeding 1 pt on anticoagulation therapy
6% 16%
Thrombotic events 2% 1%
Rasheed Int J Gynaecol Obstet 2013
PVT: Maternal outcome
Outline
• Introduction
• Is pregnancy a risk factor for vascular liver
disease?
• What are the outcomes of pregnancy in women
with vascular liver disorders ?
• Management of pregnancy and delivery
• Routine screening - before conception?
- second trimester?
• Safety of nonselective beta-blockers
- small for gestational age, preterm birth and
perinatal mortality?
- risk of neonatal hypoglycemia
Pregnancy and management of portal hypertension
Bleeding occurred mostly in patients without adequate prophylaxis
Petersen, BMJ Open 2012. Cissoko, Arch Pediatrie 2005
→ No data
• Risk/benefit of pharmacologic therapy
→ Safe in selected case reports
• Endoscopic band ligation
• Sclerotherapy
• TIPS insertion *
Scarce data on acute variceal bleeding
* 3 pregnant patients with cirrhosis
Pregnancy and management of portal hypertension
March 2016: Pregnancy
Management of anticoagulation therapy?
CASE 3
What do you propose for
anticoagulation therapy?
1. No change of anticoagulation therapy
2. Increase anticoagulation intensity
3. Shift to LMWH
4. Add-on aspirin
5. Shift to direct oral anticoagulant agents
1. No change of anticoagulation therapy
2. Increase anticoagulation intensity
3. Shift to LMWH
4. Add-on aspirin
5. Shift to direct oral anticoagulant agents
What do you propose for
anticoagulation therapy?
Risk factor for DVT/PE in pregnancy
• Underlying Thrombophilia
• History of thrombosis
• APLS or lupus
• Age > 35 yr-old
• Obesity
• Smoking
James et al., Am J. Obstet. Gynecol. 2006
Anticoagulation therapy and pregnancy
Switch from VKA to LMWH
within 4 wks of conception
VKA LMWH
Teratogenic effects Yes No
Fetal anticoagulation Yes No
Recommendations for pregnant women with previous unprovoked VTE
American College of Chest Physicians. Chest 2012
Royal College of Obstetricians and Gynecologists. April 2015
Thromboprophylaxis
•Until delivery:
•Postpartum: - LMWH for 6 weeks dose 50-75% of therapeutic dose
- or Vitamin K antagonists targeted at INR 2 to 3
- LMWHdose 50-75% of therapeutic dose
Safety of LMWH in pregnancy
• 2777 pregnancies (a systematic review)
• No maternal deaths
• Adverse effects:– Significant bleeding: 1.98%
– Allergic skin reactions: 1.80%
– Heparin-induced thrombocytopenia: 0%
– Thrombocytopenia (unrelated to LMWH): 0.11%
– Osteoporotic fracture: 0.04%
• Live births: 94.7%
Greer et al, Blood. 2005
Anticoagulation therapy: our proposal
Already on
Anticoagulation?
Consider switching
to therapeutic dose
of LMWH
preconception
Consider
Prophylactic dose of
LMWH during
pregnancy
YES NO
March 2016 : Pregnancy
Management of anticoagulation therapy?
3-week gestation
Tinzaparin 0.6 ml S/C
(12,000 anti Xa Units)
CASE 3
• Acute abdominal pain and vomiting
• No evidence of infection
• Normal LFTs - Anti Xa 0.6 Units/ml
• Doppler-US: recent thrombosis of a collateral of the right gastric vein
• Shift tinzaparin q.d. to enoxaparin b.i.d.
• Uneventful pregnancy
9-wk gestation
CASE 3
Vaginal or caesarean delivery?
Sultan, Blood 2013; Aggarwal, Int J Gynaecol Obstet 2001
• Vaginal delivery
– Variceal bleeding during active phase of
labor uncommon (selected case reports)
– Impact of labor on portal pressure?
• Caesarean section
– Injury to collateral veins, ascites
– Postpartum thromboembolism
Sultan, Blood 2013; Aggarwal, Int J Gynaecol Obstet 2001
• Vaginal delivery as a preferred option
(assisted phase of active labour)
• Caesarean section for obstetrical
reasons
Vaginal or caesarean delivery?
• 37-wk gestation:
–Induced labor
–Vaginal delivery
• No bleeding during labor or post-partum
• Apgar score 10/10
• Birth weight 2.800 kg
CASE 3
Delivery: our proposal of management of anticoagulation
• Stop LMWH 24 hrs before delivery
• Resume LMWH early after uneventful vaginal delivery if the thrombotic risk is judged to be very high.
• Resume LMWH 24 hrs after the procedure when bleeding risk is considered low
Safe platelet count for delivery
• > 50 000/mL for caesarean section
• > 20 000/mL for vaginal delivery
• > 75,000/mL for epidural anesthesia
• > 50,000/mL for spinal anesthesia
Bissonnette et al, JCEH 2015
• Can be used:
Warfarin (not excreted in breast milk)
Propanolol
• Do not use:
Hydroxyurea
Breastfeeding
Elective termination of pregnancy
• Delicate issue
• Discuss risks perceived to be too high for the
mother and/or the fetus.
• With high-risk thrombophilia and/or previous
major complications of pregnancy
Bissonnette et al, JCEH 2015
Conclusion
1. Preconception counseling
• Preterm birth and stillbirth increased
• Portal hypertension manageable
• Prothrombotic disorder manageable
• Pregnancy is not contraindicated
2. Multidisciplinary team
3. Antenatal management
• Variceal bleeding prophylaxis
• Shift to/prefer LMWH anticoagulation
4. Delivery and Postpartum
• Prefer vaginal delivery
• Anticoagulation therapy not a risk
factor for bleeding
Conclusion
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