Incidence of cirrhosis is rising, especially in women of childbearing age, but few studies have been conducted to evaluate the impact of pregnancy on liver decompensation in women with cirrhosis. To address this, researchers at Queen’s University in Canada examined associations between liver-related health events and pregnancy in women with cirrhosis.
“The evidence regarding pregnancy in patients with cirrhosis is sparse at best and what does exist is very dire,” says Monica Mullin, MD, a post-graduate trainee at Queen’s University and the study’s co-author. “We felt that more research in the area was necessary to guide practitioners in their care for patients who achieve pregnancy, if they have cirrhosis and hopefully to reassure both the mothers and physicians about the expected course throughout their pregnancy.”
Chronic liver disease increasingly is seen in adolescent and young adult patients in North America, says Jennifer A. Flemming, MD, FRCP(C), MAS, assistant professor, Division of Gastroenterology and Department of Public Health Sciences at Queen’s University, and the study’s co-author. “Practitioners caring for women of child-bearing age are increasingly faced with providing counselling and recommendations not only on the ability to achieve pregnancy, but the safety of pregnancy for both the mother and baby. In Canada, longitudinal medical care is able to be captured and linked given the universal nature of our healthcare system. We had the unique ability to provide a more generalizable and contemporary description of liver-related events in a large cohort of pregnant women with cirrhosis which we anticipate will inform not only healthcare providers and patients but will be important for the development of clinical practice guidelines,” says Dr. Flemming.
The population-based, retrospective matched cohort study used routinely collected healthcare data in Ontario from 2000 to 2017 to evaluate the association between pregnancy and liver decompensation. Women with a single-fetus pregnancy after their cirrhosis index date who carried their baby to at least 20 weeks of gestation were identified by linking mother-infant records. The researchers then matched pregnant women at the time of conception to two non-pregnant women with cirrhosis based on age (±5 years), cirrhosis etiology and socioeconomic status. Women with a previous transplant were excluded from the study. Control patients with a history of decompensation were also excluded; however, pregnant women with previous decompensation were included. The follow-up period was from time of conception to one year post-partum.
The study included 5,607 women with cirrhosis, including 1,869 pregnant and 3,738 non-pregnant women. Their median age was 31 years. Fifty-nine percent had a NAFLD/cryptogenic cirrhosis; 36 percent had viral hepatitis; and four percent had alcohol-related liver disease. A total of 33 (1.8 percent) of pregnant women in the study had a decompensation event compared to 349 (9.3 percent) of the non-pregnant women. Only five patients experienced liver decompensation before their delivery. After adjusting the results to consider co-existing illnesses the women might have been experiencing, pregnancy was associated with lower odds of liver decompensation, the study’s authors found.
“Given that our results are from a large, contemporary, diverse population of women with cirrhosis, we hope that the low rate of complications we describe provides reassurance for pregnant women that the likelihood of a serious liver-related complication during the peri-partum period is low. The next steps in this study are to better define the maternal and fetal complications to provide an accurate overall estimate of risk for both the mother and child,” says Dr. Flemming.
Dr. Mullin and Dr. Flemming will present these findings at AASLD’s press conference in Room 210 at the Hynes Convention Center in Boston on Saturday, Nov. 9 from 4 – 5:30 PM. The study entitled “LIVER-RELATED OUTCOMES IN PREGNANT WOMEN WITH CIRRHOSIS: A POPULATION-BASED STUDY” will be presented on Sunday, Nov. 10 at 10:30 AM in room 312. The corresponding abstract (number 0057) can be found in the journal, HEPATOLOGY.
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Abstract 0057: LIVER-RELATED OUTCOMES IN PREGNANT WOMEN WITH CIRRHOSIS: A POPULATION-BASED STUDY.
Authors: Dr. Monica Mullin1, Dr. Jacquie Lu1, Dr. Maria Velez2, Dr. Monika Sarkar, MD, MAS3, Dr. Susan Brogly4, Dr. Norah Terrault, MD, MPH, FAASLD5 and Dr. Jennifer A. Flemming1,6,7, (1)Medicine, Queen’s University, (2)Obstetrics and Gynaecology, Queen’s University, (3)Medicine, University of California San Francisco, (4)Surgery, Queen’s University, (5)GI and Liver Diseases, University of Southern California, (6)Ices, (7)Public Health Sciences, Queen’s University
Background: The incidence of cirrhosis is increasing especially among young birth cohorts and women. Few studies have evaluated the impact of pregnancy on liver decompensation events in women with cirrhosis. The aim of this study was to describe the association between pregnancy and liver-related events in women with cirrhosis.
Methods: Population-based retrospective matched cohort study in Ontario, Canada from 01/01/2000-12/21/2017 using routinely collected healthcare data. Women with cirrhosis were identified using a validated case definition. Those with a singleton pregnancy after cirrhosis index date who carried to at least 20 weeks gestation were identified through mother-infant record linkage. Pregnant women were matched at the time of conception to non-pregnant women with cirrhosis based on age (± 5 years), cirrhosis etiology, and socioeconomic status in a 1:2 ratio. Those with previous transplant were excluded. MELD/Child-Pugh scores were not available. Control patients with a history of decompensation were excluded however pregnant women with previous decompensation were included. Follow-up was from time of conception to 1-year post-partum. The primary outcome was hepatic decompensation identified using a validated algorithm that included ascites, variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome. The association between pregnancy and decompensation was evaluated with conditional logistic regression.
Results: A total of 5,607 women with cirrhosis (1,869 pregnant and 3,738 non-pregnant) were included. The median age was 31 years (IQR 27-35), cirrhosis etiology was NAFLD/cryptogenic (59%), viral hepatitis (36%), and alcohol-related (4%). A total of 33 (1.8%) pregnant women had a decompensation event (Table) compared to 349 (9.3%) non-pregnant women. Only 5 patients decompensated before delivery. After adjusting for co-morbid illness using the Charlson comorbidity index, pregnancy was associated with lower odds of hepatic decompensation (OR 0.17, 95% CI 0.12-0.24; P <.001).
Conclusion: In pregnant women with cirrhosis, less than 2% had liver decompensation within one year of delivery with the odds of decompensation much lower compared to non-pregnant cirrhotic controls. This may relate to liver function at the time of conception or engagement in care, though results are reassuring for preconception counseling and pregnancy management in women with cirrhosis.
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