In our study, the maternal and fetal outcomes of 20 pregnancies complicated by liver cirrhosis performed in a single healthcare institution between 2008 and 2020 were evaluated. Liver cirrhosis is a histopathologically defined, life threatening, chronic and progressive condition. Determining the etiology is crucial in terms of managing the disease as well as providing counselling regarding the prognosis of the pregnancy. The etiology of liver cirrhosis also varies according to the economic status of the countries. Alcoholic liver disease, chronic hepatitis C and non-alcoholic fatty liver disease make up 80% of patients waiting in line for a liver transplant in the United States. . Chronic hepatitis B is the most prevalent diagnosis among our patient population. While many women with liver cirrhosis may be able to pursue their pregnancies without hepatic compromise, some women may show signs of hepatic decompensation, such as ascites, variceal bleeding, encephalopathy, and hepatorenal syndrome . Previous studies reported that the rate of decompensation in pregnant women with liver cirrhosis was 24% and variceal bleeding rate was 32%, while Shaheen et al. reported a decompensation rate as 15%, ascites 11% and variceal bleeding as 5%[10, 16, 17]. In our study, decompensation was observed in 15% of the patient group, and the ascites was seen in all of these cases.
The increase in the total blood volume associated with pregnancy might worsen portal hypertension, and an increased risk of variceal bleeding is also observed, especially after the second trimester [16, 18]. Without timely diagnosis and management, it is an important cause of morbidity and mortality which can lead to catastrophic consequences. In the literature, maternal mortality rates due to liver cirrhosis during pregnancy vary between 10% and 61%, with the inclusion of earlier studies [9, 17, 19]. In our study, six patients had a history of variceal bleeding before pregnancy and none of the patients in the study encountered variceal bleeding and maternal mortality during pregnancy.
Various abnormalities in serum parameters can be seen in patients with liver cirrhosis. In addition, the disease may even manifest with these abnormalities. Some of the alterations include elevated serum bilirubin, aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, prolonged prothrombin time and INR values, as well as hyponatremia, anemia, and thrombocytopenia [20–22]. While thrombocytopenia is the most common hematological disorder, leukopenia and anemia may occur later in the disease . In our study, anemia was noted in 55% of patients, whereas thrombocytopenia was found in 65%. Preoperative prophylactic platelet transfusion was needed in approximately half of the cases with thrombocytopenia. While thrombocytopenia in cirrhosis patients is mostly due to congestive splenomegaly and portal hypertension, the development of anemia can be related to a variety of factors such as acute and chronic gastrointestinal blood loss, folate deficiency, alcohol-related toxicity, hypersplenism, anemia of chronic disease and hemolysis .
The Model for End-Stage Liver Disease (MELD) score is a clinical tool utilized to estimate the severity and survival for chronic liver disease . In the study of Westbrook et al., the MELD score of 10 and above was associated with poor maternal results . In our study, even though MELD score of 6 patients was 10 and above, the mean MELD score was 8.8. Patients with high MELD scores were associated with poor maternal and fetal outcomes.
The incidence of abortion, stillbirth and preterm delivery appears to be increased in pregnancies complicated by liver cirrhosis [10, 11]. Spontaneous abortion occurred in 10% of the cases and pregnancy was terminated in 20% of the patients. Preterm delivery rate was 42.8% and the indication for preterm deliveries were obstetric and fetal in majority of patients. There is still not enough evidence regarding the ideal delivery route in pregnancies complicated with cirrhosis. A theoretical increase in the risk of bleeding that may result from injuries to abdominal collaterals during the entry into the abdomen in cesarean section is likely. However, an increase in the risk of variceal bleeding due to increased abdominal pressure during vaginal deliveries is another concern. Due to the lack of consensus in the method of delivery, there are obvious differences among the studies reported in terms of cesarean delivery rates. In the study conducted by Rasheed et al., cesarean rate in pregnant women with cirrhosis was 91.5%, while it was reported as 26% in the study conducted by Palatnik et al [15, 24]. In our study, while cesarean delivery rate was 78.5%, most of the caesarean sections were performed due to obstetric indications. In addition, regional anesthesia was mostly preferred in cesarean deliveries due to its advantages on maternal cardiopulmonary and hemodynamic system.
It is important to emphasize that the limitations of our study include the number of the patients enrolled in the study and retrospective nature of the study.
According to the studies in the literature, many patients with chronic liver disease are able to achieve favourable maternal and fetal results without developing hepatic decompensation with appropriate management and close follow-up. Despite all these favourable advancements, termination of the pregnancy should be strongly considered in pregnant women with high risk of variceal bleeding or in the presence of symptoms concerning for hepatic decompensation. Pregnancy in patients with liver cirrhosis should be managed in a multidisciplinary approach, including a maternal-fetal medicine specialist, neonatologist and hepatologist.