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Pregnancy After Liver Transplantation: a Case Series and Review of the Literature

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Pregnancy After Liver Transplantation: a Case Series and Review of the Literature View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Archivio della ricerca - Università degli studi di Napoli Federico II The Journal of Maternal-Fetal & Neonatal Medicine ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: https://www.tandfonline.com/loi/ijmf20 Pregnancy after liver transplantation: a case series and review of the literature Fabrizio Zullo, Gabriele Saccone, Laura Donnarumma, Ignazio Marino, Maurizio Guida & Vincenzo Berghella To cite this article: Fabrizio Zullo, Gabriele Saccone, Laura Donnarumma, Ignazio Marino, Maurizio Guida & Vincenzo Berghella (2019): Pregnancy after liver transplantation: a case series and review of the literature, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2019.1680632 To link to this article: https://doi.org/10.1080/14767058.2019.1680632 Published online: 21 Oct 2019. Submit your article to this journal Article views: 15 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ijmf20 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE https://doi.org/10.1080/14767058.2019.1680632 REVIEW ARTICLE Pregnancy after liver transplantation: a case series and review of the literature Fabrizio Zulloa, Gabriele Sacconeb , Laura Donnarummaa, Ignazio Marinoc, Maurizio Guidaa and Vincenzo Berghellad aDepartment of Clinical and Experimental Medicine, School of Medicine, University of Naples Federico II, Naples, Italy; bDepartment of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy; cSidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; dDivision of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA ABSTRACT ARTICLE HISTORY Objective: To evaluate maternal and perinatal outcomes in pregnant women after liver trans- Received 1 September 2019 plantation with a case series and literature systematic review. Accepted 10 October 2019 Methods: This was a single-center case-series study performed at University of Naples Federico KEYWORDS II. All consecutive women with liver transplantation who reported pregnancy at our institution Intensive care; liver; were included in a dedicated database. In addition, a systematic literature review was per- maternal mortality; formed, including case series, population-based studies, and national registries, including mater- neonatal; preeclampsia; nal and perinatal outcomes of pregnant women with liver transplant. Studies with fewer than transplantation; ultrasound 10 cases and surveys were excluded. The primary outcome was perinatal death, defined as either stillbirth (defined as intrauterine fetal death after 20 weeks of gestation) or neonatal death (death of a live-born infant within the first 28 d of life). Results: During the study period, two women who underwent liver transplantation had a preg- nancy in our Institution. Both of them underwent liver transplantation for biliary atresia at 1 year of age. One of them received cyclosporin as immunosuppressive regime during pregnancy, while the other one received tacrolimus. Both of them had a pregnancy with no major compli- cations and delivered by cesarean section at term a baby with normal weight. One of them developed thrombocytopenia. Seventeen articles were included in this systematic review. Preterm birth at less than 37 weeks of gestations occurred in 279 women (33.6%). One-hundred women (14.9%) experienced preeclampsia, and 206 women (49.2%) delivered by cesarean deliv- ery. Graft rejection related to pregnancy occurred in 73 women (8.3%). 117 women (12.9%) experienced miscarriage, and 22 (2.3%) IUFD. Fifty-two women (9.52%) underwent elective I- TOP. 195 fetuses (33.4%) were LBW. Eight neonatal deaths were recorded (1.3%). Conclusion: The maternal and perinatal outcome is usually favorable, but with an increased risk of preeclampsia, preterm birth, and perinatal morbidity and mortality. However, appropriate counseling about risks and complications is essential but women shouldn’t be advised against pregnancy. Introduction Optimal patients’ selection is essential due to the constant organs shortage. Priority on the waiting list is Liver transplantation is a life-saving and successful based on the Child-Pugh Turcotte classification and therapeutic procedure in acute liver failure and end- MELD (Model For End-Stage Liver Disease) score. stage liver disease [1,2]. Liver transplantation is However, the final decision for graft allocation is increasing worldwide, and there is also a striking based on multiple parameters [57]. increase among women of reproductive age [3,4]. Reproductive function is often severely compro- Liver transplantation should be considered in any mised in the setting of end-stage liver disease, charac- patient with end-stage liver disease in whom the pro- cedure would extend the life expectancy beyond what terized by menstrual irregularity, amenorrhea, and the natural history of the underlying disease would infertility in half of the women [7,58]. predict [5–56]. Patients should be selected if expect- Successful liver transplantation is able to restore ancy survival is 1 year or less in absence of transplant- the menstrual cycle and function in 97% of female ation or if the patient has an unacceptable quality of patients, meaning childbearing potential is also life due to liver disease [57]. restored [59]. CONTACT Gabriele Saccone [email protected] Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy ß 2019 Informa UK Limited, trading as Taylor & Francis Group 2 F. ZULLO ET AL. In the USA alone, 14,000 women of childbearing maternal outcomes, including maternal death, cesar- age are currently liver transplantation recipients, and ean delivery, preeclampsia, gestational diabetes melli- another 500 women will undergo this procedure tus (GMD), and graft rejection related to pregnancy annually [60]. (i.e. during pregnancy or in the postpartum period); Since the first successful pregnancy following liver and neonatal outcomes, including intrauterine growth transplantation reported in 1978 by Walcott et al. [5], restriction (IUGR) (i.e. ultrasound estimated fetal several studies have been published [6–21], including weight <10th percentile for gestational age), intrauter- case report [5], case series [6–14], surveys [15,16], ine fetal death (IUFD) (i.e. fetal death after 20 weeks of population-based studies [17], and registries [18–21], gestation), miscarriage (i.e. pregnancy loss before including the National Transplantation Pregnancy 20 weeks of gestations), elective termination of preg- Registry from the USA [18–20], and the UK Transplant nancy (I-TOP), low birth weight (LBW) (i.e. neonatal Pregnancy Registry [21]. The maternal and perinatal birth weight at less than 2500 g), and neonatal deaths outcome is usually favorable, but with an increased (i.e. death of a live-born infant within the first 28 d risk of preeclampsia, preterm birth, and perinatal mor- of life). bidity and mortality [22,23]. The aim of this study was to evaluate maternal and perinatal outcomes in pregnant women after liver Data extraction and risk of bias assessment transplantation with a case series and literature review. For the systematic review, two authors (FZ, GS) reviewed all abstracts independently. Agreement Materials and methods regarding potential relevance was reached by consen- sus. Full-text copies of those papers were obtained Study design, search strategy, and study selection and the same reviewers independently extracted rele- This was a single-center case-series study performed vant data regarding study characteristics and preg- at the University of Naples Federico II (Naples, Italy). nancy outcomes. Inconsistencies were discussed by All consecutive women with liver transplantation who the reviewers and consensus reached or by discussion reported pregnancy at our institution between with a third author (VB). January 2010 and December 2018 were included in a Quality assessment of the studies included in the dedicated database. systematic review was performed using the Newcastle- In addition, a systematic literature review was per- Ottawa Scale (NOS) [25]. According to NOS, each study formed according to a protocol recommended for sys- is judged on three broad perspectives: the selection of tematic review [24]. The review protocol was designed the study groups, the comparability of the groups, a priori defining methods for collecting, extracting and and the ascertainment outcome of interest. analyzing data. The research was conducted using Assessment of the selection of a study includes the Medline, Embase, Scopus, Web of Sciences, and evaluation of the representativeness of the exposed ClinicalTrial.gov as electronic databases. The articles cohort, selection of the nonexposed cohort, ascertain- were identified with the use of a combination of the ment of exposure and the demonstration that out- relevant heading term, keywords, and word variants come of interest was not present at start of study. for: “liver transplant,”“liver transplantation” and Assessment of the comparability of the study includes “pregnancy,” from the inception of each database to the evaluation of the comparability of cohorts based January 2019. A review of articles
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