Cirrhosis in Pregnancy

Key Points

  • Cirrhosis is defined as permanent scarring of the liver as a result of continuous long term damage.
  • There are few reports of pregnancy in women with cirrhosis although some small studies have suggested that there is an increased incidence of adverse maternal and perinatal outcomes in women with cirrhosis.
  • This study will establish the incidence of cirrhosis in pregnancy women in the UK and describe the management and perinatal outcomes of pregnancies affected by cirrhosis.

Surveillance Period

1st June 2017 – 31st May 2019

Background

Cirrhosis is defined as permanent scarring of the liver as a result of continuous long term damage and it is estimated to affect 45/100,000 women of child-bearing age(1). There are few reports of pregnancy in women with cirrhosis, and therefore data regarding pregnancy outcomes and optimal management are sparse. Several studies have suggested that there are higher rates of both maternal and neonatal mortality in women with cirrhosis(1-6), and women with portal hypertension and oesophageal varices appear to be at higher risk; however none have been large enough to accurately quantify the risks. Other maternal complications include higher rates of anaemia, post-partum haemorrhage, pre-eclampsia, placental abruption and maternal death(4, 6). Fetal complications are reported to include miscarriage, pre-term delivery and intrauterine growth restriction(2-4, 6). Management of cirrhosis largely relates to treatment of the underlying pathology. There is no consensus on the optimal treatment for variceal bleeding and there are concerns over the use of injection sclerotherapy and octreotide(1). Endoscopy and ligation banding appears to be safe but there are no randomised controlled trials. Furthermore, there are limited data regarding the best way to deliver women with cirrhosis. There are concerns over women labouring as the process involves repeated Valsalva manoeuvres which raises intra-abdominal pressure and therefore increases the risk of variceal rupture(1). This study will also aim to establish the maternal outcomes associated with cirrhosis, and to determine the effect of a pregnancy on disease progression.

Objective

To use the UK Obstetric Surveillance System (UKOSS) to determine the incidence of cirrhosis amongst pregnant women in the UK and examine the management of the condition as well as maternal and neonatal outcomes.

Research Questions

  • What is the incidence of cirrhosis in pregnant women in the UK?
  • What are the perinatal outcomes of pregnancies affected by cirrhosis?
  • What are the management strategies used to treat cirrhosis in pregnancy?
  • What is the incidence of co-existent pre-eclampsia, gestational diabetes and pregnancy specific liver disease (Acute Fatty Liver of Pregnancy and Intrahepatic Cholestasis of Pregnancy) in pregnant women with cirrhosis?

Case Definition

All pregnant women with an established history of cirrhosis defined by:

EITHER confirmation by liver biopsy

OR on the basis of radiological findings (nodular liver with enlarged spleen) with either a history of complications of liver disease (ascites, variceal bleeding, encephalopathy, pervious bacterial peritonitis) or supportive laboratory findings (low platelets, low albumin, prolonged prothrombin time or INR).

Funding

This study is being funded by The Lauren Page Trust.

Ethics Committee Approval

This UKOSS methodology has received the approval of the London Multi-centre Research Ethic Committee (04/MRE02/45).

Lead Investigator

Professor Catherine Williamson, Imperial, Victoria Geenes, Michael Heneghan, Leonie Penna, King’s College London; Professor Marian Knight, NPEU

References

[1] Tan, J., et al., Liver Transpl, 2008. 14(8): p. 1081-91.
[2] Murthy, SK., et al., Clin Gastroenterol Hepatol, 2009. 7(12): p. 1367-72, 1372 e1.
[3] Pajor, A., et al., Gynecol Obstet Invest, 1994. 38(1): p. 45-50.
[4] Rasheed, S.M., et al., Int J Gynaecol Obstet, 2013. 121(3): p. 247-51.
[5] Russell, M.A., et al., Semin Perinatol, 1998. 22(2): p. 156-65.
[6] Shaheen, A.A., et al., Liver Int, 2010. 30(2): p. 275-83.

Sample Data Collection Form

Cirrhosis in Pregnancy Data Collection Form