Introduction Pregnancy in liver transplant (LT) patients has been reported to have largely favourable outcomes for the mother, foetus and allograft. Concerns remain with regards to graft rejection, the type and optimal level of immunosuppression and the ideal timing for conception following LT. We report a review of all pregnancies in LT recipients at our centre from 1988 to 2010 concentrating on maternal, foetal and graft outcomes.
Results 115 pregnancies occurred in 84 LT recipients. The median age at conception was 26 years and the median interval between LT and conception was 53 months (range 1–239 months). There were 82 (71%) live births, 13 terminations, 18 spontaneous abortions, 1 molar pregnancy and 1 intrauterine death. The mean gestation was 38 weeks (range 24–42 weeks). Regarding foetal outcomes, no congenital abnormalities occurred. A very low birth weight (<1500 g) occurred in 6% (7 babies), and all required neonatal intensive care support following delivery. On follow-up one has delayed developmental milestones. Prematurity (gestation <37 weeks) occurred in 34% 28/82. Neither choice of maternal immunosuppression nor an episode of rejection during pregnancy impacted on the birth weight or gestational period. Maternal complications encountered during pregnancy included renal failure (n=9, 8%), hypertension (n=27, 23%) and pre eclampsia (n=16, 14%). 18 (16%) cases of graft rejection occurred in association with pregnancy. Sixteen were consistent with acute cellular rejection on biopsy; with 5/16 occurring post partum. Overall 15 responded to immunosuppression augmentation and three required methyl prednisolone. The risk of graft rejection was significantly higher in patients conceiving within 12 months of LT (p<0.006). No maternal deaths occurred as a direct result of pregnancy, however two mothers required ITU support and 1 developed decompensated liver disease post partum. Seventy eight patients were on tacrolimus, 35 on cyclosporine, 1 on mycophenolate and 1 on sirolimus. Patients on cyclosporine had a higher incidence of acute rejection (p=0.04) and were more likely to be on a second immunosuppressive agent (p<0.001) or prednisolone (p<0.001) when compared to those patients on tacrolimus. Immunosuppression choice had no significant effect on pregnancy induced hypertension, pre eclampsia or gestational diabetes. The conception on mycophenolate was terminated, however the patient on sirolimus delivered at 37 weeks.
Conclusion Overall pregnancy following LT has a favourable outcome, with the majority of wanted conceptions resulting in a live birth. Immunosupression appears safe with no congenital abnormalities in this cohort. Risks however do remain with regards to acute cellular rejection and very low foetal birth weights. Patients should be educated with regards to the above information so an informed decision regarding pregnancy can be made.
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