Pregnancy with portal hypertension

Abstract

Even though pregnancy is rare with cirrhosis and advanced liver disease, but it may co-exist in the setting of non-cirrhotic portal hypertension as liver function is preserved but whenever encountered together is a complex clinical dilemma. Pregnancy in a patient with portal hypertension presents a special challenge to the obstetrician as so-called physiological hemodynamic changes associated with pregnancy, needed for meeting demands of the growing fetus, worsen the portal hypertension thereby putting mother at risk of potentially life-threatening complications like variceal hemorrhage. Risks of variceal bleed and hepatic decompensation increase many fold during pregnancy. Optimal management revolves round managing the portal hypertension and its complications. Thus management of such cases requires multi-speciality approach involving obstetricians experienced in dealing with high risk cases, hepatologists, anesthetists and neonatologists. With advancement in medical field, pregnancy is not contra-indicated in these women, as was previously believed. This article focuses on the different aspects of pregnancy with portal hypertension with special emphasis on specific cause wise treatment options to decrease the variceal bleed and hepatic decompensation. Based on extensive review of literature, management from pre-conceptional period to postpartum is outlined in order to have optimal maternal and perinatal outcomes.

Keywords: ACOG, American College of Obstetrics and Gynecology; EHPVO, extrahepatic portal vein obstruction; EST, endoscopic sclerotherapy; EVL, endoscopic variceal ligation; FDA, Food & Drug Association of America; HVPG, hepatic vein pressure gradient; NCPF, non-cirrhotic portal fibrosis; NCPH, non-cirrhotic portal hypertension; PPH, postpartum hemorrhage; PVT, portal vein thrombosis; Portal vein thrombosis; cirrhosis; non-cirrhotic portal fibrosis; portal hypertension; pregnancy.

Figure 1

Effect of pregnancy hemodynamics on portal hypertension.