Pregnancies following liver transplantation

A report describes a case of a 22-year-old living donor liver transplant(LT) recipient who was enrolled for antenatal care. The patient received successful liver transplantation for end-stage liver disease due to autoimmune hepatitis in 2016 at age twenty. After liver transplantation, she received triple immunosuppression viz Tacrolimus, glucocorticoids, and mycophenolate mofetil (MMF), along with thyroxine replacement for autoimmune hypothyroidism. 

With a stable allograft function, she discontinued MMF one year after LT and planned her first pregnancy at 19 months post-transplant. The patient delivered a healthful baby of 3.5 kg at 36 weeks gestation by LSCS. The baby showed a normal neonatal period and developmental milestones. 

The patient continued breastfeeding with close monitoring of allograft function and had regular menstruation post-lactation. Her liver function tests (LFT) remained normal. A year later, she had a spontaneous conception with normal obstetric parameters. Her initial blood parameters, including liver function tests, fell within the normal range except for low hemoglobin. She received Tacrolimus with regular monitoring for dose titration. 

At 32 weeks of gestation, she experienced significant fatigue. There were no jaundice, fever, or signs of liver failure. However, her liver enzymes ALT, AST, and GGT (5 x UNL) were elevated. Ultrasound examination revealed a mild increase in hepatic echogenicity with patent vasculature, a non-obstructed biliary system, and a viable fetus. The physicians ruled out Viral (Hepatitis A, B, C, E, and HSV) and vasculitic etiology and considered Acute cellular rejection the most likely. 

The patient received Tacrolimus and intravenous methylprednisolone. She underwent an emergency cesarean section to prevent further deterioration and delivered a preterm baby weighing 2.9 kg with a good APGAR score. The baby obtained treatment in the NICU for four days. The mother recovered well and had normal LFT on the sixth postoperative day. She received routine antibiotics, analgesics, and thromboprophylaxis.

Palanivelu LM, Patel V. Second successful pregnancy following liver transplantation. Indian Journal of Obstetrics and Gynecology Research 2023;10(1):82–84