From 2007 to 2016, the rate of cirrhosis in US pregnant adults more than doubled, and cirrhosis during pregnancy was found to be associated with multiple adverse pregnancy outcomes, including hypertensive complications, postpartum hemorrhage, and preterm birth. The study findings were published in the American Journal of Gastroenterology.
Investigators extracted data from the US National Inpatient Sample, an all-payer inpatient care database that includes information from approximately 8 million hospital admissions annually. Pregnant individuals with a discharge code for a delivery between 2007 and 2016 were included. Outcomes of interest were any adverse maternal or perinatal outcome, including preterm birth, postpartum hemorrhage, hypertensive complications, and maternal or fetal death. Logistic regression analyses were used to compare adverse outcome rates between patients with and without cirrhosis. Models were adjusted for age, race and ethnicity, multiple gestation, insurance status, and pre-pregnancy metabolic comorbidities.
Overall, researchers found that the rate of pregnancies with cirrhosis more than doubled from 2.5 to 6.5 per 100,000 pregnancies (P =.01). The most recent 5-year period of data (2012-2016) included 18,573,000 deliveries: 895 with cirrhosis, 119,875 with noncirrhotic chronic liver disease (CLD), and 18,452,230 with no CLD. Compared with patients without CLD, patients with cirrhosis had an older mean age (31.8 vs 28.5 years; P <.001) and were less likely to have private insurance (36.9% vs 51.1%; P <.001). A greater proportion of pregnancies with cirrhosis had multiple gestation compared with pregnancies with no CLD (3.4% vs 1.8%; P <.001). Comorbid diabetes (9.5% vs 1.1%; P <.001), hypertension (17.3% vs 3.1%; P <.001), and obesity (11.2% vs 7.2%; P =.04) were more common in the cirrhosis vs no CLD group. Among pregnancies with a known cause of cirrhosis, the most common etiologies were viral hepatitis (39.4%), mixed (26.9%), autoimmune (18.3%), and alcoholic liver disease (7.7%).
In adjusted regression models, cirrhosis was associated with significantly higher odds of hypertensive outcomes compared with both noncirrhotic CLD (odds ratio [OR], 4.4; 95% CI, 3.0-6.7) and no CLD (OR, 4.9; 95% CI, 3.3-7.4). Cirrhosis was also associated with increased risk for postpartum hemorrhage compared with noncirrhotic CLD (OR, 2.0; 95% CI, 1.2-3.5) and no CLD (OR, 2.8; 95% CI, 1.6-4.8). The odds of cesarean section were increased over noncirrhotic CLD (OR, 1.8; 95% CI, 1.3-2.5) and no CLD (OR, 2.1; 95% CI, 1.5-2.9). Preterm birth was more common with cirrhosis over noncirrhotic CLD (OR, 2.0; 95% CI, 1.3-3.3) and no CLD (OR, 3.1; 95% CI, 1.-4.9). A statistically significant association of cirrhosis with maternal mortality was observed compared with both noncirrhotic CLD (OR, 37.0; 95% CI, 3.6-380.9) and no CLD (OR, 108.8; 95% CI, 13.6-867.8). However, the small number of maternal deaths in the cirrhosis group affected estimate certainty.
Results from this large cohort study indicate that pregnancies with cirrhosis have increased significantly over the past decade and are more likely to have adverse outcomes. Study limitations included the use of administrative data to identify cirrhosis, which could have resulted in incomplete reporting of its true prevalence.
“These findings support the need for reproductive planning in reproductive-age women with cirrhosis, including safe and effective contraception in women wishing to avoid pregnancy, as well as optimization of cirrhosis-related complications before conception,” the investigators wrote. “Women with cirrhosis who pursue pregnancy are faced with unique challenges and risks, warranting multidisciplinary management from high-risk obstetrics, hepatologists, and neonatologists to optimize maternal and perinatal health.”
Huang AC, Grab J, Flemming JA, Dodge JL, Irani RA, Sarkar M. Pregnancies with cirrhosis are rising and associated with adverse maternal and perinatal outcomes. Am J Gastroenterol. 2022;117(3):445-452. doi:10.14309/ajg.0000000000001590