Pregnancy after liver transplantation

Today we discussed with her that women with stable renal and allograft function following an orthotopic liver transplant will in general tolerate well their pregnancies with a good maternal and neonatal outcome. She had her transplant x years ago, appears to be in general good health, her last creatinine was 0.7 (<1.3 mg/dl), LFT’s are normal, hasn’t had any evidence of recent graft rejection and is on a stable dose of her immunosuppresion regimen as seen in her hepatologist records. We will recommend a 24 hr urine collection to check 24 hr protein and creatinine clearance, C&S, CMV, HSV, Toxoplasma, IgG and IgM, HbsAg and Hep C Ab to complete her evaluation pre-pregnancy. Once pregnant she should have a baseline bilirubin, creatinine, LFT’s, tacrolimus level, 24 hr urine collection and UA C&S . These tests should be repeated every trimester until 32 wk and every other week starting at 32 wk. In case of elevated LFT’s or bilirrubin, rejection should be ruled out with liver u/s with Doppler.

Ideally, she should be vaccinated against influenza, pneumococcus, hepatitis B and tetanus if not given previously. You can also check for Hepatitis B Antibodies to see if immunity is present.

We recommended Prenatal vitamins once daily.

We explain her increase risk of preeclampsia about 20 %, preterm birth up to 50 %, IUGR 20 %, low birth weight and glucose intolerance during pregnancy. For this reason, an early 1 hr GTT should be done in the first trimester and if normal repeated at 24-28 wk. Antenatal fetal testing starting at 32 wk will be recommended. Regarding her mode of delivery, she was told she is allowed to have a vaginal delivery unless any obstetric indication.

Regarding her current medications we discussed the following:
Prograf (Tacrolimus): Class C. Association with HTN, preeclampsia and glucose intolerance. Probably OK to continue during her pregnancy since benefits outweigh risks
Cellcept: Class D Associated with increase pregnancy loss, possible risk of fetal structural defects including agenesis of corpus callosum, clef lip/palate, micrognathia, hypertelorism, microtia and ectopic kidney. We will recommend to discontinue it prior to conception if appropriate.
Dapsone: Class C. Probably OK to continue during her pregnancy since benefits outweigh risks.