Contraception and Pregnancy for people with Autoimmune Hepatitis (AIH)

Management

General information about pregnancy If you are taking medication, discuss with your doctor whether this medication is safe. Never stop taking medication because you want to become pregnant without consulting your doctor. In general, most pregnancies in women with AIH are uneventful, especially in those whose disease is well-controlled or mild. After birth, the disease may temporarily worsen. Women with AIH have slightly increased rates of gestational diabetes mellitus, hypertension during pregnancy, preterm birth and fetal growth restriction and may need closer obstetric surveillance with screening to predict and manage these disorders. You should also have ultrasound scans to check your unborn baby while you are pregnant. The mother’s liver blood test values should be checked during pregnancy (once during each trimester) and after childbirth. There must be good communication between your gynaecologist/obstetrician and liver doctor during your pregnancy. If you have advanced impairment of liver function (cirrhosis) If you have an impaired liver function, it is extra important to seek advice from your liver doctor before planning your pregnancy. In the case of AIH and especially if you have cirrhosis, ideally, pregnancy should be planned, since complications may be anticipated and prevented with appropriate counselling. People with advanced liver function impairment and its associated complications (such as abdominal fluid (ascites), jaundice and varices of the esophagus) should not be generally advised against pregnancy, but it is vital that you speak to your liver doctor when thinking about starting a family so that you can have the safest pregnancy possible. Advanced liver function impairment (cirrhosis) needs careful assessment and risk stratification. Please ask your liver doctor if he/she recommends additional tests such as a gastroscopy before pregnancy. Which medications can I take during pregnancy and breastfeeding? In principle, you can continue to take your prescribed medications for the liver disease while pregnant or breastfeeding. However, this is not the case for all medicines and so it is important that you speak to your liver doctor about your medications before you get pregnant. You should also avoid changing medications if you are pregnant without discussing it with your liver doctor. Prednisolone/prednisone Prednisolone can be continued during pregnancy, but there is an increased risk of developing gestational diabetes, and so you should be monitored more closely. Please talk to your liver doctor about safe dosage during pregnancy and after birth of your child. Azathioprine (AZA) and Mercaptopurine Both drugs can be used during pregnancy and breastfeeding. AZA is used more commonly during pregnancy. Azathioprine can be continued unchanged. It is also possible to breastfeed while taking AZA. Budesonide Budesonide can be used during pregnancy and breastfeeding. Mycophenolate mofetil (MMF) Mycophenolate should be discontinued at least 12 weeks before conception as it is harmful to the baby. Therapy with MMF should never be started during pregnancy. Please discuss this with your liver doctor, gynecologist/obstetrician and pediatrician if you are taking MMF. Cyclosporine/Tacrolimus Both cyclosporine and tacrolimus may be prescribed throughout pregnancy and breastfeeding. If your liver disease is stable on cyclosporine or tacrolimus, there may be no need to change it during your pregnancy or while breastfeeding. After the birth of your child, it is important that the paediatrician is aware of all the medications you are taking in case there is a need to monitor your child. The safety of drugs used for liver disease in pregnancy and lactation is summarized in the European Association for the Study of the Liver (EASL) Clinical Practice Guidelines on management of Liver Disease in Pregnancy (DOI: 10.1016/j.jhep.2023.03.006). Men with AIH Men with AIH are allowed to continue their medication during conception and no changes are needed. Birth In general, vaginal delivery is preferred where possible and caesarean section should only be performed for obstetric indications. Authors Leona Dold Catherine Williamson Henriette Ytting Willy Visser Maria Antonella Burza Wiebke Papenthin and Martine Walmsley, ePAG advocates On behalf of the ERN RARE-LIVER transversal working group on liver disease in pregnancy Reference: EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy, Journal of Hepatology. 2023, https://doi.org/10.1016/j.jhep.2023.03.006