Contraception and Pregnancy for people with Autoimmune Hepatitis (AIH)

Pregnancy in liver disease

Description

Autoimmune hepatitis (AIH) belongs to the group of autoimmune liver diseases and usually requires long-term treatment with immunosuppression.
AIH is a rare disease and can lead to scar tissue in the liver (called fibrosis and, when more advanced, cirrhosis) and if untreated to reduced liver function. If you have AIH, you should have regular check-ups from an experienced liver expert.

Contraception and pregnancy can affect your AIH. Therefore, it is recommended that you discuss these issues with an experienced obstetrician or gynecologist and liver doctor. In general, it is possible to become pregnant or to prevent pregnancy with all current methods.

*Please seek advice from your liver doctor before planning your pregnanc*y.

Diagnosis

Conception and contraception in autoimmune hepatitis
Menstrual cycle: Menstrual cycle irregularities can occur in people with autoimmune liver diseases and liver diseases in general. These include a prolonged cycle or missed periods. If you want to become pregnant, your autoimmune liver disease should be well-controlled, as poorly controlled AIH can lead to reduced fertility. Effective and stable treatment will reverse this.

In autoimmune hepatitis (AIH) contraception is possible using hormones or copper-containing or hormone-containing intrauterine device (IUD, a small T-shaped device that’s put into your womb (uterus) by a doctor or nurse). Some hormonal contraception needs some caution if you have advanced cirrhosis (scarring in the liver). Please talk to your liver doctor or gynaecologist about an optimal contraceptive option available to you.

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