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Autoimmune Hepatitis in Pregnancy
Abstract Number: FCH-255
Abstract Type: Case Report Case Series
Autoimmune hepatitis (AIH) is a rare, inflammatory disease of the liver with unclear etiology, and more prevalent in women than in men. Disease control and immunosuppression allows for pregnancy to occur, but the exact course of disease progression during pregnancy is not well understood1. We present a case of AIH during pregnancy.
A 20 yo G1P0 presented to consult clinic at 21 weeks EGA with a history of AIH complicated by cirrhosis, portal hypertension, thrombocytopenia (42 x 103/μl), grade 1 gastric varices (Fig. 1) and grade 2 esophageal varices. The patient was diagnosed via biopsy a year prior to pregnancy and was stable on azathioprine 100mg daily and prednisone 15mg daily with epistaxis and gingival bleeding being the primary complaints.
During the second trimester, an EGD showed stable gastric varices without bleeding, liver function tests mostly within normal limits (total bilirubin slightly elevated at 2.2mg/dL) and MELD score stable at 10 (range of 6-40, 40 being most severe). A multidisciplinary discussion was held and plans to deliver at the tertiary care center were made due to the risks of major liver decompensation, variceal bleeding, encephalopathy and worsening thrombocytopenia.
At 37 weeks EGA the patient had spontaneous rupture of membranes and was admitted for cesarean delivery. General anesthesia was induced followed by placement of arterial and central lines. There was 500ml estimated blood loss and she received one six-pack of platelets and a unit of FFP. A viable female infant was delivered and the patient was transferred to surgical ICU for post-operative care. Obstetrics and hepatology managed the patient and she remained stable throughout the five-day hospital course without any worsening of the thrombocytopenia and no signs of liver function decompensation.
AIH has an incidence of 10-20 per 100 000 people. It was once thought women with AIH were unable to have successful pregnancies, but that has been disputed by recent reports of excellent control and continued therapy leading to lower risks of complications2. As in our patient, cirrhosis is usually the first presentation in almost half of AIH patients, which in parturients increases the risk of preeclampsia, preterm delivery, low birth weight and fetal demise. These patients have the best outcomes when a multidisciplinary approach is taken and good control of AIH is established prior to conception.