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Hepatic diagnostics in pregnancy: Biopsy, biomarkers, and beyond

Managing liver disease in pregnancy is both complex and challenging. Moreover, accurate diagnosis is critical to decisionmaking, and often the most significant decision is whether to proceed to liver biopsy. Reticence exists among hepatologists and radiologists regarding biopsy procedures in this context. With minimal data to draw from, experience from single-center series and case reports has formed much of the evidence base regarding the safety and efficacy of liver biopsy in pregnancy, although such reports are largely limited to patients with autoimmune liver diseases. The publication of a population-based cohort study assessing the pregnancy outcomes of women who underwent liver biopsy during pregnancy in the current issue of HEPATOLOGY is welcomed, even if some limitations exist in its generalizability. By linking data from the Swedish Medical Birth Registry to the Swedish Patient Registry, Ludvigsson et al. identified 23 women over a 20-year period who had undergone liver biopsy during pregnancy. Seventeen women had a diagnosis of a preexisting liver condition prior to pregnancy, including 2 women who had undergone liver transplantation. Notably, 2 of 6 biopsies performed in women without preexisting liver disease were for characterization of intrahepatic malignancies. By comparing the pregnancy outcomes of the 23 women who underwent biopsy during pregnancy to 1.9 million unexposed pregnancies, moderately increased risks of preterm birth and small-for-gestational-age infants were identified. The study focused on births between 1992 and 2011, with hepatitis C virus reported as the commonest indication for liver biopsy during pregnancy. The widespread availability of transient elastography for the staging of fibrosis and the effectiveness of direct-acting antiviral therapy in achieving virologic “cure” have resulted in liver biopsy now being redundant in this context. Furthermore, the majority of women underwent biopsy in the first trimester, with >50% of biopsies performed in the first month of pregnancy. It is likely that many women were unaware of their pregnancy at the time of biopsy, making the decision to proceed to biopsy easy for the clinicians concerned. Furthermore, it is plausible that a significant number of biopsies were deferred to the postpartum period as the number of biopsies undertaken in women with liver disease in the year prepartum and postpartum was >15-fold higher (n 5 384) than the number of those performed during pregnancy. Chronic liver disease in itself has been shown to have a negative impact on pregnancy outcomes, with an increased risk of preterm birth reported in women with cirrhosis. In the study of Ludvigsson et al., when the outcomes of women who underwent liver biopsy during pregnancy were compared only to women with preexisting liver disease, the procedure itself was associated with only an increased risk of a small-for-gestational-age infant. Notably, women who underwent a liver biopsy in the year before or after pregnancy had a greater incidence of adverse pregnancy outcomes, with a substantially increased risk of neonatal death, demonstrating the significant impact that liver disease can have on maternal and fetal health. The issue of how to investigate the pregnant woman with liver enzyme abnormalities or established liver disease (or post–liver transplantation) is nuanced, with the absolute need for liver biopsy often a source of anxiety. From this study, we can say that in the first Received November 19, 2017; accepted February 23, 2018. Copyright VC 2018 by the American Association for the Study of Liver Diseases. View this article online at wileyonlinelibrary.com. DOI 10.1002/hep.29859