Liver diseases during pregnancy are classified into two categories: pregnancy-specific liver diseases and pregnancy complicated with acute or chronic liver diseases. The former affects 3% of pregnant women, while the incidence of the latter is on the rise among women of childbearing age. Both types of diseases may lead to adverse maternal and infant outcomes. The core of optimized management lies in pre-pregnancy counseling, monitoring during disease stability, and standardized treatment during pregnancy and postpartum. Clinical evaluation must comprehensively consider the impact of physiological hormonal changes during pregnancy on symptoms, as well as adjustments to normal values of laboratory tests and safety issues related to examinations. Multidisciplinary team collaboration (including obstetricians, hepatologists, anesthesiologists, pediatricians, and ICU physicians), standardized screening, and rational medication are key to improving prognosis.
PART 01 Pregnancy-Specific Liver Diseases
01 Intrahepatic Cholestasis of Pregnancy (ICP)
1. Diagnostic Criteria
❖ Core Manifestations: Pruritus during pregnancy (with typical involvement of the palms and soles), which may generalize to the entire body, mostly occurring in the third trimester.❖ Biochemical Indicators: Non-fasting serum bile acid ≥19µmol/L, often accompanied by elevated liver enzymes and occasionally mild hyperbilirubinemia.❖ Exclusion of Other Etiologies: Rule out other causes of abnormal liver function or pruritus. Retrospective confirmation can be made if symptoms and liver function return to normal within 3 months after delivery.❖ Risk Factors: High BMI, family history or personal history of ICP, previous hepatobiliary diseases, multiple pregnancies, gestational diabetes mellitus, assisted reproductive technology (ART), etc.
2. Clinical Management
❖ Pharmacological Treatment: Ursodeoxycholic acid (UDCA) is the first-line drug, which improves pruritus and biochemical indicators, and reduces the risk of preterm birth and stillbirth. Rifampicin is a potent antipruritic agent that can assist in relieving symptoms and lowering bile acid levels. S-adenosylmethionine (SAMe) and cholestyramine are not recommended as routine treatments.❖ Monitoring Protocol: After diagnosis, non-fasting serum bile acid should be tested at least once a week from 32 weeks of gestation to identify high-risk groups with levels ≥40µmol/L.❖ Timing of Delivery: For patients with serum bile acid ≥100µmol/L, elective termination of pregnancy is recommended at 35~36 weeks of gestation. Close monitoring is required for those with levels ≥40µmol/L, and early delivery may be necessary if indicated. In the absence of bile acid testing, termination of pregnancy before 37 weeks of gestation should be considered if liver function is significantly abnormal but coagulation function is normal.
3. Practical Recommendations
❖ In settings without bile acid testing capabilities, elevated liver transaminases and bilirubin may indicate disease severity but have limited predictive value for adverse outcomes.❖ Even without bile acid test results, UDCA treatment may be considered to reduce the risk of preterm birth and the severity of pruritus.
02 Acute Fatty Liver of Pregnancy (AFLP)
1. Diagnostic Criteria
❖ Epidemiology: A rare disease with an incidence of approximately 1 in 10,000 pregnancies, mostly occurring at 35~36 weeks of gestation, and occasionally in the early postpartum period.❖ Clinical Symptoms: Non-specific manifestations include nausea, vomiting, anorexia, fatigue, abdominal pain, and distension. Severe cases may present with jaundice, hepatic encephalopathy, polyuria/polydipsia, acidosis, and other signs of liver failure.❖ Laboratory and Imaging Findings: Tests for bilirubin, uric acid, liver transaminases, blood glucose, and coagulation function are recommended. Ultrasound shows increased hepatic echogenicity. The Swansea criteria have high positive predictive value; diagnosis can be confirmed if 6 or more criteria are met, and liver biopsy is almost unnecessary.❖ Risk Factors: Low BMI, multiple pregnancies, young or advanced maternal age, preeclampsia, fetal growth restriction (FGR), male fetus.
2. Clinical Management
❖ Emergency Management: After diagnosis, coagulation disorders and metabolic disturbances should be corrected immediately. Termination of pregnancy should be performed as soon as possible after the patient’s condition stabilizes, and the mode of delivery should be determined based on clinical circumstances.❖ Supportive Care: Patients with liver failure require supportive treatment; N-acetylcysteine (NAC), plasma exchange, or liver transplantation may be necessary if indicated. Most patients need to be transferred to the ICU, and early referral to a tertiary medical center is recommended.❖ Multidisciplinary Collaboration: Collaboration with hepatology specialists, obstetric anesthesiologists, neonatologists, and other teams is required. Peripartum hemorrhage management should refer to FIGO’s recommendations for postpartum hemorrhage.❖ Neonatal Evaluation: Offspring should undergo metabolic evaluation for short-chain, medium-chain, or long-chain fatty acid oxidation disorders during infancy.
3. Clinical Guidelines
❖ Indications for ICU Admission: Serum lactate >2.8mg/dL, Model for End-Stage Liver Disease (MELD) score ≥30, or meeting 7 or more Swansea criteria.❖ Recurrence Management: The recurrence rate is approximately 10%. Subsequent pregnancies should be managed as high-risk pregnancies for AFLP and preeclampsia.
PART 02 Pregnancy Complicated with Liver Diseases
01 Viral Hepatitis
1. Hepatitis A Virus (HAV)
❖ Transmission Route: Fecal-oral transmission; maternal-neonatal transmission is rare.❖ Diagnosis and Management: Diagnosed by serological testing for HAV IgG/IgM. Elevated ALT, AST, and bilirubin are common; treatment is mainly supportive.❖ Prevention: Hepatitis A vaccination is recommended for high-risk pregnant women (e.g., those traveling to endemic areas, HIV-infected individuals, patients with chronic liver disease). Vaccines and post-exposure immunoglobulin can be safely used during pregnancy.
2. Hepatitis B Virus (HBV)
❖ Transmission Route: Blood-borne, sexual, and vertical transmission. Approximately 97 million people worldwide are infected, with the highest prevalence in Africa and the Western Pacific regions.❖ Screening and Prevention: All pregnant women should be screened for HBsAg. High-risk women with negative HBsAg should receive hepatitis B vaccination. Neonates should receive hepatitis B immunoglobulin (HBIG) within 24 hours of birth, followed by a full course of hepatitis B vaccination.❖ Antiviral Treatment: For patients with HBV DNA ≥2×10⁵IU/mL or positive HBeAg, tenofovir disoproxil fumarate (TDF) should be used from 24~28 weeks of gestation to 12 weeks postpartum to reduce the risk of maternal-neonatal transmission. Patients with chronic HBV complicated by hepatic fibrosis/cirrhosis require continuous treatment.❖ Delivery and Feeding: There are no contraindications to vaginal delivery or breastfeeding. Breastfeeding can be continued normally during TDF treatment.
3. Hepatitis C Virus (HCV)
❖ Transmission Route: Blood-borne, sexual, and vertical transmission. The prevalence during pregnancy ranges from 0.24% to 7%.❖ Diagnosis and Management: Routine prenatal screening for HCV antibodies is recommended; positive cases should undergo further HCV RNA testing to confirm active infection. For patients diagnosed before pregnancy, antiviral treatment is recommended to achieve viral clearance and eliminate the risk of maternal-neonatal transmission.❖ Maternal-Neonatal Transmission: The risk of maternal-neonatal transmission is 5%~6% for isolated HCV infection, and increases in the presence of concurrent HIV infection. Routine cesarean section is not recommended; the mode of delivery should be evaluated individually. Breastfeeding is safe.
4. Hepatitis D Virus (HDV)
❖ Occurs only in chronic HBV carriers, accounting for approximately 5% of cases. Diagnosed by serum HDV antigen and HDV DNA testing.❖ Perinatal Management: The same prevention and control measures as for HBV should be adopted to prevent maternal-neonatal transmission.
5. Hepatitis E Virus (HEV)
❖ Transmission Route: Fecal-oral transmission, mostly associated with contaminated water or consumption of raw/undercooked food. Infection during pregnancy can lead to liver failure and maternal-neonatal death.❖ Diagnosis and Management: Diagnosed by HEV IgM antibody testing. Infection in the third trimester or with HEV genotype 1 is prone to progression to liver failure; treatment is mainly supportive. For severe cases with grade 1~3 hepatic encephalopathy, individualized termination of pregnancy should be considered.
02 Cirrhosis and Portal Hypertension
1. Risk Assessment
❖ Risk of Adverse Outcomes: Increased risk of preterm birth, cesarean section, preeclampsia, small for gestational age (SGA) infants, and hepatic decompensation (ascites, variceal bleeding, hepatic encephalopathy). Variceal bleeding is the leading cause of maternal death.❖ Prognostic Scoring Systems: A pre-pregnancy MELD score <6 indicates a good prognosis, while a score >10 suggests a risk of hepatic decompensation during pregnancy. An ALBI (Albumin-Bilirubin) score ≤2.7 is associated with increased live birth rates. An AST to Platelet Ratio Index (APRI) <0.84 predicts the possibility of maintaining pregnancy until term.
2. Clinical Management
❖ Pre-pregnancy Preparation: Patients with confirmed cirrhosis should undergo screening endoscopy within 1 year before pregnancy to assess variceal status; primary prophylaxis should be initiated if necessary.❖ Antenatal Treatment: Beta-blockers (carvedilol, propranolol) can be safely used to prevent variceal bleeding. Endoscopy can be performed in the second trimester with the patient in the left lateral position. In the absence of endoscopy, liver stiffness <20kPa and platelet count >150×10⁹/L suggest a low incidence of varices.❖ Management of Acute Bleeding: Prioritize resuscitation to stabilize vital signs; endoscopic variceal ligation (EVL) should be performed immediately after the patient’s condition stabilizes. Octreotide is the first-line treatment; terlipressin should be avoided.❖ Special Risks: Risk of spontaneous splenic artery aneurysm (SAA) rupture. Prophylactic interventional treatment is recommended for pre-pregnancy diagnosed SAAs with a diameter ≥2cm. New-onset abdominal pain during pregnancy requires immediate medical attention; transcatheter embolization is the preferred treatment for rupture.❖ Mode of Delivery: Vaginal delivery is preferred; the second stage of labor should be shortened to avoid excessive Valsalva maneuver. Cesarean section should strictly follow obstetric indications; coagulation disorders and thrombocytopenia should be corrected before surgery.
03 Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)
❖ Pre-pregnancy Management: Multidisciplinary team collaboration to optimize metabolic diseases such as obesity, diabetes, and hypertension. Patients should be informed of the increased risks of gestational diabetes mellitus (3-fold higher), hypertensive disorders of pregnancy (2-fold higher), and preterm birth.❖ Antenatal Intervention: Low-dose aspirin (≤150mg/d) should be used from the first trimester to 34 weeks of gestation to prevent preeclampsia. Routine screening for related complications is recommended.❖ Postpartum Recommendations: Breastfeeding is encouraged to reduce the long-term risk of metabolic syndrome in both mothers and infants.
04 Autoimmune Hepatitis (AIH)
❖ Diagnosis: Diagnostic criteria during pregnancy are consistent with those in non-pregnant individuals; liver biopsy may be performed if necessary.❖ Treatment: Continue or initiate treatment with prednisolone, budesonide, or thiopurines to maintain disease stability.❖ Risk Monitoring: Increased risk of gestational diabetes mellitus, cholestasis, and preterm birth; close screening is required. Thiopurine treatment may lead to elevated serum bile acid; the risks and benefits of treatment should be evaluated individually. The risk of postpartum recurrence is high; prophylactic dose increase of immunosuppressants may be considered.
PART 03 Pregnancy After Liver Transplantation
01 Timing of Pregnancy
Pregnancy is recommended at least 1 year after liver transplantation to reduce immunosuppressive burden, infection risk, and the incidence of preterm birth and low birth weight.
02 Clinical Management
❖ Drug Safety: Azathioprine, cyclosporine, tacrolimus, and prednisolone can be used. Mycophenolate mofetil (MMF) is teratogenic and should be discontinued 12 weeks before conception.❖ Complication Monitoring: Increased risk of hypertensive disorders of pregnancy, preeclampsia, cholestasis, gestational diabetes mellitus, and acute kidney injury (AKI). Low-dose aspirin should be initiated in the first trimester to prevent preeclampsia, and renal function should be closely monitored.❖ Mode of Delivery: Determined based on obstetric indications; routine cesarean section is not recommended. The live birth rate can reach 84%.
PART 04 Delivery Management
01 General Principles
❖ Multidisciplinary Collaboration: Delivery plans should be jointly developed by obstetricians, hepatologists, anesthesiologists, and other teams.❖ Risk Preparation: Patients with liver diseases have an increased risk of bleeding. Blood products should be readily available during the peripartum period, intravenous access should be established, and the impact of liver metabolism on drug dosage should be considered.❖ Breastfeeding: WHO and FIGO recommend breastfeeding within 1 hour after delivery. Breastfeeding is safe for patients with MASLD and viral hepatitis.❖ Postpartum Care: Pay attention to wound care, assess the risk of venous thromboembolism (VTE), and initiate preventive measures in a timely manner.
02 Management of Special Cases
❖ Patients with stable chronic liver disease can usually deliver at term.❖ Pregnancy-specific liver diseases (ICP, AFLP) may require iatrogenic preterm birth. Access to medical resources should be evaluated, and referral to a tertiary hospital is necessary if indicated.
PART 05 Pre-Pregnancy Counseling
01 Target Population
Women with chronic liver disease, a history of liver transplantation, or a history of pregnancy-specific liver disease should receive pre-pregnancy counseling from a multidisciplinary team.
02 Core Counseling Content
❖ Disease Assessment: Clarify the type, severity, and prognosis of underlying liver disease, and optimize disease control before pregnancy.❖ Medication Adjustment: Evaluate the safety of medications during pregnancy, adjust treatment plans, and avoid teratogenic drugs.❖ Risk Disclosure: Inform patients of the risk of adverse pregnancy outcomes, and develop antenatal monitoring and intervention plans.
03 Practical Recommendations
In medical institutions without routine pre-pregnancy counseling services, healthcare providers should proactively provide relevant guidance to women of childbearing age with liver diseases.
PART 06 Summary
The incidence of liver diseases during pregnancy is gradually increasing. Both pregnancy-specific liver diseases and pregnancy complicated with liver diseases may endanger maternal and infant safety. This guideline emphasizes the importance of multidisciplinary collaboration, standardized screening and monitoring, rational medication, and individualized delivery management. Pre-pregnancy counseling is a key link to optimizing maternal and infant outcomes. In clinical practice, patient-specific conditions should be considered, and best evidence and practical recommendations should be followed to balance treatment efficacy with maternal and infant safety.
Source of Graphics and Text:
Nana M, Medina V, Maxwell C, et al. FIGO guidelines on liver disease in pregnancy. International Journal of Gynecology & Obstetrics. 2025;170:28-48. doi:10.1002/ijgo.70161
Editor: Huo Pan