New AGA Guidelines for GI and Liver Disease Management in Pregnancy

Managing Gastrointestinal (GI) and Liver Conditions During Pregnancy: New Guidance from AGA

Pregnancy is a transformative period that brings about significant physiological and hormonal changes, which can have wide-ranging effects on a woman’s gastrointestinal (GI) and liver systems. As clinicians, understanding how to manage GI and liver conditions during pregnancy is vital, as these conditions can pose significant risks to both maternal and fetal health. The American Gastroenterological Association (AGA) has released an updated clinical practice guideline, highlighting the latest insights into managing GI and liver diseases during pregnancy. This new guidance stresses the importance of personalized care, multidisciplinary collaboration, and proactive management to ensure the best possible outcomes for both mother and child.

Key GI and Liver Conditions During Pregnancy

Several GI and liver conditions are commonly associated with pregnancy or may be exacerbated by pregnancy-related physiological changes. These include:

1. Hyperemesis Gravidarum (HG)
2. Intrahepatic Cholestasis of Pregnancy (ICP)
3. Acute Fatty Liver of Pregnancy (AFLP)
4. Inflammatory Bowel Disease (IBD)
5. Chronic Hepatitis B and C
6. Cirrhosis and Liver Transplantation

While some of these conditions are unique to pregnancy, others may be exacerbated or behave differently during pregnancy, requiring specialized management. Given the complexity and potential severity of these conditions, clinicians must approach each case with individualized care plans based on a careful risk-benefit assessment.

The Role of Multidisciplinary Care in Managing Pregnancy-Related GI and Liver Disorders

Pregnancy-related GI and liver disorders often require a coordinated approach that involves obstetricians, gastroenterologists, hepatologists, and maternal-fetal medicine specialists. This collaborative care model is particularly crucial for high-risk pregnancies where the management of both maternal health and fetal well-being needs to be carefully balanced. Early involvement of specialists can help guide treatment decisions and ensure that both the immediate and long-term needs of the patient and fetus are addressed.

The Importance of Preconception Care and Counseling
One of the most critical aspects of managing GI and liver conditions during pregnancy is preconception counseling. According to the AGA's updated guidance, reproductive-aged women who have existing GI or liver disorders should be counseled before pregnancy, ideally well in advance, to optimize their health and ensure a smooth pregnancy journey. This includes discussing contraceptive options, fertility, and potential risks associated with their GI and liver conditions.

Preconception counseling provides a window for clinicians to help women with chronic GI and liver diseases optimize their health status before pregnancy. For example, women with Inflammatory Bowel Disease (IBD) may require adjustments to their medications, or patients with chronic hepatitis might need antiviral therapy to reduce the risk of viral transmission to the fetus.

Individualized Approach to Care During Pregnancy
Once pregnancy is confirmed, it’s important that GI and liver issues are managed on an individual basis. Clinicians should not withhold necessary medications, procedures, or interventions solely because a patient is pregnant. Instead, treatment decisions should be made based on a thorough understanding of the risks and benefits to both the mother and the fetus. For example, medications that were previously deemed contraindicated for pregnant patients may be used if their benefits outweigh the risks.

Management of Common GI and Liver Conditions in Pregnancy

Hyperemesis Gravidarum (HG)
Hyperemesis Gravidarum (HG) is characterized by severe nausea and vomiting, which can lead to dehydration, weight loss, and electrolyte imbalances. It can significantly impact maternal health and, if left untreated, can also harm fetal development. Early management is crucial in preventing progression to severe forms of HG.

The initial approach for mild cases includes hydration, vitamin B6, and doxylamine (an antihistamine). For moderate to severe cases, ondansetron, metoclopramide, promethazine, and in extreme situations, intravenous glucocorticoids may be indicated. With early intervention, most cases of HG can be managed successfully.

Intrahepatic Cholestasis of Pregnancy (ICP)
ICP is a liver disorder that typically presents in the second or third trimester of pregnancy. Characterized by pruritus (itching) and elevated serum bile acid levels, ICP can increase the risk of preterm labor and stillbirth.

The cornerstone of treatment for ICP is ursodeoxycholic acid (UDCA), which helps to lower bile acid levels and improve symptoms. The recommended dose of UDCA is 10–15 mg/kg per day, taken orally. In cases where the condition is not well controlled with UDCA, additional monitoring and consideration of early delivery may be warranted.

Acute Fatty Liver of Pregnancy (AFLP)
Acute Fatty Liver of Pregnancy (AFLP) is a rare but serious liver disorder that can develop in the third trimester and is associated with hepatic failure. It presents with symptoms such as jaundice, vomiting, and abdominal pain. Management of AFLP requires urgent care, as it can rapidly progress to liver failure, requiring liver transplantation in severe cases. Early diagnosis and prompt delivery of the baby are critical components of treatment.

Inflammatory Bowel Disease (IBD)
For pregnant women with IBD, maintaining clinical remission is key to a healthy pregnancy. IBD, including Crohn’s disease and ulcerative colitis, can exacerbate during pregnancy, and women with uncontrolled disease have a higher risk of preterm birth, low birth weight, and fetal growth restriction.

Biologic therapies, such as anti-TNF agents, are considered safe for use during pregnancy, and they may actually improve pregnancy outcomes. However, drugs like methotrexate, thalidomide, and ozanimod should be discontinued well before conception, typically at least six months before pregnancy.

Hepatitis B and C During Pregnancy
Chronic hepatitis B (HBV) is another liver condition that requires careful management during pregnancy. Hepatitis B virus DNA levels should be monitored throughout pregnancy, and treatment with tenofovir disoproxil fumarate may be considered if viral load exceeds 200,000 IU/mL during the third trimester to prevent vertical transmission to the fetus.

Patients with hepatitis C may also require antiviral therapy during pregnancy, though direct-acting antivirals (DAAs) are typically avoided due to safety concerns.

Procedures and Interventions for Pregnant Patients with GI and Liver Conditions

For patients who require elective endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy, the timing of the procedure is critical. Elective procedures should generally be deferred until after delivery, but nonemergent but necessary procedures may be safely performed during the second trimester. In cases of choledocholithiasis, cholangitis, or gallstone pancreatitis, ERCP can be performed during the second trimester, when the risks to the fetus are minimized.

Cholecystectomy, the removal of the gallbladder, is considered safe during pregnancy. The preferred method is laparoscopic cholecystectomy, which can be performed at any stage of pregnancy, though the second trimester is considered ideal for minimizing the risk of preterm labor and fetal complications.

Special Considerations for High-Risk Pregnancies

Women with advanced cirrhosis, liver transplantation, or esophageal varices should be closely monitored throughout pregnancy. In these cases, upper endoscopy should be scheduled for the second trimester to assess the presence of esophageal varices, and beta-blockers or endoscopic variceal ligation should be considered depending on the severity.

For high-risk pregnancies, including those with pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP), daily aspirin therapy may be initiated as early as week 12 of pregnancy to reduce the risk of complications.

The Role of GI and Liver Specialists in Pregnancy Care

Experts in gastroenterology, point out the significant knowledge gap existing in managing reproductive health in the context of GI and liver disease. This gap is exacerbated by the fact that most clinical trials exclude pregnant women, making evidence-based guidance particularly scarce. Thus, gastroenterologists, hepatologists, and obstetricians must work together early on to ensure that women with GI or liver diseases receive the specialized care they need during pregnancy.

Preconception counseling, along with multidisciplinary care throughout pregnancy, is essential to optimize maternal and fetal outcomes. Clinicians should be proactive, not reactive, in addressing GI and liver conditions, with a clear focus on individualized care based on the unique circumstances of each patient.

Conclusion

Managing GI and liver conditions during pregnancy requires a comprehensive, individualized approach that accounts for the changing physiology of pregnancy, the risks to maternal and fetal health, and the latest evidence-based treatment guidelines. By adopting a proactive and multidisciplinary care model, clinicians can optimize outcomes and ensure that pregnant patients with GI and liver diseases receive the best possible care.