Maternal complications
We present only descriptive data on maternal complications since we
could not conduct a meta-analysis for maternal complications, due to a
lack of odds ratios in the published reports on this topic. Maternal
death rate was reported by eight studies and ranged from 0 to 7.8%. In
total, 25 events of maternal deaths in 2794 pregnancies of women with
cirrhosis (0.89%) were recorded, compared to 0,010% in control
pregnancies, which is an 80-fold increase in risk (OR 80.2 95% CI 27.3
- 235.1; p <0.0001) The total numbers of maternal
deaths in recent studies (range 1982-2002) were lower than in older
studies (range 2004-2016) (OR 2.9 95% CI 1.2-7.1; p = 0.02).
This trend in decreasing maternal mortality over time is illustrated by
the time sequenced plots of the incidences of included studies (Figure
S2). The most common cause of maternal death was variceal hemorrhage
(n=13), the majority of which occurred during vaginal delivery (n=9) and
some occurred during pregnancy (n=2), during cesarean section (n=1) or
in the postpartum period (n=1). Other causes of maternal mortality were
sepsis (n=2), preeclampsia (n=1), hepatic decompensation (n=2), flare of
autoimmune hepatitis (n=1) and unknown (n=6) (figure S3).
Variceal hemorrhage, either resulting in maternal death or not, occurred
113 times in 2858 pregnancies (4,0%) reported in ten studies. In most
cases the occurrence of variceal hemorrhage during pregnancy was new and
had not occurred preconceptionally. The rate of preconceptional
esophageal varices was mentioned in none of the included studies. In
total 12% of variceal hemorrhage ended in maternal death (n=13). The
total numbers of variceal hemorrhage in recent studies (range 1982-2002)
were lower than in older studies (range 2004-2016) (OR 2.7 95% CI
1.7-4.1; p <0.0001), as is illustrated in the time
sequenced plot of incidences of variceal hemorrhage (figure S4). In the
study of Rasheed et all. 47% of pregnancies were complicated by
variceal hemorrhage. The remaining seven studies found lower percentages
of variceal hemorrhage varying between 0 and 16%. Screening endoscopy
for esophageal varices during pregnancy was reported in five recent
studies with rates of 3, 17, 28, 35 and 60%. Accompanying endoscopic
therapy for (non-bleeding) esophageal varices was reported in three
studies with rates 5, 23 and 28%.
The incidence of decompensated liver cirrhosis varied between 2 and
21%, with an outlying incidence in the study of Rasheed et al., who
reported 64%. Ascites prevalence was reported in five studies and
ranged from 3 to 11%. Hepatic encephalopathy was also reported in five
studies and ranged from 1 to 13%.