Interpretation
The maternal mortality rate in women with liver cirrhosis was 0.89%
which was an 80-fold increased risk compared to pregnant controls
without cirrhosis. The most common cause of maternal mortality was
variceal hemorrhage during vaginal delivery, although there were large
differences in the reported rates of incidence of variceal hemorrhage.34 The risk of maternal death as result of variceal
bleeding may have been overestimated in our review given the decreases
of maternal mortality and variceal hemorrhage in recent studies. The
decrease of variceal hemorrhage is probably the result of the inclusion
in (inter)national clinical guidelines to screen pregnant women with
liver cirrhosis in the second trimester for early detection of
esophageal varices. 35 In addition, the availability
of treatment options like endoscopic variceal band ligation have become
widely available during the past decades, which were already used in
more recent studies included in this systematic review.4, 18, 20 This treatment is considered safe in
pregnancy 36, 37 and lowering the risk of (recurrent)
variceal hemorrhage and resulting in lower maternal morbidity and
mortality.
The risk of mortality in both pregnant and non-pregnant patients with
cirrhosis depends on etiology, severity and presence of complications,
as well as the presence of comorbid conditions. 38 The
reported overall 30-day mortality rate after an episode of variceal
bleeding is 15-20% 8, which is similar with the
mortality of 12% after a variceal bleed in pregnant women in our study.
The one year mortality of non-pregnant patients with compensated liver
cirrhosis is 1.0% and that of patients with compensated liver cirrhosis
as well as oesofageal varices 3.4%. These data apply to all cirrhosis
patients, but 67% of patients with liver cirrhosis are males older than
50 years. 39 In comparison the maternal mortality
rates (<1%) among pregnant cirrhosis patients may be slightly
lower, likely owing to the comparatively young age of pregnant women.
Due to our study design, we were not able to investigate whether
pregnancy is associated with more rapid progression of cirrhosis than
can be expected according to age.
The meta-analysis showed significant heterogeneity, mostly attributed to
two studies (Flemming et al. and Rasheed et al.) as demonstrated by our
sensitivity analysis. The study of Rasheed et al. differs in various
aspects from the other included studies. It is, in contrast to most
other included studies, a prospective cohort study of patients from a
middle-income country, possibly reflecting a lower level of care. This
study included all pregnancies including miscarriages, whereas the other
studies only described deliveries. Moreover, the etiology of liver
cirrhosis, in this study solely viral hepatitis, differs from those in
the other studies which included various causes. The study of Flemming
et al. did not have major differences on study design, study population
or etiology of liver cirrhosis. However, their case definition differed
because their analysis evaluated only primiparous women.