Westbrook and coworkers (2012) reported the outcomes of 81 pregnancies in 53 women. A third had a flare, and these were more common in those not taking medication and those with active disease in the year before conception. Maternal and fetal complications were higher among women with cirrhosis, particularly with respect to the risks of death or need for liver transplantation during the pregnancy or within 12 months postpartum. From one Swedish national database analysis, frequencies of preterm birth, low birthweight, and diabetes were higher, but not those of preeclampsia or cesarean delivery (Stokkeland, 2016). Danielsson Borssen (2016) reported stable or mild disease in 84 percent of 58 women who delivered 100 newborns. Nearly a fourth of cases were delivered before 38 weeks, and a postpartum flare developed in a third. Cirrhosis was present in 40 percent, and these women experienced more complications during pregnancy.
Chronic hepatitis and cirrhosis can result from iron and copper overload. Iron overload may stem from a primary cause that is generally inherited, such as hereditary hemochromatosis, or originates secondary to complications of certain hemoglobinopathies. Many of the gene mutations underlying hereditary hemochromatosis involve hepcidin and result in dysregulated iron transport (Chap. 4 p. 58). Some of these mutations are more common in certain populations originating from northern Europe (Pietrangelo, 2016; Salgia, 2015). Cardiomyopathy, diabetes, joint disease, and skin changes can coexist with liver disease. Pregnancy outcomes associated with iron overload in hereditary hemochromatosis are driven by the degree of liver dysfunction, although higher iron levels may afect birthweight (Dorak, 2009).
A form of neonatal hemochromatosis that does not afect the mother is now thought to be alloimmune and is called gestational aloimmune liver disease (Anastasio, 2016). With this, maternal autoantibodies cross to the fetus and mediate dysfunction of iron homeostasis, although the antigenic target of these alloantibodies remains unclear. It is associated with significant neonatal morbidity and mortality, and frequently recurs in subsequent pregnancies. In these cases, antepartum treatment with intravenous immunoglobulin (IVIG) may improve outcomes (Feldman, 2013; Roumiantsev, 2015).
Copper overload leading to chronic hepatitis and cirrhosis is Wilson disease. This systematic condition can also manifest with cardiomyopathy, renal disease, neuropsychiatric symp toms, and certain endocrine abnormalities. A Kayser-Fleischer ring surrounding the iris is highly speciic, but a suspected diagnosis generally requires genetic analysis. Autosomal reces sive mutations of the A TP7B gene underlie this disorder. his gene codes for the P-type ATPase involved in copper transport to ceruloplasmin and bile (Bandman, 2015).
With Wilson disease, infertility may be present, but preg nancy outcomes among afected women who do conceive are inluenced by disease severity. Malik and colleagues (2013) reported four cases in pregnancy, and three had associated ges tational hypertension or preeclampsia. Maternal and neonatal outcomes were good, and the authors review chelation therapy with penicillamine and zinc sulfate in pregnancy. he American