Deficiencies in reproductive health counseling in liver transplant recipients

Abstract

Background In liver transplant (LT) recipients of childbearing age, there is often rapid return of fertility post‐transplant. Our aim was to determine whether healthcare providers are documenting reproductive health counseling in LT recipients. Methods We performed a review of 365 LT recipients (164 female, 201 male) of childbearing age transplanted between 1994 and 2015 at a single center. We evaluated documentation of reproductive health counseling, content of the counseling and its provider. Results Reproductive health counseling was documented in 7% of LT recipients (14% of females, 0.5% of males). The transplant team provided the counseling in 56%, obstetrics/gynecology in 35%, and primary care in 9%. Twenty‐four post‐LT pregnancies occurred; these were unplanned in 13%. Miscarriage/stillbirth occurred in 7/24 pregnancies (29%). Mycophenolic acid was used by 20% of female recipients at conception. Only age at transplant (P = 0.001) and post‐LT pregnancy was associated with documentation of reproductive health counseling in female recipients (P = 0.0001). Conclusion Despite rapid return of fertility in reproductive‐aged LT recipients, documentation of reproductive health counseling in this population is rare in men and women. This increases the potential for adverse maternal and fetal outcomes in this high‐risk population.

Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases

“…(411) Unplanned pregnancies were more frequent among younger patients and those with shorter time from transplant to conception, highlighting the importance of pregnancy planning and a more proactive approach to contraceptive counseling. (412)(413)(414)(415)…”

Pregnancy and contraception in the post-liver transplant patient

“…An increased risk of spontaneous abortions and congenital malformations has been reported, including orofacial, esophageal, cardiac, and renal abnormalities. [2,4] Expert opinion recommends female LT patients on MPAs to be on reliable contraception for at least 4 weeks prior to initiation of MPA and at least 6 weeks after discontinuation. [8,9] Barrier protection is also recommended as a second form of contraception if a highly reliable method, such as an intrauterine device (IUD) or implant, is not in use.…”

“…Mycophenolic acid (MPA) products, common immunosuppressive agents utilized in LT recipients, are known to be teratogenic and should not be used in pregnancy. An increased risk of spontaneous abortions and congenital malformations has been reported, including orofacial, esophageal, cardiac, and renal abnormalities 2,4 . Expert opinion recommends female LT patients on MPAs to be on reliable contraception for at least 4 weeks prior to initiation of MPA and at least 6 weeks after discontinuation 8,9 .…”

“…Pregnancy in the LT population is generally considered to be a higher risk compared to the general population. Despite this, studies show that there is a void in reproductive health counseling in LT recipients both pre- and post-LTs, which could result in suboptimal pregnancy planning and contraceptive utilization 1,2 . Therefore, for these reasons, it is increasingly important that transplant clinicians need to be knowledgeable regarding the management of pregnancy and contraception in this unique population.…”

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

“…It is in particular in the late CKD stages that the widespread idea that fertility is sharply reduced may cause doctors to overlook counselling on contraception, with potentially devastating clinical and psychological effects. Careful planning of pregnancy is vitally important in all disease stages, to avoid complications for mother (for example in the case of active immunologic diseases) and foetus (for example exposure to potentially teratogenic drugs) [13][14][15][16].…”