164 Obstetrics and Gynecology Board Review •••
❍ What is the rate of maternal-fetal transmission of hepatitis C?^4
The rate of perinatal transmission of hepatitis C is proportional to the maternal viral titers. The overall risk of
vertical transmission rates is 2% to 8%. In women who were hepatitis C RNA negative, vertical transmission was
rare. Breastfeeding has not been associated with an increased risk of neonatal hepatitis C infection.
❍ Does cesarean delivery decrease the risk of perinatal transmission of hepatitis C?^4
The route of delivery has not been shown to influence the risk of vertical hepatitis C transmission, and cesarean
delivery should be performed in women with hepatitis C only for obstetric indications.
❍ What is the role of interferon alpha therapy for hepatitis during pregnancy?
Interferon alpha has been shown to produce clinical improvement in 28% to 46% of patients with hepatitis C,
and has also been shown to alter the natural history of hepatitis B and D infection. However, it has abortifacient
properties and should be avoided in pregnancy.
❍ What are typical features of fulminant hepatic failure due to herpes simplex occurring during the third
trimester of pregnancy?
Herpes simplex hepatitis can result in fulminant hepatic failure with a 40% mortality rate, with half of the
reported adult cases occurring during pregnancy. The clinical and biochemical features are usually indistinguishable
from other causes of acute liver failure; however, jaundice is characteristically absent. Typical skin lesions are
evident in less than half of patients, and diagnosis may ultimately rest on liver biopsy, cultures, and serology.
❍ True or False: Treatment of Wilson disease should be discontinued during pregnancy.
False. Discontinuing penicillamine treatment of Wilson disease increases the risk of maternal hepatic and
neurologic failure and hemolysis, and has been associated with fatal relapses. The drug itself is usually well tolerated
by both the mother and her fetus. Trientine seems to be safe as well, although fewer data are available. Zinc therapy
is also effective in preventing relapse in pregnancy.
❍ True or False: A history of Budd-Chiari syndrome precludes a subsequent normal pregnancy.^5
False. Successful pregnancy has been described in women with Budd-Chiari syndrome; however, there are
substantial risks of fetal loss and preterm birth.
❍ List the cholestatic disorders of pregnancy.
Hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, preeclampsia, and
HELLP (hemolysis, elevated liver tests, low platelets) syndrome.
❍ True or False: Pregnancy is contraindicated in patients with chronic cholestatic liver diseases.
False. Cholestasis may worsen but can be managed and usually returns to baseline after delivery in primary biliary
cirrhosis, Dubin-Johnson syndrome, and the familial intrahepatic cholestatic syndromes such as Alagille syndrome.
❍ True or False: Liver transplant is a contraindication to pregnancy.
False. Pregnancy planned at least 2 years after liver transplant with stable allograft function can have excellent maternal
and neonatal outcomes, although the risks are significant. Transplant recipients considering pregnancy should be
counseled that pregnancy complications include preterm delivery (19–20%), fetal growth restriction (10%), congenital
malformations (4–16%) spontaneous abortions (11%), graft rejection (10%), HELLP syndrome (8%), hypertension
(up to 20%), preeclampsia (4–20%), cesarean delivery (45%), and maternal deaths (up to 3%). These numbers are
higher than in the general population but lower than the corresponding outcomes quoted before 1998.