Pregnancy in women with pre-existing liver disease presents unique challenges, carrying potential risks for both mother and baby.¹ At the 5^th Malaysian Obstetric Medicine Scientific Conference, Professor Catherine Williamson from Imperial College London, United Kingdom (UK) emphasized how early recognition, appropriate risk assessment, and multidisciplinary care can improve outcomes in this high-risk group.¹

Chronic liver disease can progress to cirrhosis, which carries clinically meaningful risks.¹ Prof. Williamson highlighted that up to 2% of pregnancies in women with cirrhosis are complicated by maternal death or serious decompensation, although mortality rates have reduced in recent years. Variceal hemorrhage remains the most common cause of maternal death.¹ Although second-trimester screening endoscopy is generally recommended to assess esophageal varices and determine whether treatment is needed, uptake remains low.¹ Pregnancies in women with cirrhosis are also associated with higher rates of intrahepatic cholestasis, labor induction, preterm delivery, and puerperal infection.¹ Infants, meanwhile, face increased risk for large-for-gestational-age birth and neonatal respiratory distress.¹

Pre-pregnancy counseling plays a crucial role in mitigating these risks.¹ Prof. Williamson noted that early discussions can guide monitoring and optimize outcomes for both mother and baby; however, evidence from the 2025 UK Obstetric Surveillance System (UKOSS) study shows that only 41% of women with cirrhosis receive formal pre-pregnancy counseling.¹ She also underscored the value of early liver function assessment and scoring systems, such as the albumin-bilirubin (ALBI) grade, Model for End-Stage Liver Disease (MELD), and the United Kingdom Model for End-Stage Liver Disease (UKELD).¹ These tools help predict adverse pregnancy outcomes as well as poor maternal outcomes and guide individualized monitoring strategies.¹

Globally, metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized in pregnancy.¹ Prevalence is higher in North America and regions with elevated obesity rates compared with the UK.¹ In the UK, hepatic steatosis affects approximately 10% of pregnant women, particularly those with type 2 diabetes (T2D) or higher early-pregnancy weight.¹ Increased hepatic stiffness was observed in nearly a quarter of women and is more common in those with type 1 diabetes (T1D), T2D, and preeclampsia.¹ MASLD pregnancies are associated with higher rates of gestational diabetes, hypertensive disorders, preterm birth, and postpartum hemorrhage.¹ “If you see a patient suspected of having liver disease, a FibroScan can provide valuable early insight,” she advised, underscoring the importance of objective assessment of hepatic steatosis and stiffness.

Autoimmune hepatitis and hepatitis C are additional considerations.¹ Autoimmune hepatitis commonly affects women of reproductive age, and immunosuppressive therapy generally needs to continue during pregnancy to prevent flares.¹ Prof. Williamson noted that nearly half of these women do not receive pre-pregnancy counselling.¹ For hepatitis C, current European guidelines recommend routine testing during antenatal care.¹ Cesarean delivery is not advised solely to prevent vertical transmission, and breastfeeding remains encouraged.² For those with hepatitis C virus (HCV)/ human immunodeficiency virus (HIV) coinfection decisions around mode of delivery and lactation should be individualized.^1,2

Drug-induced liver injury also warrants careful evaluation, particularly when medications or herbal remedies are implicated.¹ Liver function should be assessed broadly, including coagulation, glucose, albumin, creatinine, and lactate.¹ Decisions regarding continuation of potentially hepatotoxic therapies should be individualized and made with multidisciplinary input.¹

In conclusion, early assessment and coordinated management are essential for optimizing outcomes in pregnancies complicated by liver disease.¹ As Prof. Williamson concluded, “Multidisciplinary team discussion is key to ensuring safety for both mother and baby.” Women with chronic liver conditions or a history of gestational liver disease should receive pre-pregnancy counseling and coordinated care from hepatologists, obstetricians, anesthetists, and midwives.¹

In an interview with Omnihealth Practice, Professor Catherine Williamson discussed the clinical implications of pre-existing liver disease in pregnancy, highlighting the importance of early assessment, careful risk stratification, and multidisciplinary care.

Q1: How does the presence of pre-existing liver disease change your approach to prenatal care compared with a typical pregnancy?

Professor Williamson: It changes the approach significantly. The priority is to understand the underlying liver condition and assess its severity, because pregnancy outcomes are closely linked to baseline liver function. The goal is always to optimize maternal health and disease control as early as possible. Women with pre-existing liver disease should be recognized as high risk, and their care planned accordingly, ideally with pre-pregnancy counselling and early specialist involvement.

Q2: For clinicians who encounter abnormal liver tests early in pregnancy, what should the initial clinical approach be?

Professor Williamson: The key is to assess liver function rather than focusing on transaminase levels alone. The first step is to determine whether the abnormality reflects an acute or chronic process. We usually start by looking at overall liver function and its downstream effects, including coagulation, glucose, albumin, creatinine, and lactate. From there, it is important to consider whether the pattern suggests hepatocellular injury or cholestasis. A careful history is essential, particularly around medication use and herbal remedies. Mild isolated transaminitis is relatively common in pregnancy, often related to infection, but it should still be interpreted carefully.

Q3: What practical advice would you give to general obstetricians managing pregnant women with liver disease?

Professor Williamson: Severity assessment should guide management decisions. Understanding liver function allows clinicians to determine when observation is appropriate and when intervention is necessary. Women with liver disease benefit most from coordinated multidisciplinary care. Early referral and structured follow-up are essential, as timely assessment and shared decision-making can help reduce maternal and fetal risk.