LETTERS TO THE EDITOR

 

Pregnancy in patient with cirrhosis and cryoglobulinemic vasculitis

 

 

Correspondence

 

 

Dear Editor,

Pregnancy is a rare event in patients with cirrhosis¹ and women with hepatitis have an increased risk of complications during pregnancy.^2,3 There are few reports on this topic. The cryoglobulinemic vasculitis associated with HCV infection is a severe systemic disease involving the kidneys; it develops due to deposits of cryoglobulins. The course is often fatal or leads to end-stage renal disease. The disease tends to relapse. Women with this disorder rarely become pregnant and conclude successfully the pregnancy.

Our experience: a 30-year-old woman suffering from HCV-cirrhosis was admitted for severe peripheral edema with proteinuria 7g/day and albumin 2.3g/dL. The glomerular filtration rate was in the normal range. Renal biopsy showed a membranous-proliferative glomerulonephritis. The patient received 1 cycle of 12 plasmapheresis associated with Mycophenolate Mofetil (MM) 2g/day and prednisone 12.5mg/day therapy. After 1 month, we observed a partial remission of proteinuria (3g/day). The MM therapy was continued. After 2 years, the patient reported amenorrhea lasting for 3 months. The beta-HCG test and U.S. scan confirmed the pregnancy. The MM was interrupted whereas prednisone therapy was maintained at 5mg/day. During pregnancy, proteinuria was always less than 2g/day and renal function was regular. The pregnancy continued without major problems. A cesarean section was performed at the thirty-sixth week of pregnancy. Laboratory tests showed: white blood cells: 3.170/mmc, Hb: 8.2g/dL. PLT: 46.000/mmc, AST: 60IU/L, ALT 33IU/L, gammaGT: 14IU/L, total bilirubine: 1.84mg/dL, total protein: 4.1g/dL, albumin: 2.16g/dL. The fetus was healthy and growth corresponded to the twenty-eighth week of pregnancy. Anti-HCV antibodies detection was negative and the child follow-up did not show any significant diseases after 3 years from birth. The patient resumed MM and prednisone therapy. One year after the child's birth, the patient showed good health with proteinuria 1g/day; she continued MM 2g/day and prednisone 5mg/day. After 18 months postpartum, proteinuria increased to 4g/day. We carried out again a cycle of six plasmapheresis, achieving a reduction of proteinuria (<1g/day). Therefore, we carried out the maintenance of MM and prednisone therapy at the same dose. Although pregnancy in patient with cirrhosis remains rare, recent improvements in the treatment of cirrhosis led to an increase in life expectancy and quality of life, making pregnancy a most frequent event. Outcomes of pregnancy in patients with cirrhosis are poorly described. Regarding neonatal well-being, there is no association between vertical transmission of HCV and gestational age at delivery or the presence of chorioamnionitis. There is no evidence demonstrating an increased risk of HCV transmission in HIV-negative women who breast feed.⁴ There are some reports regarding a worsening of HCV-liver disease after pregnancy.⁵ Regarding immunological pathology, the prognosis associated with many forms of systemic vasculitides was quite grim. Advances in this field have allowed us to focus on issues related to quality of life such as fertility, conception, and pregnancy among women with vasculitis.⁶ This case report shows the possibility of a favourable outcome, if the pregnancy occurs during a clinical stabilization phase of cirrhosis and vasculitis.

 

Conflict of interest

The authors declare that they have no conflicts of interest related to the contents of this article.

 

Gioacchino Li Cavoli, Carlo Giammarresi, Calogera Tortorici,
Luisa Bono, Angelo Ferrantelli, Ugo Rotolo
Division of Nephrology. Civic and Di Cristina Hospital. Palermo, Italy

 

Referencias bibliográficas

1. Fung TY, Li CY. Successful pregnancy in a woman with secondary biliary cirrhosis with portal hypertension from recurrent pyogenic cholangitis. A case report. J Reprod Med 1999;44:475-7.         [ Links ]

2. Reddick KL, Jhaveri R, Gandhi M, James AH, Swamy GK. Pregnancy outcomes associated with viral hepatitis. J Viral Hepat 2011;18:e394-8.         [ Links ]

3. Lodato F, Cappelli A, Montagnani M, Colecchia A, Festi D, Azzaroli F, et al. Transjugular intrahepatic portosystemic shunt: a case report of rescue management of unrestrainable variceal bleeding in a pregnant woman. Dig Liver Dis 2008;40:387-90.         [ Links ]

4. Airoldi J, Berghella V. Hepatitis C and pregnancy. Obstet Gynecol Surv 2006;61:666-72.         [ Links ]

5. Fontaine H, Nalpas B, Carnot F, Bréchot C, Pol S. Effect of pregnancy on chronic hepatitis C: a case-control study. Lancet 2000;356:1328-9.         [ Links ]

6. Seo P. Pregnancy and vasculitis. Rheum Dis Clin North Am 2007;33:299-317.         [ Links ]

 

 

Correspondence:
Gioacchino Li Cavoli,
Division of Nephrology,
Civic and Di Cristina Hospital,
via Francesco Cilea 43.
Palermo, Italy, 90144, Palermo, Italy
gioacchinolicavoli@libero.it