Key Numbers from the 2023 EASL Guidelines
(ICP, HELLP, AFLP, or hyperemesis)
(triggers delivery planning from 35 weeks)
(ASPRE trial, started before 16 weeks)
(usually mild and self-limiting)
Liver diseases affecting pregnant women are becoming more common: chronic liver disease in women aged 15-39 more than doubled in prevalence between the late 1980s and early 2010s. ref 1 This EASL guideline, published in the Journal of Hepatology in September 2023, provides the most comprehensive European evidence-based framework for managing both liver conditions that arise specifically in pregnancy and pre-existing liver diseases that are managed alongside it. The panel reviewed evidence on over 18 conditions and formulated recommendations on diagnosis, medications, monitoring, and delivery planning.
This patient summary covers the key recommendations most relevant to people with liver conditions who are pregnant, planning pregnancy, or navigating a new diagnosis during pregnancy. Every clinical claim on this page is referenced to a specific passage in the guideline. ref 2
How Pregnancy Changes Liver Blood Tests
Before interpreting any liver test during pregnancy, it is critical to know that several key values change significantly compared to the non-pregnant state. What looks abnormal outside pregnancy may be entirely normal during it, and vice versa.
| Test | Non-Pregnant Normal | Pregnant Normal | Clinical Note |
|---|---|---|---|
| ALT (IU/L) | 0-40 | 6-32 ref 3 | Lower in pregnancy; a value of 35 that looks "normal" outside pregnancy is actually elevated |
| ALP (IU/L) | 30-130 | 133-418 (3rd trimester) ref 4 | Rises dramatically due to placental ALP. Elevated ALP alone in 3rd trimester is NOT a sign of liver disease |
| Albumin (g/L) | 35-46 | 28-37 ref 5 | Falls due to haemodilution (increased plasma volume), not poor liver synthetic function |
| Bile acids, non-fasting (µmol/L) | 0-10 | 0-19 ref 6 | Higher normal range in pregnancy; ICP threshold tests use specific cutoffs above this |
Gestational Liver Disorders
These are conditions that arise specifically because of pregnancy. They affect about 3% of pregnant women and require prompt recognition. ref 2
Intrahepatic Cholestasis of Pregnancy (ICP)
ICP is the most common gestational liver disorder, affecting approximately 0.7% of women of European ancestry, roughly double that rate in Asian women, and up to 4% of women from the Andean regions of Latin America. ref 75 About 25% of affected women carry heterozygous mutations in biliary transporter genes, making family history relevant. ref 76 ICP causes pruritus (itching, often most intense on palms and soles) combined with elevated serum bile acids, with no other explanation found. Biochemical abnormalities typically resolve within 3 months of delivery. ref 84
The most important thing to know about ICP is that bile acids are a far better predictor of fetal risk than ALT or bilirubin. A large individual patient data (IPD) meta-analysis found that bile acids had an AUC of 0.83 for predicting ICP-related stillbirth, compared to 0.46 for ALT and 0.49 for AST. ref 77 This means your doctor should be ordering serum bile acid measurements, not just standard liver function tests. All women with confirmed ICP should have serum bile acids measured at least weekly from 32 weeks of gestation. ref 80
ICP Bile Acid Thresholds and Delivery Planning
| Bile Acid Level (non-fasting) | Risk and Recommended Action |
|---|---|
| Below 40 µmol/L | Lower risk — consider UDCA for pruritus; weekly monitoring; consider induction by 39 completed weeks ref 82 |
| 40 to 100 µmol/L | Increased risk of preterm birth, meconium, fetal anoxia ref 79 — offer UDCA to reduce spontaneous preterm birth risk ref 82; weekly bile acid and liver tests; consider induction by 39-40 weeks |
| Above 100 µmol/L | Significantly increased stillbirth risk after 35 weeks ref 78 — elective delivery should be planned from 35 weeks of gestation ref 81 |
The benefit of UDCA treatment in ICP is well established. An IPD meta-analysis of 6,974 women across 34 studies found that UDCA protected against a composite outcome of stillbirth and preterm birth, with a number needed to treat of 15. ref 83 UDCA has only a modest effect on pruritus but its safety profile in pregnancy is well documented, and EASL recommends it for women with bile acids above 40 µmol/L. ref 82
HELLP Syndrome and Preeclampsia
HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets) is considered a severe manifestation of preeclampsia and affects 0.5-0.9% of all pregnancies and 10-20% of those with severe preeclampsia. ref 60 Hepatic complications are common: intrahepatic haematoma occurs in up to 39% of HELLP cases. Capsular rupture occurs in 0.5-2% and carries a 17% maternal mortality rate. ref 61 Abdominal ultrasound should be performed when there are symptoms of right upper quadrant or shoulder pain in HELLP.
Prevention is now well established. The ASPRE trial showed that aspirin 150mg taken nightly, started between 11-14 weeks of gestation, reduced the rate of preterm preeclampsia by 62% compared to placebo (1.6% vs 4.3%; p=0.004). ref 62 High-risk women should start aspirin before 16 weeks of gestation and continue to 36 weeks. ref 63
For women who develop HELLP, the key management points are: magnesium sulphate to prevent or treat eclamptic seizures (it halves both the incidence and recurrence of eclampsia) ref 64; corticosteroids should not be given specifically to improve maternal HELLP outcomes (though they should be given for fetal lung maturity if delivery is needed before 35 weeks) ref 65; and delivery should occur promptly once coagulopathy and severe hypertension are corrected. ref 66
Acute Fatty Liver of Pregnancy (AFLP)
AFLP is rare, occurring in approximately 1:10,000-1:20,000 births, but is a medical emergency when it occurs. It typically presents in the third trimester. ref 67 About 60% of affected women require ICU admission and 20% need care in a specialist liver unit; maternal mortality ranges from 2-18%. ref 68 Symptoms include nausea and vomiting, abdominal pain, polydipsia and polyuria, jaundice, and signs of liver failure. AFLP can be difficult to distinguish from HELLP, and a comparison table is included in the guideline.
Treatment is delivery, and it should be expedited once coagulopathy and metabolic derangements have been corrected. A systematic review found caesarean section was associated with 44% lower maternal mortality (RR 0.56) compared to vaginal delivery in AFLP. ref 71 In a small proportion of women who progress to acute liver failure despite delivery, early referral to a liver transplant centre should be made.
Hyperemesis Gravidarum and the Liver
Hyperemesis gravidarum (HG) affects 1-3% of pregnancies and is defined by symptom onset before 16 weeks, severe nausea and vomiting, inability to eat or drink normally, and a significant impact on daily activities. ref 72 Elevated liver tests occur in 40-50% of all women with HG and account for the majority of unexplained liver test abnormalities in the first trimester. ref 73 The typical pattern is mild aminotransferase elevation (usually up to 200 IU/L); fulminant liver failure has not been reported in HG alone. ref 73
Liver test abnormalities in HG are self-limiting and typically return to baseline following rehydration and cessation of vomiting. Management is the same whether liver tests are elevated or not, including anti-emetics, rehydration, vitamin supplementation (including thiamine), and venous thromboprophylaxis. ref 74 If liver tests are markedly raised (above 5 times the upper limit of normal) or do not normalise with resolution of vomiting, screening for a primary liver disease is recommended.
Pre-existing Liver Conditions in Pregnancy
Women with pre-existing liver disease should receive specialist pre-pregnancy counselling to optimise disease control, review medications, and discuss risks before conception. ref 85
Cholestatic Liver Diseases: PBC and PSC
Both primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) require careful management during pregnancy. About10:37 PMClaude responded: 50% of women with these conditions will experience worsening or new-onset pruritus during pregnancy, but most maintain stable liver function.50% of women with these conditions will experience worsening or new-onset pruritus during pregnancy, but most maintain stable liver function. ref 8 Up to 70% of women with PBC experience worsening liver test results in the postpartum period, and preterm birth is more common in both conditions. ref 9 In PSC, the evidence for UDCA during pregnancy is striking: liver tests remained stable in 67% of women on UDCA compared to only 13% of those not taking it. ref 13
EASL is clear on medications: UDCA should be continued throughout pregnancy in both PBC and PSC, as it is safe in pregnancy and breastfeeding. ref 11 Obeticholic acid must be stopped as soon as pregnancy is confirmed and should not restart during breastfeeding, because safety data are absent. ref 12 For worsening pruritus, rifampicin (300-600 mg daily) and anion exchange resins such as cholestyramine (4-8 g/day) are suggested options. ref 14
Autoimmune Hepatitis (AIH)
The key message for AIH in pregnancy is that immunosuppression should be continued, not stopped. Treatment with prednisolone, budesonide, and thiopurines (azathioprine or mercaptopurine) should be maintained throughout pregnancy, as stopping is associated with worse maternal and fetal outcomes. ref 20 Importantly, AIH can flare after delivery: immunosuppressive doses may need to be increased in the postpartum period. ref 21
Women with AIH face elevated obstetric risks and need close surveillance. Gestational diabetes mellitus (GDM) occurs in 17% of AIH pregnancies, compared to 9% in other chronic liver disease pregnancies and 7% in women without liver disease. ref 22 Close monitoring for gestational diabetes, hypertensive disorders, preterm birth, and fetal growth restriction is recommended throughout pregnancy. ref 23
MASLD in Pregnancy
Metabolic dysfunction-associated steatotic liver disease (MASLD) affects at least 10% of women of childbearing age and is the most common cause of chronic liver disease in the US, with the fastest rise in incidence in those under 40. ref 24 Women with MASLD should be counselled that their pregnancies carry significantly higher risks: a Swedish population study found approximately three-fold higher rates of gestational diabetes, caesarean delivery, preterm birth, and small-for-gestational-age births, plus a two-fold higher risk of preeclampsia, even after adjusting for BMI and diabetes. ref 25
Hypertensive complications (preeclampsia, eclampsia, HELLP) were approximately four times more common in MASLD pregnancies (16%) compared to women without liver disease (3.8-3.9%). ref 26 There are no MASLD-specific drugs approved for use in pregnancy; management is through lifestyle modifications and dietary advice, as in non-pregnant women. ref 27 EASL specifically encourages breastfeeding in women with MASLD, as lactation is associated with lower rates of metabolic syndrome and MASLD in the mother, and may be protective for the offspring. ref 28
Wilson's Disease and Hepatic Adenomas
Women with Wilson's disease should continue their copper-chelating therapy during pregnancy. Zinc, D-penicillamine, and trientine are all continued, but chelator doses should be reduced in the second and third trimesters to avoid over-chelation of the fetus. ref 29 Stopping treatment is associated with hepatic deterioration and death. In a systematic review of 822 pregnancies, spontaneous miscarriage occurred in 21.7% but anti-copper treatment was associated with positive outcomes. ref 30
For hepatocellular adenomas (HCAs): adenomas smaller than 5 cm do not increase complication risk during pregnancy, but ultrasound surveillance each trimester is recommended as growth (greater than 20%) was observed in 25.5% of pregnancies in one prospective study. ref 17 ref 19 Adenomas larger than 5 cm should be treated before attempting pregnancy where possible, due to elevated risks of enlargement and haemorrhage. ref 18
Cirrhosis and Portal Hypertension
With specialist care, maternal mortality in cirrhosis pregnancies has fallen from as high as 14% in the 1980s to below 2% in recent series. ref 31 Pre-conception risk stratification using validated scores is essential. All women with cirrhosis or portal hypertension should receive pre-pregnancy counselling. ref 85
| Score | Threshold | Interpretation in Pregnancy |
|---|---|---|
| MELD Score | Below 6 ref 32 | Minimal risk of significant complication |
| MELD Score | Above 10 ref 33 | Predicts increased likelihood of decompensation during pregnancy |
| ALBI Score | Below -2.7 (Grade 1) ref 34 | Predicts increased likelihood of live birth |
| APRI Score | Below 0.84 ref 35 | Predicts likelihood of reaching term (beyond 37 weeks) |
Variceal bleeding is the main cirrhosis-related risk during pregnancy, occurring in up to 33% of women with cirrhosis and up to 50% of those with portal hypertension. ref 36 A screening endoscopy should be performed within 1 year before conception. ref 37 Beta-blockers (including carvedilol) should be continued or started for variceal prophylaxis, as benefits outweigh the modest fetal risks. ref 38
For delivery in women with cirrhosis, vaginal delivery is generally preferred with a shortened second stage of labour to reduce the Valsalva load. ref 40 When caesarean section is required, MRI or ultrasound can be used beforehand to map intra-abdominal and pelvic varices to plan the safest surgical approach. ref 87
Viral Hepatitis in Pregnancy
Hepatitis B (HBV)
Maternal HBV DNA level is the key factor governing mother-to-child transmission (MTCT) risk. When HBV DNA is below 200,000 IU/ml, MTCT risk is negligible at just 0.04%. ref 47 All HBsAg-positive pregnant women should be tested for HBV DNA; first-trimester HBsAg screening is recommended for all pregnant women. ref 49
When HBV DNA exceeds 200,000 IU/ml or the mother is HBeAg-positive, antiviral prophylaxis with tenofovir disoproxil fumarate (TDF) should start at 24-28 weeks of gestation and continue to 12 weeks after delivery. ref 48 Caesarean section is not routinely recommended as a strategy to reduce HBV MTCT. ref 50 Breastfeeding is not discouraged when the infant receives both HBV vaccine and hepatitis B immunoglobulin (HBIG) within 24 hours of birth; the only exception is mothers with detectable HBV DNA who have cracked nipples or an infant with oral ulcers. ref 51
Hepatitis C (HCV)
HCV testing is recommended as part of routine antenatal care for all pregnant women. ref 52 The MTCT risk is 5.8% for children of HCV RNA-positive women and 10.8% for children of HIV/HCV coinfected mothers. ref 53 Caesarean section does not reduce HCV MTCT and is not recommended for that purpose. ref 54 Breastfeeding should not be discouraged in HCV-infected mothers unless nipples are cracked or bleeding; this guidance also applies to HIV/HCV coinfected women on antiretroviral therapy. ref 55
Hepatitis E (HEV)
HEV infection during pregnancy carries serious risks: the odds of maternal death are seven times higher in the presence of HEV infection, and fetal growth and maturity may be significantly impaired. ref 56 A meta-analysis of three studies (155 pregnant women) found a 36.9% rate of vertical HEV transmission from actively infected mothers. ref 57 In the most severe cases with acute liver failure and encephalopathy grade I-III, early delivery of the fetus can be considered to reduce maternal morbidity and mortality. ref 58
HAV vaccination is recommended for pregnant women identified to be at risk during pregnancy, as the vaccine has not been shown to be harmful in this group. ref 59
Liver Transplant Recipients
Fertility often returns rapidly after a successful liver transplant, sometimes as early as 1 month. EASL recommends delaying pregnancy for at least 1 year post-transplant, and National Transplantation Pregnancy Registry data suggest that waiting more than 2 years is associated with reduced rates of low birth weight, rejection, and graft loss. ref 41 ref 42
Preterm birth is a significant concern: it occurs in approximately 39% of liver transplant pregnancies, which is 2.5 times the 14% rate in the general population. ref 43 Transplant recipients also face elevated risks of preeclampsia, gestational diabetes, and cholestasis, which is why increased antenatal surveillance is strongly recommended.
The immunosuppressants that should be continued during pregnancy are azathioprine, cyclosporine, tacrolimus, and prednisolone. ref 46 All liver transplant recipients should start low-dose aspirin 150mg in the first trimester for preeclampsia prophylaxis. ref 44 Blood markers for rejection should be checked regularly throughout pregnancy.
Stop at least 12 weeks before conception: Mycophenolate mofetil (MMF) due to teratogenicity. ref 45
Limited data, not routinely recommended: Sirolimus and everolimus. Decisions should be individualised with the transplant team.
Delivery Planning and Monitoring
Women with liver diseases associated with a significant risk of maternal or fetal complications are advised to be managed by a multidisciplinary team including a physician, obstetrician, and midwife who all have expertise in liver disease in pregnancy. ref 86 If this is not available locally, referral to a specialist centre is recommended.
Pre-pregnancy counselling is strongly recommended for all women with chronic liver disease or a history of gestational liver disease, giving the opportunity to review medications, optimise disease control, and discuss risks before conception. ref 85
Delivery Timing by Condition
Key delivery timing decisions from the guideline include: ICP with TSBA above 100 µmol/L should be delivered from 35 weeks ref 81; HELLP syndrome and AFLP require prompt delivery once the mother is stabilised ref 66 ref 71; women with cirrhosis should generally aim for vaginal delivery with a shortened second stage ref 40; and in most pre-existing liver disorders without complications, delivery can be planned in early term (38-39 weeks).