Esophageal varices in pregnancy: Strategies to optimize maternal and fetal outcomes

Table 1 Maternal and fetal risks associated with portal hypertension in pregnancy

Risk	Mechanism/description
Maternal risks
Variceal bleeding	Peak incidence in the 2nd and 3rd trimesters; triggered by increased portal venous flow and intra-abdominal pressure
Hepatic decompensation	Higher risk in advanced cirrhosis; manifestations include jaundice, ascites, and hepatic encephalopathy
Thrombocytopenia and coagulopathy	Caused by hypersplenism and reduced hepatic synthesis of clotting factors
HRS	Rare but potentially fatal; precipitated by fluid shifts, infection, or preeclampsia
Infections	Includes SBP and UTIs; risk increased by immune dysregulation
PPH	Increased due to varices, coagulopathy, and portal hypertension-related splenic sequestration of platelets
Fetal risks
FGR	Due to uteroplacental insufficiency, chronic maternal hypoxia, and hepatic dysfunction
Preterm delivery	May result from spontaneous labour or iatrogenic delivery following maternal complications
Increased perinatal mortality	Reported rates up to 20% in older studies; currently lower with improved maternal and neonatal care

HRS: Hepatorenal syndrome; SBP: Spontaneous bacterial peritonitis; UTI: Urinary tract infection; PPH: Postpartum hemorrhage; FGR: Fetal growth restriction.

Table 2 Predictors of adverse maternal and fetal outcomes

Category	Predictor	Implication
Maternal	History of variceal bleeding	Strongest predictor of peripartum hemorrhage
Maternal	Large esophageal varices	> 30% risk of bleeding in late 2nd or 3rd trimester
Maternal	Thrombocytopenia (< 50000/mm³)	Indicates hypersplenism and coagulopathy
Maternal	Coagulopathy (INR > 1.5)	Increases hemorrhagic risk during delivery
Maternal	Ascites	Marker of hepatic decompensation; predicts poor maternal outcomes
Maternal	Hepatic encephalopathy	Sign of end-stage liver disease
Maternal	Portal vein thrombosis	May worsen hepatic congestion and complicate delivery
Fetal	Maternal cirrhosis	Associated with placental insufficiency, preterm labour, and fetal loss
Fetal	Hypoalbuminemia	Indicates poor hepatic reserve and suboptimal nutritional status
Fetal	Beta-blocker therapy	Potential for FGR and bradycardia
Fetal	Acute variceal bleeding episodes	May cause fetal distress and hypoxia
Fetal	Preterm delivery	Often iatrogenic due to maternal decompensation

INR: International normalized ratio; FGR: Fetal growth restriction.

Table 3 Overview of guideline recommendations on variceal screening and management in pregnancy

Guideline	Key recommendations	Relevance to pregnancy
AASLD 2017	All cirrhotic patients should undergo upper GI endoscopy at diagnosis	Preconception or early pregnancy
EASL 2022	Screening endoscopy in all cirrhotics; repeat every 2-3 years or sooner if decompensated	Encourages evaluation before or early in pregnancy
Baveno VII Consensus	Use non-invasive markers (platelets < 150000/mm³ + liver stiffness measurement > 20-25 kPa) to decide need for endoscopy	Limited validation in pregnancy; underutilized
WGO 2014	EVL preferred in high-risk varices; NSBB first line	Safe use of carvedilol or propranolol in selected cases

AASLD: American Association for the Study of Liver Diseases; EASL: European Association for the Study of the Liver; WGO: World Gastroenterology Organization; EVL: Endoscopic variceal ligation; NSBB: Non-selective beta blockers; GI: Gastrointestinal.

Table 4 Comparative summary of guideline recommendations on esophageal varices in pregnancy

Guideline	Timing of endoscopy	Primary prophylaxis (NSBB vs EVL)
AASLD (2023)	Preconception; if not done, perform in the second trimester for high-risk cases	Recommends NSBB for small varices with high-risk features. For medium to large varices, either NSBB or EVL may be used. EVL preferred if NSBB contraindicated or not tolerated
EASL (2022)	Not specified	Both NSBB and EVL are first-line options. NSBB preferred as they improve long-term outcomes (reduce ascites, decompensation, and mortality) compared with EVL
Baveno VII (2022)	Does not specify timing in pregnancy	NSBB preferred in all patients with CSPH irrespective of variceal size; EVL only if NSBB contraindicated or not tolerated
ASGE (2021)	Second trimester preferred for safety of endoscopy	Not specified
BSGE (2021)	Second trimester preferred	Not specified
INASL (2019)	Not specified	Small high-risk varices: NSBB prophylaxis. Medium/Large varices: NSBB or EVL can be used

AASLD: American Association for the Study of Liver Diseases; EASL: European Association for the Study of the Liver; Baveno VII: Baveno Consensus Workshop on Portal Hypertension; ASGE: American Society for Gastrointestinal Endoscopy; BSGE: British Society of Gastroenterology; INASL: Indian National Association for the Study of the Liver; NSBB: Non-selective beta-blocker; EVL: Endoscopic variceal ligation; CSPH: Clinically significant portal hypertension.

Table 5 Contraceptive options in women with cirrhosis and portal hypertension

Method	WHO MEC category (compensated liver disease)	WHO MEC category (decompensated cirrhosis/portal hypertension with varices)	Key recommendations
Barrier method	1	1	Less effective alone; encourage for dual protection
Combined oral contraceptives	3	4	Avoid due to estrogenic effects; may worsen cholestasis and increase thrombosis risk
Injectable medroxyprogesterone acetate	2	3	Effective, but caution due to risk of bone loss; osteoporosis is common in cirrhosis
Progestin implant/LNG-IUS	1	2	Highly effective; preferred long-acting reversible options
Copper IUCD	1	2-3 (if severe anemia)	Acceptable if anemia is controlled; monitor for bleeding
Female sterilization	1 (if medically fit)	2-3	Surgical risk increased by collaterals and coagulopathy; laparotomy may be safer than laparoscopy

Medical eligibility criteria category definitions: 1 = No restriction; 2 = Advantages generally outweigh risks; 3 = Risks usually outweigh advantages; 4 = Unacceptable health risk. WHO: World Health Organization; MEC: Medical eligibility criteria.