Perinatal Management of Esophageal Varices.

IMPORTANCE

Physiological changes in pregnancy pose unique challenges for cirrhosis and portal hypertension, particularly during the third trimester and intrapartum setting. Pregnancy may increase the risk of worsening of esophageal varices and life-threatening variceal hemorrhage. Therefore, it is important that clinicians recognize risk factors for appropriate referral and management for delivery planning to mitigate risks associated with acute variceal bleeding in pregnancy.

OBJECTIVE

Review preconception counseling, antepartum surveillance, and intrapartum management of patients with esophageal varices, while emphasizing professional societal guidelines.

EVIDENCE ACQUISITION: A literature review identified relevant research, review articles, databases, and societal guidelines.

RESULTS

Optimal management of esophageal varices in pregnancy requires an individualized, multidisciplinary team. Preconception counseling should include a screening endoscopy within 1 year of conception; with pregnancy, a second-trimester upper endoscopy should be considered. Small varices may be managed with a beta-blocker and surveillance. Medium and large varices should be managed with therapeutic endoscopy. Counseling regarding the mode of delivery is individualized, and attempting vaginal birth is acceptable in patients at low risk of variceal bleeding and with an anticipated short duration of the second stage of labor. Cesarean deliveries may be considered for patients with intensive care coordination needs and a high risk for variceal bleeding. Postpartum follow-up should include appropriate follow-up with Hepatology, contraception counseling, and follow-up for other comorbidities.

CONCLUSIONS AND RELEVANCE: Optimal management for patients with esophageal varices due to cirrhosis and portal hypertension requires highly individualized care. Clinical advancements, as well as a steady increase in rates of cirrhosis in reproductive-aged women, has led to a higher prevalence of clinicians caring for these patients.