The larger series reports of pregnancy outcomes after liver transplantation are summarized in Table 2.

In one of the earliest reports (Scantlebury et al. 1990) of pregnancies post-liver transplantation, 17 liver transplant recipients had 23 pregnancies resulting in 19 live births (one set of twins) between 1977 and 1988. The mean gestational age was 34 weeks and the mean birthweight 1,980 g. Delivery by cesarean section was undertaken in 63 %. One recipient had an acute rejection during the third trimester which resolved quickly after delivery. At the time of publication, all of the mothers had adequate graft function save for one recipient who died of lymphoma 2.5 years after delivery. The children were reported healthy at last follow-up. The authors concluded that there was no increased risk due to the physical presence of the fetus, and that despite the increased risks of prematurity and cesarean birth, liver transplantation did not contraindicate childbearing, a conclusion endorsed by later published series (Ville et al. 1993; Wu et al. 1998; Mohammed-Ahmed et al. 2014; NTPR Annual Report 2014). Other reports all agreed (Ville et al. 1993; Wu et al. 1998; Nagy et al. 2003; Christopher et al. 2006; Costa et al. 2011; Zegarac et al. 2012; Jabiry-Zieniewicz et al. 2011) that although high-risk, these pregnancies can be successful, especially if they are planned and managed by a multidisciplinary team.

The NTPR has reported 394 pregnancies in 215 liver transplant recipients, most of whom were taking CNI-based immunosuppression during their pregnancy. The features and outcomes of those pregnancies are listed in Table 3. As in earlier reports (Christopher et al. 2006; Alvaro et al. 2013), the newborn outcomes were similar and unrelated to the primary immunosuppressant their mothers took during pregnancy (NTPR Annual Report 2014).

In a small series reporting on five liver transplant recipients with six pregnancies and focusing on maternal hemodynamics during pregnancy, there was one stillbirth and five live births, one of which was delivered at 28 weeks due to FGR and superimposed preeclampsia. All of the pregnancies were complicated by some degree of renal insufficiency most significant in the recipients having the stillbirth and the 28 week delivery; both of them having a hemodynamic shift from low to high peripheral vascular resistance during their pregnancy. Although a longer TCI did not appear to protect the recipients from hypertensive complications of pregnancy, the authors did comment that improved hypertensive control preconception may decrease the risk for preeclampsia and poor obstetric outcome in liver transplant recipients (Carr et al. 2000).

An analysis of NTPR data, comparing two groups of liver transplant recipients for graft loss associations (Table 4), revealed that those who lost their graft within 5 years of delivery were significantly younger at transplantation and at the time of conception. Whilst the proportion of live births was similar in those with and without graft loss, gestational age and birthweight were significantly lower in infants born to mothers who would go on to lose their graft within 5 years of delivery. Importantly, rejection during pregnancy was the strongest risk factor associated with graft loss within 5 years, although younger age at the time of conception was also associated with higher risk of such graft loss (Ramirez et al. 2011).