The review concluded that although pregnancy after liver transplant was feasible, the complication rates were relatively high and should be considered during patient counselling and clinical decision making. The uncertain quality of the small evidence base and potential for biases limits the reliability of the pooled results, so the authors’ conclusions should be viewed with caution.

To determine the pregnancy outcomes of liver transplant recipients.

PubMed, EMBASE and Web of Science were searched from January 2000 to January 2011 for articles in English. The reference lists of retrieved articles and relevant reviews were searched for additional studies.

Studies that reported pregnancy outcomes, obstetric complications and delivery outcomes in liver transplant recipients were eligible for inclusion. Definitions were provided in the review. Clinical trials, letters, case reports, news, reviews and commentaries were excluded. Multi-organ studies were also excluded.

The included studied were conducted in the USA, UK, Poland and Italy. The mean maternal age ranged from 25.8 to 29.1 years, where reported. The mean interval from transplantation to pregnancy ranged from 1.38 to 5.85 years, where reported.

Two reviewers undertook study selection and disagreements were resolved by the principle investigator.

The authors did not state if they assessed study quality.

Data were extracted on pregnancy outcomes, obstetric complications and delivery outcomes, and used to calculate incidence rates and 95% confidence intervals (CIs).

One reviewer extracted data, which was checked by another reviewer.

Pooled incidence rates and 95% confidence intervals were calculated using weighted Graybill-Deal estimates for continuous outcomes, and using binomial confidence intervals for binary outcomes. Data were compared with updated USA general population data from the 2005 and 2006 National Vital Statistics Reports.

Eight studies were included (306 recipients; 450 pregnancies). The study sample size ranged from five to 151 recipients.

Compared with the general population, liver transplant recipients had a trend towards higher live births (76.9% liver transplant versus 66.7% general population), higher rates of pre-eclampsia (21.9% liver transplant versus 3.8% general population), higher preterm births (39.4% liver transplant versus 12.5% general population), higher caesarean section (44.6% liver transplant versus 31.9% general population) and lower birth weight (2,866g liver transplant versus 3,298g general population). Other results were presented in the review. Results of liver transplant versus kidney transplant recipients were also presented.

Although pregnancy after liver transplant was feasible, the complication rates were relatively high and should be considered during patient counselling and clinical decision making.

Inclusion criteria for the review were broadly defined and three relevant databases were searched. There may have been the potential for language bias, as only articles in English were included. Publication bias was not considered and could not be ruled out. Attempts were made to reduce reviewer error and bias throughout the review. It was not clear if quality assessment was undertaken, which made assessing the quality of the evidence base difficult.

A limited amount of study and recipient details were provided from the individual studies. Most studies had sample sizes of less than 50 recipients. Data were pooled, but statistical heterogeneity was not assessed. The methods for the comparisons with USA general population and kidney transplant data were not fully reported, which made it difficult to determine whether the analyses may have been prone to biases or confounding factors. The authors noted that there was potential for patient overlap between studies, differences in classification criteria and reporting biases.

Overall, the uncertain quality of the small evidence base and potential for biases limits the reliability of the pooled results, so the authors’ conclusions should be viewed with caution.

Practice: The authors stated that it was necessary for a multidisciplinary team to be involved in the monitoring and counselling of liver transplant recipients before and during pregnancy.

Research: The authors stated that to improve the clinical management of pregnant liver transplant recipients, more case reports and centre reports were necessary so that information could be gathered on post-liver transplant pregnancy outcomes and complications. Continued reporting to active registries at the centre level was also highly encouraged.

Not stated.