Pregnancy Outcomes in an International Cohort of Autoimmune Hepatitis

BACKGROUND & AIMS: Autoimmune hepatitis (AIH) poses challenges in pregnancy, including immunosuppression (IMS) management and risks of adverse pregnancy outcomes. Granular AIH pregnancy data are limited. METHODS: This two-center retrospective study included pregnancies with AIH at King's College Hospital and the University of California, San Francisco between 1970-2024. Clinical characteristics, IMS regimens and pregnancy outcomes were obtained from chart review. Liver biochemical markers and prognostic scores were assessed as predictive tools for pregnancy outcomes. RESULTS: 197 AIH pregnancies occurred in 112 women. AIH pregnancies increased over time (p<0.001). Median age at conception was 29 years. Cirrhosis occurred in 43% of pregnancies. IMS was used during 84% of pregnancies. Preconception counseling (PPC) occurred in 52% of pregnancies and associated with higher IMS use (61% vs 31%, p=0.008). Live birth occurred in 88%, with preterm delivery in 24%. Gestational complications included intrahepatic cholestasis of pregnancy (9%) and preeclampsia (8%). Preterm birth was more common with cirrhosis (33% vs 16%, p=0.04) though live birth rate was similar. Loss of biochemical response occurred more frequently postpartum than during pregnancy (25% vs 6%, p=<0.001). United Kingdom Model for End-Stage Liver Disease (UKELD) was the strongest predictor of live birth (area under the receiver operating characteristic curve [AUROC] 0.75) followed by Model for End-Stage Liver Disease-Sodium (MELD-Na) (AUROC 0.73) while preconception aspartate aminotransferase (AST) <33 IU/L predicted maintenance of biochemical response (AUROC 0.65). CONCLUSIONS: Autoimmune hepatitis pregnancies carry meaningful risks, including 9% risk of intrahepatic cholestasis and increased preterm birth in those with cirrhosis. Favourable outcomes are supported by preconception counseling and immunosuppression adherence. Preconception UKELD and AST levels may guide individualized risk stratification for live birth and biochemical response.