183 Özlem KOŞAR CAN
1Batuhan BAŞPINAR
21 Dr. Öğr. Üyesi, Pamukkale Üniversitesi Tıp Fakültesi, ozlemcan@pau.edu.tr
2 Uzm. Dr., Ankara Şehir Hastanesi, batuhanbaspinar@gmail.com
17
GİRİŞ
Gebelik esnasında ortaya çıkan normal olarak kabul edilen fizyolojik ve hormonal değişiklikler ile karaciğer hastalıklarına neden olan fonksiyo- nel bozuklukların ayırıcı tanısı mutlaka yapılma- lıdır. Karaciğer fonksiyon bozukluğu gebelerin yaklaşık %3’ ünde görülmektedir (1-3). Gebelik- te görülen karaciğer hastalıkları hafif karaciğer fonksiyon bozukluğu olabileceği gibi, anne ve fetüsde morbidite ve mortalite ile sonuçlanan ciddi karaciğer hastalığı da olabilmektedir. Bun- dan dolayı karaciğer fonksiyon bozukluğunun nedenini hızlı bir şekilde değerlendirmesi gerek- mektedir. Gebelikte saptanan karaciğer hasta- lıklarının sınıflaması üç ana başlıkta toplanabi- lir; gebeliğe özgü karaciğer hastalıkları, gebelik esnasında ortaya çıkan karaciğer hastalıkları ve gebelik öncesinde de var olan karaciğer hastalık- ları (Tablo 1). Gebeliğe özgü karaciğer hastalık- ları, gebelikte saptanan karaciğer hastalıklarının en sık nedenidir (4,5). Gebeliğe özgü karaciğer hastalıkları genellikle belli gebelik haftalarında saptanmakta iken, gebeliğe özgü olmayan kara- ciğer hastalıkları herhangi bir gebelik haftasında saptanmaktadır. Gebeliğe özgü karaciğer hasta-
lıklarının tipik klinik semptomları dikkatle ayırt edilmelidir.
Anne ve fetüsün morbidite ve mortalitesi açı- sından, gebelikte saptanan karaciğer hastalıkla- rının ayırıcı tanısının dikkatlice yapılıp, uygun tedavinin en doğru zamanda başlanması önem arz etmektedir.
Tablo 1. Gebelik trimesterlerinde karşılaşılan Karaciğer hastalıkları
Gebeliğe özgü
• Hipermezis gravidarum (1. Trimester)
• Gebeliğin intrahepatik kolestazı (2. ve 3.
Trimester)
• Preeklampsi (2. ve 3. Trimester)
• HELLP sendromu (2. ve 3. Trimester) Gebelik sırasında gelişen
• Akut viral hepatit
• Budd-Chiari sendromu
• Kolelithiazis
• İlaç ilişkili hepatotoksisite Gebelik öncesinde var olan
• Kronik viral hepatit
• Otoimmun hepatit
• Siroz
• Wilson hastalığı
HEV
Endemik bölgelerde HEV enfeksiyonuna bağlı akut karaciğer yetmezliği gebelikte gebe ol- mayan kontrollere göre daha sık görülmektedir.
Gebelikte akut HEV enfeksiyonu %15-25 hasta- da mortal seyretmektedir (86). Gebelikten önce HEV ile karşılaşmış hastalarda gebelik esnasında yaşanan reinfeksiyonda akut karaciğer yetmezli- ği daha nadir görülmüştür (87). Gebe hastalarda ribavirin kullanımı önerilmemektedir. Hastalara destek tedavisi önerilirken terapötik terminasyon ile ilgili net bir öneri bulunmamaktadır (88).
KARACİĞER NAKLİ
Karaciğer nakli, kronik karaciğer hastalığına bağlı infertiliteyi çoğunlukla ortadan kaldırmak- tadır. Karaciğer nakli sonrası 24 ay kontrasepsi- yon sağlanması; immunsupresif tedavi rejiminin idame dozuna ulaşması ve organın fonksiyonu- nun değerlendirilebilmesi açısından önerilmek- tedir (89). Genel olarak karaciğer nakilli hasta- larda gebelik sonuçları iyi seyretmekle beraber bu hastalarda bazı komplikasyonlar görülebilir.
Bu hastalarda bazal böbrek fonksiyon bozuklu- ğunun daha sık olması ve immunsupresif tedavi- ler sebebiyle hipertansiyon ve preeklampsi sıktır (89). Preeklempsi ve greft rejeksiyonu sebebiyle erken doğum sıklığı artmıştır. Ek olarak, pred- nizolon kullanımına bağlı gestasyonel diyabet riski artmış olup bu hastalarda ilk trimestırda ve 24-28 haftalar arasında tarama yapılması öneril- mektedir.
Karaciğer nakli ömür boyu immunsupresif tedavi gerektirir. Kortikosteroid, takrolimus ve azatiopurin ile birlikte teratojenite riskinde hafif artış mevcuttur. Bu hastalar maternal-fetal tıp uz- manlarıyla birlikte takip edilmelidir.
Gebelik esnasında fetal ve maternal mortalite olmaksızın karaciğer nakli yapılan hastalar bildi- rilmiştir. Karaciğer yetmezliğine sebep olan olay gebelik ilişkili bir karaciğer hastalığı ise gebeliğin sonlandırılarak hastaya destek tedavi verilmesi ilk tercih olmalıdır.
SONUÇ
Karaciğer hastalıklarında tedavi imkanlarının gelişmesi ile gebelik imkanı artmıştır. Kronik ka- raciğer hastalığında gebelik öncesi dönemde has- talık kontrolü sağlanmalı, gebelik sırası ve son- rasında yakın izlemi yapılmalıdır. Gebeliğe özgü karaciğer hastalıklarının tanısı erken konularak uygun tedavi sağlanmalıdır.
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