<Hepatology Digest>: Could you give an overview of your topic, NAFLD in pregnant women, and why it is important?
Dr Wong: NAFLD is a very common chronic liver problem all over the world, including the Asia-Pacific region. The prevalence in the general adult population is around 25-30%. That is why it will also be prevalent amongst pregnant women and women of childbearing age. From the literature, the prevalence in the women of childbearing age is around 10%, which means it is very common, and will cause problems, as it is associated with other metabolic risk factors, most importantly diabetes mellitus. This increases the risk of gestational diabetes 2-4-fold, and that will have a negative impact on pregnancy and fetal outcomes. That is why it is important. It is common, and it has important prognostic implications. This is why we are promoting awareness so diagnoses can be made early on. Early intervention means pregnancy outcomes can be improved.
<Hepatology Digest>: Why is it common? Is it because of the increasing prevalence of obesity?
Dr Wong: Definitely. In the Asia-Pacific region, our lifestyle is quite westernized these days in terms of diet, and young adults have less time to exercise, which may explain why we see more young adults with NAFLD.
<Hepatology Digest>: You also said there was a health risk, obviously to the mother with metabolic syndrome, but what are the health risks for the fetus?
Dr Wong: The fetus will be large for gestational age, meaning birth weight will be higher than average. And in the future, these offspring of women with NAFLD are at risk of developing diabetes, so effectively the condition can be passed on to the next generation. This is why we advocate women controlling the metabolic risk factors prior to pregnancy and reduce the risk of NAFLD.
<Hepatology Digest>: What factors do you look for that raise suspicion of the presence of NAFLD in a pregnant woman?
Dr Wong: The first thing would be body weight. If the woman is overweight, then that would be a key risk factor. We would also do screening for common metabolic risk factors like blood pressure, fasting glucose, and lipid profile. Essentially, these are the diagnostic criteria for metabolic syndrome. If they have three or more of those, then metabolic syndrome exists, which is a strong risk factor for diabetes.
<Hepatology Digest>: If a mother-to-be is diagnosed to have gestational diabetes, then is it automatic to test for NAFLD?
Dr Wong: That would be a good idea. The current limitation would be the need for further testing to establish a diagnosis of NAFLD, but testing for gestational diabetes is usually done by the obstetrician, so normally the process stops there unless the gestational diabetes is severe. Then the patient would be referred to an endocrinologist or general internalist, and only then might ultrasound testing be requested, or other non-invasive assessments, such as fatty liver index and other blood-based parameters that help in the diagnosis of NAFLD.
<Hepatology Digest>: Once a diagnosis is established, do you treat the overall metabolism, or do you focus strictly on the hepatology?
Dr Wong: It is a more general management of the metabolic risk factors, because NAFLD is just one of the many manifestations of the metabolic syndrome. If all those metabolic risk factors are controlled, NAFLD would improve, as would other metabolic problems. The main approach would be dietary control, as initiating drug therapy in pregnancy is less desirable. As I mentioned in my talk, this involves controlling the calorie intake, as well as specific components of the macronutrients.
<Hepatology Digest>: Where there is severe metabolic syndrome present, what measures are taken then?
Dr Wong: Most of the time, that would be poor glycemic control, so insulin would be needed. However, insulin would not be a beneficial addition to liver pathology, but glycemia remains the most important component to control. If glycemia control improves, at least in the short- and mid-term, the liver condition would not deteriorate significantly. In the long-term, insulin would not be the best glycemic therapy or to improve NAFLD, so after delivery, we would switch from insulin to other oral medications, which will be more liver-friendly.
<Hepatology Digest>: So the priority in NAFLD cases is the glycemic control?
Dr Wong: And also to control weight gains. It is easy to over-eat in pregnancy, so weight gains need to be monitored closely. Usually, we would advise to limit weight gains during pregnancy between 15-20 kg, as excess weight gains will increase the risk of NAFLD.
That is very true. I have had two children and that was also my experience during pregnancy. I think if we provide adequate evidence and data illustrating that excess weight gains and consequent NAFLD are detrimental to her offspring, then they can be more motivated. You can still get good nutrition in the absence of excess weight gains. What is needed is a balanced diet. We can show them the desired components and ratios so they can still eat healthy and provide the correct nutrition for the baby.
<Hepatology Digest>: You are one of the few Chinese representatives at this meeting. Most of your mainland Chinese colleagues are unable to attend. If you could share some encouragement for your hepatologist colleagues, what would you say?
Dr Wong: Firstly, I fully understand that it is a really tough time for healthcare professionals in China, and indeed many parts of the world now, including Hong Kong. There are a lot of commitments to your patients and their families to care for them, whether that be COVID-19-related or otherwise. Their mission is to stay and care for their patients. All the general physicians and hepatologists are working very hard, and their efforts are really appreciated. There will be travel limitations temporarily over the coming months, but with technology such as the live streaming at this conference, they can still participate, learn what is new and provide feedback. I am sure that in a few months, the situation will be under control, and I look forward to doctors from different countries coming together again to exchange knowledge and experiences. I would say we are all hanging in there and trying our best to contribute at whatever level to the current situation. We hope this will be under control very soon, and we can come together again and meet face-to-face.
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