Maternal obesity and metabolic (dysfunction) associated fatty liver disease in pregnancy: a comprehensive narrative review

ABSTRACT

Introduction

Obesity and metabolic-associated fatty liver disease (MAFLD) during pregnancy constitute significant problems for routine antenatal care, with increasing prevalence globally. Similar to obesity, MAFLD is associated with a higher risk for maternal complications (e.g. pre-eclampsia and gestational diabetes) and long-term adverse health outcomes for the offspring. However, MAFLD during pregnancy is often under-recognized, with limited management/treatment options.

Areas covered

PubMed/MEDLINE, EMBASE, and Scopus were searched based on a search strategy for obesity and/or MAFLD in pregnancy to identify relevant papers up to 2024. This review summarizes the pertinent evidence on the relationship between maternal obesity and MAFLD during pregnancy. Key mechanisms implicated in the underlying pathophysiology linking obesity and MAFLD during pregnancy (e.g. insulin resistance and dysregulated adipokine secretion) are highlighted. Moreover, a diagnostic approach for MAFLD diagnosis during pregnancy and its complications are presented. Finally, promising relevant areas for future research are covered.

Expert opinion

Research progress regarding maternal obesity, MAFLD, and their impact on maternal and fetal/offspring health is expected to improve the relevant diagnostic methods and lead to novel treatments. Thus, routine practice could apply more personalized management strategies, incorporating individualized algorithms with genetic and/or multi-biomarker profiling to guide prevention, early diagnosis, and treatment.

KEYWORDS:

• Maternal obesity
• metabolic-associated fatty liver disease (MAFLD)
• metabolic dysfunction-associated steatotic liver disease (MASLD)
• nonalcoholic fatty liver disease (NAFLD)
• pregnancy
• gestational diabetes mellitus (GDM)
• antenatal care

Article highlights

• MAFLD is a growing concern among pregnant women, with prevalence rates which follow those of maternal obesity.

• Similarly to maternal obesity, MAFLD in pregnancy is also linked to a higher risk of adverse outcomes such as gestational diabetes, pre-eclampsia, and preterm birth, affecting both maternal and fetal health.

• The adverse effects of maternal MAFLD extend beyond the pregnancy period, potentially predisposing the offspring to long-term cardio-metabolic diseases, including obesity and type 2 diabetes.

• The complex pathophysiology of MAFLD involves insulin resistance, dysregulated adipokine secretion, and chronic inflammation, which are superimposed on normal pregnancy-related hormonal and metabolic changes.

• Diagnosing MAFLD in pregnancy may pose challenges due to overlapping symptoms with those often noted during pregnancy, and the limitations of current diagnostic methods. Non-invasive approaches combining biomarkers, scoring systems, and imaging techniques are key for diagnosing MAFLD in pregnancy.

• Research is needed to develop universally accepted diagnostic criteria and safe, effective treatment modalities for pregnant women. Advances in imaging, biomarker analysis, and understanding the gut-liver axis hold promise for personalized management strategies.

• Considering MAFLD assessment in pre-conception family planning and routine early screening during pregnancy could prompt timely interventions, reducing the incidence of gestational diabetes and other complications.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors would like to thank the University Hospitals Coventry and Warwickshire (UHCW) NHS Trust for the ongoing support.

Author contributions

BML contributed to conceptualization and design, data collection, writing of the initial draft, and writing-review and editing, visualizations. LL contributed to search strategies and data collection, writing of the initial draft, and writing-review and editing, visualizations. CK contributed to writing-review and editing. EK contributed to writing-review and editing. EK contributed to writing-review and editing. HSR contributed to conceptualization and design, writing-review and editing, supervision, and project administration. IK contributed to conceptualization and design, writing of the initial draft, and writing-review and editing, visualizations, supervision, and project administration. HSR and IK have contributed equally to this work and are joint senior authors.

Additional information

Funding

This paper was not funded.