Hepatitis B and pregnancy

INTRODUCTION  — Hepatitis B during pregnancy presents with unique management issues for both the mother and fetus. These include the effects of HBV on maternal and fetal health, the effects of pregnancy on the course of HBV infection, treatment of HBV during pregnancy, and prevention of perinatal transmission. Prevention of perinatal transmission is an important component of global efforts to reduce the burden of chronic HBV since vertical transmission is responsible for approximately one-half of chronic infection worldwide. (See "Epidemiology, transmission, and prevention of hepatitis B virus infection" .)

The risk of developing chronic HBV infection is inversely proportional to the age at time of exposure. The risk is as high as 90 percent in those exposed at birth, while the risk is much lower (about 20 to 30 percent) in those exposed during childhood. Maternal screening programs and universal vaccination have significantly reduced transmission rates. Identification of at-risk mothers permits prophylaxis against transmission, which can reduce transmission rates from 90 percent to as low as 5 to 10 percent. Methods of prophylaxis and risk factors for transmission despite prophylaxis are described further below.

IMPLICATIONS OF HBV INFECTION FOR THE MOTHER

Effect on pregnancy outcomes

Acute HBV  — Acute viral hepatitis is the most common cause of jaundice in pregnancy [ 1 ]. Other causes include acute liver diseases associated with pregnancy such as acute fatty liver of pregnancy, HELLP, and intrahepatic cholestasis of pregnancy (see appropriate topic reviews).

Acute HBV infection during pregnancy is usually not severe and is not associated with increased mortality or teratogenicity [ 1,2 ]. Thus, infection during gestation should not prompt consideration of termination of the pregnancy. However, there have been reports of an increased incidence of low birth weight and prematurity in infants born to mothers with acute HBV infection [ 2,3 ]. Furthermore, acute HBV occurring early in the pregnancy has been associated with a 10 percent perinatal transmission rate [ 3 ]. Transmission rates significantly

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SUMMARY AND RECOMMENDATIONS

• Hepatitis B during pregnancy presents with unique management issues for both the mother and fetus. These include the effects of HBV on maternal and fetal health, the effects of pregnancy on the course of HBV infection, treatment of HBV during pregnancy, and prevention of perinatal transmission.

• Acute HBV infection during pregnancy is usually not severe and is not associated with increased mortality or teratogenicity. (See 'Acute HBV' above.)

• Pregnancy is generally well-tolerated by women with chronic hepatitis B infection who do not have advanced liver disease. However, because occasional patients develop a hepatitis flare, HBsAg-positive mothers should be monitored closely. We obtain liver biochemical tests every three months during pregnancy and for six months postpartum. HBV DNA should be tested concurrently or when there is ALT elevation. (See 'Chronic HBV' above.)

• Various factors need to be considered when deciding on antiviral therapy during pregnancy including the indications, anticipated duration of therapy, potential adverse effects to the fetus, efficacy, and the risk of the development of drug resistance. The health of the mother and fetus must be considered independently when deciding on treatment. The safety of medication exposure in the fetus needs to be weighed against the risk of stopping or changing therapy for the mother. (See 'Antiviral therapy in women with childbearing potential' above.)

• The infection rate among infants born to HBeAg-positive mothers who do not receive any form of prophylaxis is as high as 90 percent. The high protective efficacy (95 percent) of neonatal vaccination suggests that most infections occur at birth when maternal secretions in the birth canal come in contact with the infant's mucosal membranes. (See 'Perinatal transmission'above.) The most important risk factors for transmission despite prophylaxis appear to be active viral replication and a high maternal HBV viral load. (See 'HBV replicative status' above.)

• Testing for HBsAg should be performed on all women at the first prenatal visit and repeated late in pregnancy in those at high risk for HBV infection. Newborns of carrier mothers should receive passive-active immunization. (See "Standard immunizations for children and adolescents", section on 'Hepatitis B vaccine' .) In addition to standard passive-active immunization, we suggest antiviral therapy be offered to mothers with high HBV DNA levels since it can further reduce the risk of perinatal transmission ( Grade 2B ) ( algorithm 1 ). (See 'Prevention of perinatal transmission' above.)

REFERENCES

Hepatitis C Therapy in Renal Patients

Introduction
Hepatitis C virus (HCV) was discovered 25 years ago [1] and is now about to get a cure. In the meantime, the C virus has induced tremendous morbidity and mortality mainly due to liver complications (cirrhosis, hepatocellular carcinoma). However, many extrahepatic manifestations [2] have been reported for chronic HCV infection with increased related morbidity and mortality, including cardiovascular diseases, type 2 diabetes and insulin resistance, neurocognitive dysfunction, systemic vasculitis, B cell non-Hodgkin lymphoma and chronic kidney disease [3]. Today, some new challenges remain, particularly with regard to specific populations suffering from HCV infection, such as renal patients. Our article focuses on the specificities of screening, monitoring, assessing, treating and following up, in the context of HCV infection, persons living with chronic kidney disease, end-stage renal failure or a kidney graft.

This article is based on previously conducted studies and does not involve any new studies of human or animal subjects performed by any of the authors.

Epidemiology of Hepatitis C Virus Infection in Renal Patients

Approximately 170 million people are infected with HCV worldwide and 2.35% of the total world population [4]. In dialysis patients, the prevalence of HCV infection has evolved dramatically over the last 10 years. In 2004, the Dialysis Outcomes and Practice Patterns Study (DOPPS) published the largest study analyzing the HCV serological status in 8615 randomly selected hemodialysis patients treated in 308 dialysis facilities (in 8 countries in Europe, HCV USA and Japan) [5]. It showed the HCV antibody prevalence to be 14.7% when unadjusted and 10.4% when adjusted for age, gender, race, time with end-stage renal disease, and alcohol or drug abuse in the past 12 months. The updated DOPPS study [6] found a very low prevalence of HCV treatment in dialysis patients as only 1% of the 4589 patients with available prescription data were receiving HCV medications. Among a subset of 617 HCV patients known to be on the waiting list for renal transplantation, only 3.7% were receiving HCV treatment. In the DOPPS study, the seropositivity for HCV was associated with black race [odds ratio (OR) = 1.93, P < 0.0001], male gender (OR = 1.18, P = 0.01), diabetes mellitus (OR = 1.18, P = 0.03), a history of gastrointestinal bleeding (OR = 1.22, P = 0.06), HBV infection (OR = 2.56, P < 0.0001) and prior renal transplant (OR = 1.34, P = 0.01). Drug and alcohol abuse, as reported during the 12 months prior to data collection, was also associated with HCV seropositivity (OR = 2.44, P < 0.0001 and 1.75, P = 0.0001, respectively). At that time, the risk of seroconversion was variable despite infection control measures, and HCV outcomes varied by patient characteristics, country and hemodialysis facility practice patterns. No consensus was available with regard to the need for hemodialysis patient isolation and dedicated dialysis machines to prevent HCV transmission, in addition to blood-borne precautions [5]. Adjusted HCV seroconversions/100 patient-years ranged from 1.2 (0.7–2.0) in the UK to 3.9 (2.9–5.2) in Italy. In 55.6% of facilities, the mean seroconversion rate was 0 per 100 patient-years.