Thursday, August 4, 2016

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.)

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