Viral Hepatitis in Pregnancy

UPDATE TO THE PODCAST:

SMFM and ACOG have recently updated their guidance to recommend universal hepatitis C screening in pregnancy! Check out the Practice Advisory here.

What is hepatitis anyway?

• Hepatitis typically refers to a viral infection of the liver.

• One of the most common and potentially serious infections that can occur in pregnant women!

• Typically defined by vague symptoms (malaise, fatigue, anorexia, RUQ or epigastric pain)

  • Physical findings can (but do not always) include jaundice, upper abdominal tenderness, hepatomegaly

  • Other findings: dark urine, gray/white stool; if severe, coagulopathy or encephalopathy

•  Five different types of hepatitis that can affect pregnancy: A, B, C, D, E

Hepatitis Basics by Virus

Hepatitis A

a.    Small RNA virus 

b.    Transmission: fecal-oral contamination, most commonly by children who are asymptomatic

                                               i.     Ex. Poor hand hygiene or food handling

c.     Complications: serious complications rare (1%)

d.    Chronic infection: no, although 10-15% of symptomatic individuals can have symptoms lasting up to 6 months

Hepatitis B/D

a.    Small DNA virus

b.    Transmission: parenteral and sexual contact

                                               i.     At risk – IVDU, high risk sexual behavior

c.     Complications:

                                               i.     Mortality 1%

d.    Chronic infection: 

                                               i.     10-15% will be chronically infected but asymptomatic, no lab abnormalities

                                             ii.     Small subset (15-20%) of those chronically infected will be at risk of developing chronic liver disease (hepatitis, cirrhosis, hepatocellular carcinoma)

e.    Hepatitis D – can only occur with or after Hep B infection (‘co-infection’); produces severe disease more rapidly than Hep B alone

                                               i.     70-80% will develop cirrhosis and portal hypertension, 15% of which will occur with 2 years

                                             ii.     Mortality approaches 25%

Hepatitis C

a.    Transmission: parenteral (blood transfusions – 1 in 1,000,000; IVDU), NOT sexual contact

b.    Complications: 75% infections asymptomatic

c.     Chronic infection: might higher than Hep B, at least 50% infected individuals progress to chronic infection 

                                               i.     20% of chronically infected developed hepatitis or cirrhosis

                                             ii.     Increased risk of B-cell lymphomas and cryoglobulinemia

Hepatitis E

a.    Rare in US, more common in developing countries

b.    Like Hepatitis A, usually due to poor sanitation such as fecal contamination of drinking water

c.     Typically self-limited; however notably high maternal mortality rate (20%) in pregnant women in third trimester. 

Testing for Hepatitis Virus

Hep A

a.    Acute infection – IgM antibodies

b.    No chronic infection, but past infection or vaccination will show +IgG antibodies

Hep B

a.    Three principal antigens:

                                               i.     Hep B surface antigen (HBsAg) present on surface of virus and circulates freely in the serum 

                                             ii.     Hep B core antigen (HBcAg) present only in liver cells, does not circulate in serum

                                            iii.     Hep B e antigen (HBeAg) indicates extremely high viral load and active viral replication 

                                            iv.     Serologic course:

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Image by Kaplan / American Med Association

1.    In general, positive HBsAg in pregnancy should prompt further workup for either acute infection or chronic carrier state

Hep C

                                               i.     Diagnosed by detection of Hep C antibody (may not present until 6- 10 weeks after onset of clinical illness)

                                             ii.     Can also detect HCV viral RNA load

Prevention and treatment of maternal infection

Hepatitis A

a.    Vaccination!

                                               i.     Recommended for adults at increased risk of infection or complications from liver disease – i.e. patients with chronic liver disease, men who have sex with men, drug use, traveling to endemic areas

b.    Post-exposure treatment: both HAV vaccine + immune globulin 

Hepatitis B

a.    Vaccination!

                                               i.     Recommended for healthcare workers, hemodialysis patients, drug users, persons with multiple sexual partners (>1 during past 3 months??) or STD diagnosis, traveling to endemic areas

                                             ii.     Can receive either separate HAV/HBV vaccine or together in combination vaccine

                                            iii.     Not contraindicated in pregnant women – actually recommended if at risk for infection!

b.    Post-exposure treatment: both HBV vaccine + immune globulin (same as Hep A)

                                               i.     Within 24 hours of exposure but not more than 14 days after exposure

General treatment of hepatitis in pregnant women:

a.    Acute -  Can generally be managed as outpatient with supportive management unless:

1.    Encephalopathy

2.    Coagulopathy – administer blood or clotting factors as needed

3.    Severe debilitation 

                                             ii.     All patients should avoid upper abdominal trauma, avoid contact with household members and sexual partners until treated/received appropriate prophylaxis

b.    Chronic – referred for evaluation to a liver specialist

Perinatal Transmission 

Hep B

a.    Perinatal transmission is the single largest cause of chronically infected individuals worldwide!!!

                                               i.     ACOG recommends routine prenatal screening of all pregnant women

What if mom has Hep B?

                                               i.     Without prophylaxis, 10-20% of seropositive women will transmit the virus to the fetus

1.    These babies will have 85-95% risk of chronic infection (vs. 5-10% risk if acquired as an adult)

                                             ii.     If acute infection occurs in pregnancy -> Higher rate of transmission later in gestation (10% if maternal infection occurs in first tri, 80-90% if maternal infection occurs in third tri)

iii. Avoid FSE/early amniotomy in labor to reduce risk of transmission.

What if mom’s Hep B status is unknown?

                                               i.     If mom is seropositive or if status unknown -> baby should receive HBIG and Hep B vaccine within 12 hours of birth (active immunization)

                                             ii.     However, this treatment will not prevent HBV infection if baby already infected in utero

 Hep C

a.    Unlike Hep B, universal prenatal screening not recommended; should only be screened for Hep C ab if at increased risk

b.    Vertical transmission rate 2-8% with moms who have detectable levels of HCV RNA in blood (rare if viral load undetectable)

c.     No known preventive measures to lower risk of vertical HCV infection of neonates

d.    Should not alter mode of delivery

How should women with viral hepatitis be treated during pregnancy and postpartum?

a.    No specific therapy is available for treatment of acute infection 

b.    Hep B: antiviral medication (lamivudine) can treat chronic infection and suppress viral replication decreasing the risk of in utero HBV infection 

c.     Hep C: no current antiviral treatment recommended in pregnancy

d.    Breastfeeding not contraindicated with the following:

                                               i.     HAV with proper hygiene

                                             ii.     HBV if infant received HBIG and HBV vaccine

                                            iii.     HCV