Viral Hepatitis in Pregnancy, with Dr. Brenna Hughes
/We were lucky enough to get a sneak peak at ACOG’s newest Clinical Practice Guideline #6 on Viral Hepatitis in Pregnancy. We sat down with co-author Dr. Brenna Hughes, professor of obstetrics and gynecology and Vice Chair of Obstetrics and Quality at Duke University, to get highlights of the newest updates and changes concerning hepatitis in pregnancy.
Background
There are five types of viral hepatitis: A, B, C, D, E
A and B are preventable through vaccination
B and C are recommended for screening in pregnancy.
Screening and vaccination is important, as these infections cause morbidity for pregnant folks.
Recall we reviewed some of this in our prior podcast on hepatitis.
Hepatitis A — small case-fatality and rare complications
Associated with food-borne outbreaks
Fecal-oral contamination or foodborne outbreaks related to contaminated food/water
Hepatitis B — highly pathogenic and infectious
Perinatal transmission is single largest cause of chronic infection worldwide.
Also associated with sexual contact, IV drug use, contaminated blood product.
Mortality 1%
85-90% of adults will experience resolution of physical findings and develop antibody.
10-15% will develop chronic infection, with a minority of those continuing with viral replication and active viral DNA synthesis.
Hepatitis C
Most commonly reported bloodborne infection in the US
Principal risk factor: IV drug use
75% of individuals are asymptomatic with infection
Can be concomitantly spread with HIV
Hepatitis D
Incomplete viral particle that exists only in presence of hepatitis B
Transmission primarily blood borne
Produces more severe disease than other forms of chronic hepatitis
70-80% develop cirrhosis and portal hypertension, 15% within 2 years of initial onset of acute illness
This is compared to just 15-30% of patients with Hep B alone who develop cirrhosis and portal hypertension over time.
Hepatitis E
Similarly to hepatitis A, associated with fecal-oral transmission
Generally self-limited viral illness
In pregnant persons, higher risk of fulminant hepatitis E with 20-35% fetal mortality and significant maternal morbidity (including need for transplant).
Rare in US
New Updates in Screening for Hepatitis B
ACOG recommends triple panel screening for all pregnant patients without documented negative triple screen after age 18, or haven't completed HepB vaccine series, or who have ongoing risk for HepB infection regardless of prior vaccination / testing.
This encompasses obtaining a:
HepB surface antigen (Hep B sAg)
HepB anti-surface antibody (anti-HBs)
HepB total core antibody (total anti-HBc)
A triple panel provides opportunity to inform decisions regarding treatment (if needed) or vaccination.
If positive surface antigen — additional testing will help determine type of infection and chronicity.
ACOG still recommends early universal prenatal screening for HepB sAg in all pregnancies regardless of testing and vaccination status.
12-18% of patients still don’t receive even this baseline level of screening.
ACOG CPG 6
Managing Hepatitis B in Pregnancy
Pregnancy is well tolerated in those with hepatitis B infection without advanced liver disease.
There is a risk of hepatitis flare, particularly postpartum.
Those with chronic hepB and a viral load of > 200,000 IU/mL should be on antiviral therapy in the third trimester to reduce risk of perinatal transmission.
Some patients with lower VL may also be on antivirals if indicated for their own risk/health.
Vertical transmission is low with amniocentesis and shared-decision making can be employed when making decisions on this.
There is insufficient evidence to suggest invasive obstetric procedures (FSE, episiotomy, operative delivery) increase transmission risk, but there are some reports of increased risk with neonate coming to contact with infected blood.
All neonates of individuals with HBsAg-positive status or unknown status should receive HBIG and hepatitis B vaccine within 12 hours of birth.
Breastfeeding can proceed unless there are other contraindications.
Tenofovir can be continued during breastfeeding.
Hepatitis C: Screening, Treatment, and Pregnancy Pearls
ACOG recommends pre-pregnancy screening for hepatitis C virus infection and treatment.
Ideally, pregnant folks will get screened for hepatitis C antibody at the first prenatal visit of each pregnancy.
If positive —> assess hepatitis C viral PCR testing to confirm active infection vs cleared infection or false positive.
There are no treatment options for hepatitis C diagnosed in pregnancy — but there are really successful treatment options outside of pregnancy.
OB/GYNs can help get these patients to successful treatment in the postpartum period with prenatal screening.
Ribavirin achieves virology cure in large proportion of patients.
If patients are taking prior to pregnancy, couples should wait 6 months after completion of therapy due to possible teratogenic effects.
In pregnancy, there are no known preventive measures to reduce risk of vertical transmission.
Risk is generally low for amniocentesis and CVS: use shared decision making in decision to proceed.
There is insufficient evidence to suggest routine invasive obstetric procedures should be avoided (internal monitoring, episiotomy, operative delivery) but can be considered/minimized when possible.
No evidence pre labor cesarean decreases transmission risk.
Breastfeeding is not discouraged in patients with active hepatitis C.
Not enough data on cracked/bleeding nipples.
Immunization in Pregnancy
Both hepatitis A and hepatitis B vaccination are safe in pregnancy!
Newer hepatitis B vaccines do not have sufficient data (HepBZ-CpG and Hepb Vaccine Recombinant) — so need to know your manufacturer.
There is a combination vaccination for adults that can be used in pregnancy as well!