Hepatitis B Kronik pada PERSALINAN :

Tata Laksana dan Pencegahan Transmisi

Vertikal

Pokja Infeksi Sistem Reproduksi

Perkumpulan Obstetri dan Ginekologi Indonesia (POGI)
2019
 Transmisi Hepatitis B

Shephard CW, Simard EP, Finelli L, Fiore AE, Bell BP. Hepatitis B Virus Infection: epidemiology and vaccination. Epidemiol Rev. 2006;28:112-25
 Hepatitis in pregnancy
Hepatitis Mechanism of Best Carrier Perinatal
Vaccine Remarks
Infection Transmission Diagnostic Test State Transmission
Antibody Passive immunization
A Fecal–oral No No Yes
detection with immunoglobulin
High maternal
Antibody
E Fecal–oral No Rare No mortality in developing
detection
countries
Passive immunization
Parenteral/
B Antigen detection Yes Yes Yes with hepatitis B
sexual contact
immunoglobulin
Prevented
Virus cannot replicate
Parenteral/ Antibody by
D Yes Yes in absence of hepatitis
sexual contact detection hepatitis B
B infection
vaccine
Cesarean delivery for
Parenteral/ Antibody women with
C Yes Yes No
sexual contact detection detectable serum HCV-
RNA
Parenteral/ Antibody No clinical significance
G Yes Yes No
sexual contact detection of infection
Duff P. Hepatitis in pregnancy. In: Queenan JT, Spong CY, Lockwood CJ, editors. Management of High-Risk Pregnancy : An Evidence-Based
Approach. 5th ed. Massachusetts: Blackwell Publishing Ltd; 2007. p. 238-41.
 Prevalensi Transmisi Hepatitis B di Eropa
Tahun 2006-2012

Transmisi vertikal dari ibu ke anak menempati porsi

terbesar dalam transmisi Hepatitis B kronik

Duffell EF, Laar MJW, Amato-Gauci AJ. Enhanced surveillance of hepatits B in the EU, 2006-2012. Journal of Viral Hepatitis. 2015;22:581-89.
 Manifestasi Hepatitis B pada Kehamilan

Hepatitis B
Akut

§ Sering asimptomatik
Hepatitis B § Gejala yang dapat muncul adalah tanda-
tanda sirosis
Kronik § Perlunya deteksi dini

Tan YT, Sun C, Liu CX, Xie SS, Xiao D, Liu L, Yu JH, et al. Clinical features and outcome of acute hepatits B in pregnancy. BMC Infectious
Disease. 2014;14:368
 Pemeriksaan Laboratorium pada
Pasien dengan HBsAg Positif

Laboratorium Rutin Serologi/Virologi

• Darah Perifer Lengkap

(DPL) • HBeAg / anti-Hbe
• SGOT/SGPT • Kadar DNA-VHB
• Bilirubin total • Anti-HCV
• Alkaline fosfatase • Anti-HIV disarankan
• Albumin bagi mereka yang tidak
• Nilai INR pernah screening
• Alpha Feto Protein (AFP) sebelumnya
• Gamma GT

Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD Guidelines for Treatment of Chronic Hepatitis B. Hepatology. 2015: 1-23.
 Pemeriksaan Pencitraan pada
Pasien dengan HBsAg Positif

USG Abdominal

FibroScan

Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD Guidelines for Treatment of Chronic Hepatitis B. Hepatology. 2015: 1-23.
 Perubahan Fisiologis selama Kehamilan

Tran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016
 Definisi Transmisi Vertikal VHB

HbsAg atau DNA-VHB positif selama 6-12 bulan pertama

kehidupan pada bayi yang lahir dari ibu terinfeksi VHB

Gentile I, Borgia G. Vertical transmission of hepatitis B virus: challenges and solutions. InternationalJournal of Women’s Health. 2014;6:605-11
 HbsAg dan DNA-VHB (+) saat lahir :
- Sering hanya bersifat sementara (fenomena transien)
- Tidak menggambarkan transmisi

Papaevangelou V. Perinatal HBV Viremia in Newborns of HbsAg(+) mothers is a transient phenomenon that does not necessarily imply HBV
infection transmission. Journal of Clinical Virology. 2012; 54:202
 Anti Hbe dan anti Hbc (+) dari lahir hingga usia 2 tahun:
tidak berhubungan dengan infeksi VHB kronik

Karena anti-Hbe dan anti-Hbc

didapat dari ibuku melalui
plasenta

Papaevangelou V. Perinatal HBV Viremia in Newborns of HbsAg(+) mothers is a transient phenomenon that does not necessarily imply HBV
infection transmission. Journal of Clinical Virology. 2012; 54:202
 Tata Laksana Hepatitis B dan Pencegahan
Transmisi Vertikal

Pemberian Antiviral pada Ibu Hamil Vaksin Hepatitis B dan HBIg

Proses Kelahiran
Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD Guidelines for Treatment of Chronic Hepatitis B. Hepatology. 2015: 1-23.
 Immunoprofilaksis

• Vaksin Hepatitis B paling baik diberikan dalam waktu 12 jam

setelah lahir
• Hepatitis Immunoglobulin (HBIg) diberikan pada ekstremitas
yang berbeda
• Kombinasi vaksin dan Ig menurunkan risiko transmisi vertikal
dari >90% menjadi <10%

1. Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD Guidelines for Treatment of Chronic Hepatitis B. Hepatology. 2015: 1-23.
2. Rekomendasi Ikatan Dokter Anak Indonesia (IDAI). Jadwal Imunisasi Anak Umur 0-18 Tahun. 2014.
 Kegagalan Immunoprofilaksis

Zou H, Chen Y, Duan Z, Zhang H, Pan C. Virologic factors associated with failure to passive-active immunoprophylaxis in infants born to HBsAg-positive
mothers. Journal of Viral Hepatitis. 2012.
 Per Vaginam atau Sectio Caesaria ?

Rekomendasi 8A

9. Seksio caesaria tidak diindikasikan dikarenakan kurangnya data dan

mempertimbangkan risk-benefit dari SC dibandingkan pervaginam.

Terrault NA, Bzowej NH, Chang KM, Hwang JP, Jonas MM, Murad MH. AASLD Guidelines for Treatment of Chronic Hepatitis B. Hepatology. 2015: 1-23.
 Per Vaginam atau Sectio Caesaria ?
Meta-analisis Risiko Transmisi VHB pada section caesaria vs per vaginam

Chang MS, Gavini S, Andrade PC, Baltar JM. Caesarian section to prevent transmission of hepatits B: a meta-analysis. Can J
Gastroenterol Hepatol. 2014:28(8):439-44
 Interpretation of serologic test results for hepatitis B
virus

Abbreviations: Anti-HBc, antibody to hepatitis B core antigen; Anti-HBs, antibody to

HBsAg; HBsAg, hepatitis B surface antigen; IgM, immunoglobulin M.
Adapted from Centers for Disease Control and Prevention. Sexually transmitted disease
treatment guidelines 2010. MMWR Recomm Rep 2010;59(RR-12):1–110.

Rac MW, Sheffield JS. Prevention and management of viral hepatitis in pregnancy. Obstet Gynecol Clin North Am.
2014;41(4):573-92.
 Diagnosis of hepatitis B
Serologic markers Clinical significance
HBcAb IgM (Hepatitis B core
Acute infection
antibody IgM
HBeAg (Hepatitis B e antigen) High infectivity
HBeAb (Hepatitis B e antibody) Low infectivity
HBsAb (Hepatitis B surface antibody) Immunity
HBcAb IgG and HBsAg Chronic infection
HBcAb IgG and HBsAb Resolved infection
HBV DNA level (May be undetectable
Acute or chronic infection
in chronic inactive HBV infection)

Dunkelberg JC, Berkley EM, Thiel KW, Leslie KK. Hepatitis B and C in pregnancy: a review and recommendations for care. J
Perinatol. 2014;34(12):882-91.
 Immunoprophylaxis of neonates

HBV vaccine HBIG HBIG+HBV vaccine

MTCT of HBV 26–36% 15–20% 5–10%a
Abbreviations: HBIG, hepatitis B immune globulin; HBV, hepatitis B virus; MTCT, mother-to-child
transmission. References: 23, 47. aA major risk for immunoprophylaxis failure is maternal HBV DNA level
>200 000 IUml − 1 (>6 log10 copies ml− 1).

Immunoprophylaxis of neonates with HBIG+HBV vaccine is superior to monotherapy

with either agent alone for prevention of MTCT of HBV infection

Dunkelberg JC, Berkley EM, Thiel KW, Leslie KK. Hepatitis B and C in pregnancy: a review and recommendations for
care. J Perinatol. 2014;34(12):882-91.
Distribution of HBV (a) among the HBeAg-positive group (n = 367)
DNA levels among
pregnant women
with different
HBeAg status

(b) among the HBeAg-negative group (n = 608).

Sun KX, Li J, Zhu FC, Liu JX, Li RC, Zhai XJ, et al. A predictive value of quantitative HBsAg for serum HBV DNA level among
HBeAg-positive pregnant women. Vaccine. 2012;30(36):5335-40.
 Serology Status and Vertical Transmission Rate of HBV

No immunoprophylaxis HBIg + vaccine

Persistent Persistent
Infection rate Transient
infection (>6 infection (>6
infection (%)
mo) (%) mo) (%)
a
HBeAg+ 10.1 78.8 7.4
a
HBeAg– eAb– 9.1 6.8 3
a
HBeAg– eAb+ 9.3 1.5 3
b
HBcAg+ only 6.6b NA 0
a
Different vertical transmission rate observed by Burk et al.
b
Transient infection that is based on detectable DNA and observed by Walz et al.

Pan CQ, Duan ZP, Bhamidimarri KR, Zou HB, Liang XF, Li J, et al. An algorithm for risk assessment and intervention of
mother to child transmission of hepatitis B virus. Clin Gastroenterol Hepatol. 2012;10(5):452-9.
 Risk Factors and Likelihood of MTCT
Infants received HBIg and vaccine on schedule
Threaten preterm
High risk HBeAg+ HBsAg+ DNA >200,000 IU/mL
labor
Genotype/ S
Moderate risk Genetic factors Mother education
mutation
Low risk or Forceps/ vacuum
Amniocentesis Breastfeeding
inconclusive delivery

Infants missed or received delayed HBIg and/or vaccine

High risk HBeAg+ HBsAg+ DNA >200,000 IU/mL High titer of HBsAg
DNA 2000–200,000
Moderate risk HBeAg– HBsAg+ Breastfeeding
IU/mL
Low risk or
Amniocentesis DNA <2000 IU/mL Low titer of HBsAg
inconclusive

Pan CQ, Duan ZP, Bhamidimarri KR, Zou HB, Liang XF, Li J, et al. An algorithm for risk assessment and intervention of
mother to child transmission of hepatitis B virus. Clin Gastroenterol Hepatol. 2012;10(5):452-9.
 Hepatitis B Vaccine and HBIg Schedule for Infants Who
Are Born to Mothers With Chronic Hepatitis B
Full-term infants (>2000 g) Premature infants (<2000 g)
Single-antigen Single-antigen + Dose Single antigen with or without
vaccine combination vaccine combination vaccine at age
Dose Age Dose Age Vaccine
a
a a Birth (<12 h)
1 Birth (<12 h) 1 Birth (<12 h) b
b
HBIg Birth (<12 h) HBIg
b
Birth (<12 h) HBIg Birth (<12 h)
a
2 1–2 mo 2 2 mo 1 1 mo
4 mo 2
c 3 2–3 mo
3 6 mo c 6 mo (Pediarix) or
4 3
c
7 mo
12–15 mo (Comvax)
Vaccine Test for HBsAg and antibody to
outcome HBsAg after completion of vaccine
series at age 9–18 mo (next well-
child visit after the third dose)

a
Recombivax HB or Engerix-B should be used for the birth dose. Comvax and Pediarix cannot be administered at birth
or before age 6 weeks.
b
HBV globulin (0.5 mL) administered intramuscularly in a separate site from vaccine.
c
Final dose of vaccine series should not be administered before age 24 weeks (164 days).

Pan CQ, Duan ZP, Bhamidimarri KR, Zou HB, Liang XF, Li J, et al. An algorithm for risk assessment and intervention of
mother to child transmission of hepatitis B virus. Clin Gastroenterol Hepatol. 2012;10(5):452-9.
Rekomendasi
Bulin dg Hbs Ag pos
akut kronik
Hbe Ag
Pos negative

Double gloving/ SC?

Neonatus: Imunisasi