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HEPATITIS B IN

PREGNANCY
DR. OTOGIE EDISENIMI
MBBS, MADONNA UNIVERSITY
OUTLINE

 Introduction
 Epidemiology
 Route of transmission
 Factors influencing vertical transmission
 Clinical features
 Investigations
 Risk of perinatal transmission
 Interventions/treatment
 Prevention
 Conclusion
 References
INTRODUCTION

 HBV is one of the viruses that cause hepatitis. Other viruses


implicated include HAV, HCV, HDV, HEV.
 HBV is an hepadnavirus, a DNA virus and it’s a reportable disease.
 Incubation period is 3-6 months
EPIDERMIOLOGY

 After acute hepatitis in an adult;


90% recover completely
10% develops chronic hepatitis.
 MTCT makes up 50% of patients with chronic hepatitis.
90% of infected infants will become chronic carriers.
 HBV is the 2nd carcinogen of hepatocellular carcinoma following
tobacco use.
ROUTE OF TRANSMISSION

 Exposure to blood or body fluids that contain blood


 RISK FACTORS include
Unprotected sex
History of STDs
Illegal iv drug users
Perinatal transmission(most common route of transmission)
Health workers
Blood transfusion
Sharing of sharps
FACTORS THAT INFLUENCE VERTICAL
TRANSMISSION
 Presence of maternal HBeAg
 History of preterm labour
 High titre of HBsAg
 Increase HBV DNA titre
 Presence of HBV DNA in villous capillary endothelial cells
CLINICAL FEATURES

 Approximately 70% of patients with acute hepatitis B are asymptomatic


with the remainder having jaundice.
 Rarely(<1%) patients present with fulminant hepatic failure.
 Constitutional symptoms like nausea, anorexia, jaundice, RUQ
discomfort may be present but these symptoms generally disappear
between 1-3months
 For chronic infection, patient may present with the stigmata of chronic
liver disease such as jaundice, palmar erythema, breast atrophy,
abdominal distention, caput medusa e t c.
IMPACT OF HBV ON FETUS
HBV infection is not commonly associated with adverse pregnancy
outcome but babies are likely to have lower AS, preterm deliveries and
following delivery they are at risk of coming down with chronic hepatitis.
CF cont’d

 IMPACT OF PREGNANCY ON HBV


In majority of women pregnancy does not worsen liver disease but
there are reports of hepatic exacerbations/ fulminant hepatic failures.
SHORT TERM EFFECTS OF HBV INFECTION
Symptoms and signs resolves in 1-3months in 90% of patients
10% develops chronic infection.
LONG TERM EFFECTS OF HBV INFECTION
Increase rate of transmission of virus
Increase rate of developing cirrhosis, hepatic failure, hepatocellular
cancer and infertility.
INVESTIGATIONS

 In pregnancy HBsAg is one of the routine investigation requested,


when test is positive a 5- PANEL test is done;
 5- PANEL test consist of hepatitis B lab markers which consist of
HBsAg- which is a marker of current infection.
HBeAg- is a marker of active replication (identifies persons at
increase risk of transmission).
HBcAg- is a marker of chronic infection.
Anti-HBs- is a marker of resolved infection or immunity after
immunization.
Anti-Hbe- is a marker that identifies persons at lower risk of
transmitting HBV.
Also HBV DNA can be done and this gives an idea of the patient’s viral
load and effects on delivery.
RISK OF PERINATAL TRANSMISSION

 Positive HBsAg + positive HBeAg without post exposure


prophylactics – 70% -90% of infants will be infected.
 Positive HBeAg only – the risk of transmission will be < 10%.
 HBV DNA <1,000000000 copies/ml =0% transmission rate
>1,000000000 copies/ml = 32% risk transmission rate.
INTERVENTIONS/ TREATMENTS

 PRECONCEPTION
Vaccination of all women of reproductive age with the vaccine.
Reduce the viral load of infected women to a minimum level before
conception.
 IN-UTERO
Do routine HBsAg for all pregnant women coming for ANC registration
When a positive result is gotten, the woman should be adequately
counseled and a 5- panel test + Viral load testing is done.
Husband and close relatives are also counseled, tested and
vaccinated where need be.
At 32weeks with viral load >1000000000 copies/ml, the woman is placed
on antiviral like lamivudine 100mg/day for 1month. This reduces viral
load from 28 to 12.5% thereby reducing risk of peri partum transmission.
INTERVENTION/TREATMENT

 LABOUR
When in labour, modified obstetric practices are strictly adhered to
they include;
Avoid External cephalic version
Avoid Multiple vaginal examinations
Avoid Artificial rupture of membranes or delay ARM
Avoid Episiotomy as much as possible
Ensure early cord clamping
Avoid milking of the cord
Avoid vigorous suctioning
 FOLLOWING DELIVERY
Baby is placed on post exposure prophylaxis which will involve;
HBIG 0.06mls/kg within 24-48hrs of delivery. It gives protection for 3-
6months as an adjunct to HB vaccine.
HB vaccine which contains HBsAg in attenuated form. It is given IM
and can be given simultaneously with other vaccines. It is given in 3
divided doses.
BREATFEEDING AND INFECTIVITY
Traces of the virus can be found in the breast milk but breastfeeding is not
contraindicated in babies on post exposure prophylaxis.
BEFORE DISCHARGE
Parents are counseled on risk of transmission of infection from use of
sharps, blood transfusion and scarification marks.
PREVENTION

 PRIMARY LEVEL
ANC Attendance.
Use of vaccine in women of reproductive age.
Ensure HBsAg testing during pregnancy.
SECONDARY LEVEL
Treatment with antivirals to reduce viral load.
Modified obstetric practices.
Post exposure prophylaxis.
TERTIARY LEVEL
Prompt identification and treatment of complications.
CONCLUSION

 Prevention of MTCT of hepatitis is a possibility and its key to saving a


child from chronic hepatitis.
REFERENCES

 SMS OBSTETRICS
 CURRENT OBSTETRICS AND GYNAECOLOGY
 MEDSCAPE
THANK YOU