Hepatitis B in Pregnancy

Contributor:  John Dacus, MD
Last Update: 1/20/16

Hepatitis B is found worldwide and is especially prevalent in Asia and Africa.  It is a major cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma.  Chronic infection occurs in 5 ¨C 10% of infected adults and 70 ¨C 90% of infected infants.  Fifty percent or more of acute cases are asymptomatic and are diagnosed by serology.  The Hepatitis B virus (Dane particle), Hepatitis B core antigen, Hepatitis B surface antigen, Hepatitis B e antigen and their corresponding antibodies are detectable by serum studies.

Of those 5 ¨C 10% who become chronic hepatitis B carriers, approximately 20 – 30% may develop cirrhosis and/or hepatocellular carcinoma of the liver.  Co-infection or superinfection with the Delta virus or the persistence of the e-antigen may increase the incidence of cirrhosis or hepatocellular carcinoma to 80% or more of the cases.

Hepatitis B may be transmitted by infected blood, saliva, vaginal secretions, semen, or from mother to newborn.  Mode of delivery does not affect incidence of neonatal disease.

All newborns whose mother is Hepatitis B surface antigen positive should receive Hepatitis B immunoglobulin (HBIG) and begin the Hepatitis B vaccine regimen within 12 hours of birth.  This will prevent 90 ¨C 95% of the transmission rate to the newborn even if the mother is positive for the Delta virus.

Diagnosis:
The presence of Hepatitis B surface antigen confirms infection.
The presence of Hepatitis B surface antigen obtained on 2 separate occasions at least 6 months apart confirms chronic infection.

Obstetric Management:

• Establish diagnosis by universal screening and education.
• Repeat the Hepatitis B Surface antigen in 6 months (to diagnose chronic carrier state).
• Obtain transaminases for baseline.
• Encourage close family members and sexual partners to be screened and vaccinated through the health department.
• Give patient appointment with Infectious Disease clinic or New Horizons clinic for follow-up post partum.
• Reserve amniocentesis or chorionic villous sampling for selected patients.
• Reserve scalp electrode, forceps, vacuum and episiotomy for carefully chosen patients.
• Notify pediatrician of patient’s Hepatitis B status.
• Arrange appropriate post partum follow-up for chronic Hepatitis B possible complications.
• Breast feeding is permissible.
• In recent literature, it appears that the use of oral Tenofovir 300 mg daily beginning at 28 weeks gestation in patients with viral load of > 1,000,000 will reduce in utero transmission to the fetus. 
  • Check viral load on patients with chronic hepatitis B at 26 – 28 weeks gestation
  • Institute Tenofovir 300 mg orally each day to patients with viral load >1,000,000.
  • Obtain complete metabolic panel (CMP) upon initiation of Tenofovir.

References

1. Gabbe, SG, Niebyl JR., Simpson JL. Obstetrics:  Normal and Problem Pregnancies, 5th ed; 2007:  1223.
2. 2008 Compendiuin, Volume 2; Practice Bulletins:  963-977.
3. Society for Maternal–Fetal Medicine. Hepatitis B in pregnancy screening, treatment, and prevention of vertical transmission. SMFM Consult Series no. 38. Am J Obstet Gynecol  Jan 2016;6-14.