Jaundice in pregnancy can be caused by conditions related or unrelated to pregnancy. Obstetric cholestasis is a common cause of jaundice in the third trimester and increases risks of preterm labor and fetal complications without treatment. Viral hepatitis is also a frequent cause, with hepatitis B posing risks of mother-to-child transmission without immunoprophylaxis including vaccination and immunoglobulin for the newborn. Management involves supportive care, monitoring fetal wellbeing, and hepatitis B immunoprophylaxis to reduce transmission risk.

1. Jaundice in Pregnancy
Mukesh Sah, MD

2. Jaundice
• When the serum bilirubin level exceeds 2 mg% (normal being
0.2-0.8%), visible yellow staining of the tissue appear .

3. Causes of jaundice
Jaundice peculiar to the pregnancy state
• Intrahepatic cholestasis (obstetric hepatitis) may be recurrent
• Severe pre-eclampsia, eclampsia , HELLP syndrome.
• Acute fatty liver (acute yellow atrophy of the liver)

4. • Severe hyperemesis gravidarum
• Endotoxic shock-Disseminated intravenous coagulation (DIC)

5. Jaundice unrelated to pregnancy state:
• Viral hepatitis
• Gall stone- obstructed jaundice
• Drug induced-isoniazide, phenothiazines
• Hemolytic jaundice- mismatched blood transfusion,
malaria, clostridium welchii infection etc.

6. Jaundice when pregnancy is superimposed on chronic liver
disease
• Chronic hepatitis
• Cirrhosis, tumors

7. Obstetric cholestasis (OC)
• It is the second most common cause of jaundice in pregnancy,
the first one being viral hepatitis.
• This is idiopathic condition that usually begins in the third
trimester of pregnancy, but can occasionally present as early
as first trimester.
• Its cause is unknown, although genetic, geographical and
environment factors are considered to be contributory factors.

8. • It is not a life-threatening condition for the women, but there
is an increased risk of pre-term labor, fetal compromise and
meconium staining, and the stillbirth risk is increased unless
there is active management of the pregnancy.

9. Clinical presentation
• Pruritus without a rash.
• Insomnia and fatigue as a result of the pruritus
• Insomnia and fatigue as a result of the pruritus.
• Fever, abdominal discomfort, nausea and vomiting.
• Urine may be darker and stools paler than usual
• A few women develop mild jaundice.

10. Management
• Application of local antipruritic agents, such as
antihistamines.
• Vitamin K supplements are administered to the women, 10mg
orally daily, as her absorption will be poor, leading to
prothombinaemia which predisposes her to obstetric
hemorrhage if left untreated.
• Monitor fetal wellbeing possibly by Doppler of the umbilical
artery blood flow.

11. • Advise the women that her pruritus should disappear within
3-14 days of the birth.
• If the women chooses to use oral contraception in the future,
she should be advised that her liver function should be
regularly monitored.

12. Hepatitis
• Acute viral hepatitis is the most common cause of
pregnancy.

13. At present six distinct types of highly contagious hepatitis
virus has been identified.
• Hepatitis-A
• Hepatitis-B
• Hepatitis-C
• Hepatitis-D
• Hepatitis-E
• Hepatitis-G

14. Hepatitis A
• Infection is spread by faecal-oral route.
• Diagnosis is confirmed by detection of IgM antibody to hepatitis
A.
• The virus is not teratogenic. Pregnant women expose to HAV
infection should receive immunoglobin 0.02ml/kg. within 2 weeks
of exposure. She should also have hepatitis A vaccine single dose
o.06ml IM.
• It is safe in pregnancy.
• Vertical transmission of HAV during the pregnancy or puerperium.

15. Hepatitis B
• Globally, hepatitis B virus (HBV) infection is the most
common form of chronic hepatitis around the world.
• Chronic HBV infection leads to increased risk for chronic
hepatic insufficiency, cirrhosis, and hepatocellular carcinoma
(HCC).

16. • The virus is transmitted by parenteral route, sexual contact,
vertical transmission and also through breast milk.
• The risk of transmission to fetus ranges from 10% in first
trimester to as high as 90% in third trimester and it is a
specially high(90%) from those mother who are seropositive
to hepatitis B surface antigen (HBSAg) and e-antigen
(HBeAg).

17. Neonatal transmission:
• it is mainly occur at or around the time of birth through
mixing of maternal blood and genital secretion.
• Approximately 20% of the carrier neonate will die from
cirrhosis or hepatic carcinoma, between late childhood to
early adulthood. HBV is no teratogenic.

18. Maternal infection:
• The acute infection is manifestation by flue like illnes as
malaise, anorexia, nausea and vomiting.
• They may be arthralgia and skin rashes. In majority, it
remains a symptomatic. Jaundice is a rare and fever is
uncommon

19. Diagnosis is confirmed by serological detection of HBsAg,
HBeAg (denote high infective) and antibody to hepatitis B
core antigen (HBcAg) and HBV DNA titre.
Chronic carrier are diagnosed by presence of HBsAg or HBeAg
and anti HBc antibody 6 months after the initial infection.
Liver enzymes are elevated during the initial phase

20. Screening:
All pregnant women should be screened for HBV infection at
first antenatal visit and it should be repeated during the third
trimester for ‘high risk’ groups (intravenous drug users, sexual
promiscuity, patients on hemodialysis or having multi sex
partners).

21. Hepatitis C
• Hepatitis C is an inflammation of the liver due to a viral infection.
The virus that causes the infection is called hepatitis C virus
(HCV).
• The transmission of hepatitis C infection occurs identical to
Hepatitis B. it is more prevalent in IV drug users, transfusion of
blood and organ transplantation.
• The incubation period is 2-26weeks.
• Detection is by antibody to HCV by EIA, which develops usually
late in the infection.

22. Signs and symptoms:
• Fatigue
• Muscle aches
• Tenderness in the upper abdomen.
• Yellow tinge to the skin and eyes. Dark urine (Jaundice)
• Light-colored bowel movements.

23. Hepatitis D
• Hepatitis D is caused by the hepatitis delta virus (HDV),
defective RNA virus that can only cause hepatitis in
individuals who are infected with HBV.
• HDV infections can occur as a coinfection with HBV or as a
superinfection on chronic HBV infection; thus, chronic HBV
carriers are at risk for infection with HDV.

24. • A baby relies on the mother’s liver to remove bile acids from the blood.
Therefore elevated levels of maternal bile cause stress on the baby’s liver.
• IgM is the first antibody to appear in the response to initial exposure to an
antigen.

25. • Neonatal immunoprophylaxis for HBV is almost effective
against HDV.

26. Hepatitis E
• Hepatitis E is caused by the hepatitis E virus (HEV).
• HEV is usually passed by fecal-oral transmission through a
contaminated water supply.
• It behaves similar to hepatitis A virus infection.
• ELISA can detect HEV specific IgG and IgM antibodies.
• Perinatal transmission is uncommon.
• Maternal mortality is high (15-20%)

27. Hepatitis G
• It is related to hepatitis C virus. It is more prevalent but less
virulent than HCV.
• Co-infection with hepatitis A, B, C and HIV is common.
Chronic carrier state is known and perinatal transmission is
documented.

28. Management
Prophylaxis:
• Improvement in sanitation, supply of safe drinking water and
adequate care of personal hygiene are the essential
prerequisites. Use of disposal syringe or boiling of syringe
prior to use are the positive steps in prevention.
• Screening of blood donors for HBs Ag should be routinely
done.

29. Management of HBV during pregnancy
• HBV infection can be prevented by vaccination and the
recombinant vaccine is safe in pregnancy.
• Pregnant women who are seronegative, should have HB
immunoglobulin (HBIG), 0.06ml/kg IM, soon following exposure
and a second dose after 1 month.
• Then she should be given recombinant DNA vaccine,
intramuscularly 1ml, 3 doses at 0,1 and 6 months.
• All infants born to HBsAg positive mothers should have HBIG
0.5ml IM within 12 hours of birth.

30. • Active immunization with HB vaccine (0.5Ml) is also given IM at
a separate site at the same time schedule. This very effective (85-
95%) to protect the infants from HBV infection.
• Breast feeding not contraindicated.
• Similar to HIV, perinatal transmission of HBV depends on
maternal viral load.
• Lamivudine and HBIG are effective to reduce the transplacental
transmission of HBV to the fetus.
• Lamivudine is given 150mg/day from 34 weeks.

31. Treatment
• There is no specific treatment for viral hepatitis. It is
generally supportive.
Rest: The patient should be put to bed rest, if necessary by
hospitalization.
Isolation: The patient should be kept in isolation. Blood
samples are to be collected with gloved hand. Disposable
syringe should be used. The excreta is to be disposed
carefully.

32. Nutrition: Diet rich in carbohydrate and adequate protein is to
be prescribed. Initially, glucose drink, fruit juice may be
given.
Dietary fat restriction is not necessary. If the patient cannot
tolerate oral feeding, 10% glucose may be given intravenously.

33. During labor
• Hepatotoxic drugs should be avoided.
• To administer vitamin K, 5mg intramuscularly to raise the
prothrombin level
• prophylactic oxytocin is to be given.

34. • https://emedicine.medscape.com/article/1562368-overview