This document discusses various types of hepatitis that can occur during pregnancy including hepatitis A, B, C, D, and E. It provides details on the clinical features, diagnosis, effects on pregnancy, management, and prevention of transmission from mother to child for each type of hepatitis. Key points include that hepatitis A and B can often be prevented by vaccination, while hepatitis C transmission is typically low at less than 5%. Management involves supportive care and preventing transmission to newborns through procedures like hepatitis B immunoglobulin administration. The nursing priorities are also outlined which focus on supporting the liver and preventing complications.

1. CLINICAL TEACHING
Hepatitis

2. Liver disease in pregnancy
1. The patient has a liver disease induced by
pregnancy:
• Acute fatty liver disease of pregnancy
• Intrahepatic cholestasis of pregnancy
• Hyperemesis gravidarum
• Preeclampsia or HELP syndrome

3. • 2. The patient has developed a new liver
disease during pregnancy mainly
hepatobiliary disease.
• 3. the patient has preexisting chronic liver
disease, mainly chronic hepatitis B and C

4. Hepatitis in pregnancy
• Hepatic diseases that can occur in pregnancy can
run a more severe course in contrast to the non-
pregnant state. Maternal mortality and morbidity,
and fetal survival may also be affected due to the
disease, and, therefore, the need for early
delivery.

5. Viral hepatitis in pregnancy
• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis E

6. • Hepatitis A and B can be prevented effectively
through vaccination. However, globally there are
a large number of unvaccinated, nonimmune
women who remain at risk for developing viral
hepatitis in pregnancy. Governmental and non-
governmental programs are under way to
achieve universal immunization against hepatitis
A and B in India.

7. HEPATITIS A
• Hepatitis A virus (HAV) behaves the same way in
pregnancy as in nonpregnant women. Hepatitis
A virus infection occurs due to person-to-person
transmission through fecal-oral contamination.

8. Clinical features of hepatitis A
• Symptoms
• Malaise
• Fever
• Fatigue
• Anorexia
• Nausea
• Right upper quadrant or epigastric pain

9. • Signs
• Jaundice of varying degrees
• Tender hepatomegaly
• Hepatomegaly
• High coloured urine
• Stool chalky white or acholic

10. • Fulminant hepatitis
• Coagulopathy
• Encephalopathy

11. Diagnosis
• The diagnosis is made by a combination of clinical features,
laboratory investigations, and serological testing.
• Laboratory findings
• Laboratory findings include the following:
• Serum aminotransterases
• Elevated >1000-2000 U/L
• Alanine aminotransferase (ALT) > aspartate aminotransferase (AST)
• Serum total and direct bilirubin
• Peak after elevation in ALT and AST
• Usually elevated to >10 mg/dL
• Serology
• Serum immunoglobulin M (IgM for anti-hepatitis A virus (HAV) is the
gold standard for detection of acute illness and remains positive for
4-6 months.

12. • Course in pregnancy
• The disease tends to be more severe with
increasing gestational age. Severe illness during the
third trimester may be associated with an
increased risk for preterm labor. Pregnancy
complications include the following
• Preterm labor
• Placental abruption
• Prelabor rupture of the membranes
• Perinatal transmission of the virus does not occur.
There are no neonatal consequences.

13. • Management in pregnancy
• The disease is usually self-limited.
• Treatment in pregnancy consists of rest and a
balanced diet.
• Patients with fulminant infection require
aggressive supportive therapy and should be
transferred to a tertiary care center.
• Infected women should avoid handling food that
will be eaten by others in the family. Breastfeeding
is permissible with appropriate hygienic
precautions.

14. • Postexposure prophylaxis
• A woman with close personal contact with some-
one known to have an acute hepatitis A infection
should receive:
• Single 0.02 mL/kg IM dose of immunoglobulin
• Should be given within 2 weeks' exposure
• Provides protection for up to 3 months
• Is 80%-90% effective
• If the patient is infected in the third trimester,
the newborn should be given passive immune
prophylaxis with hepatitis A immunoglobulin
within 48 hours of delivery.

15. Hepatitis B
• The hepatitis B virus (HBV) is acquired through
multiple routes, including mucosal, parenteral,
sexual, and mother-to-child transmission.
Hepatitis B in pregnancy has an impact on both
maternal and fetal health.

16. • The hepatitis B virus
• Antigen
The hepatitis B virus (HBV) contains three
principal antigens:
• Hepatitis B surface antigen (HBsAg)
• Present on the surface of the virus
• Circulates freely in the serum
• Hepatitis B core antigen (HBcAg)
• Present only in hepatocytes
• Does not circulate in the serum
• Hepatitis B antigen (HBeAg)
• Presence indicative of active viral replication
• Indicative of high infectivity

17. • Chronic hepatitis or carrier state
• If the HBsAg persists for more than 6 months
after the acute infection, the woman is
considered to have a chronic carrier state.
Hepatitis B surface IgG antibody (anti-HBs) is
absent in the carrier state.

18. • Antibody
• Anti-HBs is formed after the HBsAg is cleared
from the body after an acute infection. It also
forms after vaccination against HBV. Its presence
confirms immunity to HBV.

19. • Risk factors for hepatitis B infection
• Although HBsAg has been detected in a variety
of body fluids, only serum, semen, and saliva
have been proved to be infectious. All pregnant
women should be screened for hepatitis B by
testing for HBsAg in the first trimester. Their
immunization status for hepatitis B should also
be checked.

20. • Clinical features
• Clinical presentation is similar to hepatitis A
infection.

21. • Diagnosis
• As in hepatitis A infection, the transaminase
levels are increased and are usually >1000 U/L.
The serum bilirubin is raised to >10 mg/dL. It is
not possible to differentiate between HAV and
HBV infection without a serum test for the
presence of HBsAg. Diagnosis of acute hepatitis
B infection is made with detection of
• HBsAg
• IgM antibodies to HBcAg.

22. • Transmisssion to husband
• If a woman is found to be HBsAg positive, her
husband/parther should be tested for HBsAg. If
he is negative, he should receive the rapid
immunization course with hepatitis B vaccine (0,
1, and 2 months). Until the husband's/partner
immunity is confirmed, they should be advised
to use a condom since HBV can be sexually
transmitted.

23. • Transmission to medical paramedical staff
• A woman infected with HBV is highly infectious
anyone handling her bodily fluids. Standard
universal precautions should be taken to prevent
contamination.
• The effects of HBV infection on pregnancy
outcomes

24. • The following are the effects of HBV infection
on pregnancy outcomes:
• The following are the effects of HBV infection on
pregnancy is usually not severe
• Acute HBV infection during pregnancy is usually
not severe.
• It is not associated with increased mortality or
teratogenicity.
• Hepatitis B infection during gestation is not an
indication for termination of pregnancy.
• There is an increased risk of
• Low birth weight
• Preterm birth

25. • Management in pregnancy
• Management of HBV in pregnancy focuses on
• Treatment of HBV during pregnancy
• Prevention of perinatal transmission.

26. • Treatment of HBV during pregnancy
• Treatment of acute infection during pregnancy is
mainly supportive. Monitoring of liver function
tests and prothrombin time (PT) indicates the
severity of disease. Antiviral therapy is
unnecessary, except in women who have acute
liver failure or protracted severe hepatitis.

27. • Prevention of perinatal transmission
• Vertical transmission from mother to child
accounts for half of the cases of HBV in the world.
Maternal-infant transmission can occur in utero,
at birth, or after birth. The commonest route of
transmission is at birth when maternal secretions
in the birth canal come in contact with the
infant's mucosal membranes. Post exposure
immunoprophylaxis with hepatitis B immune
globulin and HBV vaccine can help prevent 85%-
95% of cases of perinatal transmission.

28. • The risk of perinatal transmission of HBV to the newborn
from mothers who are HbsAg positive is:
• Infection in the first trimester 10%
• Infection in the second trimester 10%
• Infection in the third trimester 60%
• With neonatal prophylaxis 10- 20%
• Presence of HBeAg
• Without neonatal prophylaxis, risk of infection 90%
• HBeAg should be tested at 34-36 weeks. If positive, the risk
of perinatal transmission can be very high if prophylaxis is
not given.
• Prevention of transmission of HBV from an HBsAg - positive
woman during pregnancy and at delivery is outlined

30. • Intrapartum care
• The route of delivery depends on obstetric
indications. Caregivers must use standard
universal precautions to avoid acquiring the
infection.
• Breastfeeding
• Breastfeeding is not contraindicated for women
who are HBsAg-positive at the time of delivery
since the benefits of breastfeeding outweigh the
risks.

31. Hepatitis C
• The incidence of hepatitis C virus (HCV) in
pregnant women is the same as in the general
population (0.5%-1.4%6).

32. • Route of transmission
• Needle stick injuries
• Intravenous drug use
• Transfusion of unscreened blood products
• Perinatal transmission <5%

33. • Clinical features
• 70% asymptomatic
• Present with symptoms similar to hepatitis A or B
• Route of screening of pregnant women not
recommended

34. • Management
• General supportive measures
• Route of delivery does not affect transmission
• No neonatal vaccination

35. Hepatitis D
• Hepatitis D virus (HDV) is an incomplete viral particle that
depends on the presence of HBV for survival. It can occur
as a coinfection along with HBV infection or may follow
HBV infection (superinfection). It is transmitted through
percutaneous or mucosal contact with blood.
• Chronic infection with hepatitis D produces more severe
disease than the other forms of hepatitis. Approximately
70%-80% of patients with chronic hepatitis D develop
cirrhosis and portal very rapid and result in cirrhosis
within 2 years.
• Perinatal transmission can Occur at the time of delivery,
but neonatal prophylaxis against hepatitis B is effective at
decreasing transmission rates

36. Hepatitis E
• Hepatitis E virus (HEV) is more easily acquired
and has more adverse effects in pregnancy than
in the nonpregnant state. It is also associated
with a greater mortality rate in pregnancy. It is
not associated with chronic hepatitis or cirrhosis.
It is endemic in developing countries. It is
primarily transmitted through:
• Fecal-oral contamination
• Contaminated water supplies.

37. • Clinical presentation
• Asymptomatic infection 40%
• Fulminant hepatitis with hepatic encephalopathy
60%
• Can be confused with acute fatty liver of
pregnancy
• 25-100% mortality
• Self limited disease lasting 1-4 weeks
• Associated with increased rates of
• Abortion
• Still birth
• Neonatal deaths.

38. • Intrapartum care
• In the absence of signs of acute maternal
disease, transmission doses not depend on the
route of delivery. A vaginal delivery or a cesarean
section may be undertaken based on obstetric
infections.
• Breastfeeding
• Breastfeeding is not contraindicated

39. Nursing management
• Nursing priorities
• Reduce demands on liver while promoting physical
well being
• For a safe conferment
• Prevent complication
• Enhance self support, acceptance of situation
• Provide information about disease process,
prognosis, and treatment needs

40. • Discharge goals
• Meeting basic self care needs
• Complications prevented/ minimized
• Dealing with reality of current situation
• Plan in place to meet needs after discharge

41. • Nursing care
• Universal precautions – gloves are worn when there is to
be contact with blood and body fluids
• Specimens are treated as biohazard. Linen and used
material are treated as infectious
• Establish if the patient is in the acute phase, a carrier or
not
• Bed rest with controlled activity
• Prevent infection
• Assess for bleeding
• Treat dry itchng skin: no soap, soft linens,
lotions,antihistamines
• Assess neuro status
• Psychological support

42. • H- hand washing
• E- eat low fat and high carbohydrate
• P- personal hygiene products not shared
• A- activity conservation
• T- toxic substance avoided –alcohol, aspirin,
acetamenophen
• I- individual bathrooms
• T- testing results
• I- infection prevention
• S- small but frequent meals

43. • REFERENCES
• Lakshmi seshadri, essentials of obstetrics, 1st
edition, page no. 779-783
• D.C Dutta text book of obstetrics , 7th edition
289-295