Hepatitis and pregnangy

L/ Radwa Rasheedy
Lecturer of obstetrics and gynecology
Ain shams university


 Pregnancy is associated with many physiological changes
that must be considered in the diagnosis of hepatobiliary
diseases:
 Outside pregnancy, the liver receives up to 25–35% of the
cardiac output and this does not change significantly
during pregnancy.
 Spider angiomas and palmar erythema, which are
classically associated with chronic liver disease, are also
common during pregnancy and usually disappear after
delivery
physiological changes


 Because of hemodilution, serum albumin levels
decrease.
 The most significant changes are the decreased liver
transaminases levels to 25% pre-pregnancy levels by
the third trimester.
 Alkaline phosphatase levels can increase up to four
times due to placental alkaline phosphatase and
increased maternal bone turnover.


 Bilirubin levels usually unchanged or slightly
decreased
 Total bile acid concentrations not significantly
different.


 is inflammation of the liver.
 Viral infection is the most common cause of hepatitis
in the world
 other causes are drug-induced , autoimmune,
alcoholic and ischemic hepatitis.
Hepatitis


 halothane, acetaminophen, phenytoin, methyldopa,
isoniazid, and diclofenac are the most common
causes
 Mgm by stopping the offending drug and follow up
by serial biochemical measurements
 Recovery should be expected in the majority of
patients after discontinuing the drug. However,
acute liver failure caused by an idiosyncratic drug
reaction has a mortality rate of over 80 percent
without liver transplantation
Drug induced hepatitis


 bilirubin greater than two times the upper limit of
normal in the setting of an ALT greater than three
times the upper limit of normal) following
introduction of a drug potentially portends a poor
prognosis and should also prompt immediate
referral for hepatologist.
 N-acetylcysteine for acetaminophen toxicity and L-
carnitine for cases of valproic acid overdose
improves the outcome.


 Autoimmune hepatitis is a chronic hepatitis that occurs
women of childbearing age.
 It has a heterogeneous and fluctuating nature, leading to
marked variability in its clinical manifestations from
asymptomatic patients to debilitating disease with acute
liver failure.
 The disease activity is usually attenuated during
pregnancy, and dosages of medication can be decreased
Nonetheless, flares have occurred in 11% of patients
during gestation and up to 25% in the postpartum period
Autoimmune hepatitis


 One clue to diagnose autoimmune hepatitis the
coexistence of other diseases with autoimmune
features(hemolytic anemia, idiopathic
thrombocytopenic purpura, type 1 diabetes mellitus,
thyroiditis)


 pregnancy in women with AIH has been associated with
an increased risk of prematurity, low birth weight and
fetal loss.
 The presence of anti-Ro/SSA,anti-La/SSB and
anticardiolipin antibodies was associated with adverse
pregnancy outcome.
 Patients need to be monitored carefully during pregnancy
and several months post-partum because of the risk of
flares in disease activity(In women with abnormal liver
function tests, also measure the prothrombin time and a
blood glucose level. A full blood count may reveal
thrombocytopenia in women with hyperslenism


 Usual therapy consists of glucocorticoids and/or
azathioprine, both of which are safe during pregnancy.
 Doctors caring for women with AIH should also consider
increasing the dose of immunosuppressive therapy in the
third trimester or immediately after delivery.
 women with uncomplicated disease who have not had a
flare should be able to have a normal labor and delivery.
If a woman with AIH has portal hypertension, it is
advisable to avoid pushing in the second stage of labor.


 Issues related to medications and lactation
Azathioprine and prednisolone/prednisone enter
breast milk in low concentrations and should be
continued during lactation
 Contraceptive recommendations
In well-controlled disease, any form of contraception
can be used.
If hepatic impairment is present, estrogen-containing
contraceptives are usually discouraged


 refers to diffuse hepatic injury resulting from acute hypo
perfusion.
 The term hepatitis is somewhat a misnomer since the
injury is not mediated by an inflammatory process.
Nevertheless, the profound elevation in
aminotransferases is similar to that seen in acute viral and
toxic hepatitis
 Ischemic hepatitis is usually first detected because of
elevations in liver biochemical tests following a
hypotensive episode.
 Occasional patients have symptoms suggesting acute
hepatitis, including nausea, vomiting, anorexia, malaise,
and right upper quadrant pain
Ischemic hepatitis


 rapid rise in serum aminotransferase levels associated
with an early massive rise in lactate dehydrogenase
(LDH) levels. Peak aminotransferase levels are typically
25 to 250 times the upper limit of normal and are reached
within one to three days of the hemodynamic insult.
 aminotransferase levels subsequently decline steadily,
usually returning to normal within 7 to 10 days. The
serum bilirubin level rarely rises above four times the
upper limit of normal, usually beginning its rise after
aminotransferase levels have begun to decline.
 Hepatic synthetic function usually remains normal or is
only mildly impaired.


features may suggest an ischemic rather
than a viral cause of liver injury.
 An early rapid rise in the serum LDH level is unusual in viral
hepatitis.
 A ratio of serum alanine aminotransferase to LDH of less than
1.5 early in the course of acute hepatitis may be more likely to
suggest ischemic hepatitis.
 A rapid fall in serum aminotransferase levels after the initial
rise is characteristic of ischemic liver injury and atypical for
other causes of hepatitis.
 Ischemic hepatitis is often accompanied by additional evidence
of end-organ hypo perfusion, especially acute tubular necrosis
of the kidney.


 Management of ischemic hepatitis should be aimed
at restoring cardiac output and reversing the
underlying cause of hemodynamic instability.
 Limited data suggest that intravenous
administration of dopamine, at either "renal" or
"cardiac" doses, leads to preservation, and perhaps
augmentation, of hepatic blood flow,
 treatment with intravenous N-acetylcysteine was
described in a case report. The mechanism of benefit
may have been due to a cytoprotective effect.


 The commonest cause of hepatic dysfunction in
pregnancy.
 Caused by:
1. hepatitis virus A,B,C,Dor E
2. CMV
3. HSV
4. EBV
 With exception of hepatitis E,HSV infection the
clinical features don't differ from non pregnant
female.
Viral hepatitis


 Some people with hepatitis have no symptoms and
When symptoms occur, they can include:
1. jaundice
2. abdominal pain
3. loss of appetite
4. nausea and vomiting
5. diarrhea
6. fever
Acute hepatitis


 Symptoms of chronic hepatitis can include:
1. feeling unusually tired all the time
2. depression
3. jaundice
4. a general sense of feeling unwell
 Both hepatitis A&E don't cause chronic disease

Chronic hepatitis


 The course of hepatitis A during pregnancy is
generally similar to that in non pregnant patients.
 severe illness during the third trimester may be
associated with an increased risk for premature labor
and premature rupture of membranes
 It is not an important cause of maternal or neonatal
morbidity, yet it can be transmitted from mother to
child.
Hepatitis A


Pathogenesis of mother-to-child transmission
 it is very rare.
 Only two cases of intrauterine transmission following
maternal infection in the first trimester have been
reported and resulted in fetal meconium peritonitis.
 Maternal infection in the third trimester may result in
asymptomatic neonatal infection and/or self-limited
neonatal cholestasis
 Breastfeeding is not implicated in transmission


 Around 90% of pregnant female with acute infection
transmit infection to infant while only 10-20% in
chronic cases and this risk is high, if the infection is
acquired during the third trimester or if the infected
mother is positive for (eAg) and the viral DNA count
is elevated
 90% of Infected newborn will be chronic carrier
&upto25% will develop cirrhosis or HCC if not
receive vaccine& immunoglobulin
Hepatitis B


 Hepatitis C virus has the particular ability to
establish chronic infections, leading to cirrhosis and
hepatocellular carcinoma.
 The predominant mechanism of MTCT has
traditionally been thought to be intrapartum
&debate exists about whether a greater proportion
happens in utero
Hepatitis C


 The highest incidence of HEV infection is in Africa,
Middle East, and Central America
 HEV is the second most common cause of sporadic
hepatitis in North Africa and the Middle East.
 It causes a self-limited acute infection, although
fulminant hepatitis can develop.
 Chronic hepatitis does not develop after acute HEV
infection.
Hepatitis E

 For reasons that are not understood, fulminant hepatic
failure occurs more frequently during pregnancy,
resulting in high mortality rate of 15 to 25 percent.
 primarily in women in the third trimester , resembling
liver failure from acute fatty liver of pregnancy, hepatic
infarction in (HELLP), or herpes simplex hepatitis
 Trans placental transmission of HEV has been
documented by specific HEV IgM in cord blood and virus
isolation by PCR, in up to 33% of neonates born to women
infected in the third trimester ,resulting in neonatal
massive hepatic necrosis and death. Nonetheless, other
infants have recovered from in utero infection


 Affected patients may have a prodrome of fever and
upper respiratory tract symptoms. Usually more
severe when occurring in the third trimester.
 A vesicular eruption, if present, should suggest the
diagnosis.
 Despite marked abnormalities in serum
aminotransferases and the prothrombin time, they
are usually anicteric at presentation.
 delivery is usually unnecessary and therapy with
acyclovir is often successful.
Herpes simplex


 Hepatitis A is transmitted predominantly by the fecal-
oral route.
 Prevention can be aided by adherence to sanitary
practices such as hand washing, heating foods
appropriately, and avoidance of water and foods in
endemic areas.
 Hospitalized patients with HAV do not require isolation
or contact precautions unless incontinent. Frequent hand
washing should be enough to prevent spread in the hospital
setting.
prevention


 INDICATIONS FOR VACCINATION :
1. Persons with clotting-factor disorders or chronic liver disease.
2. Persons traveling to countries with high or intermediate endemicity(one
dose of HAV vaccine at least 2 weeks before traveling, and a booster dose
6–12 months after the initial vaccination).
3. Persons with HIV infection.
4. Close family contacts of index cases.
5. Persons with recent exposure for post-exposure prophylaxis.
 Prevention of maternal illness after a known exposure to
HAV:
Passive immunization with immunoglobulin within 2 weeks of
exposure & HAV vaccination is effective in preventing 80–90% of HAV cases


Hepatitis B
 All pregnant women should be routinely screened
for HBsAg and HBsAb, regardless of previous
testing or vaccination.
 If vaccination is indicated in pregnancy, it is safe and
effective
Indication for vaccination:
 Household contacts of patients with hepatitis B
 Intravenous drug users


 Healthcare workers
 Patients on chronic hemodialysis
 patients requiring repeated blood or blood product
transfusion
 Patients with chronic liver disease
 All unvaccinated persons traveling to areas with
intermediate to high levels of endemic HBV infection
Both hepatitis A,B vaccines &immunoglobulin are safe
during pregnancy.


 should receive both HBV vaccination and HBV
immunoglobulin (HBIG 400 IU IM), preferably
within 24 hours of exposure but can be administered
up to 72 hours post exposure.
 Hepatitis D
 The mainstay of prevention of HDV infection is
vaccination against its helper virus
WOMEN EXPOSED TO HBV DURING
PREGNANCY


 Hepatitis E is a water-borne pathogen transmitted
by the fecal-oral route.
 To reduce the risk of contracting HEV while
traveling to endemic areas, it is important to
maintain hygienic practices such as hand washing
with safe water, particularly before handling food,
avoiding drinking water and avoiding eating
unpeeled fruits and vegetables.
 Currently there is no vaccine available


 Pregnancy is generally well tolerated by women
with chronic hepatitis who don't have advanced ds.
 Reactivation of the virus and exacerbation of the
disease during or after gestation are uncommon.
Preconception


Mild liver ds& will achieve
pregnancy soon
Elect to finish ttt before
pregnancy
Pt got pregnant on
antiviral ttt(discuss
risk/benefit of
discontinuation
• Defer ttt till complete
family
• PG/INF
(48mo)+contraception
• Change drug category C to
B
• Can discontinue if no
cirrhosis
Options for HBV ttt in CBP


 treatment be considered in patients with HBeAg
positive or HBeAg negative chronic hepatitis.
Patients with compensated cirrhosis and HBV DNA
>2,000 IU/mL and those with decompensated
cirrhosis and detectable HBV DNA by PCR assay
should be considered for antiviral therapy,
regardless of the serum ALT level.
WHO SHOULD BE
TREATED


 Patients in whom therapy is indicated: acute liver
failure, clinical complications of cirrhosis, cirrhosis
or advanced fibrosis with high serum HBV DNA, or
reactivation of chronic HBV after chemotherapy or
immunosuppression.
 Patients for whom therapy may be indicated:
patients in the immune-active phase who do not
have advanced fibrosis or cirrhosis (HBeAg-positive
or HBeAg-negative chronic hepatitis).
criteria for treatment were suggested in a 2008
consensus conference from the United States
National Institutes of Health


 Patients for whom immediate therapy is not
routinely indicated: (1) Patients with chronic HBV in
the immune tolerant phase (with high levels of
serum HBV DNA but normal serum ALT levels or
little activity on liver biopsy); (2) Patients in the
inactive carrier or low replicative phase (with low
levels of or no detectable HBV DNA in serum and
normal serum ALT levels); (3) Patients who have
latent HBV infection (HBV DNA without HBsAg)


 Counseling both male and female patients about the risks
of pregnancy while on RBV therapy, and for six months
after discontinuing treatment, is critically important.
 RBV cause limb abnormalities, craniofacial defects,
anencephay& anophthalmia.
 any woman that becomes pregnant on RBV should
immediately notify their physician, and receive
appropriate counseling about teratogenicity and the
option for therapeutic abortion.
 So advise all patients on RBV to practice at least two
forms of contraception
Chronic hepatitis C


 All pregnant women should be offered screening for
HBV,HCV,HIV at the booking visit.
 All women who exhibit ‘high risk’ behaviors for
contracting blood-borne viruses should be
rescreened for HBV and HCV and HIV in the third
trimester
Antenatal care


For Women positive for hepatitis B or C:
 Liver function tests (transaminases, albumin,
bilirubin and INR) should be performed every 3
months till 6 months postpartum(rare risk of flare).
 Hepatitis A virus immunity (HAV IgG)
As There is evidence that patients with any
acute/chronic HBV or HCV are at increased risk for
adverse outcomes if they acquire HAV. It is
recommended that if they are not immune to HAV, to
be vaccinated


 woman test positive to antibodies for HCV then a
blood test for HCV RNA Polymerase Chain Reaction
(PCR) should be ordered to detect the presence or
absence of the virus in the blood, the viral load, and
the genotype
 woman with HBsAg positive HBeAg , anti-HBe and
HBV DNA levels should be measured.


 Women positive for hepatitis B or C, particularly
those with a high viral load, should be counseled
about the potential risk of transmission with invasive
procedures. Non-invasive prenatal testing may be
an option for some women. In those requiring
invasive procedures, amniocentesis is probably safer
than CVS, and transplacental amniocentesis is best
avoided, if possible
Invasive procedure


 At 26-28 wk perform HBV DNA level to determine
need for ttt as number of studies have shown
lamivudine and recently telbivudine therapy used
during the third trimester of pregnancy in HBsAg-
positive women to be safe and to reduce the risk of
intra-uterine and perinatal transmission of HBV if
given in addition to passive and active vaccination.
Antiviral therapy


1. Conflicting data of increased DM risk in chronic
HBV infection
2. No evidence of change management in case of
PPROM.
3. HCV ab positive female at higher risk of obstetric
cholestasis which occur at earlier gestation.
Effect of disease on pregnancy

HBV HCV
HBsAg +ve & HBe Ag –ve & DNA –
ve ==2-15%
HCV Ab +ve& HCV RNA –ve
=<1%
HBsAg +ve & HBe Ag +ve & DNA
+ve==80-95%
HCV Ab +ve& HCV RNA +ve
=11%
HCV Ab +ve& HCV RNA +ve
&HIV Ab +ve =16%
4-Risk for perinatal transmission


 Usually cases with advanced cirrhosis infertile due
to anovulation. But pregnancy can occur in early
cases of cirrhosis which increases the risk of:
1. FGR
2. PTB
3. IUFD
4. Gestational HTN
5. Placental Abruption
6. Peripartum hemorrhage
5-complications associated with cirrhosis


 Management don't differ in pregnancy
 Endoscopy for variceal screening safe during
pregnancy
 Banding & sclerotherapy is mgm of active bleeding
 Beta blocker used with caution
 Octreotide not used due to risk of uterine ischemia


 CS does not appear to reduce the risk of transmission
 Avoid procedures that may increase risk of vertical
transmission :
• fetal blood sampling
• fetal scalp electrode use
• early artificial rupture of membranes should be avoided
where possible
• Prolonged rupture of membranes (>6 hours) may increase the
risk of transmission, so it is recommended that the second
stage of labor be kept short
• if assisted delivery is required the use of soft cup vacuum
extraction or forceps is preferred over a metal cup which poses
increased risk for scalp injury
Intra partum


 The neonate should be bathed to remove maternal
body secretions prior to administering intramuscular
injections


Prevention of neonatal infection:
1=hepatitis A:
 Immunoglobulin at a dose of 0.02 mg/kg is
recommended to prevent neonatal infection if
maternal illness develops 2 weeks before or 1 week
following delivery
2= hepatitis B:
 all newborn infants receive a monovalent hepatitis B
vaccine at birth (within 24 hours). Followed by 3
doses at 2, 4 and 6 months of age
Postpartum


 If an infant has not received a birth dose within the 1st 7 days
of life, a primary 3-dose course of vaccine should be given, at 2,
4 and 6 months of age; catch-up of the birth dose is not
necessary.
 In addition infants should receive passive immunization with
HBIG at birth (preferably within 12 hours and certainly within
48 hours).
 This regimen has an overall efficacy of 95%but the efficacy is
lower for mothers with very high HBV viral load
 Anti-HBs antibody and HBsAg levels should be measured in
infants born to mothers with chronic hepatitis B infection 3 to
12 months after completing the primary vaccine course.
 Referral to a pediatrician with expertise in viral hepatitis is
recommended if HBsAg positive


 Although breast milk from chronically HBV-infected
mothers is known to contain the virus. breastfeeding
does not seem to increase the risk of transmission to
the neonate above that already posed by pregnancy
and delivery .
 In addition, appropriate neonatal active and passive
immunization has been shown to eliminate any
theoretical risk of transmission through this route
 However, some advise temporary suspension of
breastfeeding if a woman develops cracked nipples
or mastitis.


3= hepatitis C
 HCV infection acquired from perinatal transmission
progresses to chronic HCV in 80% of cases, with very
few children clearing it spontaneously.
 Cord blood testing of HCV is not recommended as it
can yield false-positive or false-negative results
 child at risk of perinatal transmission exposure to
HCV should be tested for HCV antibodies at 18
months of age. Testing prior to this time is limited
due to passive transfer of maternal antibodies


 if diagnosis of vertical transmission necessary prior
to 18 months of age (e.g. parental request) then
testing of infant serum HCV RNA can be obtained
when the infant is 2 and 6 months of age.
 Hepatitis B virus (HBV) vaccination is recommended
within 12 hours of birth as these neonates are at
higher risk of infection, and if a child is infected with
HCV they may be more prone to severe infection if
they contract HBV


 ACOG&AAP support breast feeding in HCV Ab positive
female.
 studies have shown that HCV RNA has been detected at low
levels in breast milk, but that the virus is likely to becomes
inactive in the neonatal digestive tract
 • risk for transmission is higher if the woman has damaged,
cracked or bleeding nipples. Advise the mother to express and
discard breast milk until the nipples are healed, and to
artificially feed until then.
 If one breast/nipple is undamaged she may be able to feed the
neonate from that side and provide top-ups as required until
healing occurs.

Hepatitis and pregnangy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Hepatitis and pregnangy

Similar to Hepatitis and pregnangy (20)

Recently uploaded

Recently uploaded (20)

Hepatitis and pregnangy