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Hepatitis B in pregnancy (query

bank)
Published: 25/01/2012

Question
What is the best course of action regarding the management of a lady
who is P2, 29 weeks gestation who found to be HBsAg positive? She is
clinically asymptomatic.

Answer
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The following guidelines on the management of hepatitis B in pregnancy
were identified:
United Kingdom national guideline on the management of the
viral hepatitides A, B & C
Pregnancy and Breastfeeding

Vertical transmission (mother to infant) of infection occurs in ninety


percent of pregnancies where the mother is hepatitis B e antigen
positive and in about ten percent of surface antigen positive, e
antigen negative mothers. Most (>90%) of infected infants become
chronic carriers.

Infants born to infectious mothers are vaccinated from birth, usually


in combination with Hepatitis B specific Immunoglobulin 200 i.u. i.m.
This reduces vertical transmission by ninety percent.

There is some evidence that treating the mother in the last month of
pregnancy with lamivudine may further reduce the transmission
rate if she is highly infectious (HBVDNA >=.2 x 10 9 geq/ml), but this
needs to be further substantiated.
Infected mothers should continue to breast feed as there is no
additional risk of transmission

Hepatitis B may exacerbate after the end of pregnancy


Map of Medicine
A care map for the management of hepatitis B in pregnancy has
been approved by the UK National Screening Committee for use in
England. This includes the following sections:

Assessment and testing of the pregnant woman.


All pregnant women with hepatitis B infection should be referred for
a comprehensive assessment by an appropriate specialist with
expertise in the management of hepatitis B (eg hepatology,
gastroenterology, infectious diseases). A specialist assessment
should be undertaken within 6 weeks of the screening test result
being reported to maternity services. This is to ensure that:

o further tests are undertaken,

o the womans identity is confirmed,

o advice on the infection is ofered,

o treatment options are considered.


It is also an opportunity for clinicians to notify the Health
Protection Agency and to discuss the need for management of
contacts.
All women referred to an appropriate specialist should undergo testing as
outlined in the BVHG guidelines for initial testing and referral of individuals
who are HBsAg positive. These are:

HBV serology - including HBeAg status

HBV DNA level

Delta virus testing

HCV testing

Lver function tests, including tests of synthetic function (INR)

Liver ultrasound
Results from these tests should be fed back to maternity services.
HIV results should be made available to the clinician by maternity
services. HIV testing should be re - ofered if this was declined during the
initial screening encounter.
www.basl.org.uk/media/uploads/referralguidelines.pdf Notifications
Reference: Health Protection (Notification) Regulations 2010. This can be
accessed at www.opsi.gov.uk/si/si2010/pdf/uksi_20100659_en.pdf The
regulation states that diagnostic laboratories must notify the HPA and sets
out the details of information to be transferred. This information includes
ways in which the spread of [hepatitis B infection] can be prevented or
controlled and should be supplied in liaison with a registered medical
practitioner where necessary. The woman should be informed that this
action should be taken.

Management of pregnancy and delivery


Maternity services should ensure that the woman has attended
the specialist appointment and that information relevant to the
place of delivery and infant vaccination, such as test results, is
appropriately recorded.
Non attendance at appointments should be reviewed within a
multidisciplinary framework and a management / action plan
developed.
Systems, protocols and pathways should be in place to support
this.

Indications for HBIG:


Where indicated hepatitis B immunoglobulin (HGIB) should be
administered with the first hepatitis B vaccine within 24 hours of
birth. The requirement for HBIG is assessed during pregnancy. It
should be administered if the mother is:

o HBsAg and HBeAg positive

o HBsAg positive HBeAg/anti-HBe negative

o HBsAg positive and e markers not available

o HBsAg positive and infant birth-weight =1500g

o HBsAg positive and HBV DNA level = 1x10 6IU/ml*


or has

o acute hepatitis B during pregnancy


European Association for the Study of the Liver Management of
chronic hepatitis B
Recent reports suggest that lamivudine therapy during the last trimester
of pregnancy in pregnant HBsAg-positive women with high levels of
viremia reduces the risk of intra-uterine and perinatal transmission of HBV
if given in addition to passive and active vaccination by HBIg and HBV
vaccination.
American College of Obstetricians and Gynecologists. Viral
hepatitis in pregnancy.
Persons with diagnosed chronic HBC and HCV infection should be referred
for evaluation to a physician experienced in the management of chronic
liver disease.
Women who are chronic carriers of HBV or HCV should inform sexual,
household, and needle-sharing contacts of their status and learn about
and use methods to prevent or reduce the risk of transmission of infection
to others.
Current guidelines stipulate that infants of women who are HbSAg
positive or whose status is unknown at the time of delivery also should
receive both HBIG [hepatitis B immune globulin] and hepatitis B vaccine
within 12 hours of birth given simultaneously at diferent sites
intramuscularly. It should then be followed by two more injections of
hepatitis B vaccine in the first 6 months of life.
(Evidence level IV)
Two meta-analyses by Shi et al were also identified. One investigated the
use of Hepatitis B immunoglobulin injection in pregnancy to interrupt
hepatitis B virus mother-to-child transmission and found that multiple
injections of HBIG in HBV carrier mothers with a high degree of
infectiousness in late pregnancy, efectively and safely prevent HBV
intrauterine transmission.
The other evaluated the efficacy of lamivudine in reducing in utero
transmission of hepatitis B virus (HBV), concluding that lamivudine in HBV
carrier-mothers with high degree of infectiousness in late pregnancy
efectively prevented HBV intrauterine infection and mother-to-child
transmission.
(Evidence level 1a).

References
American College of Obstetricians and Gynecologists. Viral hepatitis
in pregnancy. Washington (DC): American College of Obstetricians
and Gynecologists; 2007 Oct. (ACOG practice bulletin; no.
86). Summary
Clinical Efectiveness Group. United Kingdom national guideline on
the management of the viral hepatitides A, B & C 2008. London
(UK): British Association for Sexual Health and HIV (BASHH); 2008.

European Association for the Study of the Liver. EASL Clinical


Practice Guidelines: Management of chronic hepatitis B. Journal of
Hepatology 50 (2009) 227242

Map of Medicine. Management of hepatitis B in pregnancy

Shi Z, Li X, Ma L, and Yang Y. Hepatitis B immunoglobulin injection in


pregnancy to interrupt hepatitis B virus mother-to-child
transmission: a meta-analysis.International Journal of Infectious
Diseases 2010 Vol 14(7): e622-e634

Shi Z, Yang Y, Ma L, Li X, Schreiber A. Lamivudine in late pregnancy


to interrupt in utero transmission of hepatitis B virus: a systematic
review and meta-analysis. Obstet Gynecol. 2010 Jul;116(1):147-59.

Search date
January 2012

Classification of evidence levels


Ia: Evidence obtained from meta-analysis of randomised controlled
trials.

Ib: Evidence obtained from at least one randomised controlled trial.

IIa: Evidence obtained from at least one well-designed controlled


study without randomisation.

IIb: Evidence obtained from at least one other type of well-designed


quasi-experimental study.

III: Evidence obtained from well-designed non-experimental


descriptive studies, such as comparative studies, correlation studies
and case studies.

IV: Evidence obtained from expert committee reports or opinions


and/or clinical experience of respected authorities.

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