Treatment HIB In Pregnancy

Transmission

Hepatitis B virus (HBV) is a double-stranded DNA virus in the Hepadnaviridae family.
The incubation period from time of exposure to onset of symptoms is 6 weeks to 6 months. HBV is found in highest concentrations in the blood, and lower concentrations in semen, vaginal secretions, and wound exudates. Sexual transmission accounts for most adult HBV infections in the United States [1]. Approximately 25% of the regular sexual contacts of infected individuals will themselves become seropositive. [2]

About one half of acute HBV infections are symptomatic in adults with 1% of cases resulting in acute liver failure and death. Acutely infected individuals develop clinically apparent acute hepatitis with loss of appetite, nausea, vomiting, fever, abdominal pain and jaundice [1]. 10-20% of women seropositive for HBsAg transmit the virus to their neonates in the absence of immunoprophylaxis. In women who are seropositive for both HBsAg and HBeAg vertical transmission is approximately 90% [2]. In patients with acute hepatitis B vertical transmission occurs in up to 10% of neonates when infection occurs in the first trimester and in 80 -90% of neonates when acute infection occurs in the third trimester [2].

Sequelae
Chronic infection occurs in about 90% of infected infants, 60% of infected children aged <5>Who to test [1]

• Test all pregnant women at the first prenatal visit for hepatitis B surface antigen (HBsAg).
• Women admitted for delivery who have not had prenatal HBsAg testing should have blood drawn for testing [5].
• Send a copy of the original lab report to the hospital.
• “More than 90% of women found to be HBsAg-positive on routine screening will be HBV carriers, routine follow-up testing later in pregnancy is not necessary for the purpose of screening. In special situations, such as when the mother is thought to have acute hepatitis, when there has been a history of exposure to hepatitis, or when particularly high-risk behavior such as parenteral drug abuse has occurred during the pregnancy, an additional HBsAg test can be ordered during the third trimester” [6]
• Test all susceptible contacts (including all family members) with hepatitis B panel (HBsAg, antiHBc, antiHBs).
• Screening and vaccination of susceptible contacts should be done by the family's pediatrician, primary health-care provider, or the physician evaluating the clinical status of the HBsAg-positive pregnant women.

Interpretation of the Hepatitis B Panel Tests Results Interpretation

Tests	Results	Interpretation
HBsAg anti-HBc anti-HBs	negative negative negative	susceptible
HBsAg anti-HBc anti-HBs	negative positive positive	immune due to natural infection
HBsAg anti-HBc anti-HBs	negative negative positive	immune due to hepatitis B vaccination
HBsAg anti-HBc IgM anti-HBc anti-HBs	positive positive positive negative	acutely infected
HBsAg anti-HBc IgM anti-HBc anti-HBs	positive positive negative negative	chronically infected
HBsAg anti-HBc anti-HBs	negative positive negative	four interpretations possible *

* 1. May be recovering from acute HBV infection. 2. May be distantly immune and test not sensitive enough to to detect very low level of anti-HBs in serum. 3. May be susceptible with a false positive anti-HBc. 4. May be undetectable level of HBsAg present in the serum and the person is actually a carrier.

Source: http://www.cdc.gov/ncidod/diseases/hepatitis/b/Bserology.htm

A positive HBsAg in the absence of IgM anti-HBc is indicative of chronic infection.If positive, this test result should be reported to state perinatal immunization or HBV prevention programs to ensure proper case management of the mother and appropriate postexposure immunization of her at-risk infant [1]. The baby's health-care provider should be notified about the mother's HBsAg-positive status and receive hepatitis B immune globulin (HBIG) and HBV vaccine.

Treatment
The treatment of acute HBV infection is supportive.Persons with chronic hepatitis B should be referred to health-care professionals with experience in the treatment of hepatitis B for treatment with alpha-interferon or lamivudine [1]. Interferon does not appear to adversely affect the embryo or fetus. However, the data is limited, and the potential benefits of interferon use during pregnancy should clearly outweigh possible hazards [7-9]. Initial data do not suggest that Lamivudine is teratogenic [10]. Lamivudine has been used in the latter half of pregnancy in attempt to prevent perinatal transmission of hepatitis B virus infection with mixed success [11,12]

Postexposure Prophylaxis for Susceptible Pregnant Women [1, 13]

Exposure to Persons Who Have Acute Hepatitis B
When exposure has occurred as a result of sexual contact within 14 days after the most recent sexual contact administer

A course of HBV vaccine into the deltoid

• The two available monovalent hepatitis B vaccines for preexposure immunization and postexposure prophylaxis are Recombivax HB® (Merck and Co., Inc.) and Engerix-B (SmithKline Beecham Biologicals).

A dose of Hepatitis B immune globulin (HBIG) 0.06 mL/kg IM into the contralateral arm.

• For prophylaxis after percutaneous or mucous membrane injury, a second dose of HBIG should be given 1 month later.

Exposure to Persons Who Have Chronic HBV Infection
Active postexposure prophylaxis with hepatitis B vaccine alone is recommended for sex or needle-sharing partners and non-sexual household contacts of persons with chronic HBV infection

Other Candidates for Vacination
• Household contacts and sex partners of HBsAg-positive women identified through prenatal screening should be vaccinated [5] .
• Persons with history of an STD.
• Persons on hemodialysis, persons receiving clotting factor concentrates, or persons who have occupational exposure to blood.
• All persons who have not been previously vaccinated who receive services in drug treatment programs and long-term correctional facilities
• Pregnant women seeking STI treatment who have not been previously vaccinated and test negative for hepatitis B, should receive the hepatitis B vaccine.

Antepartum
Pregnant Hepatitis B carriers should be advised to
• Obtain vaccination against hepatitis viruses A as indicated.
• Abstain form alcohol use
• Avoid hepatotoxic drugs such as acetaminophen (Tylenol) that may worsen liver damage.
• Not donate blood, body organs, other tissue, or semen.
• Not share any personal items that may have blood on them (e.g., toothbrushes and razors).
• Inform the infant’s pediatrician, OB/GYN, and labor staff that they are a hepatitis B carrier.
• Make sure their baby receives hepatitis B vaccine at birth, one month, and six months of age as well as H-BIG at birth.
• Be seen at least annualy by their regular medical doctor.
• Discuss the risk for transmission with their partner and discuss the need for counseling and testing
b. Liver function testing is recommended for women who test positive for HBsAg [1]

The following recommendations from The Society of Obstetricians and Gynecologists of Canada may be helpful in counseling women considering amniocentesis.

SOGC Recommendations [14]

• “The risk of fetal hepatitis B infection through amniocentesis is low. However, knowledge of the maternal hepatitis B e antigen status is valuable in the counselling of risks associated with amniocentesis.
• For women infected with hepatitis B, hepatitis C, or HIV, the addition of noninvasive methods of prenatal risk screening, such as nuchal translucency, triple screening, and anatomic ultrasound, may help in reducing the age-related risk to a level below the threshold for genetic amniocentesis.
• For those women infected with hepatitis B, hepatitis C, or HIV who insist on amniocentesis, every effort should be made to avoid inserting the needle through the placenta. “

Delivery
Although cesarean delivery has been proposed as a means of reducing mother to child transmission (MCT) of HBV [15] The mode of delivery does not appear to have a significant effect on the interruption of HBV maternal-baby transmission by immunoprophylaxis [16]. Delivery by cesarean section for the purpose of reducing MCT of HBV is note presently recommended by either the CDC [1] or the ACOG [2].

Breast feeding.
With appropriate hepatitis B immunoprophylaxis, breast-feeding poses no additional risk for transmission from infected hepatitis B virus carriers [17,18]

REFERENCES:
1. Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines --- 2002 .MMWR May 10, 2002 / 51(RR06);1-80
2. ACOG educational bulletin. Viral hepatitis in pregnancy. Number 248, July 1998 . American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1998 ;63:195-202. MEDLINE
3. Shepard TH. Catalog of Teratogenic Agents pp 1309. 9th ed.Baltimore, MD: Johns Hopkins University Press, 1998 .p1309
4. Hieber JP, Dalton D, Shorey J, Combes B.Hepatitis and pregnancy.J Pediatr. 1977 Oct;91(4):545-9. MEDLINE
5. Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP) MMWR November 22, 1991 / 40(RR-13);1-19
6. Recommendations of the Immunization Practices Advisory Committee Prevention of Perinatal Transmission of Hepatitis B Virus: Prenatal Screening of all Pregnant Women for Hepatitis B Surface Antigen MMWR June 10, 1988 / 37(22);341-6,351
7. Briggs GG,Freeman RK, Yaffe SJ, Drugs in Pregnancy and Lactation 5th edition,Baltimore, MD: Williams & Wilkins,1998 p 716-720.
8. Ozaslan E, Yilmaz R, Simsek H, Tatar G. Interferon therapy for acute hepatitis C during pregnancy.
Ann Pharmacother. 2002;36:1715-8. MEDLINE
9. Hiratsuka M, Minakami H, Koshizuka S, Sato I. Administration of interferon-alpha during pregnancy: effects on fetus. J Perinat Med. 2000;28(5):372-6. MEDLINE
10. Briggs GG,Freeman RK, Yaffe SJ, Drugs in Pregnancy and Lactation 5th edition,Baltimore, MD: Williams & Wilkins,1998 p 761-766.
11. van Zonneveld M, van Nunen AB, Niesters HG, de Man RA, Schalm SW, Janssen HL. Lamivudine treatment during pregnancy to prevent perinatal transmission of hepatitis B virus infection.J Viral Hepat. 2003 ;10(4):294-7. MEDLINE
12. Kazim SN, Wakil SM, Khan LA, Hasnain SE, Sarin SK. Vertical transmission of hepatitis B virus despite maternal lamivudine therapy. Lancet. 2002;359(9316):1488-9 MEDLINE
13. Centers for Disease Control. Protection against viral hepatitis. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1990;39(RR-2):1-26
14. Davies G et al Society of Obstetricians and Gynaecologists of Canada. Amniocentesis and women with hepatitis B, hepatitis C, or human immunodeficiency virus. J Obstet Gynaecol Can. 2003 ;25(2):145-48, 149-52. MEDLINE
15. Lee SD, Lo KJ, Tsai YT, Wu JC, Wu TC, Yang ZL, Ng HT. The role of cesarean section in the prevention of mother-infant transmission of hepatitis B virus. Lancet. 1988;2:833-4. MEDLINE
16. Wang J, Zhu Q, Zhang X. Effect of delivery mode on maternal-infant transmission of hepatitis B virus by immunoprophylaxis. Chin Med J (Engl) 2002 Oct;115(10):1510-2 MEDLINE
17. Hill JB et al , Risk of hepatitis B transmission in breast-fed infants of chronic hepatitis B carriers.
Obstet Gynecol. 2002 ;99(6):1049-52. MEDLINE
18. Wang JS, Zhu QR, Wang XH. Breastfeeding does not pose any additional risk of immunoprophylaxis failure on infants of HBV carrier mothers. Int J Clin Pract. 2003 ;57(2):100-2. MEDLINE

ADDITIONAL READING:

Hepatitis B infection in pregnancy
1999 Contemporary OB/GYN

Hepatitis
Center for Disease Control and Prevention