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H epatitis B and C during pregnancy and lactation. Anne Kirss Women’s Clinic of Tartu University Hospital 15.09.2006. Prevalence of hepatitis B . All over the world about 350 million people are infected with hepatitis B Estonia has medium prevalence of hepatitis B 2-8% of population

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H epatitis B and C during pregnancy and lactation

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H epatitis b and c during pregnancy and lactation l.jpg

Hepatitis B and C during pregnancy and lactation

Anne Kirss

Women’s Clinic of Tartu University Hospital

15.09.2006


Prevalence of hepatitis b l.jpg

Prevalence of hepatitis B

  • All over the world about 350 million people are infected with hepatitis B

  • Estonia has medium prevalence of hepatitis B

    • 2-8% of population

  • Transmission of HBV occurs via blood and sexual contact

  • HBV is stable in environment at least 7 days


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Prevalence of hepatitis C

  • In Estonia the estimated prevalence of hepatitis C is 1% of population

  • Transmission of HCV occurs mainly via infected blood

  • Up to 70% of cases of chronic viral hepatitis are caused by HCV


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Hepatitis B and C and pregnancy

  • Do not influence the course of pregnancy


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HBV infection

  • Is not teratogenic

  • Acute hepatitis may cause:

    • Prematurity

    • Low birth weight


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Vertical transmission of hepatitis B

  • Intrauterine infection of the fetus is very rare

  • Mostly during delivery, after delivery

  • Transmission to the baby in the absence of imuune profylaxis

    • HBsAg positive mothers10-20%

    • HBsAg +HBeAg positive mothers90%

      • It is possible that HBeAg crosses the placental barrier and makes the newborn susceptible to HBV

  • Acute hepatitis B

    • During the I trimester – transmission to the child 10%

    • During the III trimester - transmission to the child 80-90%


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Amniocentesis

  • The risk of HBV transmission is low

  • Noninvasive methods of following the fetus should be preferred (ultrasound)

  • Avoid passing the needle through placenta


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Delivery

  • With immunoprofylaxis the method of delivery is not important

  • Elective caesarean section is not considered necessary

    • Centers of Disease Control & Prevention Sexually Transmitted Diseases Treatment Gudelines 2002


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Neonatal hepatitis B

  • 75-85% of perinatally infected children will be carriers of virus

  • Becomes evident 6 months after birth

  • Usually the course is subclinical, chronic

  • Greater risk of hepatic cirrhosis and hepatic cancer

  • Fulminant disease more frequently occurs in newborns whose mothers are chronic carriers of HBV


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Prevention of neonatal hepatitis B

  • Postinfection profylaxis for newborns (infection mainly during delivery or directly after)

    • Immunglobulin within 12 hours after birth

    • Simultaneous vaccination

    • Vaccination at 1 and 6 months of age

    • This way 90% of HBV infections can be avoided

      • Acta Gastroent Jan 1999


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Vaccination against hepatitis B

  • Allowed during pregnancy for

    • contacts of chronic hepatitis B patients

  • Hepatitis B immunglobulin also allowed for

    • Contacts of acute hepatitis B patients

    • In the presence of skin lesion the second dose after 1 month

  • When the newborn gets immune profylaxis, the mother may breast-feed


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Treatment of chronic hepatitis B

  • Few data about use in pregnant women

  • Interferon Alfa

    • Probably does not cross placental barrier

      • A study of 2 HIV-positive pregnant women

        • Medical abortion in week 19 and 24

    • Not teratogenic in rabbits and rats

    • Higher risk of spontaneous abortion in Rhesus monkeys

    • Data of pregnant women with leukemia and hepatitis C

      • Normal babies, normal pregnancies

  • Is secreted into breast milk

    • Effect on the infant is not known


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Lamivudine

  • Is not teratogenic – no malformations

  • Has been used during the second half of pregnancy to avoid transmission – questionable success

    • Kazim SN et al. Lancet 2002; van Zonneveld M et al. J Viral Hepat 2003

  • Crosses placental barrier

    • anaemia,

    • hypocalcaemia,

    • neutropenia,

    • arrhythmias (VPB)

      of the baby


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    Lamivudine

    • In HIV infection the potential benefit is bigger

    • Lactation

      • Concentrates in breast milk

        • serum/milk 1:3

      • Breast-feeding is not recommended


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    Hepatitis C

    • Usual pregnancy risks

    • Cholestasis of pregnancy may occur more often

    • Endogenous fetoplacental interferone may have a favourable effect on the course of hepatitis C

    • At the presence of oesophagel varices or coagulopathy the risks are higher


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    Hepatitis C

    • Measure ASAT, ALAT once every trimester

    • In addition: albumin, bilirubin, INR, anti-HBs, anti-HA IgG, HCV-RNA

    • Follow the pregnancy as usual


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    Pregnancy and hepatitis C

    Pregnancy has a favourable effect on the necrosis of hepatocytes in HCV positive women

    Hepatology 2000, March;31

    J Watch Gastroenterology 2000, May


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    Vertical transmission of hepatitis C

    • Infrequent

    • 6% in HCV-RNA positive

    • 15% if HCV+HIV

    • The risk of HCV transmission is dependent on the level of mother’s viraemia

      • HCV-RNA negative – risk for the baby almost 0


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    Hepatitis C and delivery

    • The method of delivery is not important in transmission

      • Caesarean section is not indicated

    • Induction of delivery due to hepatitis C is not necessary

    • Prefer external methods of following the fetus, although there are no data of infection transmission via using the scalpel electrode

    • Breast feeding is allowed

      • No transmission via breast milk has been documented, although a-HCV and HCV-RNA may be present in breast milk


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    Neonatal hepatitis C

    • Not much experience

      • The virus was discovered in 1989

    • HCV is not teratogenic

      • Babies have been born healthy

      • When infected, the baby has chronic infection

    • No vaccine

    • No immunoglobulin

    • Recommended to do lab tests of the child once a year


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    Baby of HCV positive mother

    • Not necessary to test umbilical blood

      • Mother’s antibodies (IgG) cross the placental barrier

        • All newborns are a-HCV positive

      • Mother’s antibodies may be present in the baby’s blood even for 12-15 months

        • The higher the mother’s HCV-RNA, the longer the antibodies stay in the baby’s blood

    • Tests at the age of 4-6 months at the earliest

    • a-HCV, HCV-RNA, AST, ALT

    • Hepatitis has benign course in children and usually does not require treatment


    Treatment of hepatitis c l.jpg

    Treatment of hepatitis C

    • Few data about use in pregnant women

    • Interferon Alfa

      • Probably does not cross placental barrier

        • A study of 2 HIV-positive pregnant women

          • Medical abortion in week 19 and 24

      • Not teratogenic in rabbits and rats

      • Higher risk of spontaneous abortion in Rhesus monkeys

      • Data of pregnant women with leukemia and hepatitis C

        • Normal babies, normal pregnancies

    • Is secreted into breast milk

      • Effect on the infant is not known


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    Ribavirin - must not be used

    • Teratogenic in all animal experiments

      • Malformations of the limbs, palate, sceleton, gastrointestinal tract and brain

    • Can be found in blood up to 4 weeks after discontinuation of the medication

      • Concentrates in red blood cells

    • Breast feeding

      • No data available


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    In summary

    • Pregnancy has a favourable effect on hepatitis

    • The risk of transmission of viral hepatitis from mother to fetus is low (6%)

    • Newborn with neonatal hepatitis needs careful observation and treatment (HBV vaccine)

    • Caesarean section is not necessary, breast feeding is allowed

    • Medical personnel has high risk of viral hepatitis

      • SELF DEFENCE (HBV vaccination, gloves, aprons, masks, spectacles)


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