Hepatitis B and C in pregnancy: a review and recommendations for care

Abstract

Our objective was to provide a comprehensive review of the current knowledge regarding pregnancy and hepatitis B virus (HBV) or hepatitis C virus (HCV) infection as well as recent efforts to reduce the rate of mother-to-child transmission (MTCT). Maternal infection with either HBV or HCV has been linked to adverse pregnancy and birth outcomes, including MTCT. MTCT for HBV has been reduced to approximately 5% overall in countries including the US that have instituted postpartum neonatal HBV vaccination and immunoprophylaxis with hepatitis B immune globulin. However, the rate of transmission of HBV to newborns is nearly 30% when maternal HBV levels are greater than 200 000 IU ml(-1) (>6 log10 copies ml(-1)). For these patients, new guidelines from the European Association for the Study of the Liver (EASL) and the Asian Pacific Association for the Study of the Liver (APASL) indicate that, in addition to neonatal vaccination and immunoprophylaxis, treating with antiviral agents such as tenofovir disoproxil fumarate or telbivudine during pregnancy beginning at 32 weeks of gestation is safe and effective in preventing MTCT. In contrast to HBV, no therapeutic agents are yet available or recommended to further decrease the risk of MTCT of HCV, which remains 3 to 10%. HCV MTCT can be minimized by avoiding fetal scalp electrodes and birth trauma whenever possible. Young women with HCV should be referred for treatment post delivery, and neonates should be closely followed to rule out infection. New, better-tolerated treatment regimens for HCV are now available, which should improve outcomes for all infected individuals.

Figure 1

Phases of chronic HBV infection. In the immune-tolerant phase of chronic HBV infection, ALT levels are normal whereas HBV DNA levels are markedly elevated. In the immune-reactive or chronic active phases, ALT and HBV DNA levels are elevated. In chonic inactive phases of HBV infection, ALT and HBV DNA levels are decreased; <1000 IU ml⁻¹ is equivalent to <6 × 3 log₁₀ copies ml⁻¹; >200 000 IU ml⁻¹ is>6 log₁₀ copies ml⁻¹.

Figure 2

HBsAg is checked in all pregnant women. HBsAg-positive patients should have HBV DNA level and HBeAg checked. We recommend checking HBsAb and immunizing HBsAb-negative patients.

Figure 3

Pregnant women with HBV DNA levels >200 000 IU ml⁻¹ (>6 log₁₀ copies ml⁻¹), or any HBsAg-positive woman with a threatened abortion, are at high risk for MTCT and should receive antiviral treatment in the third trimester.