Hepatitis E associated determinants and diagnostic biomarkers during pregnancy and its prenatal consequences in Multan, Punjab tertiary care setting (Pakistan)

Abstract

Objective: Hepatitis E virus (HEV) is the most common cause of acute viral hepatitis in the world. Hepatitis E infection is commonly widespread by the fecal oral routes and contaminated water. This study was designed to explore the prevalence and risk factors of hepatitis E infection in pregnant women of the Multan district, Pakistan.

Methods: The study comprised of a total of 500 enrolled patients, among which, 105 pregnant females with hepatitis E infection fulfilled the criteria for anti-HEV antibodies. Pregnant women without significant complications and without hepatitis E infection were excluded from this study. Hepatic profile, complete blood count, coagulation markers, and standard protocol were also assessed for fetal maternal hemorrhage.

Results: Our results showed that 105 patients (66.66%, CI 95%) had HEV infection with mean age 25±5 years. Serum bilirubin levels were increased in 74 patients (70.47%), aspartate transaminase was elevated > 200 IU/L in 71 patients (67.61%), alanine transaminase was above the 100 IU/L in 65 patients (245 IU/L), and low platelet counts were found in 45 patients (42.85%). Moreover, fetal distress cases were 9 (10.84%) and maternal distress cases were about 11 (13.25%). Fetal mortality cases were 39 (37.14%), and maternal mortality cases were about 22 (20.95%) due to hepatic comma, intravascular coagulation, and hepatic failure.

Conclusion: It was concluded that the prevalence of Hepatitis E during pregnancy is associated with high risk factors of unhygienic practices, blood transfusion, and noncompliance with universal infection control techniques. Maternal fatalities and fetal consequences were exacerbated by HEV infection.

Keywords: Viral hepatitis; fetal outcomes; hygiene condition; pregnancy complications; water borne diseases.

Figure 1

Demographic, clinical disposition of Hepatitis E and possible modes of Hepatitis E virus transmission; Unhygienic practices and contaminated water, via food and zoonotic transmission holds 64% of infection. Eleven percent of pregnant patients acquired HEV from the family and direct contact with the nearby inhabitants. Almost 25% HEV transmission occurred by blood transfusion.

Figure 2

Maternal and foetal outcomes of pregnant patients with Hepatitis E. Intrauterine deaths and maternal distress were the worst-case situations (39 and 11 cases respectively). Most fatalities went through premature labour ending to delivery (8 cases), which either occurred naturally or was induced for medical reasons. Neonatal deaths reported in 12 cases, while 9 fetus experienced distress.

Figure 3

Flow sheet depicting causal mechanisms leading to liver cirrhosis in hepatitis E during pregnancy. Pregnancy brings surge of estrogen, progesterone and Human chrionic gonadotrophin (HCG). Hormonal surge and cell mediated Immune response suppression by flooding cytokines IL-4, IL-10, TNF, INF-γ and tumor growth factor (TGF) production influenced hepatitis E infection in pregnancy. Whereas, decreased nutritional status and NF-kB encourages viral attack. Further viral replication is enhanced by viral proteins.