Postpartum hepatitis flares in mothers with chronic hepatitis B infection

Abstract

Postpartum elevation of alanine aminotransferase (ALT) in mothers with chronic hepatitis B (CHB) presents a significant clinical challenge. However, the existing literature demonstrates inconsistencies regarding its incidence and predictors in mothers infected with the hepatitis B virus (HBV). Recent advancements in antiviral prophylaxis against mother-to-child transmission of HBV and postpartum cessation of antiviral therapy further complicate this issue. Our literature review, spanning PubMed, and two Chinese-language databases (CNKI and Wanfang) from 1 January 2000 to 31 December 2023 aimed to consolidate and analyse available data on the frequency and severity of postpartum ALT flares, identify risk factors, and propose a management algorithm. Data from 23 eligible studies involving 8,077 pregnant women revealed an overall incidence of postpartum ALT elevation: 25.7% for mild cases, 4.4% for moderate cases, and 1.7% for severe cases. In the subgroup of mothers who were HBeAg-positive and on antiviral prophylaxis for preventing mother-to-child transmission, postpartum intermediate and severe ALT elevations were reported with pooled rates of 5.9% and 0.8%, respectively. Importantly, none resulted in mortality or necessitated liver transplantation. Identified risk factors for postpartum ALT flares in mothers with CHB included HBV DNA levels, ALT levels during pregnancy, postpartum cessation of antiviral treatment, and HBeAg status. By leveraging this evidence and recent data on predictors of intermediate or severe postpartum ALT flares, we propose a risk-stratified algorithm for managing postpartum ALT elevation and selecting therapy in mothers with CHB, tailoring different approaches for treatment-naive vs treatment-experienced populations. These recommendations aim to provide guidance for clinical decision-making and enhance patient outcomes.

Keywords: ALT elevation; HBV; disease activation; hepatitis flares; liver inflammation.

Figure 1.

Data search and selection process. The literature search encompassed PubMed and two Chinese-language databases (CNKI and Wanfang) from 1 January 2000 to 31 December 2023, seeking publications in English or Chinese. Based on the pre-specified search term, relevant articles (n = 1,389) were identified initially. Among these articles, 23 met the eligibility criteria and were included in the current review. CNKI = China National Knowledge Infrastructure.

Figure 2.

Management algorithm for postpartum ALT elevation in mothers with CHB. Risk-stratified algorithm for managing postpartum ALT elevation and selecting therapy in mothers with CHB, adapting different approaches for treatment-naive vs treatment-experienced populations. ALT elevation is defined by the authors as levels exceeding the local laboratory cut-off value or 40 U/L. Postpartum hepatitis B flares are classified into three scales among mothers without hepatic decompensation: mild ALT elevation (above ULN but less than 5 × ULN); intermediate ALT elevation (5 × ULN but less than 10 × ULN); and severe hepatitis B flare (>10 × ULN). ALT = alanine aminotransferase, ULN = upper limit of normal, CHB = chronic hepatitis B, MTCT = mother-to-child transmission, HBV = hepatitis B virus, TAF = tenofovir alafenamide, TDF = tenofovir disoproxil fumarate, MASLD = metabolic dysfunction-associated steatotic liver disease.