Adult viral hepatitis is the most common cause of jaundice in pregnancy. Hepatitis is the type of infection that can seriously damage your liver and if you are pregnant you can pass onto your baby. You can have one of three most common types of Hepatitis viruses A, B and C and usually, it won’t hurt your unborn baby or affect your pregnancy. If your doctor knows you have it, she can help you manage it during your pregnancy to lower the chances of any long-term liver disease for you and your baby.
Jaundice is the characteristic feature of the liver disease. The
clinical signs and symptoms are indistinguishable from the various forms of
hepatitis. Therefore, diagnosis requires serological tests for virus-specific
diagnosis. Biochemical assessment of liver functions is also done.
Differential diagnosis includes mono-mere and EBV virus infection with
liver failure, gallbladder disease, HELLP syndrome, acute fatty liver of
pregnancy. The most useful tests to diagnose are urine bilirubin and
urobilinogen, total and direct serum bilirubin, Alanine Aminotransferase (ALT),
ALP, PT, total protein, albumin, CBC in some cases and serum ammonia.
Effects of Different Types of Hepatitis
on Pregnancy
Hepatitis A
It is the most common cause of acute viral hepatitis in the general
population but it is infrequently reported among pregnant women. It is
transmitted via the fecal-oral route either by direct contact with the infected
person or ingestion of contaminated food. Inoculation period is 15 to 40 days.
It is common in developing countries owing to poor hygiene and sanitation
systems. Transmission
of HAV from mother to fetus is uncommon. If Hepatitis A infection
occurs in pregnant women. It can
cause pre-term labor especially if infection occurs in 2nd and 3rd trimester.
Hepatitis A infection is also associated with other complications like
premature rupture of membranes, premature uterine contractions, and placental
abruption. In some cases, fever and hypoalbuminemia can be there. If
transmission occurs from mother to child, there can be meconium peritonitis and
perforation of the distal ileum. An HAV vaccine is available and can be
administered to the mother before traveling to endemic countries. Breastfeeding
should not be discouraged. The child should be protected through the
administration of immunoglobulins or the inactivated vaccine.
Hepatitis B
Of the 400 million infections with chronic HBV worldwide, 50% acquired
their infection prenatally. 90% of the infected infants will become chronic
carriers of Hepatitis B. It is a double-stranded DNA virus in the core
particle. The incubation period is up to 180 days.
Clinical picture – in pregnancy, chronic infection is symptomatic. In
acute infection, 50% asymptomatic, urticarial rash, arthralgia, arthritis,
hepatomegaly and or right upper quadrant tenderness. Jaundice is less common.
After acute hepatitis, 90% of patients recover completely, 10% go into chronic
hepatitis. Lab markers are –HbsAg → current infection, HbcAg→ active
replication, and HBV DNA→ viral load.
Effect of HBV on Pregnancy
Gestational diabetes, preterm delivery, no worsening of liver disease in
pregnancy, peri-natal transmission. HbcAg positive in 70-90% of cases, HbcAg
negative in 10-40% of cases without immunoprophylaxis. In the uterus,
transplacental viral infection is uncommon. Viral DNA is rarely found in
amniotic fluid or cord blood. Most neonatal infections are vertically
transmitted by peripartum exposure. Breastfeeding is not associated with
transmission. Mode of delivery
has no effect on HBV transmission. All neonates who are correctly
immunized can be breastfed.
Prevention
§ Antivirals to
suppress the HBV in mother to reduce vertical transmission.
§ Post-exposure
prophylaxis to the infant. Active plus passive immunization is most effective
to prevent vertical transmission. Protective efficacy of 95%.
§ If the liver
disease is in advance stage, treatment can be given before pregnancy and during
pregnancy and continued after delivery. If moderate disease, treatment before
pregnancy. If good response, stop treatment during pregnancy.
§ If mild disease,
treatment is given in the last trimester with B category drug with post-partum
discontinuation.
§
Hepatitis C
For women of reproductive age with known HCV infection, antiviral
therapy is recommended before continuing pregnancy, whenever practical and
feasible to reduce the risk of HCV infection to offspring. Women should be
counseled about the benefit of anti-viral treatment prior to pregnancy.
At the first antenatal visit, HCV RNA and routine liver function tests
are recommended to assess the risk of mother and child vertical transmission
and degree of liver disease. HCV infected pregnant women with pruritus or jaundice
have increased the risk of intrahepatic cholestasis
of pregnancy. Assessment of ALT, AST and bile acids should be done. HCV
infected women should be counseled about the increased risk of adverse maternal
and perinatal outcomes. Antenatal and perinatal care should be coordinated with
a maternal-fetal medicine
There can be pre-term delivery, low birth infants and congenital
anomalies with maternal HCV infection. However, pregnant women with cirrhosis
are at increased risk for the poor maternal outcomes like preeclampsia,
hemorrhagic complication, and death. Pregnancy itself does not appear to
negatively affect chronic HCV infection. Serum ALT level decrease during the
third trimester and increases after delivery.
Breastfeeding is not a risk for HCV transmission. Studies showing
similar rates of maternal infection in breastfed and bottle-fed infants. In
breastfeeding women have cracked nipples, bleeding, they should refrain from
breastfeeding. Women with HCV infection should have their HCV RNA evaluated approximately
9-12 months after delivery to assess for spontaneous clearance.
