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H epatitis B and C during pregnancy and lactation

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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  1. Hepatitis B and C during pregnancy and lactation Anne Kirss Women’s Clinic of Tartu University Hospital 15.09.2006

  2. 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

  3. 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

  4. Hepatitis B and C and pregnancy • Do not influence the course of pregnancy

  5. HBV infection • Is not teratogenic • Acute hepatitis may cause: • Prematurity • Low birth weight

  6. 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 mothers 10-20% • HBsAg +HBeAg positive mothers 90% • 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%

  7. Amniocentesis • The risk of HBV transmission is low • Noninvasive methods of following the fetus should be preferred (ultrasound) • Avoid passing the needle through placenta

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Lamivudine • In HIV infection the potential benefit is bigger • Lactation • Concentrates in breast milk • serum/milk 1:3 • Breast-feeding is not recommended

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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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