Approach hepatitis B in Pregnancy

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Approach to Hepatitis B in Pregnancy:

Approach to Hepatitis B in Pregnancy Dr. Rakesh Kumar.Adi M.D., (D.M)

Background:

Background Of the estimated 350 million individuals with chronic HBV worldwide, atleast 50% acquired their infections perinatally . 90% of infected infants will become chronic carriers of hepatitis B 25% of those infected will die of HBV-related disease Liver International 2009; 29 : 135

Case Scenario:

Case Scenario A 24-yr-old women, who is 20 weeks pregnant is tested positive for hepatitis B on routine antenatal checkup. She has no symptoms / signs of liver disease Her LFT : Bil < 1 mg/dl ; HbsAg +ve AST/ALT < 40 U/L

Issues for Doctor:

Issues for Doctor How to manage her ? What is the risk of perinatal transmission hep B to infant ? How to minimize the risk of maternal-fetal transmission ?

Contd….:

Contd…. Can Antiviral Treatment reduce vertical HBV Transmission? Post Exposure Prophylaxis (PEP) for infant against hep B infection ? What about breastfeeding ?

Natural History of HBV Infection:

Natural History of HBV Infection Fattovich G: Natural history of hep B. Semin Liver Dis  2003; 23 Optimal Treatment time Optimal Treatment time >95% <5% 2–15%/year 5%

Hepatitis B Lab Markers:

Hepatitis B Lab Markers HBsAg - Marker of current infection Anti-HBs - marker of resolved infection /immunity after immunization

Hepatitis B Lab Markers:

Hepatitis B Lab Markers HBeAg - marker of active replication, Identification of persons at increased risk for transmitting HBV Anti-HBe - Identification of person with lower risk for transmitting HBV HBV DNA - Viral load

Phases of Chronic HBV Infection:

Phases of Chronic HBV Infection Immune tolerant ALT –N , HBeAg +ve, antiHBe -ve Immune clearance ALT – INC ,HBeAg +ve, antiHBe -ve Inactive carrier ALT –N , HBeAg -ve , antiHBe +ve Reactivation ALT –INC , HBeAg -ve , antiHBe +ve Lancet 2009; 373: 582

How to manage Her ?:

How to manage Her ? LFT HBeAg Anti HBe HBV DNA ( 28 wks) Decide the phase of CHB Immune tolerant Inactive carrier Anti viral treatment not required

Risk of Perinatal Hep B Transmission ?:

Risk of Perinatal Hep B Transmission ? If mother positive for HBsAg and HBeAg * - 70%-90% of infants get infected - 90% of infected infants become Chronic Carriers If positive for HBsAg only * - <10% of infants infected - 90% of infected infants become Chronic Carriers *In the absence of PEP MMWR 2005:54:5

How to minimize the risk of transmission ?:

How to minimize the risk of transmission ? Antivirals to suppress the HBV in mother Post Exposure Prophylaxis (PEP) to infant

Anti virals to mother:

Anti virals to mother Role of maternal HBV DNA (28wks) on transmision HBV DNA < 10 8 copies/mL = 0% transmission HBV DNA > 10 8 copies/mL = 32% transmission World J Gastroenterol 2004; 10: 3215–7.

:

Lamivudine given 1 month before delivery in patients with HBV DNA > 10 8 copies/mL decreased transmission from 28.0% to 12.5% No complete prevention of transmission, even in case of successful LAM treatment Lancet. 2002;359;1488-1489 Contd…..

Post Exposure Prophylaxis (PEP):

Post Exposure Prophylaxis (PEP) Active plus passive immunization most effective to prevent vertical transmission This regimen has a protective efficacy of 95% USPSTF, Screening for Hepatitis B infection. Recommendation statement 2004

Regimen :

Regimen Dose #1 of Hep B vaccine in the thigh within 12 hrs of birth. & HBIG 0.5 ml in the opposite thigh IM within 12 hrs of birth but no later than 7 days . Liver International 2009; 29 : 135 -139

Contd….:

Contd…. Dose #2 of hepatitis B vaccine at 1-2 mons of age Dose #3 of hepatitis B vaccine at 6 mons of age The Infant < 2000 gms should receive a total of 4 hep B doses ( Do not count the birth dose as part of the hepatitis B vaccination series ) Liver International 2009; 29 : 135 -139

Post-vaccination testing:

Post-vaccination testing Post-vaccination testing (PVT) should be done in all infants after the third dose of hepatitis B vaccine. Ideally at the child’s 9 or 12 month visit

Post-vaccination testing:

Post-vaccination testing If HBsAg -ve & anti-HBs +ve > 10 mIU/mL  infant is protected If HBsAg -ve & anti-HBs <10 mIU/mL  revaccinate with 3-dose hep B series  retest 1–2 months after final dose If HBsAg +ve  refer infant for medical evaluation of chronic hepatitis B

Slide 20:

Mode of Delivery has No effect on HBV transmission All Neonates who are correctly immunized can be breast-fed Yang J, et al. Virol J 2008;5:100 Cornberg , et al. J Viral Hepat. 2008;15

Slide 21:

Algorithm for management of HBV Pregnant woman First trimester : Check HBsAg, anti HBs HBsAg (- ve) Initiate maternal HBV vaccination series Infant receives vaccine at birth HBsAg (+) 28 wks HBV DNA < 10 8 copies/mL Infant receives HBIg + vaccine at birth HBV DNA > 10 8 copies/mL ? treatment with lamivudine at 32 wks CLEVELAND J OF MEDICINE (76) MAY 2009

Take Home Message:

Take Home Message Perinatal is the most common mode of transmission of HBV Best prevention for transmission is active/passive immunization Post-vaccination testing should be done in all vaccinated infants Neonates that are correctly immunized can be breast-fed

Slide 23:

ThanQ

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