1 / 18

Management of hepatitis B in pregnancy

Management of hepatitis B in pregnancy. Dr. MOHINISH CHHABRA DM Gastroenterology SENIOR CONSULTANT DEPARTMENT OF GASTROENTEROLOGY FORTIS MULTISPECIALITY, HOSPITAL MOHALI. Hepatitis B and pregnancy. Perinatal transmission of HBV is major mode of transmission worldwide

abner
Download Presentation

Management of hepatitis B in pregnancy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of hepatitis B in pregnancy Dr. MOHINISH CHHABRA DM Gastroenterology SENIOR CONSULTANT DEPARTMENT OF GASTROENTEROLOGY FORTIS MULTISPECIALITY, HOSPITAL MOHALI

  2. Hepatitis B and pregnancy • Perinatal transmission of HBV is major mode of transmission worldwide • Immunoprophylaxis is of proven benefit in prevention of perinatal HBV transmission and is recommended • High maternal viremia is associated with higher rate of perinatal transmission • Should treatment be initiated in pregnancy?

  3. HBV prevalence High > 8% Intermediate 2-8% Countries with HBV vaccine birth dose 44% 53% Implementation of newborn vaccination world wide 2006 WHO data

  4. Case • 24 yr female presented with incidental detection of HBsAg + during blood donation • PMH Non contributory • Recently married, no children • Family history unknown • ROS Non contributory • P/E NORMAL

  5. CaseLaboratory • HBsAg positive • HBeAg positive • Anti HBe Negative • ALT 18, AST 20, AP 100, TSB 0.8 • CBC Normal • USG abdomen Normal • HBV DNA 5 x 109 IU/ml

  6. CASE

  7. CASE • Immune tolerant – Elect not to treat her • 8 months later she presents with pregnancy • What to do?

  8. Treatment during pregnancy2 separate issues • Treatment for woman’s benefit Why treat now? • Advanced disease • Already on treatment – concern for withdrawal flare • Concern for progression • Prevention of transmission to infant • No clear AASLD guidelines on treatment • Risk / benefit of treatment in 3rd TM

  9. Maternal HBV status HBV DNA + HBeAg + HBV DNA < 105 copies/ml 105-108 copies/ml > 108 copies/ml Perinatal transmission 3% 7% p = .039 0% 0% 8.5% p= .031 Wiseman et al, Med J Aust 2009;190:489492 HBV DNA level and perinatal transmission of HBV (N=138)

  10. Transplacental spread • Xu et al 402 HBsAg + pregnant women – 3.7% newborn infants were HBsAg + within 24 hours of birth, HBeAg + mothers intrauterine infection 9.8% , placental infection rate 44% Xu DZ et al J Med VIROL 2002;67:20-26 • Indian study- 11524 pregnant mothers screened 133 HBsAg +, babies screened for HBsAg, HBeAg, HBV DNA in serum and cord blood- 66% babies positive for HBV DNA in cord blood, 4% positive serum markers. Maternal HBV DNA 1.5 X 105 copies/ml significantly associated with intrauterine transmission Pande C et al, Abstract 252 DDW May 2008

  11. Hepatitis B and pregnancyTreatment dilemmas • Transmission risk > 8% is it worth treating the mother during pregnancy? • Do we know how much treatment will decrease the risk? • Concern that HBIG + vaccine at birth may not prevent infection in those born already infected supports the need to treat during pregnancy

  12. Lamivudine (N=56) HBsAg + 18% HBV DNA + 20% Anti HBs + 84% Control (N=59) 39% P= .014 46% P=.003 65% P=.008 Xu WM et al J Virol Hepat 2009;16:94-1003 Third trimester use of Lamivudine reduces the risk of perinatal transmissionInfant outcomes at week 52

  13. HBV transmissionTreated vs. Non treated % of infants HBsAg + Telbivudine Untreated n= 95 n=92 At birth 6.32% 30.43% p=<.001 28 Weeks 2.15% 13.04% p=.004 Han G et al, 615 AASLD 2010

  14. Antiviral agents used for treatment of chronic hepatitis B Agent Pregnancy category Adefovir C Entecavir C Lamivudine C Telbivudine B Tenofovir B

  15. Safety profile of LAM or TDF during pregnancy – The Antiretroviral pregnancy registry study Birth defect rate 1st TM 2nd/3rd TM Any retroviral 2.8% 2.5% Exposure (n) 4702 6100 LAM 2.9% 2.5% Exposure (n) 3314 5017 TDF 2.4% 1.7% Exposure (n) 756 461 Normal pregnancy 2-3%

  16. CASE • After discussion of risk/benefits of treatment patient opts for treatment in 3rd TM starting at 32 weeks • HBV DNA drops by 5 logs by delivery • Infant receives HBIG/ vaccine within 12 hours • Mother expresses her desire to breast feed the baby for at least 5 months a) Stop antiviral treatment b) Advise against breastfeeding to minimize the risk of transmission of HBV to newborn c) Continue antiviral given its safety profile in pregnancy d) Switch to Tenofovir/Telbivudine as Pregnancy category B drug

  17. Hepatitis B and breast feeding • Is HBV transmitted through the breast milk? • Are anti viral safe to take while breast feeding? • What is the risk to the mother of discontinuing anti viral during the breast feeding period?

  18. TAKE HOME PEARLS • Vaccination/ immunoprophylaxis is the MOST important preventive strategy • Perinatal transmission risk is greatest in those with high maternal viremia : HBV DNA > 8 logs • Third trimester treatment may reduce the risk of HBV transmission, but data is limited: Risks /benefit to be discussed • Breast feeding is safe

More Related