Hepatitis in Pregnancy

1. Hepatitis in Pregnancy Woman’s Hospital School of Medicine Zhejing University He jin

2. Summary of physiological changes in the liver during pregnancy Increased: Blood volume and cardiac ouput rise by 35%–50% Alkaline phosphatase levels rise threefold or fourfold due to placental production Clotting factor changes create a hypercoagulable state Decreased: Gallbladder contractility Hemoglobin Uric acid levels Albumin, total protein, and antithrombin III concentrations No change: Liver aminotransferase levels (aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase) Bilirubin level Prothrombin time

3. The impact of pregnancy on the hepatitis • The course of most hepatitis viral infections is not affected by pregnancy • To made the pathogenetic conditionviral exacerbations and complicated • The high incidence of severe hepatitis and hepatic coma

4. Hepatitis on pregnancy • First trimester • Hyperemesis gravidarum increased • the high incidence of abortion and fetal malformation • associated with the incidence of Down syndrome • Second and third trimesters • a higher incidence of hypertensive disorders in pregnancy • a higher incidence of postpartum hemorrhage

6. Vertical transmission of hepatitis virus (Mainly by hepatitis B)

7. HAV • There is no evidence that HAV causes birth defects • There is no evidence of maternal-fetal transmission • In rare circumstances in which the mother has acute HAV infection at the time of delivery • immune serum globulin may be administered to the infant • Even under these conditions, the risk of transmission to the infant seems very small • Anti-HAV IgG antibodies is not transmitted frominfected mothers to newborn infants

8. HBV • Evidence suggests that transmission of HBV to infants is common • when mothers have acute infection in the third trimester • when they are chronic carriers of HBV infection and have positive results for HBeAg or HBV DNA • The risk of transmission is highest in mothers who are HBeAg - positive at the time of delivery • Newborn baby has a 90% likelihood of becoming infected. • Approximately 25% of infected infants will become chronic carriers.

9. The rate of vertical transmission of hepatitis C is less than 5% The risk is higher if the mother is co-infected with (HIV) if she is viremic at the time of delivery if her viral DNA load is greater than 1 million copies/ml if the time from the rupture of membranes to delivery is more than 6 hours. HCV

10. Transmission occurs intrapartum and peripartum through close contact of mother and neonate. Significant vertical transmission among HEV-RNA positive mothers of up to 50%. Among women with symptomatic infection the rate of transmission is up to 100%, with significant perinatal morbidity and mortality. HEV

11. HGV • Most cases of hepatitis G are transferred through contaminated blood products. • It is most commonly found among individuals infected with hepatitis C or HIV. • Perinatal transmission does occur, however, evidence suggests that it does not cause clinical disease in newborns. • Currently no therapy is available other than prevention

12. Diagnoses • Epidemiological history • Clinical manifestations • Laboratory Studies : the most useful tests • evaluation of urine bilirubin and urobilinogen, total and direct serum bilirubin, ALT and/or AST, alkaline phosphatase, prothrombin time, total protein, albumin, complete blood count, and in severe cases serum ammonia. • the differential diagnosis with other forms of viral hepatitis requires serologic testing for a virus-specific diagnosis. • Type of hepatitis during pregnancy

13. Type of hepatitis during pregnancy • Acute hepatitis • Chronic active hepatitis • Acute severe hepatitis

14. Differential Diagnosis of Liver Disease in Pregnancy

15. Management of Acute Viral Hepatitis inPregnancy

16. Acute severe hepatitisDiagnostic points • Severe gastrointestinal symptoms • Rapidly deepening jaundice • Hepatic encephalopathy • Liver function :severely abnormal • Renal failure • Coagulopathy

17. Guidelines for severe hepatitis • Protect the liver • glucagon - insulin - glucose • Prevention of encephalopathy • control blood ammonia • control protein intake • Prevention of DIC • Prevention of hepatorenal syndrome • Strict limits on the amount of fluid

18. Obstetrics treatment • Early pregnancy: acute hepatitis • Mild should be actively treated, can continue the pregnancy. • Scend and third trimester • try to avoid termination of pregnancy • avoid surgery • avoid drugs on liver • Intrapartum: • Vitamin K1 • Fresh blood • Prevention of prolonged labor • To prevent the birth canal damage and residual placenta.

19. Obstetrics treatment • Severe hepatitis • the active control • termination of pregnancy after 24 hours • cesarean section • Postpartum • Rest • nutrition • Protect the liver

20. HBV • Taking lamivudine before becoming pregnant and continuing to take it throughout the pregnancy • lower rates of transmission of the virus from mother to newborn • Lower transmission rates have also been seen in pregnant women with a high viral DNA load

21. HBV • The administration of hyperimmune globulin and HBV vaccine protects 90% to 95% of infants from HBV infection. • It is recommended that 0.5 ml, of HBIG be given at birth and that three doses of HBV vaccine be given beginning at birth.

22. HCV • The mode of delivery does not seem to influence the rate of transmission from mother to child • Infection prior to delivery has been shown to occur in as many as 33% of patients • An elective cesarean section has been suggested for patients co-infected with HIV • reduce maternal-fetal transmission by up to 60%

23. Gestational Diabetes

24. Definition: • CHO intolerance of variable severity that begins or is first recognized during pregnancy. • Applies regardless of whether insulin is used for treatment or the condition persists after pregnancy. • Does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy.

25. Classification of Diabetes

26. Class A: Abnormal GTT at any age or of any duration treated only by diet therapy A1 -Diet Controlled GDM A2 -Insulin-treated GDM Classification of Diabetes in Pregnancy

27. Maternal: Hypoglycemia Infection Ketoacidosis Deterioration in retinopathy’ Increased proteinuria+edema Miscarriage Polyhydramnio Shoulder dystocia Preeclampsia Increased caesarean rate Future type 2 diabetes Fetal: Congenital abnormalities Increased neonatal and perinatal mortality Macrosomia Birth trauma Late stillbirth Neonatal hypoglycemia Polycythemia Jaundice Hyperbilirubinemia Complications of pregnancy in GDM

28. RISK FACTORS FOR GDM • Previous diagnosis of GDM • A strong FH of type 2 DM • Previous delivery of a macrosomic infant • Member of a high-risk population (Aboriginal, Hispanic, South Asian, Asian or African descent) • Age  35 years • Obesity (BMI  30 kg/m2) • Polycystic ovarian syndrome and / or hirsutism • Acanthosis nigricans • Corticosteroid use

29. Screening-cont: Women (at low risk) with ALL of the following characteristics need not be screened with a laboratory blood glucose test. • Less than 25 years of age • Normal body weight with BMI < 25 • No first degree relative with DM • Not a member of an ethnic group at increased risk for type 2 DM: women of Hispanic, African, Native American, South or East Asian or Pacific Islands ancestry • No hx of abnormal glucose metabolism • No hx of poor obstetric outcome

30. Screening-cont: • For women who do not meet the above criteria, screening should be conducted at 24 -28 wks of gestation with use of a 50 g one hour oral glucose load • An abnormal one hour screening test with a venous plasma glucose of >140 mg/dL necessitates a full diagnostic 75g three hours oral glucose tolerance test (GTT)

31. SCREENING SCREENING All pregnant women between 24 and 28 weeks If multiple risk factors are present, assess during each trimester. 1hPG following 50-g glucose load at any time of day 1hPG=7.8-10.2 1hPG10.3 75-g OGTT. Measure FPG, 1hPG, 2hPG If 2 values are met or exceeded FPG  5.3 1hPG10.6 2hPG 8.9 GDM IGT of pregnancy If 1 value is met or exceeded

32. Gestational diabetesDiagnosis • WHO criteria 1998, 75 gm glucose fasting 2 hr (mmol/L) Impaired fasting glucose 6.1-6.9 IGT <or =7 and 7.8-11 DM >or = 7or > or=11.1

33. Dx of GDM with Use of a 100 gram Oral Glucose Load

34. Management • The goal is to prevent adverse pregnancy outcomes. • A multidisciplinary approach is used. • Patient is seen every 1-2 wks until 36 wks gestation and then weekly. • Patient is asked to keep an accurate diary of their blood glucose concentration.

35. Management • The glycemic targets associated with the best pregnancy outcome in GDM are: • Preprandial < 5.3 mmol/L • 1-hour postprandial < 7.8 mmol/L • 2-hour postprandial < 6.7 mmol/L • Women with GDM should carry out frequent fasting and postprandial home blood glucose monitoring in order to achieve glycemic targets.

36. Management • Blood glucose monitoring • Diet • Exercise • Physical activity should be encouraged • Insulin • Oral Hypoglycemic Medications

37. Know your blood sugar level & keep it under control You may have to test four times a day: In the morning before eating breakfast, referred to as the Fasting glucose level 1 or 2 hours after breakfast 1 or 2 hours after lunch 1 or 2 hours after dinner You may also have to test your glucose level before you go to bed at night. This is referred to as your nighttime or nocturnal glucose test. 37 of 42

38. Dietary Therapy • Nutrition therapy is the primary treatment of GDM, although evidence on the optimal diet is lacking. • Carbohydrate intake should be distributed over 3 meals and at least 3 snacks (one of which should be at bedtime). • Hypocaloric diets are not recommended. Refer to a dietitian

39. Insulin Regimen • Pt should check their fasting glucose and a 1 hour or 2 hour postprandial glucose level after each meal, for a total of four determinations each day. • If the fasting value is ≥ 5.8mmol/L, 2 hr value > 6.7mmol/L, insulin therapy needs to be initiated.

40. Insulin Regimen:

41. First trimester u/s and a fetal echo to assess congenital cardiac anomalies. Second trimester u/s to assess fetal growth. Twice weekly testing NSTs and amniotic fluid volume determination beginning at 32 wks gestation to assess fetal well-being. Antepartum Testing

42. Delivery • Timing and mode of delivery individualised • Early delivery may be indicated for: • women with poor glycemic control • pregnancies complicated by fetal abnormalities Otherwise, pregnancies are allowed to go to term.

43. Delivery • Most common complication = shoulder dystocia • 31% of neonates weighing >4,000g* • Data does not support the use of C-section to avoid birth trauma *13% error rate estimating fetal weight by untrasound

44. What is a reasonable approach? Offer elective C-section • Estimated fetal weight >4,500g • Patient history and pelvimetry • Discuss risks and benefits

45. Delivery No indications to pursue delivery before 40 weeks in patients with good glycemic control… *Unless other maternal or fetal indications are present

46. Intrapartum The goal is to maintain normoglycemia in order to prevent neonatal hypoglycemia. • Check patient’s glucose q1-2 hours. • Start insulin drip to maintain a glucose level of between 4.4-6.1mmol/L • Observe infant closely for hypoglycemia, hypocalcemia, and hyperbilirubinemia after birth.

47. Postpartum Care After delivery: • Measure blood glucose. -fasting blood glucose concentrations should be < 5.8mmol/L, and one hour postprandial concentrations should be < 7.8mmol/L • Administer one half of the pre-delivery dose before starting regular food intake.

48. Postpartum Care-cont: Follow up: • Per American Diabetes Association, a 75 g two hours oral GTT should be performed 6-8 wks after delivery.

49. Postpartum Care-cont: Follow up: • If the pt’s postpartum GTT is normal, she should be re-evaluated at a minimum of 3 years interval with a fasting glucose. • All pts should be encouraged to exercise and lose wt. • All pts should be evaluated for glucose intolerance or DM before a subsequent pregnancy.

50. Thanks four your listening