EPIDEMIOLOGY AND PUBLIC HEALTH BURDEN

• Globally, about 325 million people were living with chronic hepatitis in 2015.Hepatitis B resulted in deaths, mostly from complications (including cirrhosisand hepatocellular carcinoma).1

• HBV prevalence in India is in intermediate range3. Every year 100,000 Indians diedue to HBV infection related illnesses.3

• In India, chronic hepatitis B (CHB) is acquired predominantly by horizontaltransmission in early childhood (mostly from family contacts) and to lesser extentby perinatal transmission4.

• Overall, the seroprevalence of HBsAg reported among pregnant females in threerecent studies that involved screening of 3686, 20104 and 4000 ranged from 0.9%to 1.1% respectively. HBV reportedly constitutes 25.6% of liver disease inpregnancy.4

• Likelihood that infection becomes chronic depends upon the age at which aperson becomes infected. Children less than 6 years of age who become infectedwith the hepatitis B virus are the most likely to develop chronic infections.So prevention of mother to child transmission is very important to decrease overall burden of hepatitis B in population5.

Chronic Hepatitis B: HBsAg Positive for more than 6 months

Question 1:Screening recommendations for Hepatitis B in pregnancy?

Universal screening for all pregnant women is recommended,to prevent chronic infected state in children there by, reducing disease burden of community.

Question 2: HbsAg positive – what further tests to do?

1) Clinical criteria

Clinical features of advanced liver disease/cirrhosis may include:Hepatomegaly, splenomegaly, pruritus, fatigue, arthralgia, palmar erythema, and edema.

Clinical features of decompensated cirrhosis:Portal hypertension (ascites, variceal hemorrhage and hepatic encephalopathy), coagulopathy, or liver insufficiency (jaundice)

2) Complete LFT including GGT

3) HBV viral load

4) HBeAg, Anti HBe,

5)Anti HBcIgM( only in those with clinical features suggesting acute infection)

6) Baseline renal function ( Creatinine , Urine dipstick for proteinuria)

7) Hemogram,PT8) Alfa feto protein9) USG whole abdomen

Question 3:Management of Hepatitis B carrier in pregnancy?

Chronic Hepatitis B carrier with pregnancy, treatment is not generally indicated, but monitoring is required for reactivation and hepato cellular carcinoma.

●Monitor ALT and AST monthly

Q4:Management of chronic active Hepatitis B in pregnancy?

Patient education:

●Risk of maternal liver disease status

●Effect on fetal development

●Vertical transmission

●Long term plan for treatment and followup care

Treatment indications for chronic Hepatitis B infected patients:

The treatment does not differ from non-pregnant state as maternal life is at stake.

• All patients with cirrhosis should be referred to Gastroenterologist for furthercare.

• All further complications of decompensated cirrhosis in pregnancy should bedealt with in consultation with Gastroenterologist.

Question no.5:When to do viral load in pregnancy with Hepatitis B infection?

1)For Inactive HBsAg carriers HBV DNA should be done at 26 weeks( normal ALT,HBeAg negative, anti HBe positive, normal ultrasound)

2) In others who does not fit into above criteria HBV DNA level should be checked twicea.

a. First at booking – to treat motherb.

b. Again at 26 weeks- for mother to child transmission prevention

Question 6:When to start antivirals for preventing mother to child transmission in pregnancy and when to stop in postpartum period in postpartum period ?

Start at 30 weeks

To continue till 6 weeks postpartum

Question no.7 :What antivirals to be used in pregnancy?

Tenofovir disoproxil fumarate – dosage 300 mg/day once daily

Question no. 8: Hbs Ag negative couple management?

The couple should be screened for HBsAg.If the couple is known to be HBsAg negative, hepatitis B vaccine should be given in the 0–6 weeks–6 months schedule.( Ideally for all, atleast for those with close family contacts of Hepatitis B positive individuals)