Caring for Pregnant

Women and Newborns

with Hepatitis B or C
http://www.aafp.org/afp/2010/1115/p1225.html

Maternal infection with hepatitis B virus (HBV) or hepatitis C
virus (HCV) can expose the newborn to a subsequent chronic hepatitis
infection. However, perinatally acquired HBV is a largely preventable
condition. The risk of vertical transmission depends on the time at which
the pregnant woman acquired HBV infection, and on her statuses of
hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg).
Without prophylaxis, the risk of perinatal HBV infection in an infant with
an HBsAg positive mother is less than 10 percent if the mother's HBeAg
status is negative, but is 70 to 90 percent if her HBeAg status is positive.
1

If infected at birth, an infant has approximately a 90 percent chance of
becoming a chronic HBV carrier and, when chronically infected, has a 15
to 25 percent risk of dying in adulthood from cirrhosis or liver cancer.
2

However, the combination of hepatitis B vaccine and hepatitis B immune
globulin is 85 to 95 percent effective in reducing HBV infection from
vertical transmission when given within 12 hours of birth.

Hepatitis B
The overall U.S. prevalence of HBV infection is 4.9 percent.
1
For
infants and children, the two primary sources of HBV infection are
vertical transmission from infected mothers during pregnancy, and
horizontal transmission from infected household contacts after birth.
1

MATERNAL TREATMENT
Proper management of maternal hepatitis during the prenatal phase
ensures better outcomes in the infant. Pregnant women who are positive
for HBsAg should be referred to the appropriate local case management
program, as well as for counseling and medical management of HBV
infection.
10,11
Patients should be advised that all household, sexual, and
needle-sharing contacts should be tested for HBV and vaccinated if not
infected. Patients should also be educated about the need for infant
immunoprophylaxis at birth. If risk factors for HBV infection exist during
their pregnancy, women should receive the hepatitis B vaccine series
regardless of HBsAg status.
12

Pregnant women who are positive for HBsAg should be referred to
a subspecialist for evaluation and management of chronic HBV
infection.
12
Therapeutic agents have been approved by the U.S. Food and
Drug Administration for the treatment of chronic HBV infection. Most of
these medications are pregnancy category C; however, telbivudine
(Tyzeka) and tenofovir (Viread) are pregnancy category B
medications.
13,14
Recent research demonstrated some potential benefit
from lamivudine (Epivir) in decreasing the risk of in utero HBV infection
during the last months of pregnancy
15
; however, this intervention is of
limited value because transmission usually occurs at the time of delivery.
Hospitalization of pregnant women with acute HBV infection is
recommended if there are any signs of liver decompensation, such as
ascites, hepatic encephalopathy, jaundice, coagulopathy, or variceal
bleeding. Patients should remain hospitalized until treatment is initiated
or liver function test results improve.
6


PERINATAL PREVENTION AND TREATMENT
Newborns are most commonly infected with HBV via exposure to
infected maternal blood at the time of delivery. In utero infection is
uncommon, representing no more than 5 percent of perinatal HBV
infections.
16
Factors that seem to be associated with in utero infection
include the presence of maternal HBeAg, history of preterm labor, high
HBsAg and HBV DNA titers, and the presence of HBV DNA in villous
capillary endothelial cells.
16
No evidence exists that caesarean delivery
provides additional protection against transmission. Women with HBV
infection should be counseled that breastfeeding does not increase the
likelihood of infection in their children.
17

Communication among members of the health care team is
important to ensure proper preventive techniques are implemented, and
standing hospital orders for HBV testing and prophylaxis can reduce
missed opportunities for prevention. Prevention of perinatal HBV
infection begins with good communication regarding maternal HBV
status before delivery. The Centers for Disease Control and Prevention's
Advisory Committee on Immunization Practices recommended in 2005
that delivery hospitals implement policies and procedures designed to
identify and administer prophylaxis to infants at increased risk of
perinatal HBV transmission.
1,18
A 2006 Cochrane review concluded that
hepatitis B immune globulin and hepatitis B vaccine, alone or combined,
reduce transmission of HBV compared with placebo or no intervention;
that hepatitis B immune globulin plus hepatitis B vaccine was superior to
hepatitis B vaccine alone; and that adverse events associated with
prophylaxis were minor and uncommon.
19

Because they are at the highest risk of infection, newborns of
HBsAg-positive mothers should receive hepatitis B immune globulin and
hepatitis B vaccine within 12 hours of birth. Newborns of mothers with
unknown HBV status should also receive vaccine within 12 hours of
birth, and maternal HBsAg serology should be obtained. If the mother is
positive for HBsAg, hepatitis B immune globulin should be administered
as soon as possible. Newborns of HBsAg negative mothers should begin
the hepatitis B vaccine series before hospital discharge. This practice
reduces missed opportunities to prevent transmission in cases of
communication errors regarding maternal HBsAg status. Preterm infants
weighing less than 4 lb, 6 oz (2,000 g) should receive modified dosing
schedules based on concerns about adequacy of immune response.
Recommendations for the care of newborns based on maternal HBsAg
status are summarized in Table 2.
1
Completion of the infant hepatitis B vaccine series can be
accomplished with a variety of single-ingredient or combination products.
However, combination products should be used only in infants older than
six weeks. Infants of HBsAg-positive mothers should complete three
doses of vaccine by six months of age. After completion of the vaccine
series, infants of HBsAg-positive mothers should be tested for hepatitis B
surface antibody (anti-HBs) and HBsAg in order to evaluate response to
the vaccine and rule out perinatal infection. This testing should be
conducted between nine and 18 months of age; before nine months, anti-
HBs related to hepatitis B immune globulin administration could be
present, interfering with interpretation of results. Infants with anti-HBs
levels less than 10 mIU per mL should be revaccinated with a second
three-dose vaccine series and then retested for anti-HBs one to two
months after completion of the series.
18
CDC Recommendations for HBV Vaccination of
Infants
http://www.hepb.org/patients/infant_vaccination_cdc_summary.ht
m

First Dose: Birth to two months. Children whose mothers are
hepatitis B surface antigen positive or whose hepatitis B
surface antigen status is unknown should get this dose within
12 hours of birth.
All infants should receive the first dose of hepatitis B vaccine
soon after birth and before hospital discharge; the first dose
may also be given by age 2 months if the infant's mother is
hepatitis B surface antigen negative. Only monovalent
hepatitis B vaccine can be used for the birth dose. Monovalent
or combination vaccine containing Hep B may be used to
complete the series; four doses of vaccine may be
administered if combination vaccine is used.
Infants born to hepatitis B surface antigen positive
mothers should receive hepatitis B vaccine and 0.5 milliliters
of hepatitis B immune globulin (HBIG) within 12 hours of birth
at separate sites.
Infants born to mothers whose hepatitis B surface
antigen status is unknown should receive the first dose of
the hepatitis B vaccine series within 12 hours of birth.
Maternal blood should be drawn at the time of delivery to
determine the mother's hepatitis B surface antigen status; if
the test is positive, the infant should receive H BIG as soon as
possible (no later than one week).
Second Dose: One to four months, but at least 4 weeks after
the first dose, except for Hib-containing vaccine which cannot
be administered before age 6 weeks.
For infants born to hepatitis B surface antigen positive
mothers, the second dose is recommended at age 1-2
months and the vaccination series should be completed (third
or fourth dose) at age 6 months.
Third Dose: Six to 18 months, but at least 16 weeks after the
first dose and at least 8 weeks after the second dose. The last
dose in the vaccination series (third or fourth dose) should not
be administered before age 6 months.
For infants born to hepatitis B surface antigen
positive mothers, the vaccination series should be completed
(third or fourth dose) at age 6 months.
LINK PDF

overview
http://www.perinatology.com/exposures/Infection/HepatitisB.htm
guideline
http://www.immunize.org/catg.d/p2130.pdf
flyer hep b in pregnant woman
http://www.cdc.gov/hepatitis/HBV/PDFs/HepBPerinatal-
ProtectWhenPregnant.pdf
journal
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1628803/pdf/archdisch
00728-0007.pdf