Hepatitis B Infection in Pregnancy

Hepatitis is a contagious liver disease that causes inflammation of the liver. It occurs when a person is infected with Hepatitis B virus (HBV). Once infected, the virus can dwell in the person’s body for the rest of his or her life and cause chronic problems. It is important that an expecting woman gets herself tested for Hepatitis B. If the result of the HBsAg test is positive, the doctor should prescribe proper vaccines and medications to lower the risk for her unborn baby.

What is Hepatitis B?

Hepatitis B is the term used for describing inflammation of the liver, and is caused by a virus. It is usually transmitted through body fluids like blood, vaginal fluids or semen. It can be warded off sooner if you have a good immune system. Often, infected people tend to carry the virus leading them to suffer from chronic Hepatitis. It may cause serious damage to the liver. This damage can be slowed down by getting good medical care and following a healthy lifestyle. Hepatitis B may be classified into two kinds:

Acute Hepatitis B Infection

Most adults who are infected have the acute Hepatitis B infection. Their immune system can usually clear the virus from the body in about 2-3 months. In some cases, it may lead to chronic infection.

Chronic Hepatitis B Infection

When one’s immune system is incapable of fighting off the acute Hepatitis infection, and it lasts for 6 months or more, it results in chronic Hepatitis B infection. This can lead to major complications such as liver cancer or cirrhosis.

Hepatitis B & Pregnancy

If you are pregnant and infected with Hepatitis B, you hold the risk of passing on the virus to your baby. To prevent such situations, a routine blood test is recommended for all pregnant women to determine the presence of Hepatitis B. A Hepatitis B reactive or HBsAg positive would mean the presence of Hepatitis B virus in the blood. In case you have the virus, there are certain vaccinations which can be administered post-delivery, which protect your baby. There are even some medications and Hepatitis B vaccines in pregnancy, for those whose virus levels are high.

How Common is Hepatitis B?

About 10-15% of the world’s population is carriers of Hepatitis B. It is quite prevalent in India where around 100,000 Indians die from Hepatitis infection every year. Besides, it is one of the major causes of liver cancers, chronic liver disease and cirrhosis.

Pregnant? Should You Be Tested for Hepatitis B?

Some studies have estimated that about 0.8-6.3% of expecting women are tested positive for Hepatitis B. In immune-competent adults, an acute Hepatitis B virus is likely to be cleared soon. But through perinatal transmission of HBV, children carry a high risk of illness like liver carcinoma and liver cirrhosis. About 90% of babies infected at delivery tend to become chronic carriers of the virus. Hence, if you are pregnant, it is necessary to get tested for Hepatitis B infection. If you are infected with HBV, you should focus on preventing transmission of the virus to your baby.

How Does HBV Spread?

Hepatitis B virus is most commonly spread if you come in contact with body fluids like blood, saliva or semen of infected persons. However, it can be difficult to detect the exact cause of HBV, for it takes a long time to showcase its signs. The most common ways in which the virus may spread are:

• Medical or dental treatment in a place where sterilisation does not take place properly.
• Having a blood transfusion without examining the blood for the presence of the virus.
• Mother to child: A pregnant woman, who is infected with HBV, may transmit the virus to her baby during delivery or post-delivery.
• Sharing of Needles: Using shared needles or syringes for injections.
• Sexual contact: Having unprotected sex with a hep B-infected person.
• Through needle injury to persons working in a healthcare division.
• Infected blood getting in your body through some open wound or scratch.
• Through contaminated needles used for piercing and tattoos.
• Sharing a razor or toothbrush with an infected person.
• Accidental needle sticks: It is a major concern for those working in healthcare centres and others who come in contact with human blood.

Symptoms of Hep B in Pregnancy

Many times, pregnant women are unaware that they are infected with HBV. It is because symptoms of Hepatitis B are hard to diagnose. They appear at a later stage and may be felt only vaguely. The symptoms become noticeable almost 2-3 months after being infected by the virus. Although, there are cases where some of the signs tend to come and go. Some of these include:

• Abdominal pain
• Fatigue
• Nausea
• Stomach ache
• Diarrhoea
• Vomiting
• Loss of appetite
• Jaundice
• Fever
• Difficulty in breathing

Effect of Hepatitis B on Pregnancy & Baby

Generally, if you are infected with Hepatitis B in pregnancy, it doesn’t have any adverse effect on the unborn baby. But this depends on the viral load in your blood. If the level is high, there are slight chances of your baby getting affected before birth. In case of acute infection, there are increased chances of low birth weight and premature birth, whereas, for the mother, the possible effects of HBV infection include gestational diabetes mellitus and antepartum haemorrhage.

The baby is at utmost risk during the delivery as he is exposed to maternal blood and faeces. If the baby gets infected at that stage and goes untreated, he is at risk of developing a lifelong liver disease. Hence, it is essential that the mother gets Hepatitis B therapy while pregnant, to lower the risk of passing on the infection to the baby.

Can You Breastfeed with Hep B?

In normal cases, breastfeeding by an infected mother does not stimulate the transmission of HBV to the baby. Although HBV is found in breast milk, researchers state that it is safe for an infected mother to nurse her baby. It is because the baby is already exposed to the virus at delivery and hence, immunised at birth with hep B vaccinations. But it is strictly recommended that the mother take good care of her nipples throughout the period of breastfeeding. If the nipples crack or bleed, there arises the risk of transmitting HBV to the baby through blood. In such cases, the mother should bottle-feed the baby with either the expressed milk or formula milk until the nipples heal.

Risk of Mother to Baby Transmission

A pregnant woman is usually recommended to get HBsAg test done. For, if she is infected with HBV, there is a high risk that she may pass on the virus to the baby. There are three main ways in which transmission of HBV may take place. These are:

Transplacental Transmission of HBV In Utero

In general, it is difficult for the virus to cross the placenta in the womb. However, there are cases, when it may happen. The possible causes for intrauterine transmission of Hepatitis B virus are listed as follows:

• A breach of the placental barrier
• Placental infection

Transmission During Delivery

The baby is at optimum risk of catching the Hepatitis B virus from the mother during this period. The reasons for transmission of HBV during birth are:

• Exposure to the cervical secretions of the infected mother
• Exposure to maternal blood containing the virus

Postnatal Transmission During Care or Through Breastfeeding

Breast milk of an infected mother does not pose a risk to the infant but bleeding nipples can infect the baby. It is recommended that the mother safeguard her nipples while breastfeeding. She should ensure proper latch-on and allow the nipples to dry to avoid cracking or bleeding as HBV can be transmitted through blood.

Treatment of Hepatitis B in Pregnancy

When you are tested positive for Hepatitis B in early stages of pregnancy, doctors may recommend certain blood tests. Depending on viral load in your system and whether it’s acute Hepatitis b reactive or a chronic one, you may be prescribed a shot of the vaccine Hepatitis B immune globulin (HBIG). This vaccine contains antibodies against the Hepatitis B virus and thus, gives additional protection. In case, your condition is serious, the doctor may advise on conducting a liver biopsy, to determine if your liver has been damaged. As per the severity of your infection, you may be required to undergo following treatments:

Antiviral Medications

There are certain drugs that have been approved by the FDA for treatment of Hep B in pregnancy. These antiviral medications are prescribed when your liver is not working well enough and the peginterferon alpha 2a injection is not suitable for you. The side effects include vomiting, feeling sick and dizziness. These drugs have to be taken as per doctor’s advice.

Peginterferon Alpha 2a or Interferon Alpha 2b

It is the initial medication offered if your liver is fairly well. It is also a solution for those not willing to undergo long-term treatment. Doctors recommend it once a week for up to 48 weeks. It stimulates the immune system to fight and regain control over the HBV. It has some common side effects like fever, joint pain and other flu-like symptoms. Some may also experience chest tightness, depression and difficulty in breathing.

Liver Transplant

Liver transplant is the last option, when your liver has been severely damaged and no other treatment would work. During the liver transplant, the surgeon replaces your damaged liver with a healthy one.

Hepatitis B & Pregnancy Complications

Hepatitis B is an endemic liver infection, caused when the person is infected with Hepatitis B virus. For most adults with strong immune system, recovery is within 2-3 months. But for those women for whom the infection has lasted for about 6 months, it results into a chronic Hepatitis B. This increases the risk of permanent scarring of the liver. Certain complications may develop as indicated below:

Acute fatty liver

This condition arises when you have had the infection for a long period and the liver has been affected by cirrhosis. The increased demands on your liver during pregnancy causes this additional health issue. Sometimes this condition may escalate and become severe. In such case, you will require immediate medical intervention and may be suggested early delivery. It is recommended you pay attention to your diet and intake foods that are liver friendly.

Gallstones (cholelithiasis)

It is found among approximately 6% of pregnancies. This occurs due to change in bile salts during pregnancy. In a pregnant woman, the gallbladder slows down. As a result, the emptying process happens slowly and causes collection of bile salts for a longer duration. This condition can cause jaundice or may worsen, where removal of gall bladder becomes necessary.

Cirrhosis

Cirrhosis defines scarring of the liver and affects one in five people suffering from chronic Hepatitis B. Its symptoms get noticeable very late when extensive damage has already been done to the liver. At such a stage, it causes weight loss, sickness, itchy skin, swelling in the tummy and ankles, loss of appetite and fatigue.

Hepatocellular carcinoma or Liver cancer

One in 20 people suffering from cirrhosis have the potential to develop liver cancer. Symptoms for liver cancer include feeling sick, unexplained weight loss, jaundice and loss of appetite.

Liver failure

This condition arises when almost all the vital parts of the liver stop functioning. In such a case, liver transplant becomes mandatory to sustain life.

Fulminant Hepatitis B

In some cases, acute Hepatitis B can get elevated to a serious problem of fulminant Hepatitis B. This is a rare condition and it happen s about 1 in 100 cases. In this circumstance, the immune system itself attacks the liver and causes serious damage, requiring prompt treatment. Its symptoms include severe jaundice, delirium, collapsing and swelling of the tummy.

Precautions for Hepatitis B While Pregnant

Hepatitis B vaccines are available to guard the babies against being infected by Hepatitis B. Those are given to them as per the routine vaccination schedule for babies. Apart from the vaccinations, there are general precautionary measures to be considered. It is advisable that the following points are taken seriously, so that you can reduce the risk of getting infected.

Know the HBV status of your partner

It is highly recommended that you stay away from unprotected sex, unless you are sure that your partner is clear from all infections.

Use a latex or polyurethane condom during each intercourse

If you are unaware of the HBV status of your partner, try not to rely completely on any condom. Though condoms can reduce the transmission risk, there can be exceptions. Prefer only the branded ones and use a new one for each time.

Avoid using illicit drugs

Keep away from taking unnecessary drugs without doctor’s prescription. Even if you have to take the injection, ensure that you use a sterile needle. Do not share the used needles.

Be careful about piercings or body tattoos

If you wish to get any piercings or tattoo done on your body, prefer a reputed centre. Ask in detail about the equipment used and its cleaning methods. Make sure that sterile needles are used. If not, you should look for other options.

Don’t share personal belongings

Do not share razor blades or toothbrushes, as they might carry traces of infected blood. Any open sores, abrasions or cuts should be immediately covered with a waterproof dressing.

Enquire about Hepatitis b vaccine before your travel

When planning to travel to someplace, where Hepatitis B is common, consult your doctor regarding hep B vaccination.

Post Pregnancy Follow-Up

At the time of birth, the baby should be given two injections, which are a dose of Hepatitis B and a dose of Hepatitis B immune globulin. These shots should be administered within the first 12-hour period immediately after delivery. With these two injections, there is a 90% chance of protecting the baby against lifelong Hepatitis B infection. Apart from these doses, two more doses are given. One is given at 2-3 months of age and the next at 6 months. Babies born to an HBsAg-positive mother, should be strictly followed up for medical review. This follow-up should be timed after 2 months of initial immunisation course, which lasts for 8 to 12 months. During this follow-up, the baby’s blood should be tested for presence of Hepatitis B virus. If the mother is infected, she needs to be followed up post pregnancy every 12 months. This is done to assess their viral markers and liver functioning.

Conclusion

Prenatal care to check the risk of such infections is a must for every pregnant woman. Even if they are previously vaccinated or tested, a mandatory test for the virus in the first trimester is an absolute essential.