HEPATITIS INFECTION DURING PREGNANCY.pptx

HEPATITIS DURING PREGNANCY

1. HEPATITIS DURING PREGNANCY 1

2. Summary of Physiologic Changes Increased: Blood volume and cardiac output rise by 35% –50% Alkaline phosphatase levels rise threefold or fourfold due to placental production Clotting factor changes create a hypercoagulable state 2

3. Cont Physiologic changes…. Decreased : Gallbladder contractility Haemoglobin U ric acid levels Albumin " total protein" and antithrombin concentrations 3

4. Cont Physiologic changes… No change : L iver aminotransferase levels (aspartate aminotransferase), Alanine aminotransferase, gamma&glutamyl transferase ) Bilirubin level P rothrombin time 4

5. The impact of pregnancy on the hepatitis The course of most viral infections is not affected by pregnancy T o made the pathogenetic condition viral exacerbations and complicated T he high incidence of severe hepatitis and hepatic coma 5

6. Hepatitis on pregnancy F irst trimester Hyperemesis gravidarum increased The high incidence of abortion and fetal malformation A ssociated -with the incidence of down syndrome S econd and third trimesters Higher incidence of hypertensive disorders in pregnancy Higher incidence of postpartum hemorrhage 6

7. Liver disease in pregnancy Three possible etiologic relationship : 1. The patient has a liver disease induced by pregnancy; -acute fatty liver disease of pregnancy -intrahepatic cholestasis of pregnancy -hyperemesis gravidarum -preeclampsia or HELLP syndrome 7

8. 2. The patient has developed a new liver disease During pregnancy mainly hepatobiliary disease. 3. The patient has pre-existing chronic liver disease, mainly chronic hepatitis B and C 8

9. HAV(Hepatitis A Virus) There is no evidence that HAV causes birth defects T here is no evidence of maternal & fetal transmission In rare circumstances in w hich the mother has acute HAV infection at the time of delivery immune serum globulin may be administered to the infant E ven under these conditions" the risk of transmission to the infant seems very small Anti&HAV IgG antibodies is not transmitted from infected mothers to new-born infants 9

10. HBV(Hepatitis B Virus) 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 T he risk of transmission is highest in mothers who are HBeAg positive at the time of delivery New-born baby has a 40% likelihood of becoming infected Appro x imately 65% of infected infants will become chronic carriers 10

11. HCV(Hepatitis C Virus ) The rate of vertical transmission of hepatitis C is less than 5 % The risk is higher: If the mother is co-infected with HIV I f she is viremic at the time of delivery I f her viral DNA load is greater than 1 million copies/ml I f the time from the rupture of membranes to delivery is more than 9 hours 11

12. HEV(Hepatitis E Virus) Transmission occurs intrapartum and peripartum through close contact of mother and neonate S ignificant 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 12

13. HGV(Hepatitis G Virus) M ost cases of hepatitis G are transferred through contaminated blood products I t is most commonly found among individuals infected with hepatitis C or HIV P erinatal transmission does occur however, evidence suggests that it does not cause clinical disease in newborns Currently no therapy is available other than prevention 13

14. Diagnoses E pidemiological history Clinical manifestations L aboratory studies ; T he most useful tests are 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 T he differential diagnosis with other forms of viral hepatitis requires serologic testing for a virus&specific diagnosis 14

15. Type of hepatitis during pregnancy Acute hepatitis Chronic active hepatitis Acute severe hepatitis 15

16. Acute Hepatitis Acute severe hepatitis Diagnostic points:- Severe gastrointestinal symptoms Rapidly deepening jaundice H epatic encephalopathy L iver function ;severely abnormal R enal failure Coagulopathy 16

17. Guidelines for severe hepatitis Protect the liver P revention of encephalopathy P revention of DIC P revention of hepatorenal syndrome 17

18. Management of Acute Viral Hepatitis in Pregnancy Establish type of serologic test Institute appropriate isolation and precautions Determine need for contact prophylaxis with serum globulin Preparation and/or vaccine Activity determined by tolerance Diet: patient preference, parentral if necessary Antiemetics : phenothiazines may be used Corticosteroids not indicated Immunoprophylaxis of infant: if hepatitis B is present 18

19. Responsibilities of perinatal Hepatitis B prevention program Assure identification of all HBsAg positive women and their infants Assure all exposed infants receive HBIG and 1st dose of hep. B vaccine with in 12 hours of birth Assure that all susceptible household and sexual contacts are vaccinated Assure completion of (doses of hepatitis B vaccine and post vaccination testing of exposed infants Conduct active surveillance and quality assurance and outreach to improve program 19

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 20

21. Cont…. The administration of hyperimmune globulin and HBV vaccine protects 90 % to 95 % of infants from HBV infection I t is recommended that 0.5 ml" of HBIG be given at birth and that three doses of HBV vaccine be given beginning at birth 21

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

23. ACOG Level A Recommendations Routine prenatal screening of all pregnant women by hepatitis B surface antigen (HBsAg ) testing is recommended  Newborns born to hepatitis B carriers should receive combined immuno prophylaxis consisting of hepatitis B immune globulin (HBIG) andhepatitis B vaccine within 12 hours of birth 23

24. Cont ACOG Recommendations Hepatitis B infection is a preventable disease, and all at-risk individuals, particularly health care workers, should be vaccinated .  All infants should receive the hepatitis B vaccine series as part of the recommended childhood immunization schedule . 24

25. Cont ACOG Recommendations …. Breast feeding is not contraindicated in : women with hepatitis A virus (HAV) infection with ppropriate hygienic precautions in those chronically infected with hepatitis B if the infant receives HBIG passive prophylaxis and vaccine ac4ve prophylaxis or in women with hepatitis C virus (HCV) infection . 25