Adult viral hepatitis is the most common cause of jaundice in pregnancy. Hepatitis is the type of infection that can seriously damage your liver and if you are pregnant you can pass onto your baby. You can have one of three most common types of Hepatitis viruses A, B and C and usually, it won’t hurt your unborn baby or affect your pregnancy. If your doctor knows you have it, she can help you manage it during your pregnancy to lower the chances of any long-term liver disease for you and your baby.
Jaundice is the characteristic feature of the liver disease. The clinical signs and symptoms are indistinguishable from the various forms of hepatitis. Therefore, diagnosis requires serological tests for virus-specific diagnosis. Biochemical assessment of liver functions is also done.
Differential diagnosis includes mono-mere and EBV virus infection with liver failure, gallbladder disease, HELLP syndrome, acute fatty liver of pregnancy. The most useful tests to diagnose are urine bilirubin and urobilinogen, total and direct serum bilirubin, Alanine Aminotransferase (ALT), ALP, PT, total protein, albumin, CBC in some cases and serum ammonia.
Effects of Different Types of Hepatitis on Pregnancy
It is the most common cause of acute viral hepatitis in the general population but it is infrequently reported among pregnant women. It is transmitted via the fecal-oral route either by direct contact with the infected person or ingestion of contaminated food. Inoculation period is 15 to 40 days. It is common in developing countries owing to poor hygiene and sanitation systems. Transmission of HAV from mother to fetus is uncommon. If Hepatitis A infection
occurs in pregnant women. It can cause pre-term labor especially if infection occurs in 2nd and 3rd trimester. Hepatitis A infection is also associated with other complications like premature rupture of membranes, premature uterine contractions, and placental abruption. In some cases, fever and hypoalbuminemia can be there. If transmission occurs from mother to child, there can be meconium peritonitis and perforation of the distal ileum. An HAV vaccine is available and can be administered to the mother before traveling to endemic countries. Breastfeeding should not be discouraged. The child should be protected through the administration of immunoglobulins or the inactivated vaccine.
Of the 400 million infections with chronic HBV worldwide, 50% acquired their infection prenatally. 90% of the infected infants will become chronic carriers of Hepatitis B. It is a double-stranded DNA virus in the core particle. The incubation period is up to 180 days.
Clinical picture – in pregnancy, chronic infection is symptomatic. In acute infection, 50% asymptomatic, urticarial rash, arthralgia, arthritis, hepatomegaly and or right upper quadrant tenderness. Jaundice is less common. After acute hepatitis, 90% of patients recover completely, 10% go into chronic hepatitis. Lab markers are –HbsAg → current infection, HbcAg→ active replication, and HBV DNA→ viral load.
Effect of HBV on Pregnancy
Gestational diabetes, preterm delivery, no worsening of liver disease in pregnancy, peri-natal transmission. HbcAg positive in 70-90% of cases, HbcAg negative in 10-40% of cases without immunoprophylaxis. In the uterus, transplacental viral infection is uncommon. Viral DNA is rarely found in amniotic fluid or cord blood. Most neonatal infections are vertically transmitted by peripartum exposure. Breastfeeding is not associated with transmission. Mode of delivery
has no effect on HBV transmission. All neonates who are correctly immunized can be breastfed.
- Antivirals to suppress the HBV in mother to reduce vertical transmission.
- Post-exposure prophylaxis to the infant. Active plus passive immunization is most effective to prevent vertical transmission. Protective efficacy of 95%.
- If the liver disease is in advance stage, treatment can be given before pregnancy and during pregnancy and continued after delivery. If moderate disease, treatment before pregnancy. If good response, stop treatment during pregnancy.
- If mild disease, treatment is given in the last trimester with B category drug with post-partum discontinuation.
For women of reproductive age with known HCV infection, antiviral therapy is recommended before continuing pregnancy, whenever practical and feasible to reduce the risk of HCV infection to offspring. Women should be counseled about the benefit of anti-viral treatment prior to pregnancy.
At the first antenatal visit, HCV RNA and routine liver function tests are recommended to assess the risk of mother and child vertical transmission and degree of liver disease. HCV infected pregnant women with pruritus or jaundice have increased the risk of intrahepatic cholestasis of pregnancy. Assessment of ALT, AST and bile acids should be done. HCV infected women should be counseled about the increased risk of adverse maternal and perinatal outcomes. Antenatal and perinatal care should be coordinated with a maternal-fetal medicine
There can be pre-term delivery, low birth infants and congenital anomalies with maternal HCV infection. However, pregnant women with cirrhosis are at increased risk for the poor maternal outcomes like preeclampsia, hemorrhagic complication, and death. Pregnancy itself does not appear to negatively affect chronic HCV infection. Serum ALT level decrease during the third trimester and increases after delivery.
Breastfeeding is not a risk for HCV transmission. Studies showing similar rates of maternal infection in breastfed and bottle-fed infants. In breastfeeding women have cracked nipples, bleeding, they should refrain from breastfeeding. Women with HCV infection should have their HCV RNA evaluated approximately 9-12 months after delivery to assess for spontaneous clearance.