Vani Malhotra Hepatitis-2015 Orlando, USA July

HEPATITIS B INFECTION DURING PREGNANCY –EXPERIENCE AT TERTIARY CARE CENTRE OF NORTH INDIA Dr Vani Malhotra MD MICOG Professor Department of Obstetrics and Gynecology PGIMS, Rohtak, India

Hepatitis B Virus (HBV) infection is a global problem with nearly 350 million carriers at risk for cirrhosis and hepatocellular carcinoma 50% carriers have acquired their infection vertically from mothers (MTCT) 90% of vertically acquired infection become chronic

AASLD All pregnant women be screened for HBsAg during the first trimester, even if previously vaccinated or tested Lok ASF, McMahon BJ. Chronic Hepatitis B: update Hepatology 2009; 50: 661-2

AASLD & ACOG– POSITIVE MOTHERS Medical evaluation immediately -duration of disease -extent of liver disease -risk factors for MTCT(HBeAg status & viral load)

VERTICAL TRANSMISSION (MTCT) Transmission of pathogen from mother to child during pregnancy or childbirth or by breastfeeding

ROUTE OF TRANSMISSION Transplacental transmission of HBV in utero Natal transmission during delivery Postnatal transmission during care of infant or through breast milk

IN UTERO-TRANSMISSION Main risk factors  Maternal HbeAg positivity  High maternal viral load  History of threatened abortion or preterm labor

NATAL TRANSMISSION Transfusion of mothers blood to fetus during labor contractions(microtransfusions) Infection after rupture of membranes Direct contact of the infants mucosal membranes

POSTNATAL TRANSMISSION Ingestion of virus or by contact with skin lesions on mothers breast

RISK FACTORS FOR MTCT High maternal viral load Positive HBeAg status

ANTIVIRAL DRUGS Potent antiviral suppression Safe & well tolerated Reduces perinatal HBV transmission

problems Viral drug resistance Contraindication to breast feeding Hepatitis flares upon discontinuation

DrugFDA CategoryRemarks LamivudineCRecommended TelbivudineBRecommended TenofovirBMay be recommended EntecavirCNot Recommended AdefovirCNot Recommended

IMMUNOPROPHYLAXIS Infants born to HBsAg –positive mothers should receive both HBIG and HBV within 12 hours of birth Next two doses should be given within six months of birth 90-95% protection

Follow up of infants HBsAg and anti HBs at 9 months of age HBsAg negative + anti-HBs>10mIU/ml are disease free Anti-HBs <10mIU/ml- revaccinated(Immunoprophylaxis failure)

RECOMMENDATIONS FOR BREAST FEEDING With appropriate immunoprophylaxis, breastfeeding of infants of chronic HBV carriers posos no additional risk of transmission of HBV, however antiviral drugs should be stopped

PRESENT STUDY Prospective study carried at PGIMS, Rohtak from Jan 2014-Dec 2014 Women in any trimester of pregnancy were tested for HBsAg using ELISA Women who tested positive were enrolled for the study & liver function tests, HBeAg, HbeAb, IgM Anti HbC& HBV DNA analysis was done using PCR

contd Women with abnormal liver function tests, positive HBeAg & HBV DNA more than 1lakh copies/ml were given tablet lamivudine 100 mg to reduce the transmission

AIMS & OBJECTIVES To investigate the Seroprevalence of hepatitis B surface antigen in pregnant women Management of chronic HBV infection in pregnant mothers To prevent Mother to child transmission (MTCT) of HBV

OBSERVATIONS Total cases included in the present study are 15,000 Out of these, 52 cases were found to be HBsAg positive Seroprevalence 0.34 (52/15,000)

AGE GROUP(YEARS) N=52 <2047.6% % % >3047.6%

PARITY (n=52) P0917.3% P1815.3% P % P % P4713.4%

RISK FACTORS (n=52) Tattoing2242.3% Blood transfusion 713.4% Previous surgical procedures % No risk1121.1%

AREA DISTRIBUTION N=52 Urban2038.4% Rural %

SOCIOECONOMIC STATUS N=52 Lower2853.8% Middle % Higher47.6%

HUSBAND HBsAg Status N=52 Positive59.6% Negative2038.9% Declined2751.9%

ACTIVITY OF DISEASE ACUTE HEPATITIS % CHRONIC HEPATITIS %

RISK FACTORS FOR MTCT 12 (23.07%) patients out of 52 patients were HBsAg positive & their DNA titres were more than 1 lac copies/ml, so tab lamivudine was started

MODE OF DELIEVERY N=52 FTVD3159.6% PTVD1426.9% LSCS611.5% FT ASSISTED DELIEVERY 11.9%

INDICATION OF LSCS N=6 Fetal Distress350% Previous 2 LSCS233.30% Breech113.3%

MATURITY N=52 Term % Preterm1528.8%

BIRTH WEIGHT(KG) N=52 < % % > %

All the babies received HBIG & HBV vaccine within 12 hrs of birth Breast feeding was recommended in all

MORTALITY & MORBIDITY MATERNAL MORTALITY MORBIDITYFETAL MORTALITY MORBIDITY 1(HEPATIC ENCEPHALOPAT HY) SEPSIS-1 DIC-2 15 (ADMISSION TO NICU)

SUMMARY 50% patients belong to year age group 34.6% were Para 2 Tattoing was the risk factor in 42.3% patients 53.8% patients belong to lower S/E status

SUMMARY In 23.3% patients, HBeAg positivity & high DNA assay was found and were given Tab Lamivudine 88.4% delivered vaginally 51.9% were having birth weight in the range of kg All the babies received HBV vaccine & HBIG within 12 hrs of birth

COMPARISON NO OF PREGNANT WOMEN SCREENED PREVALENCE OF HBsAg(%) Pande et al(2011)20, Sandesh et al(2006)70, Abbas et al(2001)6, Present Study(2014) 15,

CONCLUSION Universal screening of all pregnant women for HBV infection Pregnant women found to be HBsAg positive should be investigated for risk factors for MTCT Maternal high HBV DNA & HBeAg positivity are important risk factors for MTCT

CONCLUSION In women with these risk factors, use of antiviral drugs should be considered for preventing antenatal transmission All the babies should receive both HBV vaccine and HBIG within 12 h of birth Breast feeding of infants is recommended, however, mothers should stop these antiviral drugs to limit the exposure of infants to these drugs

TAKE HOME MESSAGE Appropriate treatment & follow-up to HBV infected mothers and their newborns is critical in preventing HBV MTCT & eradicating HBV infection

THANK YOU

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