Viral hepatitis in pregnancy

Viral Hepatitis in Pregnancy and Pediatric Practice

Stokes and colleagues first described transmission of hepatitis B virus (HBV) infection from a mother who was an HBV carrier to an infant born by cesarean section in 1954. Evidence of clinical hepatitis with jaundice, detected at 2 months of age, was later complicated by chronic active hepatitis. The infant died at 18 months of age with advanced cirrhosis of the liver. In the past decade tests have been developed that are specific for hepatitis B antigens and antibodies and they have enabled physicians to identify acute hepatitis B infection during pregnancy, as well as the presence of a chronic carrier state. Thus it has been possible to assess the effect of maternal HBV infection on the newborn infant. The attack rate of HBV infection in infants has been reported to range between 10% and 70%. Infection is usually detectable by 1 to 3 months of age. Although most infections are asymptomatic, fulminant hepatitis is seen on rare occasions. Of major significance is the tendency for the infected infants to become chronic HBV carriers with possible progression to chronic active hepatitis, cirrhosis, and rarely hepatoma. Hepatitis A virus (HAV) infection has not been a problem in the newborn. Hepatitis A is now an uncommon infection among adults in Western countries while in developing areas it is primarily a disease of childhood.

SAT367 - Prospective study of viral hepatitis in pregnancy and its vertical transmission in the northeast region of India

Introduction Hepatitis in pregnancy is an important medical disorder seen more often in developing countries than in developed ones. Viral hepatitis is a major public health problem in India. Hepatitis in pregnancy is commonly associated with abortion, premature delivery, postpartum hemorrhage, coagulation defect, obstetric shock, coma, death and increased perinatal mortality and morbidity. This study was carried out to know the effect of viral hepatitis on pregnancy and to study its maternal and fetal outcome. Materials and methods This prospective clinical study was conducted in the Department of Obstetrics and Gynecology NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Nagpur, from January 2010 to December 2012. All the antenatal cases attended Obstetrics and Gynecology Department were investigated for HBsAg and looked for any symptoms and signs suggesting hepatitis like fever, jaundice, nausea, vomiting. If present, they were admitted and further investigated to detect viral hepatitis. Patients were counseled for follow-up and strict hospital delivery. Patients with viral hepatitis were analyzed for the effect on pregnancy, maternal and fetal outcome. Results There were total 30 cases of viral hepatitis 24 (80%) cases were HBsAg positive, but all were asymptomatic 6 (20%) cases were hepatitis E positive. No HAV, HCV, HDV and hepatitis G infected cases were detected in our study. Maternal and fetal morbidity was significantly higher in hepatitis E infected women. Fetal mortality was observed in one case. Conclusion Pregnancy with viral hepatitis requires early diagnosis, hospitalization and treatment. In the present study hepatitis E was found to be the chief etiological agent associated with increased maternal morbidity, and high fetal morbidity and mortality. How to cite this article Kose V, Joshi S. Pregnancy Outcome in Viral Hepatitis. J South Asian Feder Obst Gynae 2013;5(2): 60-63.

Of 253 prospectively studied cases of acute viral hepatitis (AVH), 47 were fulminant (18.6%). There were 15 males and 32 females. Their age ranged from 7 to 60 years (mean, 29 years). Serological evidence of AVH-A was found in one case (2%), AVH-B in 13 cases (28%), AVH-D in one case (2%), and AVH-NANB in 32 cases (68%). Fulminant hepatitis was found in 2.6% of AVH-A cases, in 16.25% of AVH-B cases, in one of two AVH-D superinfections, and in 24.8% of the AVH-non-A, non-B (NANB) cases. The clinical picture in the two main etiological categories, namely the AVH-B and the AVH-NANB, showed that the latter possessed a more prolonged and severe clinical course with higher mortality (P<0.001). It also showed a higher mortality in females of the child bearing age, compared with males of the same age group (P<0.001).

To determine the incidence of hepatitis in pregnancy and its association with various social, personal and environmental risk factors, a study was conducted at a Tertiary Maternity Care Hospital, Srinagar. During the one year study period patient selection was based on presence of clinical features suggestive of liver disease. The suspected patients were subjected to liver function tests and hepatitis serology (hepatitis A, hepatitis E, hepatitis B, hepatitis C) for diagnosis. The incidence of viral hepatitis was found to be 0.8 per 1000 pregnant women and etiology in all cases was Hepatitis B viral infection. Fortunately none of the pregnant women had positive hepatitis E serology which has a fatal outcome in pregnancy. Pregnant women who are positive for Hepatitis B viral infection needs to be closely followed up for the adverse perinatal outcome and chronic morbidity associated with the condition. Risk factors associated with the development of infection were prevalent in the form of parental drug use, dental extractions, blood transfusion, residence at endemic areas and poor food hygiene. Sociodemographic variables and risk factors were found to have significant association with hepatitis. Hepatitis patients were mostly anicteric showing inadequacy of serum bilirubin in diagnosis. Screening for hepatitis in future should become an important component of antenatal care.

The hepatitis viruses are a diverse group that has as their common feature the liver as their primary target of infection. They come from several families of viruses, cause infection via different mechanisms, and have a variety of clinical manifestations. The differential diagnosis for hepatitis in pregnancy includes other viruses (cytomegalovirus, Epstein-Barr virus), toxic exposures (acetaminophen), autoimmune disease (e.g., systemic lupus erythematosus), and other entities unique to pregnancy (e.g., HELLP [hemolysis, elevated liver enzymes, and low platelet count]).KeywordsVertical TransmissionFulminant Hepatic FailureThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Introduction: Herpes Simplex Virus (HSV) hepatitis is a rare but potentially fatal presentation of HSV that can affect immunocompromised individuals such as pregnant women, particularly in the 3rd trimester. It can lead to liver failure with mortality up to 75%. Early recognition with the initiation of antivirals and supportive therapy has been shown to reduce mortality, however, insult to the liver can lead to liver failure complicated with encephalopathy and ascites. We present a case of HSV hepatitis in pregnancy which despite supportive therapy and acyclovir, resulted in demise. Case Description/Methods: A 24 year old pregnant female at 23 weeks gestation presented to a facility with complaints of fevers and fatigue. She was discharged and treated symptomatically. 2 weeks later she developed encephalopathy, profound liver failure, and thrombocytopenia, with induction of labor and loss of the infant. She was intubated and developed shock requiring pressors. She was placed on Molecular Adsorbent Recirculating System (MARS) dialysis for support. Cultures were collected, including HSV panel, which was positive for HSV-1. Acyclovir was immediately started, and patient continued to be on supportive therapy. She improved on MARS and acyclovir, with improvement of her liver enzymes and viral load, and later extubated. Patient appeared to return to baseline, however days later, patient developed jaundice, ascites significant for spontaneous bacterial peritonitis, and encephalopathy refractory to lactulose and rifaximin. Despite acyclovir, broad-spectrum antibiotics, and prior MARS therapy, her liver enzymes increased and patient had to be reintubated, where she had multiorgan failure and expired to disseminated HSV. Discussion: This case demonstrates a rare occurrence of HSV hepatitis in a pregnant woman. Recognition of HSV occurred once patient developed acute liver failure and encephalopathy, however, based on her history patient likely presented with HSV symptoms, such as fevers, and fatigue that remained untreated. Despite supportive therapy such as MARs and Acyclovir, patient expired of liver failure from HSV. This case shows the importance of considering HSV in the pregnant population, for if it were recognized and treated earlier, patient may not have reached fulminant liver failure resulting in death. In conclusion, HSV hepatitis and initiation of early antiviral therapy should be considered in all pregnant patients with concern for evolving hepatic failure.