Hepatitis During Pregnancy

When a woman has hepatitis and becomes pregnant, one of her first questions is “How will this affect my baby?” While this question does not have a simple answer, the information below can help with understanding.

Her next question is often, “How will being pregnant affect my hepatitis?” Here, I will give a brief overview.

Normally, being pregnant will not affect the course of the hepatitis, unless a woman has hepatitis E, which can worsen severely in some cases. Pregnancy itself will not hasten the disease process or make it worse, although if the liver is already burdened and scarred with cirrhosis, the extra demands of pregnancy may predispose the expectant mother to a condition called acute fatty liver of pregnancy.

Acute fatty liver of pregnancy may be related to liver disease, deficiency of an enzyme normally produced by the liver that allows the pregnant woman to metabolize fatty acids, or the cause may not be known. This condition can quickly become severe, and also affect the unborn child (who may also be born with a deficiency in this enzyme). The treatment is a quick delivery, and treatment in intensive care. Normally, the pregnant woman will recover quickly after the birth, and has a good prognosis if the liver damage is not severe.

Another complication that can occur in both women with hepatitis and those without it are gallstones (cholelithiasis), which often create jaundice during pregnancy. It occurs in 6 % of all pregnancies, in part because of changes in the bile salts during pregnancy. Also, the gall bladder empties more slowly during pregnancy, meaning the bile sits longer and the risk of gallstones goes up.

This condition is often treated with laparoscopy during the first six months of pregnancy, but during the last three months, the uterus is so enlarged that this procedure can’t be done.

Hepatitis A and Pregnancy

Hepatitis A is transmitted by the oral-fecal route (such as from contaminated water or diapers, for example). It occurs in roughly 1 in every thousand pregnant women worldwide. It can be diagnosed by checking the levels of IgM anti-HAV antibodies (which can persist for months after the infection). The main treatment is rest and a nutritious diet, and usually the woman will recover within one to two months.

If a newborn is exposed, the infection is usually mild and they will have a lifelong immunity to the disease.

If a pregnant woman is exposed (such as when traveling or by contact with known carriers) she will be given immune gamma globulin (IG) to help protect her from getting the disease.

Hepatitis B

Hepatitis B is one of the most highly transmitted forms of hepatitis from mother to child around the world, especially in developing countries. In the United States, 15,000 women a year who are positive for the hepatitis B surface antigen (meaning they have the disease) deliver.

Although the mother will usually become jaundiced during the acute stage, some women have no symptoms of hepatitis, which is one reason way CDC guidelines include mandatory screening of all women for hepatitis B during the first prenatal visit. Why?

Because this virus is highly contagious, and the risk that the newborn infant will develop hepatitis B is 10 to 20% if the mother is positive for the hepatitis B surface antigen, and as high as 90 percent if she is also positive for the HbeAg.

Usually, the disease is passed on during delivery with exposure to the blood and fluids during the birth process.

If a pregnant woman tests positive during her prenatal visits for hepatitis B, she will receive hepatitis B immune globulin, and be told to completely abstain from alcohol. When her infant is born, the newborn will receive hepatitis B immune globulin at birth, and should be vaccinated with a hepatitis B vaccine at one week, one month, and six months after birth. This reduces the risk that the infant will become infected with hepatitis B to a range of zero to three percent, and is one reason why the Center for Disease Control and Prevention (CDC) has recommended that all newborn infants be vaccinated for hepatitis B.

Hepatitis C:

Most women become pregnant during the years between 20 and 40, which is also the age group in which the incidence of hepatitis C infection is rising most quickly. Any woman with risk factors for hepatitis C (such as exposure to transfusions, contaminated needles, or injected drug use) should be screened for hepatitis C before and during pregnancy.

The risk of a pregnant woman passing the hepatitis C virus to her unborn child has been related to the levels of quantitative RNA levels in her blood, and also whether she is also HIV positive. The risk of transmission to the infant is less (0 to 18%) if the mother is HIV negative and if she has no history of i.v. drug use or of blood transfusions. Transmission of the virus to the fetus is highest in women with hepatitis C RNA titer greater than 1 million copies/mL. Mothers without hepatitis C RNA levels detected did not transmit hepatitis C infection to their infants.

There is no preventive treatment at this time that can influence the rate of transmission of the virus from mother to infant.

A pregnant woman with hepatitis will need to be followed by a specialist who can check their liver function tests on a regular basis.

Lab Values:

In a normal pregnancy, alkaline phosphatase levels can increase three to four times because the placenta creates alkaline phosphatase. ALT levels can go up if viral hepatitis or damage to the liver occurs (from drugs, gall stones, severe vomiting, or acute fatty liver of pregnancy).

Medications:

Interferon therapy should be discontinued during pregnancy since the effect on the fetus is unknown. At this time, there have not been sufficient studies or information to determine the risk to the baby.

Women should not become pregnant while on Rebetron (interferon and ribavirin combination therapy). In fact, it is recommended by the manufacturer that a woman of childbearing age use effective contraception during treatment and for 6 months after treatment ends, because of the high risk for birth defects in the fetus.

Mothers taking Rebetron medication should not breast feed because of the potential for an adverse reaction from the drug in their infant.

Summary:

In general, pregnancy will not change the course of most forms of hepatitis. With hepatitis A and B, although there is a risk of transmission to the fetus, immunoglobulin therapy and vaccination can decrease it. The risk of transmission of hepatitis C to the infant seems related to the mother’s level of viral RNA and other factors. A pregnant woman may experience certain symptoms such as gallstones and elevated enzymes that may or may not be related to her disease, and she should check with her physician and her liver specialist before starting or discontinuing any medications.

Resources:

M.D. Hunt, Christine, “Liver Disease in Pregnancy”, American Family Physician, Feb 15, 1999
“Hepatitis and Other Liver Diseases During Pregnancy’, Atlanta Maternal-Fetal Medicine, Volume 4, Number 1 – January 16, 1996
“Hepatitis B Virus (HBV)”from the Baby Center Online prenatal Health Index
Tucker, D.E., MRCOG,”Hepatitis B and Pregnancy”, Sept. 1998, Women’s Health, UK
“Important Safety Information”, Rebetron.com
Agarwal, A.K., Rewari, B. B., Goel, Neeria,”Drug Prescribing in Pregnancy”