Hepatitis in pregnancy
  • Mothers with chronic hepatitis B can breastfeed their babies regardless of the presence of cracked or bleeding nipples
    • Babies of these mothers are protected from hepatitis B infection at birth by the administration of hepatitis B immunoglobulin and hepatitis B virus (HBV) vaccination
  • Mothers with hepatitis C can breastfeed their babies. If cracked or bleeding nipples —  advise to express and discard milk until bleeding areas healed

Hepatitis B

Testing for hepatitis B

  • Test all pregnant women regardless of recorded status
    • Take blood for HBsAg, anti-HBc, anti-HBs
  • Review result — see Classification of hepatitis B status
    • Interpreting hepatitis B serology results can be hard — get help if needed
  • Medical consult about need for further testing or immunisation
    • Immunisation recommended during pregnancy if benefits outweigh risks

Table 2.13   Risk of transmission of hepatitis B to baby

If woman HBsAg positive

Do

  • LFT, UEC
  • Hepatitis A — HAV IgG
  • Hepatitis B — HBeAg, anti-HBe
  • Hepatitis B viral load — HBV DNA — best at 24–26 weeks, but can do any time between 20 and 28 weeks
  • Hepatitis C — anti-HCV
  • HIV serology
  • Make sure other blood tests from antenatal checklist are done

Urgent specialist consult — doctor should phone specialist for advice if

  • Hepatitis B viral load more than 200,000 IU/mL
  • OR raised LFT
  • If hepatitis B viral load very high — antiviral medicine in third trimester may reduce risk of transmission to baby. Safe in pregnancy

Manage infection risk

  • Manage as hepatitis B in non-pregnant women
    • Talk with woman about reducing risk of infecting others — use of condoms with new or non-immune partners, not sharing needles, razors or toothbrushes
  • Offer testing for hepatitis B to sexual partners and household contacts
    • Household contacts may be eligible for free hepatitis B immunisation
  • Advise staff involved in birth of hepatitis B status
    • Need to avoid invasive procedures before and during birth
    • Particularly important for woman with high viral load
    • Baby will need immunoglobulin and immunisation at birth

Babies of HBsAg positive mothers

  • Babies infected with hepatitis B at birth have 90% chance of long-term infection, high risk of severe complications
  • Give hepatitis B immunoglobulin AND hepatitis B immunisation at birth to prevent infection
  • Carefully wash injection sites with warm water and dry thoroughly before giving
  • Test baby at 9-18 months of age to check if infected during birth — take blood for HBsAg, anti-HBc, anti-HBs

If woman HBsAg, anti-HBc and anti-HBs negative

This result suggests that woman may have no effective protection against hepatitis B from either previous infection or immunisation and is at risk of hep B infection

  • High risk if
    • Household member with hepatitis B
    • Sexual behaviours that increase risk of contracting hepatitis B, eg. multiple partners, partner with Hep B
    • Intravenous drug use
  • If high risk — give woman hepatis B immunisation during pregnancy
  • If not high risk — give woman immunisation postpartum (after birth of baby)
  • Check HAV IgG. If non-immune — can give combined HAV/HBV immunisation

Hepatitis C

Risk factors for hepatitis C

  • Intravenous drug use, needle sharing
  • Tattooing or body piercing
  • Has been in prison

Testing for hepatitis C

  • Offer testing for hepatitis C (anti-HCV) at first antenatal visit
    • If anti-HCV positive — additional test for HCV PCR needed
  • Hepatitis C test can take up to 3 months to become positive after infection — known as 'window' period. Consider re-testing at 3 months if woman experienced risk factors during that period

If woman hepatitis C RNA positive

Check

  • Check hepatitis A and hepatitis B status. If not immune — offer immunisation

Do

  • Take blood for LFT, FBC, INR, UEC
  • At beginning of pregnancy take blood for HCV viral load, genotype testing
  • If signs of advanced liver disease — medical consult for urgent referral to liver clinic
  • If no signs of advanced liver disease — medical consult about hepatitis treatment after baby is born

Babies of hepatitis C positive mothers

  • About 5% of babies born to mothers with hepatitis C are infected during birth
  • Advise staff involved in birth of hepatitis C status — can modify practices to protect baby
    • Foetal scalp monitoring contraindicated during birth
    • Avoid delivery methods that may damage baby’s skin
  • Caesarean section doesn't reduce risk of baby becoming infected
  • Carefully wash injection sites with warm water and dry thoroughly before giving any injection after the birth
  • Test baby at 12–18 months of age — take blood for anti-HCV
    • Before this age tests may be positive due to antibodies transferred from mother to baby, even if baby not infected
    • Can test after 12–18 months if missed

Supporting resources