Viral Hepatitis in Pregnancy: Evaluation, Risks, and Management

1. Overview

Viral hepatitis (principally hepatitis A, B, and C; with regional contributions from hepatitis E and D) represents a significant cause of maternal morbidity and potential adverse perinatal outcomes. The clinical impact varies by virus type, gestational timing of infection, maternal disease severity, and preventive interventions applied (e.g., immunoprophylaxis for hepatitis B). Early recognition and tailored management reduce risks of preterm birth, fetal compromise, vertical transmission, and maternal hepatic decompensation.

2. Virology & Transmission Summary

| Virus | Genome / Type | Primary Transmission | Pregnancy-Specific Concerns | Vertical Transmission Risk (Without Intervention) |
|——-|—————|———————-|—————————–|———————————————–|
| HAV | RNA, picornavirus | Fecal–oral (contaminated food/water) | Usually self-limited; cholestasis possible | Rare (peripartum) |
| HBV | DNA, hepadnavirus | Blood, sexual, perinatal | High viral load → neonatal chronicity | 70–90% if HBeAg+ & high DNA; <10% with proper prophylaxis |
| HCV | RNA, flavivirus | Blood exposure (needles, transfusion pre-screen era) | Higher risk with HIV co-infection | ~5–7% (higher with high viremia) |
| HDV | Defective RNA (needs HBV) | Blood / percutaneous | Superinfection → severe hepatitis | Mirrors HBV severity |
| HEV | RNA, hepevirus | Fecal–oral (endemic areas) | Fulminant hepatitis in 3rd trimester (genotypes 1 & 2) | Possible stillbirth, high maternal mortality |

3. Maternal & Fetal Outcome Risks

| Factor | Potential Outcome |
|——–|——————|
| Severe acute hepatitis (any virus) | Maternal coagulopathy, encephalopathy, ICU care |
| HBV high viral load (late pregnancy) | Elevated perinatal transmission risk |
| HEV infection (3rd trimester) | Fulminant hepatic failure, high mortality, fetal loss |
| Cirrhosis (chronic HBV/HCV) | Portal hypertension, variceal bleeding, fetal growth restriction |
| Decompensated chronic liver disease | Contraindication to pregnancy continuation in severe cases |

4. Hepatitis B: Focused Management

4.1 Screening

• Universal HBsAg screening at first prenatal visit.
• If positive: Test HBeAg, HBV DNA level, ALT, and assess fibrosis (non-invasive methods preferred in pregnancy).

4.2 Risk Stratification

| HBV DNA Level | HBeAg | Management Implication |
|—————|——-|————————|
| <2,000 IU/mL | Negative | Standard monitoring; neonatal prophylaxis still required |
| 2,000–200,000 IU/mL | +/- | Consider repeat DNA in 3rd trimester; monitor ALT |
| >200,000 IU/mL | Often positive | Initiate antiviral (tenofovir) at 28–32 weeks to reduce vertical transmission |

4.3 Antiviral Therapy

| Agent | Category | Pregnancy Data | Notes |
|——-|———-|—————|——-|
| Tenofovir disoproxil fumarate (TDF) | NRTI | Extensive safety record | Preferred for high viral load reduction |
| Tenofovir alafenamide (TAF) | NRTI | Emerging pregnancy data | Consider if TDF intolerant (monitor weight gain and lipids) |
| Lamivudine | NRTI | Safe but resistance risk | Use if TDF contraindicated |
| Entecavir | NRTI | Limited data | Generally avoided in pregnancy |

4.4 Delivery & Neonatal Prophylaxis

| Situation | Intervention |
|———–|————-|
| All infants born to HBsAg+ mother | Hepatitis B vaccine + HBIG within 12 hours of birth |
| High maternal viral load despite therapy | Ensure timely prophylaxis; verify cold chain |
| Missed prophylaxis window (>24h) | Give ASAP; schedule accelerated vaccine series |

4.5 Postpartum

• Continue antiviral until at least 12 weeks postpartum if started for transmission prevention; monitor for hepatic flare on cessation.
• Breastfeeding permitted (tenofovir compatible); ensure infant immunization schedule adherence.

5. Hepatitis C in Pregnancy

| Aspect | Guidance |
|——–|———-|
| Screening | Risk-based + expanding toward universal in some regions |
| Antiviral (DAA) therapy | Generally deferred until postpartum (limited safety data) |
| Vertical transmission risk modifiers | High maternal viral load, HIV co-infection |
| Intrapartum management | Avoid fetal scalp electrodes, prolonged rupture intervals |
| Infant follow-up | HCV RNA at 2–3 months (or antibody after 18 months) |

6. Hepatitis A & E

| Virus | Clinical Course in Pregnancy | Key Management |
|——-|—————————–|—————-|
| HAV | Usually self-limited; rare cholestatic form | Supportive care; vaccinate high-risk non-immune women pre- or postpartum |
| HEV (endemic regions) | Higher fulminant risk (3rd trimester); ↑ maternal and fetal mortality | Early recognition, intensive supportive care; no widely available vaccine (type-dependent) |

7. General Supportive Care Principles

| Domain | Strategy |
|——–|———|
| Rest & Activity | Balance rest with avoidance of prolonged immobility (VTE risk) |
| Nutrition | Adequate protein & calories; avoid hepatotoxic supplements |
| Medication Review | Discontinue non-essential hepatotoxins (e.g., high-dose acetaminophen) |
| Monitoring | Serial LFTs, INR if severe, platelet count, viral load where relevant |
| Vaccination | HAV & HBV vaccination safe if indicated; no live attenuated hepatitis vaccines exist |

8. Obstetric Considerations

| Scenario | Considerations | Action |
|———-|—————|——–|
| Early pregnancy acute severe hepatitis | Risk of miscarriage; maternal stabilization priority | Hospitalize; individualized counseling on continuation |
| Third-trimester acute HBV flare | Risk for preterm labor | Antiviral if high DNA; optimize maternal status |
| Coagulopathy at delivery | PPH risk | Correct INR/platelets; multidisciplinary plan |
| Cholestasis vs viral flare | Overlapping pruritus, elevated bile acids | Differentiate with serology & pattern of LFTs |

9. Prevention of Vertical Transmission (HBV Focus)

| Step | Rationale |
|——|———–|
| Maternal screening | Identify carriers early |
| Viral load assessment (third trimester) | Decide on antiviral initiation |
| Timely neonatal HBV vaccine + HBIG | Blocks perinatal transmission |
| Completion of vaccine series + post-vaccination serology (9–12 months) | Confirm immunity (anti-HBs ≥10 mIU/mL) |

10. Laboratory & Monitoring Schedule (Example HBV High Load)

| Timepoint | Maternal Labs | Fetal/Neonatal Actions |
|———-|—————|————————|
| Baseline (1st visit) | HBsAg, HBeAg, HBV DNA, ALT, fibrosis assessment | Routine prenatal care |
| 28–32 weeks | HBV DNA (confirm level), ALT | Initiate TDF if >200,000 IU/mL |
| 36 weeks | ALT, adherence check | Delivery planning; ensure prophylaxis supplies |
| Delivery | LFTs if symptomatic | Administer HBV vaccine + HBIG |
| 6–12 weeks postpartum | ALT, HBV DNA (flare check) | Infant 2nd vaccine dose per schedule |
| 9–12 months (infant) | — | Anti-HBs & HBsAg serology |

11. Red Flags Requiring Urgent Evaluation

• INR prolongation, rising bilirubin, encephalopathy → Assess for acute liver failure.
• Rapidly increasing transaminases with jaundice in late pregnancy → Consider HEV (if endemic) or acute fatty liver / HELLP differential.
• Severe thrombocytopenia or variceal bleeding in cirrhosis → Tertiary care referral.

12. Patient Education Points

| Topic | Message |
|——-|———|
| Transmission myths | Casual contact does not transmit HBV/HCV. |
| Breastfeeding | Allowed in HBV (with prophylaxis) and HCV (unless nipples cracked & bleeding). |
| Medication adherence | Continuation of antivirals reduces infant infection risk. |
| Follow-up importance | Infant serology confirms protection—do not skip. |

13. Key Takeaways

• Different hepatitis viruses carry distinct maternal and perinatal risks—HBV vertical prevention and HEV severity (where endemic) are critical focuses.
• High HBV DNA (>200,000 IU/mL): third-trimester tenofovir substantially lowers transmission when coupled with neonatal vaccine + HBIG.
• Most HCV treatment deferred postpartum; intrapartum strategies reduce exposure.
• Structured monitoring, vaccination, and timely prophylaxis convert high-risk scenarios into manageable pathways.
• Multidisciplinary coordination (obstetrics, hepatology, neonatology) improves outcomes.

Disclaimer: Educational summary; follow regional guidelines (e.g., WHO, AASLD, EASL, ACOG) and consult specialists for complex cases.