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Hepatitis in Pregnancy

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Presentation on theme: "Hepatitis in Pregnancy"— Presentation transcript:

1 Hepatitis in Pregnancy

2 Summary of physiological changes in the liver during pregnancy
Increased: Blood volume and cardiac ouput rise by 35%–50% Alkaline phosphatase levels rise threefold or fourfold due to placental production Clotting factor changes create a hypercoagulable state Decreased: Gallbladder contractility Hemoglobin Uric acid levels Albumin, total protein, and antithrombin III concentrations No change: Liver aminotransferase levels (aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transferase) Bilirubin level Prothrombin time

3 The impact of pregnancy on the hepatitis
The course of most viral infections is not affected by pregnancy To made the pathogenetic conditionviral exacerbations and complicated The high incidence of severe hepatitis and hepatic coma

4 Hepatitis on pregnancy
First trimester Hyperemesis gravidarum increased the high incidence of abortion and fetal malformation associated with the incidence of Down syndrome Second and third trimesters a higher incidence of hypertensive disorders in pregnancy a higher incidence of postpartum hemorrhage

5 Hepatitis A antibody IgM and IgG types
Hepatitis C Hepatitis B Hepatitis A Characteristics RNA DNA Virus type 30-60 nm 42 nm 27 nm Virus size 30 – 160 days 30 – 180 days 15 – 50 days Incubation period Parentral sporadic Parentral or body fluid Fecal – oral Transmission Uncommon Common Not observed Vertical transmission to fetus Hepatitis C antibody RNA by PCR HBs Ag, HBs Ab, IgM, and IgG types HBe Ag, Ab, Hepatitis B virus DNA Hepatitis A antibody IgM and IgG types Serologic diagnosis HIV co- infected Prodrome or HBe Ag Positive Prodrome Maximum infectivity 50 – 85% 5 – 10% None Carrier state Asymptomatic to sever relapsing Asymptomatic to fulminant Acute clinical forms Chronic persistent hepatitis Chronic active hepatitis Cirrhosis Chronic clinical forms

6 Vertical transmission of hepatitis virus (Mainly by hepatitis B)

7 HAV There is no evidence that HAV causes birth defects
There is no evidence of maternal-fetal transmission In rare circumstances in which the mother has acute HAV infection at the time of delivery immune serum globulin may be administered to the infant Even under these conditions, the risk of transmission to the infant seems very small Anti-HAV IgG antibodies is not transmitted from infected mothers to newborn infants

8 HBV Evidence suggests that transmission of HBV to infants is common
when mothers have acute infection in the third trimester when they are chronic carriers of HBV infection and have positive results for HBeAg or HBV DNA The risk of transmission is highest in mothers who are HBeAg - positive at the time of delivery Newborn baby has a 90% likelihood of becoming infected. Approximately 25% of infected infants will become chronic carriers.

9 HCV The rate of vertical transmission of hepatitis C is less than 5%
The risk is higher if the mother is co-infected with (HIV) if she is viremic at the time of delivery if her viral DNA load is greater than 1 million copies/ml if the time from the rupture of membranes to delivery is more than 6 hours.

10 HEV Transmission occurs intrapartum and peripartum through close contact of mother and neonate. Significant vertical transmission among HEV-RNA positive mothers of up to 50%. Among women with symptomatic infection the rate of transmission is up to 100%, with significant perinatal morbidity and mortality.

11 HGV Most cases of hepatitis G are transferred through contaminated blood products. It is most commonly found among individuals infected with hepatitis C or HIV. Perinatal transmission does occur, however, evidence suggests that it does not cause clinical disease in newborns. Currently no therapy is available other than prevention

12 Diagnoses Epidemiological history Clinical manifestations
Laboratory Studies : the most useful tests evaluation of urine bilirubin and urobilinogen, total and direct serum bilirubin, ALT and/or AST, alkaline phosphatase, prothrombin time, total protein, albumin, complete blood count, and in severe cases serum ammonia. the differential diagnosis with other forms of viral hepatitis requires serologic testing for a virus-specific diagnosis. Type of hepatitis during pregnancy

13 Type of hepatitis during pregnancy
Acute hepatitis Chronic active hepatitis Acute severe hepatitis

14 Differential Diagnosis of Liver Disease in Pregnancy
Serum Transaminases Bilirubin Coagulopathy Histology Other Features Acute Hepatitis B >1000 >5 - Hepatocellular necrosis Potential for perinatal transmission Acute Fatty Liver <500 <5 + Fatty infiltration Coma, renal failure, hypoglycemia Intrahepatic Cholestasis <300 <5, mostly direct Dilated bile canaliculi Pruritis, increased bile acids HELLP >500 Variable periportal necrosis HTN, edema, thrombocytopenia

15 Management of Acute Viral Hepatitis in Pregnancy
Establish type by serologic test Institute appropriate isolation and precautions Determine need for contact prophylaxis with scrum globulin preparation and/or vaccine Activity: determined by tolerance Diet: patient preference, parentral if necessary Antiemetics: phenothiazines may be used Corticostcroids: not indicated Immunoprophylaxis of infant: if hepatitis B is present

16 Acute severe hepatitis Diagnostic points
Severe gastrointestinal symptoms Rapidly deepening jaundice Hepatic encephalopathy Liver function :severely abnormal Renal failure Coagulopathy

17 Guidelines for severe hepatitis
Protect the liver Prevention of encephalopathy Prevention of DIC Prevention of hepatorenal syndrome

18 Six Responsibilities of Perinatal Hepatitis B Prevention Program
Assure identification of ALL HBsAg positive women and their infants Assure all exposed infants receive HBIG and 1st dose of hep. B vaccine w/in 12 hours of birth Prevention of Perinatal Hepatitis B Transmission Assure completion of 3 doses of hepatitis B vaccine and post vaccination testing of exposed infants Assure that all susceptible household and sexual contacts are vaccinated This is an overview of the big picture of the program to accomplish the goal of eliminating perinatal hepatitis B. Conduct active surveillance, quality assurance, and outreach to improve program

19 HBV Taking lamivudine before becoming pregnant and continuing to take it throughout the pregnancy lower rates of transmission of the virus from mother to newborn Lower transmission rates have also been seen in pregnant women with a high viral DNA load

20 HBV The administration of hyperimmune globulin and HBV vaccine protects 90% to 95% of infants from HBV infection. It is recommended that 0.5 ml, of HBIG be given at birth and that three doses of HBV vaccine be given beginning at birth.

21 HCV The mode of delivery does not seem to influence the rate of transmission from mother to child Infection prior to delivery has been shown to occur in as many as 33% of patients An elective cesarean section has been suggested for patients co-infected with HIV reduce maternal-fetal transmission by up to 60%

22 Gestational Diabetes

23 Definition: CHO intolerance of variable severity that begins or is first recognized during pregnancy. Applies regardless of whether insulin is used for treatment or the condition persists after pregnancy. Does not exclude the possibility that unrecognized glucose intolerance may have antedated the pregnancy. Impt to know the difference between pre-existing DM that manifest during pregnancy vs. GDM. Each results in different consequences: effects of organogenesis. For women who develop GDM before 20 wks of gestation and have an elevated HgbA1c, they most likely have had pre-existing DM.

24 Classification of Diabetes

25 Classification of Diabetes in Pregnancy
Class A: Abnormal GTT at any age or of any duration treated only by diet therapy A1 -Diet Controlled GDM A2 -Insulin-treated GDM

26 Complications of pregnancy in GDM
Maternal: Hypoglycemia Infection Ketoacidosis Deterioration in retinopathy’ Increased proteinuria+edema Miscarriage Polyhydramnio Shoulder dystocia Preeclampsia Increased caesarean rate Future type 2 diabetes Fetal: Congenital abnormalities Increased neonatal and perinatal mortality Macrosomia Birth trauma Late stillbirth Neonatal hypoglycemia Polycythemia Jaundice Hyperbilirubinemia

27 RISK FACTORS FOR GDM Previous diagnosis of GDM
A strong FH of type 2 DM Previous delivery of a macrosomic infant Member of a high-risk population (Aboriginal, Hispanic, South Asian, Asian or African descent) Age  35 years Obesity (BMI  30 kg/m2) Polycystic ovarian syndrome and / or hirsutism Acanthosis nigricans Corticosteroid use

28 Screening-cont: Women (at low risk) with ALL of the following characteristics need not be screened with a laboratory blood glucose test. Less than 25 years of age Normal body weight with BMI < 25 No first degree relative with DM Not a member of an ethnic group at increased risk for type 2 DM: women of Hispanic, African, Native American, South or East Asian or Pacific Islands ancestry No hx of abnormal glucose metabolism No hx of poor obstetric outcome

29 Screening-cont: For women who do not meet the above criteria, screening should be conducted at wks of gestation with use of a 50 g one hour oral glucose load An abnormal one hour screening test with a venous plasma glucose of >140 mg/dL necessitates a full diagnostic 75g three hours oral glucose tolerance test (GTT) a 50 g one hour oral glucose load, administered without regard to the time of the day or the time of last meal. A value of 200 mg/dL on screening is so likely to be associated with the dx of GDM that the GTT need not to be performed and treatment can be started.

30 SCREENING SCREENING All pregnant women between 24 and 28 weeks
If multiple risk factors are present, assess during each trimester. 1hPG following 50-g glucose load at any time of day 1hPG10.3 1hPG= 75-g OGTT. Measure FPG, 1hPG, 2hPG If 2 values are met or exceeded FPG  5.3 1hPG10.6 2hPG 8.9 GDM IGT of pregnancy If 1 value is met or exceeded

31 Gestational diabetes Diagnosis
WHO criteria 1998, 75 gm glucose fasting hr (mmol/L) Impaired fasting glucose IGT <or = and DM >or = or > or=11.1

32 Dx of GDM with Use of a 100 gram Oral Glucose Load
(performed after an overnight fast with the patient consuming her usual unrestricted daily diet in the 3 days preceding the test) Two or more abnormal values are diagnostic for GDM.

33 Management The goal is to prevent adverse pregnancy outcomes.
A multidisciplinary approach is used. Patient is seen every 1-2 wks until 36 wks gestation and then weekly. Patient is asked to keep an accurate diary of their blood glucose concentration. A multidisciplinary approach with a dietitian, a nurse, a diabetic educator, a social worker and a physician is used.

34 Management The glycemic targets associated with the best pregnancy outcome in GDM are: Preprandial < 5.3 mmol/L 1-hour postprandial < 7.8 mmol/L 2-hour postprandial < 6.7 mmol/L Women with GDM should carry out frequent fasting and postprandial home blood glucose monitoring in order to achieve glycemic targets.

35 Management Blood glucose monitoring Diet Exercise Insulin
Physical activity should be encouraged Insulin Oral Hypoglycemic Medications

36 Know your blood sugar level & keep it under control
You may have to test four times a day: In the morning before eating breakfast, referred to as the Fasting glucose level 1 or 2 hours after breakfast 1 or 2 hours after lunch 1 or 2 hours after dinner You may also have to test your glucose level before you go to bed at night. This is referred to as your nighttime or nocturnal glucose test. 36 of 42 36

37 Dietary Therapy Nutrition therapy is the primary treatment of GDM, although evidence on the optimal diet is lacking. Carbohydrate intake should be distributed over 3 meals and at least 3 snacks (one of which should be at bedtime). Hypocaloric diets are not recommended. Refer to a dietitian

38 Insulin Regimen Pt should check their fasting glucose and a 1 hour or 2 hour postprandial glucose level after each meal, for a total of four determinations each day. If the fasting value is > 95 mg/dL, or 1 hr value > mg/dL or 2 hr value > 120 mg/dL, insulin therapy needs to be initiated. The goal of insulin therapy is to maintain glucose levels below the above values.

39 Antepartum Testing First trimester u/s and a fetal echo to assess congenital cardiac anomalies. Second trimester u/s to assess fetal growth. Twice weekly testing NSTs and amniotic fluid volume determination beginning at 32 wks gestation to assess fetal well-being. If fetal macrosomnia is detected, with accelerated growth of the fetal abdominal circumference, and fetal wt estimated >4500 g, cesarean delivery should be considered to reduce the risk of shoulder dystocia.

40 Delivery Timing and mode of delivery individualised
Early delivery may be indicated for: women with poor glycemic control pregnancies complicated by fetal abnormalities Otherwise, pregnancies are allowed to go to term. If delivery is scheduled before 39 wks gestation, an amniocentesis to assess for fetal lung maturity is performed. If corticosteroids are used to accelerate lung maturity, insulin requirement needs to be increased in the next 5 days. [Transient hyperglycemia; the steroid effect begins approximately 12 hours after the first dose and may last for five days. Blood glucose conc is checked q1-2 for 48 hrs after betamethasone is administered.] [Elective early delivery was done in the past to prevent fetal death. No longer necessary given better glycemic control and better methods of fetal surveillance.] In pts with well controlled GDM, there is no evidence to support routine delivery before 40 wks of gestation. There is also no data to support cesarean delivery purely on the basis of GDM. If estimated fetal wt >4500 g, cesarean delivery may be considered since it may reduce the likelihood of permanent brachial plexus injury in the infant. (3)

41 Delivery Most common complication = shoulder dystocia
31% of neonates weighing >4,000g* Data does not support the use of C-section to avoid birth trauma *13% error rate estimating fetal weight by untrasound

42 What is a reasonable approach?
Offer elective C-section Estimated fetal weight >4,500g Patient history and pelvimetry Discuss risks and benefits

43 Delivery No indications to pursue delivery before 40 weeks in patients with good glycemic control… *Unless other maternal or fetal indications are present

44 Intrapartum The goal is to maintain normoglycemia in order to prevent neonatal hypoglycemia. Check patient’s glucose q1-2 hours. Start insulin drip to maintain a glucose level of between mg/dL. Observe infant closely for hypoglycemia, hypocalcemia, and hyperbilirubinemia after birth.

45 Postpartum Care After delivery: Measure blood glucose.
-fasting blood glucose concentrations should be <105 mg/dL and one hour postprandial concentrations should be < 140 mg/dL. Administer one half of the pre-delivery dose before starting regular food intake. Insulin requirements decrease rapidly after delivery. As insulin resistance quickly resolves, so does the need for insulin. Women who are dx with GDM early in gestation who are obese and have required insulin/glyburide therapy are most likely to demonstrate persistent glucose intolerance or DM.

46 Postpartum Care-cont:
Follow up: Per American Diabetes Association, a 75 g two hours oral GTT should be performed 6-8 wks after delivery.

47 Postpartum Care-cont:
Follow up: If the pt’s postpartum GTT is normal, she should be re-evaluated at a minimum of 3 years interval with a fasting glucose. All pts should be encouraged to exercise and lose wt. All pts should be evaluated for glucose intolerance or DM before a subsequent pregnancy.

48 Thanks four your listening

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