1. كيس I تاريخ مراجعه بهمن ماه 1381
بيمار خانم 25 ساله كه اولين حاملگي وي مي باشد يك هفته قبل از بستري در بيمارستان در سن حاملگي 34 هفته دچار درد در قسمت فوقاني شكم، تهوع، استفراغ، بي اشتهائي و تب خفيف مي گردد سپس از سه روز قبل از بستري دچار تغيير رنگ ادرار بصورت پررنگ شدن ادرار و در روز مراجعه دچار اختلال هوشياري مي گردد.
در Past.H سابقه تزريق خون، كار دندانپزشكي، و مسافرت ندارد.
علائم حياتي:
140
T= RR= PR= ـــــ BP= 90
در معاينه بيمار كنفوريون دارد – ردور گردن ندارد، اسكراايكتريك است سمع قلب تاكيكاردي و سمع ريه نرمال است در معاينه شكم آسيت مختصر دارد، طحال لمس نشد، لمس هيپوكندر است تندرنس دارد، كاپوت مدوزا، اريتم پالمر ندارد در معاينه ادم 1+ در اندامها تحتاني دارد بابنسكي دو طرفه منفي است.

2. هپاتيت در حاملگی
دکتر داوود يادگاری

3. 1- تشخيص افتراقي بيماري عبارتند از:
2- چه آزمايشي هائي را براي بيمار درخواست مي نمائيد.
3- اگر جواب آزمايش اوليه بيمار به شرح ذيل باشد چه تشخيص هائي براي بيمار فوق بيشتر مطرح مي‌شود.
WBC=20/ Hb= Pt= FBS=40
35= بيليروبين T= Hct= %=پلي
20= مستقيم = LDH %= لنف
180< فيبرينوژن SGPt= SGot= = پلاكت
نرمال = chst--Ray نرمال = كامل ادرار
4- آيا براي بيمار فوق ختم سريع حاملگي را توسط سزارين توصيه مي كنيد.
5- آيا براي تشخيص قطعي تر آزمايش ديگري را پيشنهاد مي نمائيد.
6- اگر در آزمايش بيمار HBSAg مثبت گزارش شود اقدام بعدي چيست.
7- براي نوزاد وي چه اقدامي را توصيه مي كنيد.
8- اگر بجاي HBSAg، AntiHcv بيمار مثبت باشد اقدام مناسب چيست.
9- براي نوزاد مادر مبتلا به Hcv چه اقدامي را توصيه مي كنيد.
10- اگر HBSAg مادر منفي و AntiHcv منفي گزارش شود چه اقدامي را براي بيمار توصيه مي نمائيد.

4. Approach to HBs Ag+ Dr. D. Yadeghari (Shahid Beheshti University) &
In the Name of God
Approach to HBs Ag+
Dr. D. Yadeghari
(Shahid Beheshti University)
&
Dr. Sh. Sali
(Karaj District Social Security)
Infectious Diseases Specialists
January 2004

5. Hepatitis B Virus is a common cause of CLD in Iran.
Chronic liver disease (CLD) represents a major public health problem in the world, as well as in Iran.
Hepatitis B Virus is a common cause of CLD in Iran.

6. Number of HBsAg +Patients
Prevalence %
Number of HBsAg +Patients
World 5
350,000,000
Iran 3
2,000,000
USA
1,250,000

7. Family/ Household Sexual Conduct
Prevalence of HBV Serologic Markers in Population Groups Who Should be Screened for HBV Infection
Population
Prevalence of HBV Serologic Markers(%)
HBsAg
All Markers
Born in Endemic Areas 13
70-85
Homosexuals 6
35-80
IV Drug Users 7
60-80
Dialysis
3-10
20-80
HIV Infection
8-11
89-90
Pregnant Women -
Family/ Household Sexual Conduct
3-6
30-60

8. Epidemiology Endemic Regions of HBV: Asia South Pacific
Sub Saharan Africa
Alaska – Green land , north Canada
Australia
Newsealand
South America
Mid East

9. 3Paterns of HBV Transmission
Perinatal Transmission
Person to Person in Childhood
Sexual Transmission in Adulthood
(in developed countries)

10. Hepatitis B HBsAg- is the first evidence of HBV infection
persistence of HbsAg after the acute illness is evidence of chronic hepatitis
Anti HBs- specific antibody to HBs Ag appears after clearance of HBsAg and after successful vaccination
disappearance of HBsAg and appearance of anti HBs signals recovery and non infectivity

11. Labs markers Anti HBc- appears shortly after HBs Ag is detected.
Its presence indicates a diagnosis of acute hepatitis B
HBeAg- is a soluble protein found only in HBs Ag-Positive area
indicates viral replication and infectivity
HBV DNA- is more sensitive and precise marker of viral replication and infectivity

12. 2. Diagnostic Criteria: Chronic Hepatitis B: Resolved Hepatitis B:
1- HBsAg+ > 6 m
2- HBV DNA > 10 5
3- Persistent or Intermittent ALT/AST
4- Liver Biopsy Score ≥ 4
Resolved Hepatitis B:
1- Previous known history of hepatitis or anti-HBC ± anti HBs
2- HBsAg -
3- Undetectable HBV DNA
4- Normal ALT

13. In-active Carrier State:
- HBeAb+
- Normal ALT
- Minimal or No Necroinflammation
- Outcome is Benign
- Serial tests should be performed before determined
- 20% can have exacerbations:
- ALT > 5 – 10 times
- HBeAg±
- Repeat can lead to progressive Fibrosis

14. Outcome of In-active Carriers
- 0.5% will Clear HBsAg Yearly
(Low level DNA in 50% of these Persons)
- 0.5 per 1,000 years incidence of de-compensated Cirrhosis

15. -Personal History -Medical History
History of Icter
Hospitalisation
surgery(major or minor-time )
Delivery or abortion
Tooth Cleaning
Dental surgery ( time-kind )
Experimental dentist
Endoscopy
Dialysis
Hejamat
HBV vaccination
Blood donation
Transfusion

16. Organ transplant CRF Hemophillia Major thallasemia
Special Disorders:
Organ transplant
CRF
Hemophillia
Major thallasemia

17. Needle Sticks Accidents War Injuries Electerolysis,Tatooing
Blood Contact
Needle Sticks
Accidents
War Injuries
Electerolysis,Tatooing

18. Occupational Exposure
Physicians
Nurses
Hospital staffs
Laboratory Personnel

19. History of high risk behavior:
Addiction: IV or non IV
Imprison
Sexual contact
-Heterosexual
-Homosexual
-Bisexual

20. History of Hepatitis History of HCC or Cirrhosis
Family History
History of Hepatitis
History of HCC or Cirrhosis

21. Traveling History:
Traveling Abroad

22. Symptoms : Weight loss Malaise Fatigue Concentration i Mood i Nausea
Vomiting
Diarrhea
Constipation
Pale stool
Dark urine
Pruritis
Jaundice
Hemorrhage
Edema
Irregularity of Mensturation
Impotence

23. Physical Examination :
Pale Conjectiva
Icteric Sclera
Palmar Erythema
Skin Pigmentation
Clubbing
Fetor Hepaticus
Caput Medusa
Gynecomastia
Muscle wasting
Ascitis
Small liver
Splenomegaly
Umblical hernia
Excoriation

24. Laboratory Tests -a1 -a2 -b -g Globulin CBC,Plt Liver function tests :
FBS-chol-TG
HBsAg,HBsAb,HBeAg,HBeAb,HBcAb
CBC,Plt
Liver function tests :
Ast Alt,Alkp,GGt
Bili(T,D)PT,PTT
Total protein
Albumin

25. In High Risk Patients
HIV Ab
HCV Ab
HDV Ab

26. HBsAg-HBeAg-HBeAb - HBcAb- HBsAb i Confirmation of HBsAg(+) Filing
1-Hepatits B panel
HBsAg-HBeAg-HBeAb - HBcAb- HBsAb i
Confirmation of HBsAg(+)
Filing

27. Abdominal Sonography
Liver-Spleen-Diameter of Portal vein
Liver Biopsy
Grading
Staging

28. Evaluation of patients with chronic HBV infection
Initial evaluation
History and physical examination
Laboratory tests to assess liver disease -complete blood counts with platelets, hepatic panel, and prothrombin time
Tests for HBV replication-HBeAg/anti-HBe, HBV DNA
Tests to rule out other causes of liver disease -anti-HCV,anti -HDV
Tests to screen for HCC-AFP and, in high risk patients, ultrasound
Liver biopsy to grade and stage liver disease-for patients who meet criteria for chronic hepatitis

29. Follow-up for Patients Not Considered for Treatment
1- HBeAg+, HBV DNA>105, Normal ALT
- ALT Every 3-6 months
- If ALT > 1-2 uln, Every 1-3 m.
- If ALT>2, for 3-6 m., Consider Liver Biopsy and Treatment
- Screening for HCC

30. 2- In-Active HBsAg Carrier State
- ALT Every 6-12 months
- If ALT > 1-2 x U.L.N, Check HBV DNA and Exclude Other Causes of Liver Disease
- Screening for HCC

31. Outcome of Inactive HBsAg Carriers:
-Generally Benign
Exacerbation of hepatitis to 20%
(as evidenced by  Alt )
Seroconversion of HBsAg to Anti HBs
(0.5-1%per year)
Progression to cirrhosis or HCC

32. - De-Compensated – 14% at 10y
Outcome of Cirrhosis
- HBeAg+ 72%
- Compensated – 84% at 5y
- HBeAg- 97%
- 68% at 10 y
- De-Compensated – 14% at 10y
Risk Factors for De-compensation:
- HBeAg+
- Failure to Respond to Interferon

33. Counseling and Prevention of Hepatitis B
- Life style Modification and Prevention of Transmission
- Non-Specific Dietary Unless Use of Alcohol > 40 g/d
- Precautions to Prevent Sexual Transmission
- Perinatal Transmission
- Blood Spill
- Pregnant Women HBsAg+ should be Counseled:
1- HBIG and Vaccine can be Administrated to new born baby, immediately after delivery.
2- Follow up Testing Their Infant at 1 year of age

34. - Screening of Family Members of the patient and Vaccination, if the Screening Tests (HBsAg, HBsAb) are Negative
- Available Vaccines Against HBV:
- Given 3 times:
At Start, 1 & 6 Months Later
Age Limited?
None, Can Give in Newborns
HBV Prevention

35. Carriers of any age, even Asymptotic Persons with Normal ALT and Minimal or Absent Liver Disease, Can Develop HCC

36. AFPr Testing: Normal is Less than 8-12 ng/ml
- Sensitivity for Small HCC, 50-75%
- Specificity is Above 90%
- Negative Predictive Value > 99%
- Positive Predictive Value is: 9-30%

37. Neonates >95 Age(YEARS) 2-19 ~99 20-29 ~95 30-39 ~90 40-49 ~85
Anti-HBs Seroconversion Rates after Hepatitis B Vaccination(%)
Neonates >95
Age(YEARS)
~99
~95
~90
~85
~70
> ~50
Renal failure, HIV infection,
Other immunosupperession
Liver disease

38. Hepatitis A Incubation period- 30 days
excreted in faeces for up to 2 weeks before onset of illness
early presence of antibody in course of illness (anti HAV)
IgM anti HAV is test for diagnosing acute hepatitis which peaks during 1st week and disappear within 3-6 months
low mortality rate

39. Continuation Hepatitis A
Chronic hepatitis A does not occur
No carrier state
The presence of IgG anti HAV alone indicates previous exposure

40. Hepatitis C Single stranded RNA Virus
in past HCV responsible for 90% cases of post transfusion
50%- post intravenous drug use
high risk in body piercing
risk of sexual and maternal-neonatal transmission is low
diagnosis based on an enzyme immunoassay
in Fiji still carrying out surveillance on HCV

41. Overview of Hepatitis B and C

42. Chronic Hepatitis C US Data 150,000 new cases/yr 3.5 million infected
8,000-10,000 chronic HCV patients die annually from liver related complications
Canadian Data
1635 cases notified in 1993 (acute and chronic)
305 cases notified to Sentinel Health Units
28% transfusion related
71% injection drug use related
14% both risk factors
0.3% blood donors anti-HCV+

43. Chronic Hepatitis C Incubation period is 6 to 12 weeks
Chronicity rate exceeds 80%
10-20% each decade get cirrhosis
<85% acute hepatitis C patients become carriers
Vast majority are symptom free for at least 20 years
“Healthy” carrier state does not exist

44. Chronic Hepatitis C High Risk Groups
Recipients of multiple blood transfusions
Hemophiliacs
Hemodialysis patients
Infants of HCV+ mothers
Intravenous drug users
Healthcare workers

45. Chronic Hepatitis Risk Factors
Needle-stick injuries %
Dialysis unit 2-3%
Hematology units
Newborns of Anti-HCV+ mothers 6%

46. Chronic Hepatitis C Liver Transplantation
Chronic hepatitis C is a frequent cause of end-stage liver disease
Recurrence of hepatitis C after transplantation is almost universal
Liver transplantation for chronic hepatitis C costs $ million (U.S.) annually

47. Chronic Hepatitis C Routes of Transmission
Blood transfusion
Blood products
Perinatal
Intrafamilial
Hemodialysis
Shared needles
Tattooing
Needle-stick and sharps injuries
Sexual
Saliva

48. Chronic Hepatitis C Routes of Transmission

49. Hepatitis D
Defective RNA Virus causes Hepatitis only in association with Hepatitis B
specifically in presence of HBsAg
it is clear only when the latter is clear
Diagnosis is by detection of antibody to hepatitis D antigen
best prevented by preventing Hepatitis B

50. Hepatitis E RNA Virus responsible for waterborne virus
outbreaks in India,Afghanistan and Mexico

51. Hepatitis G
(HGV) been applied to a flavivirus that is percutaneously transmitted and associated with chronic viremia lasting at least 10 years
been detected in blood donors, intravenous drug user, hemodialysis patients and patients with chronic hepatitis B or C but it does not appear to cause important liver disease.
In Fiji, Lepstopirosis was not detected earlier and caused few death in rural areas mistaken for Viral Hepatitis
Symptoms similar to viral hepatitis
Hepatitis A is common in rural areas