1. Hepatitis B and C during pregnancy and lactation Anne Kirss Womens Clinic of Tartu University Hospital 15.09.2006

2. Prevalence of hepatitis B All over the world about 350 million people are infected with hepatitis B Estonia has medium prevalence of hepatitis B 2-8% of population Transmission of HBV occurs via blood and sexual contact HBV is stable in environment at least 7 days

3. Prevalence of hepatitis C In Estonia the estimated prevalence of hepatitis C is 1% of population Transmission of HCV occurs mainly via infected blood Up to 70% of cases of chronic viral hepatitis are caused by HCV

4. Hepatitis B and C and pregnancy Do not influence the course of pregnancy

5. HBV infection Is not teratogenic Acute hepatitis may cause: Prematurity Low birth weight

6. Vertical transmission of hepatitis B Intrauterine infection of the fetus is very rare Mostly during delivery, after delivery Transmission to the baby in the absence of imuune profylaxis HBsAg positive mothers10-20% HBsAg +HBeAg positive mothers90% It is possible that HBeAg crosses the placental barrier and makes the newborn susceptible to HBV Acute hepatitis B During the I trimester – transmission to the child 10% During the III trimester - transmission to the child 80-90%

7. Amniocentesis The risk of HBV transmission is low Noninvasive methods of following the fetus should be preferred (ultrasound) Avoid passing the needle through placenta

8. Delivery With immunoprofylaxis the method of delivery is not important Elective caesarean section is not considered necessary Centers of Disease Control & Prevention Sexually Transmitted Diseases Treatment Gudelines 2002

9. Neonatal hepatitis B 75-85% of perinatally infected children will be carriers of virus Becomes evident 6 months after birth Usually the course is subclinical, chronic Greater risk of hepatic cirrhosis and hepatic cancer Fulminant disease more frequently occurs in newborns whose mothers are chronic carriers of HBV

10. Prevention of neonatal hepatitis B Postinfection profylaxis for newborns (infection mainly during delivery or directly after) Immunglobulin within 12 hours after birth Simultaneous vaccination Vaccination at 1 and 6 months of age This way 90% of HBV infections can be avoided Acta Gastroent Jan 1999

11. Vaccination against hepatitis B Allowed during pregnancy for contacts of chronic hepatitis B patients Hepatitis B immunglobulin also allowed for Contacts of acute hepatitis B patients In the presence of skin lesion the second dose after 1 month When the newborn gets immune profylaxis, the mother may breast-feed

12. Treatment of chronic hepatitis B Few data about use in pregnant women Interferon Alfa Probably does not cross placental barrier A study of 2 HIV-positive pregnant women –Medical abortion in week 19 and 24 Not teratogenic in rabbits and rats Higher risk of spontaneous abortion in Rhesus monkeys Data of pregnant women with leukemia and hepatitis C Normal babies, normal pregnancies Is secreted into breast milk Effect on the infant is not known

13. Lamivudine Is not teratogenic – no malformations Has been used during the second half of pregnancy to avoid transmission – questionable success –Kazim SN et al. Lancet 2002; van Zonneveld M et al. J Viral Hepat 2003 Crosses placental barrier anaemia, hypocalcaemia, neutropenia, arrhythmias (VPB) of the baby

14. Lamivudine In HIV infection the potential benefit is bigger Lactation Concentrates in breast milk serum/milk 1:3 Breast-feeding is not recommended

15. Hepatitis C Usual pregnancy risks Cholestasis of pregnancy may occur more often Endogenous fetoplacental interferone may have a favourable effect on the course of hepatitis C At the presence of oesophagel varices or coagulopathy the risks are higher

16. Hepatitis C Measure ASAT, ALAT once every trimester In addition: albumin, bilirubin, INR, anti- HBs, anti-HA IgG, HCV-RNA Follow the pregnancy as usual

17. Pregnancy and hepatitis C Pregnancy has a favourable effect on the necrosis of hepatocytes in HCV positive women Hepatology 2000, March;31 J Watch Gastroenterology 2000, May

18. Vertical transmission of hepatitis C Infrequent 6% in HCV-RNA positive 15% if HCV+HIV The risk of HCV transmission is dependent on the level of mothers viraemia HCV-RNA negative – risk for the baby almost 0

19. Hepatitis C and delivery The method of delivery is not important in transmission Caesarean section is not indicated Induction of delivery due to hepatitis C is not necessary Prefer external methods of following the fetus, although there are no data of infection transmission via using the scalpel electrode Breast feeding is allowed No transmission via breast milk has been documented, although a-HCV and HCV-RNA may be present in breast milk

20. Neonatal hepatitis C Not much experience The virus was discovered in 1989 HCV is not teratogenic Babies have been born healthy When infected, the baby has chronic infection No vaccine No immunoglobulin Recommended to do lab tests of the child once a year

21. Baby of HCV positive mother Not necessary to test umbilical blood Mothers antibodies (IgG) cross the placental barrier All newborns are a-HCV positive Mothers antibodies may be present in the babys blood even for 12-15 months The higher the mothers HCV-RNA, the longer the antibodies stay in the babys blood Tests at the age of 4-6 months at the earliest a-HCV, HCV-RNA, AST, ALT Hepatitis has benign course in children and usually does not require treatment

22. Treatment of hepatitis C Few data about use in pregnant women Interferon Alfa Probably does not cross placental barrier A study of 2 HIV-positive pregnant women –Medical abortion in week 19 and 24 Not teratogenic in rabbits and rats Higher risk of spontaneous abortion in Rhesus monkeys Data of pregnant women with leukemia and hepatitis C Normal babies, normal pregnancies Is secreted into breast milk Effect on the infant is not known

23. Ribavirin - must not be used Teratogenic in all animal experiments Malformations of the limbs, palate, sceleton, gastrointestinal tract and brain Can be found in blood up to 4 weeks after discontinuation of the medication Concentrates in red blood cells Breast feeding No data available

24. In summary Pregnancy has a favourable effect on hepatitis The risk of transmission of viral hepatitis from mother to fetus is low (6%) Newborn with neonatal hepatitis needs careful observation and treatment (HBV vaccine) Caesarean section is not necessary, breast feeding is allowed Medical personnel has high risk of viral hepatitis SELF DEFENCE (HBV vaccination, gloves, aprons, masks, spectacles)