Download Hepatitis on pregnancy

Hepatitis
in Pregnancy
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
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
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
Characteristics
Hepatitis A
Hepatitis B
Hepatitis C
Virus type
RNA
DNA
RNA
Virus size
27 nm
42 nm
30-60 nm
Incubation period
15 – 50 days
30 – 180 days
30 – 160 days
Transmission
Fecal – oral
Parentral or body fluid
Parentral sporadic
Vertical transmission
to fetus
Not observed
Common
Uncommon
Hepatitis A antibody
IgM and IgG types
HBs Ag, HBs Ab, IgM, and
IgG types
HBe Ag, Ab, Hepatitis B
virus DNA
Hepatitis C antibody
RNA by PCR
Prodrome
Prodrome or HBe Ag
Positive
HIV co- infected
None
5 – 10%
50 – 85%
Asymptomatic to
fulminant
Asymptomatic to fulminant
Asymptomatic to
sever relapsing
Serologic diagnosis
Maximum infectivity
Carrier state
Acute clinical forms
Chronic clinical forms
None
Chronic persistent hepatitis
Chronic active hepatitis
Cirrhosis
Chronic persistent
hepatitis
Chronic active
hepatitis
Cirrhosis
Vertical transmission of
hepatitis virus
(Mainly by hepatitis B)
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
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.
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.
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.
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
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
Type of hepatitis during
pregnancy
• Acute hepatitis
• Chronic active hepatitis
• Acute severe hepatitis
Differential Diagnosis of Liver
Disease in Pregnancy
Serum
Transaminas
es
Bilirubin Coagulo
pathy
Histology
Other Features
Acute
Hepatitis B
>1000
>5
-
Hepatocellu
lar 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
<5
+
Variable
periportal
necrosis
HTN, edema,
thrombocytopenia
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
Acute severe hepatitis
Diagnostic points
• Severe gastrointestinal symptoms
• Rapidly deepening jaundice
• Hepatic encephalopathy
• Liver function :severely abnormal
• Renal failure
• Coagulopathy
Guidelines for severe
hepatitis
• Protect the liver
• Prevention of encephalopathy
• Prevention of DIC
• Prevention of hepatorenal syndrome
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
Prevention
hours of birth
of
Perinatal
Hepatitis B
Transmission
Assure that all
susceptible
household and
sexual contacts
are vaccinated
Assure
completion of 3
doses of hepatitis
B vaccine and post
vaccination testing
of exposed infants
Conduct active
surveillance, quality
assurance, and outreach to
improve program
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
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.
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%
Gestational Diabetes
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.
Classification of Diabetes
Diabetes in pregnancy
Pre-existing diabetes
IDDM
(Type1)
NIDDM
(Type2)
Gestational diabetes
Pre-existing diabetes
True GDM
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
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
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
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
Screening-cont:
• For women who do not meet the above
criteria, screening should be conducted at
24 -28 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)
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=7.8-10.2
1hPG10.3
75-g OGTT. Measure FPG, 1hPG, 2hPG
GDM
IGT of pregnancy
If 2 values are met or
exceeded
If 1 value is met or exceeded
FPG  5.3
1hPG10.6
2hPG 8.9
Gestational diabetes
Diagnosis
• WHO criteria 1998,
75 gm glucose
fasting
Impaired fasting glucose
IGT
DM
6.1-6.9
<or =7
>or = 7
2 hr (mmol/L)
and
or
7.8-11
> or=11.1
Dx of GDM with Use of a 100
gram Oral Glucose Load
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.
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.
Management
• Blood glucose monitoring
• Diet
• Exercise
Physical activity should be
encouraged
• Insulin
• Oral Hypoglycemic
Medications
Know your blood sugar level
& keep it under control
•
You may have to test four times a day:
1. In the morning before eating breakfast,
referred to as the Fasting glucose level
2. 1 or 2 hours after breakfast
3. 1 or 2 hours after lunch
4. 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
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
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 > 130-140 mg/dL or 2 hr value >
120 mg/dL, insulin therapy needs to be
initiated.
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 wellbeing.
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.
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
What is a reasonable
approach?
Offer elective C-section
• Estimated fetal weight >4,500g
• Patient history and pelvimetry
• Discuss risks and benefits
Delivery
No indications to pursue delivery
before 40 weeks in patients with
good glycemic control…
*Unless other maternal or fetal
indications are present
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 80 - 110
mg/dL.
• Observe infant closely for
hypoglycemia, hypocalcemia, and
hyperbilirubinemia after birth.
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.
Postpartum Care-cont:
Follow up:
• Per American Diabetes Association, a 75 g
two hours oral GTT should be performed
6-8 wks after delivery.
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.
Thanks four your
listening