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Hepatitis-2015
Orlando, USA
July 20 - 22 2015
Vani Malhotra
HEPATITIS B INFECTION DURING
PREGNANCY –EXPERIENCE AT TERTIARY
CARE CENTRE OF NORTH INDIA
Dr Vani Malhotra
MD MICOG
Professor
Department of Obstetrics and
Gynecology
PGIMS, Rohtak, India



Hepatitis B Virus (HBV) infection is a global
problem with nearly 350 million carriers at
risk for cirrhosis and hepatocellular
carcinoma
50% carriers have acquired their infection
vertically from mothers (MTCT)
90% of vertically acquired infection become
chronic
AASLD

All pregnant women be screened for HBsAg
during the first trimester, even if previously
vaccinated or tested
Lok ASF, McMahon BJ. Chronic Hepatitis B:
update 2009. Hepatology 2009; 50: 661-2
AASLD & ACOG– POSITIVE
MOTHERS
Medical evaluation immediately
-duration of disease
-extent of liver disease
-risk factors for MTCT(HBeAg status & viral
load)
VERTICAL TRANSMISSION (MTCT)
Transmission of pathogen from mother to child
during pregnancy or childbirth or by
breastfeeding
ROUTE OF TRANSMISSION
• Transplacental transmission of HBV in utero
• Natal transmission during delivery
• Postnatal transmission during care of infant or
through breast milk
IN UTERO-TRANSMISSION
Main risk factors

Maternal HbeAg positivity

High maternal viral load

History of threatened abortion or preterm
labor

NATAL TRANSMISSION



Transfusion of mothers blood to fetus during
labor contractions(microtransfusions)
Infection after rupture of membranes
Direct contact of the infants mucosal
membranes
POSTNATAL TRANSMISSION

Ingestion of virus or by contact with skin
lesions on mothers breast
RISK FACTORS FOR MTCT


High maternal viral load
Positive HBeAg status
ANTIVIRAL DRUGS



Potent antiviral suppression
Safe & well tolerated
Reduces perinatal HBV transmission
problems



Viral drug resistance
Contraindication to breast feeding
Hepatitis flares upon discontinuation
Drug
FDA Category
Remarks
Lamivudine
C
Recommended
Telbivudine
B
Recommended
Tenofovir
B
May be recommended
Entecavir
C
Not Recommended
Adefovir
C
Not Recommended
IMMUNOPROPHYLAXIS



Infants born to HBsAg –positive mothers
should receive both HBIG and HBV within 12
hours of birth
Next two doses should be given within six
months of birth
90-95% protection
Follow up of infants



HBsAg and anti HBs at 9 months of age
HBsAg negative + anti-HBs>10mIU/ml are
disease free
Anti-HBs <10mIU/mlrevaccinated(Immunoprophylaxis failure)
RECOMMENDATIONS FOR BREAST
FEEDING

With appropriate immunoprophylaxis,
breastfeeding of infants of chronic HBV
carriers posos no additional risk of
transmission of HBV, however antiviral drugs
should be stopped
PRESENT STUDY



Prospective study carried at PGIMS, Rohtak
from Jan 2014-Dec 2014
Women in any trimester of pregnancy were
tested for HBsAg using ELISA
Women who tested positive were enrolled for
the study & liver function tests, HBeAg,
HbeAb, IgM Anti HbC& HBV DNA analysis
was done using PCR
contd

Women with abnormal liver function tests,
positive HBeAg & HBV DNA more than 1lakh
copies/ml were given tablet lamivudine 100
mg to reduce the transmission
AIMS & OBJECTIVES



To investigate the Seroprevalence of hepatitis
B surface antigen in pregnant women
Management of chronic HBV infection in
pregnant mothers
To prevent Mother to child transmission
(MTCT) of HBV
OBSERVATIONS



Total cases included in the present study are
15,000
Out of these , 52 cases were found to be
HBsAg positive
Seroprevalence 0.34 (52/15,000)
AGE GROUP(YEARS)
N=52
<20
4
7.6%
20-25
26
50%
25-30
18
34.6%
>30
4
7.6%
PARITY
(n=52)
P0
9
17.3%
P1
8
15.3%
P2
18
34.6%
P3
10
19.23%
P4
7
13.4%
RISK FACTORS
(n=52)
Tattoing
22
42.3%
Blood
transfusion
Previous
surgical
procedures
No risk
7
13.4%
12
23.07%
11
21.1%
AREA DISTRIBUTION
N=52
Urban
20
38.4%
Rural
32
61.53%
SOCIOECONOMIC STATUS
N=52
Lower
28
53.8%
Middle
20
38.46%
Higher
4
7.6%
HUSBAND HBsAg Status
N=52
Positive
5
9.6%
Negative
20
38.9%
Declined
27
51.9%
ACTIVITY OF DISEASE
ACUTE
HEPATITIS
8
15.38%
CHRONIC
HEPATITIS
44
84.6%
RISK FACTORS FOR MTCT

12 (23.07%) patients out of 52 patients were
HBsAg positive & their DNA titres were more
than 1 lac copies/ml, so tab lamivudine was
started
MODE OF DELIEVERY
N=52
FTVD
31
59.6%
PTVD
14
26.9%
LSCS
6
11.5%
FT ASSISTED
DELIEVERY
1
1.9%
INDICATION OF LSCS
N=6
Fetal Distress
3
50%
Previous 2 LSCS
2
33.30%
Breech
1
13.3%
MATURITY
N=52
Term
37
71.15%
Preterm
15
28.8%
BIRTH WEIGHT(KG)
N=52
<2.5
10
19.2%
2.5-3.0
27
51.9%
>3.0
15
28.8%


All the babies received HBIG & HBV vaccine
within 12 hrs of birth
Breast feeding was recommended in all
MORTALITY & MORBIDITY
MATERNAL
MORTALITY
MORBIDITY
FETAL
MORTALITY
MORBIDITY
1(HEPATIC
ENCEPHALOPAT
HY)
SEPSIS-1
DIC-2
1
5 (ADMISSION
TO NICU)
SUMMARY




50% patients belong to 20-25 year age group
34.6% were Para 2
Tattoing was the risk factor in 42.3% patients
53.8% patients belong to lower S/E status
SUMMARY




In 23.3% patients, HBeAg positivity & high
DNA assay was found and were given Tab
Lamivudine
88.4% delivered vaginally
51.9% were having birth weight in the range
of 2.5-3.0kg
All the babies received HBV vaccine & HBIG
within 12 hrs of birth
COMPARISON
NO OF PREGNANT
WOMEN
SCREENED
PREVALENCE OF
HBsAg(%)
20,104
1.11
Sandesh et al(2006) 70,659
0.25
Abbas et al(2001)
6,910
1.01
Present
Study(2014)
15,000
0.34
Pande et al(2011)
CONCLUSION



Universal screening of all pregnant women
for HBV infection
Pregnant women found to be HBsAg positive
should be investigated for risk factors for
MTCT
Maternal high HBV DNA & HBeAg positivity
are important risk factors for MTCT
CONCLUSION



In women with these risk factors, use of
antiviral drugs should be considered for
preventing antenatal transmission
All the babies should receive both HBV
vaccine and HBIG within 12 h of birth
Breast feeding of infants is recommended,
however , mothers should stop these antiviral
drugs to limit the exposure of infants to these
drugs
TAKE HOME MESSAGE
Appropriate treatment &
follow-up to HBV infected
mothers and their newborns
is critical in preventing HBV
MTCT & eradicating HBV
infection
THANK YOU
Meet the eminent gathering once again at
Hepatitis-2016
Dubai, UAE
October 17 - 19, 2016
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