CARE OF PREGNANT WOMAN WITH HEPATITIS B Definition of Terms Antibodies: Proteins found in the blood produced in reaction to foreign

substances, such as bacteria and viruses that cause infection. Antigen: A substance, such as an organism causing infection or a protein found on the surface of blood cells that can induce an immune response and cause the production of an antibody. Hepatitis B Immune Globulin (HBIG): A substance given to provide temporary protection against infection with hepatitis B virus. Sexually Transmitted Diseases (STDs): Diseases that are spread by sexual contact, including chlamydial infection, gonorrhea, genital warts, herpes, syphilis, and infection with human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]).

Hepatitis B Virus (HBV) Hepatitis B virus (HBV) is a double-stranded DNA virus in the Hepadnaviridae family. It infects and damages the liver, the organ which cleanses the blood of toxins and waste. Infection with the virus can cause both an acute and a chronic illness. In infected persons HBV is found in highest concentrations in the blood, and lower concentrations in saliva, semen, vaginal secretions, and wound exudates. HBV can remain viable for >7 days on environmental surfaces at room temperature. The average incubation period is 90 days from time of exposure to onset of symptoms, but may vary from 6 weeks to 6 months. Acutely infected individuals develop clinically apparent hepatitis with loss of appetite, nausea, vomiting, fever, abdominal pain and jaundice. Some may have dark urine and gray stool. About one half of acute HBV infections in adults are symptomatic and about 1% of cases result in acute liver failure and death. Sexual transmission accounts for most adult HBV infections in the United States, where approximately 25% of the regular sexual contacts of infected individuals will themselves become seropositive. 10-20% of women seropositive for HBsAg transmit the virus to their neonates in the absence of immunoprophylaxis. In women who are seropositive for both HBsAg and HBeAg vertical transmission is approximately 90%. In patients with acute hepatitis B vertical transmission occurs in up to 10% of neonates when infection occurs in the first trimester and in 80 -90% of neonates when acute infection occurs in the third trimester.

Who to Test

Test all pregnant women at the first prenatal visit for hepatitis B surface antigen (HBsAg). Women admitted for delivery who have not had prenatal HBsAg testing should have blood drawn for testing. Send a copy of the original lab report to the hospital. More than 90% of women found to be HBsAg-positive on routine screening will be HBV carriers, routine follow-up testing later in pregnancy is not necessary for the purpose of screening. In special situations, such as when the mother is thought to have acute hepatitis, when there has been a history of exposure to hepatitis, or when particularly high-risk behavior such as parenteral drug abuse has occurred during the pregnancy, an additional HBsAg test can be ordered during the third trimester. Test all susceptible contacts (including all family members) with hepatitis B panel (HBsAg, antiHBc, antiHBs). Screening and vaccination of susceptible contacts should be done by the family's pediatrician, primary health-care provider, or the physician evaluating the clinical status of the HBsAg-positive pregnant women. Interpretation of the Hepatitis B Panel Tests Results Interpretation
Tests HBsAg anti-HBc anti-HBs HBsAg anti-HBc anti-HBs HBsAg anti-HBc anti-HBs HBsAg anti-HBc IgM anti-HBc anti-HBs HBsAg anti-HBc IgM anti-HBc anti-HBs HBsAg anti-HBc anti-HBs Results negative negative negative negative positive positive negative negative positive positive positive positive negative positive positive negative negative negative positive negative Interpretation susceptible

immune due to natural infection

immune due to hepatitis B vaccination

acutely infected

chronically infected

Four interpretations possible *

* 1. May be recovering from acute HBV infection. 2. May be distantly immune and test not sensitive enough to detect very low level of anti-HBs in serum.

3. May be susceptible with a false positive anti-HBc. 4. May be undetectable level of HBsAg present in the serum and the person is actually a carrier.

Prevention The best method of protecting both the mother and her baby is to have the former protect herself from infection. There are several ways of to reduce the risk of infection. The woman should always practice safe sex by reducing the number of her sexual partners and using latex condom during sexual intercourse. For pregnant women who are injecting drugs, it is best to either stop the practice or avoid the use of shared needles, thus reducing the risk of infection. Another way to reduce the risk of hepatitis B infection is to be vaccinated against the virus. The hepatitis B vaccine consists of a series of three injections with the second injection given at least 1 month after the first and the third injection given 6 months after the first. The vaccine is considered very safe. Hepatitis B vaccination is recommended for children, intravenous drug users, people with multiple sexual partners, people with kidney or liver disease, people who live with someone infected with hepatitis B, and all health care workers. However, anyone who would like to be immunized against hepatitis B can receive the vaccine. Because the vaccine contains no living virus, pregnant women and breastfeeding mothers can safely receive the vaccine.

Screening During pregnancy, all expectant mothers should be screened for hepatitis B. Screening is done by testing blood drawn at the first prenatal visit. At this time, the obstetrician looks for evidence of either an acute hepatitis B infection or carrier status; only those mothers who are currently ill (either with acute or chronic hepatitis) and those mothers who are carriers without illness are at risk for transmitting the virus to their babies.

Delivery Both vaginal delivery and Cesarean section are safe methods of delivery for mothers infected with hepatitis B. Due to the risk of transmission of the virus during delivery, all infants of infected mothers receive the first dose of the hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) within 12 hours of delivery. Newborns have undeveloped immune systems, and HBIG contains the specific proteins needed to boost the infants ability to fight off a hepatitis B infection acquired during delivery. If the hepatitis B status of a mother is unknown at delivery, the infant should receive the first dose of the hepatitis B vaccine within 12 hours of birth, and the mothers blood should be tested as soon as possible to determine if the infant needs HBIG.

Newborn Vaccination If a woman is positive for HBV, her baby would need a series of shots to protect against infection. At birth, a newborn who has been exposed to the virus should receive 2 shots. The first dose is the hepatitis B vaccine and the second dose is the Hepatitis B immune globulin (HBIG). The vaccine prompts the newborns body to produce hepatitis B antibodies while the HBIG contains hepatitis B antibodies that will protect the newborn until the newborns body is capable of producing its own antibodies. These injections, if given within the first 12 hours of life, give the baby up to a 95 percent chance of avoiding infection. At one to two months, the baby should be given a second dose of hepatitis B vaccine and at six months the baby should receive the third dose of the said vaccine. Between nine and eighteen months after birth, the baby should have a blood test to confirm that he or she does not have hepatitis B infection. Since 1991, medical guidelines in the United States have recommended that all babies be vaccinated against hepatitis B, following the same schedule as mentioned earlier, but without the HBIG dose. The vaccination will provide the child lifelong immunity against hepatitis B and reduce risk of death by liver disease or liver cancer.

Breastfeeding Mothers with positive prenatal blood tests can safely breastfeed their babies; there is no evidence that the hepatitis B virus is transferred through breast milk.

Screening Pregnant Women for Hepatitis B Surface Antigen (HBsAg)

All pregnant women should be: 1. Routinely tested for HBsAg during an early prenatal visit (e.g., first trimester) in each pregnancy, even if they have been previously vaccinated, tested or identified as chronically infected. 2. Assessed for risk of hepatitis B virus (HBV) infection if HBsAg-negative. 3. Counseled on methods to prevent HBV transmission and vaccinated if high risk. 4. Retested in their last trimester if they are at risk for HBV infection (e.g., an immigrant from an endemic area, more than one sex partner in the previous 6 months, evaluated or treated for a sexually transmitted disease, a partner of or a recent or current injection-drug user, a household or sexual contact of an HBsAg-positive person, incarcerated, hemodialysis patient, or had clinical hepatitis since previous testing). 5. Informed of their HBsAg results and advised to notify delivery staff.

6. Provided or referred for medical evaluation if they are HBsAg-positive. 7. Referred to a case-management program, if they are HBsAg-positive, to ensure their infants, household and sexual contacts receive appropriate prophylaxis, testing and follow-up to prevent HBV infection. 8. Reported within 24 hours to the local health department (LHD) in the county where the patient resides if they are HBsAg-positive (including women previously reported due to chronic infection). 9. Reported to the labor and delivery unit by transmitting information regarding care during pregnancy, by recording HBsAg test results on all forms, and by transferring a copy of the original HBsAg laboratory report for this pregnancy.

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