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

HBs Ag, HBs Ab, IgM, and

IgG types
HBe Ag, Ab, Hepatitis B
virus DNA

Hepatitis C antibody
RNA by PCR

Prodrome or HBe Ag
Positive

HIV co- infected

5 10%

50 85%

Asymptomatic to fulminant

Asymptomatic to
sever relapsing

Serologic diagnosis

Maximum infectivity
Carrier state
Acute clinical forms

Chronic clinical forms

Hepatitis A antibody
IgM and IgG types

Prodrome
None
Asymptomatic to
fulminant

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:

Fetal:

Hypoglycemia
Infection
Ketoacidosis
Deterioration in retinopathy
Increased proteinuria+edema
Miscarriage
Polyhydramnio
Shoulder dystocia
Preeclampsia
Increased caesarean rate
Future type 2 diabetes

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=7.810.2

1hPG10.
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
1hPG10.6
2hPG 8.9

Gestational diabetes
Diagnosis
WHO criteria 1998,
75 gm glucose
fasting
(mmol/L)
Impaired fasting glucose
IGT
DM

6.1-6.9
<or =7
>or = 7

2 hr

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 patients 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 pts 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