Hepatitis and Pregnancy
Hepatitis in majority of cases is a viral infection of liver with inflammation and necrosis of hepatic cells causing clinical, biological, and histological changes. In pregnancy jaundice may occur due to hepatic and non hepatic causes. There are certain specific conditions like cholestatic jaundice and acute fatty liver occur in pregnancy. The commonest cause of jaundice in pregnancy is Hepatitis.
Hepatic causes in Pregnancy : areas follows-
• Pre-Existing Liver Disease
• Usual liver diseases complicating pregnancy
• Liver diseases etiologically related to pregnancy;
-Toxaemia of pregnancy
-Acute fatty liver of pregnancy
-Idiopathic cholestatic jaundice of pregnancy
-Budd Chiari syndrome-due to increased tendency to thrombosis
Hepatitis in Pregnancy :
Hepatitis is the most common cause of jaundice in pregnancy. It has higher rate of complications in the mother and new born. Due to improved methods of prevention especially of Hepatitis B by immunisation, complications in the mother and the neonate can be prevented.
In pregnancy viral hepatitis can occur by hepatitis viruses which are A, B, C, D and E.
The incidence of different types varies according to the geographical area. The serological study confirms the presence of virus in the human serum. Hepatitis A and Hepatitis E is spread from person to person by drinking or eating contaminated water and food or come in contact with materials having virus while Hepatitis B, C and D are transmitted by percutaneous route.
Clinical features of Hepatitis :
In pregnancy Viral Hepatitis has the same clinical features as in other population which are as follows:
• Loss of appetite
• Nausea and vomiting
• Dark coloured urine
• Pain and discomfort over upper abdomen etc.
Laboratory tests :
Diagnosis of Acute viral Hepatitis is established by-
• Liver Function Test like Serum Bilirubin, SGOT, SGPT. All three LFT are increased in acute viral hepatitis.
• Serological profile confirms the diagnosis of types of viral hepatitis. It consists of Anti HAV IgM, HB surface antigen, Hepatitis B Anticore Antigen IgM. Hepatitis Non A and Non B Hepatitis virus is also be detected.
Consequences of Hepatitis in Mother :
An increased death rate in pregnancy with Hepatitis is observed in developing countries. This increase death rate is seen in 3rd trimester of pregnancy. Cause of higher mortality is not known though malnutrition is contributory without sufficient evidence. There is no effect of Hepatitis on the rate of congenital malformation, Stillbirth or abortions but there has been an high risk of Prematurity
Consequences of Hepatitis in New born :
Infectious Hepatitis or Hepatitis A in pregnancy often not transmitted by Non A, Non B in the mother can be transmitted to the neonate. Incidence and consequences are still not known. Tests for detection of Non A & Non B is available in very specialised labs and research centres.
Incidence of transmission of Hepatitis B to the Neonate :
Incidence of Hepatitis B infection to the neonate depends on trimester of pregnancy. When Hepatitis occurs in the 1st or 2nd trimester the rate of spread is very low i.e. less than 10% while during 3rd trimester has a 60-70% chance of transmitting the infection to the offspring. The factors that decide the rate of transmission are:
(i) Presence of Hb 'e' antigen
(ii) Race of mother
(i) Presence of Hb 'e' antigen:
Presence of Hb 'e' antigen increases the risk of transmission to 80-90%. Presence of 'e' antibody those with no markers of 'e' antigen or antibody have approximate transmission rate of 25 & 12% respectively.
(ii) Race of Mother:
A very high rate of transmission about 65% been reported in Chinese, 30% in black people and very low percentage in Europeans.
Mode of transmission to offspring is supposed to be "contact" transmission occurring during birth or early postpartum period. Gastric contents, cord blood, amniotic fluid have been shown to contain HBsAg. Breast milk though showed to contain antigen is not considered an important mode of transmission.
Neonate complications of Hepatitis :
• Acute symptomatic hepatitis
• Fulminant hepatitis
• Asymptomatic hepatitis is more common
• 85% changes into chronic carrier state
• 50% of chronic carrier develops hepato cellular carcinoma, cirrhosis or both.
This is a global public health problem.
Preventive Measures :
1. Screening of Mothers: All pregnant mothers must be screened for HbsAg during pregnancy or just after delivery. Breast milk can transmit Hepatitis B and so carrier women must be cautioned against this.
2. Prevention of Neonatal Hepatitis:
Hepatitis B vaccine gives very effective prophylaxis. All new born carrier mothers must receive vaccine 0.5 ml i/m at birth and at one & six months later. A simultaneous administration of Hepatitis B immune globulin increases the chance of preventing infection in the offspring (new born).