Hepatitis B in the pregnancy

Perinatal Transmission - Epidemiology

 • HBV is contagious and relatively easy to be transmitted
• by blood-to-blood contact during delivery,
• invasive procedures such as caesarean section,
• unprotected sex, sharing needles, parenteral routes such as
intravenous drug use, or blood product transfusion.
• Blood-borne pathogens may also transmit from infected patients to
health care workers as well as from infected health care workers to
patients.
Getahun A, Baekalia M, Panda N, Lee A, Puiahi E, Khan , et al. Seroprevalence of hepatitis B surface antigen in pregnant women attending antenatal clinic in Honiara Solomon IslandsWorld Journal of
Hepatology. 2016; 8(34): 1521-1528
Molla A, Munshea A, Nibret E. Seroprevalence of hepatitis B surface antigen and anti HCV antibody and its associated risk factors among pregnant women attending maternity ward of Felege Hiwot
referral Hospital, northwest Ethiopia: a cross sectional study. Virology Journal. 2015;12: 204
 • To prevent transmission of blood-borne pathogens,
• it is important that health care providers adhere to standard
precautions,
• follow fundamental infection-control principles,
• and use appropriate procedural techniques.
• All obstetrician-gynecologists who provide clinical care should receive
the hepatitis B virus vaccine series.

Committee on Gynecologic Practice. Committee Opinoi, Hepatitis B, hepatitis C, and Human Immunodeficiency Virus Infections in obstetrician-Gynecologists. The American College of
Obstetrician an Gynecologists. 2016. Number 655
• The American Congress of Obstetric and Gynecology (ACOG)
recommended that every pregnant women should undergo HBV
screening.
• Levels of HBsAg and surface antibody should measured at the earliest
prenatal visit.
• If the testing shows positivity, should confirm infection with
quantitative measurement of HBV DNA at baseline and at week 28,
along with HBeAg status and ALT levels.

Ayoub WS, Cohen E. Hepatitis B management in the pregnant patient: An update. Journal of Clinical and
Translational Hepatology. 2016. Vol 4: 241-247
Testing for Hepatitis B Virus Infection During Pregnancy
Flowchart for Prenatal Providers

www.CDC.gov/hepatitis/perinatalHepB
 PATHOGENESIS
• Hepatitis B is the most common form of viral hepatitis in obstetric
patients.
• a DNA virus that is transmitted parenterally and via sexual contact.
• Viruses are very tiny capsules with genetic material inside.
• Viruses invade living, normal cells and use those cells to multiply and
produce other virus particles like themselves.

Queenan JT, Hobbins JC, Spong CY. Protocol for High-Risk Pregnancies, an Evidence-Based Approach. 5thed. Singapore.2010.43;242-246
Reece EA, Barbieri RL. Obstetics and Gynecology The Essentials of Clinical Care. 2010.New York, NY 10001, USA
 PATHOGENESIS (cont’d)
• This process eventually kills the cells, which can make the infected
person sick.
• If that person is pregnant, her baby can become sick as well.
• Viral infections are hard to treat because viruses live inside the body’s
cells, and they are often “protected” from treatments by their host
cells.

Queenan JT, Hobbins JC, Spong CY. Protocol for High-Risk Pregnancies, an Evidence-Based Approach. 5thed. Singapore.2010. 43;242-246
Reece EA, Barbieri RL. Obstetics and Gynecology The Essentials of Clinical Care. 2010.New York, NY 10001, USA
 PATHOGENESIS (cont’d)
• Acute hepatitis B occurs in 1 in 1,000 pregnancies, and chronic
hepatitis B is seen in 10 in 1,000 pregnancies.
• Acute viral hepatitis is the most common cause of jaundice in
pregnancy.
• Other manifestations include: right upper quadrant pain, elevated
liver function tests, and (rarely) coagulopathy and encephalopathy.
• Serious long‐term complications include cirrhosis and hepatocellular
carcinoma.
Queenan JT, Hobbins JC, Spong CY. Protocol for High-Risk Pregnancies, an Evidence-Based Approach. 5thed. Singapore.2010.43;242-246
Walker TY, Smith EA, Fenlon N, Lazarof JE, Dusek C, Finesi P. Characteristics of pregnant women with hepatitis B virus infections in %US public health jurisdictions. Public Health Report. 2016. Vol
131(%): 685-694
Devine A, Harvey R, Min AM, Gilder ME, Pow MK, Kang J, et al. Strategies for the prevention of perinatal hepatitis b transmission in a marginalized population on the Thailand-Myanmar Borde : a
cost-effectiveness analysis. Biomed Central Infectious Diseases. 2017; 17: 552
PATHOGENESIS (cont’d)
 Factors associated with MTCT
• Maternal HBeAg status
– Transplacental HBeAg from the mother induces a
specific unresponsiveness of helper T cells to
HBeAg and HBcAg in neonates born to HBeAg-
positive HBsAg carrier mothers
Routes of mother-to-child HBV transmission

– Intrapartum transmission
(transmission during delivery)
• Is the main route of MTCT of HBV infection
• Association with duration of the first stage of labour
lasting >9 hours.
• Occurs through:
– Exposure of baby to HBV-containing maternal body fluids
when passing through the birth canal
– Partial placental leakage due to uterine contractions or
instrumentation trauma during labour
Bila ibu HBs Ag(+)
Bayi disuntik HBIG (Imunoglobulin Hep B) 0,5 ml IM
pada lengan atas segera setelah lahir (dalam 12 jam
kelahiran) dan
Vaksin hepatitis B dengan dosis 0,5 ml (5 μg) IM pada
lengan atas sisi lain pada saat yang sama kemudian
pada usia 1 bulan dan 6 bulan.
Tidak ada perbedaan pemberian HBIG dan vaksinasi
hepatitis B pada bayi prematur namun pemberian
vaksinasi hepatitis B diberikan dalam 4 kali pemberian
yaitu pada bulan ke-0, 1, 6, dan 8 bulan.
Tidak ada larangan pemberian ASI
eksklusif pada bayi dengan ibu HbsAg
positif terutama bila bayi telah divaksinasi
dan diberi HBIG setelah lahir
Bila ibu HBs Ag(-)
Vaksin hepatitis B dengan dosis 0,5 ml (5 μg)
IM pada lengan atas pada usia ke-0, 1 bulan,
dan 6 bulan.
References
• Queenan JT, Hobbins JC, Spong CY. Protocol for High-Risk Pregnancies, an Evidence-Based Approach. 5thed. Singapore.2010.43;242-246
• Getahun A, Baekalia M, Panda N, Lee A, Puiahi E, Khan , et al. Seroprevalence of hepatitis B surface antigen in pregnant women attending
antenatal clinic in Honiara Solomon Islands World Journal of Hepatology. 2016; 8(34): 1521-1528
• Molla A, Munshea A, Nibret E. Seroprevalence of hepatitis B surface antigen and anti HCV antibody and its associated risk factors among
pregnant women attending maternity ward of Felege Hiwot referral Hospital, northwest Ethiopia: a cross sectional study. Virology Journal.
2015;12: 204
• Walker TY, Smith EA, Fenlon N, Lazarof JE, Dusek C, Finesi P. Characteristics of pregnant women with hepatitis B virus infections in %US
public health jurisdictions. Public Health Report. 2016. Vol 131(%): 685-694
• Ayoub WS, Cohen E. Hepatitis B management in the pregnant patient: An update. Journal of Clinical and Translational Hepatology. 2016. Vol
4: 241-247
• Imunization Action Coalition. Guidance for developing admission orders in labor & delivery and newborn units to prevent Hepatitis B virus
transmission. Saint paul Minnesota. 2017. 651-647-9009
• Devine A, Harvey R, Min AM, Gilder ME, Pow MK, Kang J, et al. Strategies for the prevention of perinatal hepatitis b transmission in a
marginalized population on the Thailand-Myanmar Borde : a cost-effectiveness analysis. Biomed Central Infectious Diseases. 2017; 17: 552
• Nelson NP, Jamieson DJ, Murphy TV. Prevention of perinatal hepatitis B virus transmission. Journal of the pediatric Infectious diseases
Society. 2014; vol 3: suppl 1, pp.S7-S12
• Committee on Gynecologic Practice. Committee Opinoi, Hepatitis B, hepatitis C, and Human Immunodeficiency Virus Infections in
obstetrician-Gynecologists. The American College of Obstetrician an Gynecologists. 2016. Number 655
• Reece EA, Barbieri RL. Obstetics and Gynecology The Essentials of Clinical Care. 2010.New York, NY 10001, USA
• Committee on Gynecologic Practice. Committee Opinoi, Hepatitis B, hepatitis C, and Human Immunodeficiency Virus Infections in
obstetrician-Gynecologists. The American College of Obstetrician an Gynecologists. 2016. Number 489
• Committee on Gynecologic Practice. Committee Opinoi, Hepatitis B, hepatitis C, and Human Immunodeficiency Virus Infections in
obstetrician-Gynecologists. The American College of Obstetrician an Gynecologists. 2016. Number 332
Thank You