Hepatitis B and pregnancy

Hepatitis is an inflammation of the liver. Hepatitis B (a specific type of hepatitis) is a serious viral infection of the liver that can become chronic, leading to progressive liver disease. If appropriate preventive measures are not taken, a mother may transmit hepatitis B to her infant before, during or after birth.


Anatomy
Your liver is found behind your lower ribs on the right side of your abdomen. It's normally the size of a football. The liver fights infection and controls bleeding. It also produces bile, which helps the body digest food, stores energy and removes drugs and other harmful products from your blood. The liver is essential for life.

Causes/associated factors
Generally, hepatitis can be caused or aggravated by a variety of factors, including medications, alcohol, toxins, parasites, bacteria and viruses. Specifically, hepatitis B is caused by the hepatitis B virus (HBV), which infects cells of the liver and is found in the blood and other body fluids of infected persons. In the United States, acute hepatitis B is most common in young adults ages 15 to 39. Thanks to vaccination programs, the overall incidence of hepatitis B has dropped.
Most adults who have acute hepatitis B recover completely within six months. People who do not fully recover can become chronic carriers of HBV and infect others with the disease, as well as develop serious complications, as described below. In the United States, there are more than 1 million chronic carriers of HBV. Five to 10 percent of adults, 30 percent of children and up to 90 percent of infants with hepatitis B become chronic carriers.


The pregnancy factor
During pregnancy, acute hepatitis B is associated with an increased risk of premature delivery. The baby may also become infected with hepatitis B before, during or after birth. Rarely, the infection spreads through the placenta. More often, the baby becomes infected by ingesting blood or amniotic fluid at birth, having close contact with the mother directly after birth, or through the mother's breast milk.
The risk of infection is higher if the mother contracts hepatitis just before or after delivery. As many as 50 percent of these infants will become infected if preventive measures are not taken. Because up to 90 percent of infected infants become chronic carriers and develop serious complications, the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) recommend all women be tested for HBV during pregnancy.

You may be at higher risk for contracting hepatitis B if you:

have multiple sexual partners
have household or sexual contact with someone who is infected with hepatitis B
have a sexually transmitted disease
inject illegal drugs
live or work in a prison or other crowded institutional setting
receive clotting factors for a blood clotting disorder
receive hemodialysis (an external method of removing unwanted material from your blood, which is normally a function of the kidneys)
are routinely exposed to blood, blood products or human bites (such as health care workers, members of the police force, firefighters and military personnel)
live in, travel to, or emigrated from a region of the world where hepatitis B is prevalent (including infants and children of immigrants from areas where hepatitis B is prevalent)
Testing donated blood has dramatically reduced the spread of hepatitis B through blood transfusions.


Transmission
The hepatitis B virus circulates in your blood. The infection spreads through exposure to infected blood or body fluids (such as semen and saliva). Again, it can spread from an infected mother to her baby, most commonly during birth. An infected person's blood, either fresh or dried, is highly contagious during the one to two months before and after symptoms appear. People who develop antibodies (compounds that help neutralize or destroy foreign substances in the blood) and recover completely from the disease will not remain contagious. Those who develop chronic hepatitis B, however, have the potential to spread the virus indefinitely.
During pregnancy, the risk of infecting your baby is low if you have acute hepatitis during the first trimester (12 weeks). As you progress through the pregnancy, the risk steadily increases.

The incubation period (time from exposure until symptoms develop) is 45 to 160 days. The average is 120 days.


Signs/symptoms
Many people who have acute hepatitis B have no symptoms. When symptoms are present, they usually develop slowly. In some cases, symptoms may be severe, especially if you also have hepatitis D at the same time.
Symptoms may include:

jaundice (yellowing of the skin and whites of the eyes)
fatigue and weakness
appetite loss
nausea and vomiting
low-grade fever
tea-colored urine
abdominal discomfort or pain
sometimes, joint pain, rash or kidney problems

Diagnosis
The doctor will review your medical history, including potential exposure to hepatitis, medication use, blood transfusions and sexual history. Your doctor will also do a physical exam, and you'll need blood tests to detect hepatitis B antigens (foreign substances in the body) and antibodies. These blood tests can help the doctor determine how far the infection has progressed and how best to treat your condition. Liver function studies can help the doctor determine the severity of liver involvement.
There are several blood tests used to help diagnose HBV and determine if the infection is active, cured or chronic.

The hepatitis B surface antigen (HBsAg) is the outer covering of the hepatitis virus. This antigen can be detected in your blood during the incubation period, as early as one to two weeks after exposure to the virus, and during the early weeks of symptoms. You are considered to be a chronic hepatitis carrier if this antigen is still present after the illness is over.

The hepatitis B surface antibody (HbsAb) is one of your body's defenses against the hepatitis B virus. The antibody can be detected in your blood about four weeks after the hepatitis B surface antigen disappears. The antibody's presence indicates that the infection is over and your body is protected against any future contact with the hepatitis B virus -- you are immune. The antibody is also present after you've been vaccinated against HBV.

The hepatitis B core antibody (HBcAb) is produced as a defense against the hepatitis B core antigen, which is found inside the virus. This antibody is present during the infection and usually persists. It's the only hepatitis indicator found in your blood between the disappearance of the hepatitis B surface antigen and the appearance of the hepatitis B surface antibody.
Again, routine testing for the presence of the hepatitis B surface antigen (HBsAg) is recommended during pregnancy. If the test is negative and you're at high risk for developing HBV, you can be vaccinated during pregnancy. If the test is positive, your baby is at risk but can be protected with proper treatment.


Treatment
There is no specific treatment or cure for acute hepatitis B, so prevention is essential. General treatment measures may include the following:
Get plenty of rest. Your doctor may also recommend that you limit your physical activity (especially during the acute phase of the disease).

Eat well.

Don't drink alcohol. Because alcohol is metabolized in the liver, drinking puts added strain on the organ. (Of course, alcohol should be avoided during pregnancy in any case because of the potential adverse effect on the fetus.)

Take only medications that have been recommended by your doctor, including prescription and over-the-counter medications and herbal remedies. The breakdown of certain medications can also add strain to the liver.
Your doctor may prescribe medication if you have severe nausea and vomiting or you're too ill to eat well. In severe cases, hospitalization may be necessary.

Once the infection clears up, follow-up blood tests to monitor your liver function will be done periodically for several months. Blood testing for certain types of hepatitis B antigens is recommended for six to nine months after an acute infection to determine whether you've developed chronic hepatitis B.


Complications
Hepatitis B may lead to:
chronic infection
chronic liver disease
cirrhosis (a chronic liver disease that may result in liver failure)
liver failure
liver cancer
For carriers, complications may occur years later. In some cases, hepatitis B may be fatal.


Prevention
Prevention is crucial because there is no cure for hepatitis B. Learn how hepatitis B spreads, and modify any high-risk behaviors. To protect yourself from hepatitis B, as well as other infections that spread through body fluids (such as HIV and hepatitis C), it's important to:
Avoid using and injecting illegal drugs. If you inject drugs, stop. Try to get into a substance abuse treatment program. If you cannot stop injecting drugs, never reuse or share injection equipment.
Avoid sharing personal care items, such as toothbrushes and razors, that could have blood on them.
Avoid touching anyone else's blood. If this is unavoidable, wear protective gloves.
Only have body piercing and tattooing done under sterile conditions.
Avoid having sex with an infected person. Unless you're in a monogamous relationship with an uninfected partner, use a condom each time you have sex.
To avoid the risk of occupational exposure, always follow universal precautions if you work in health care or public safety.
Hepatitis B immunization
The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis B immunization for anyone age 18 or younger. As part of a plan to eliminate hepatitis B, the Centers for Disease Control and Prevention advises that all infants receive a hepatitis B vaccination at birth, preferably before leaving the hospital. If you're older than 18, the ACIP recommends immunization if you're in a high-risk group. The vaccine is highly effective -- after three injections, 80 to 100 percent of those vaccinated are protected from hepatitis B.

If you test negative for hepatitis B and are at risk of being infected with the virus, you'll be offered the hepatitis B vaccination as soon as possible during pregnancy. The vaccine is given in the upper arm in three separate injections. The second dose is often given one to two months after the first dose, and the third is given at least two months after the second and four months after the first.

If the interval between doses of hepatitis B vaccine is longer than recommended, the final antibody concentrations will not be affected. You will not have to start the series over or receive extra doses. However, if the interval between doses is less than recommended, the antibody response may be reduced. Any doses given without adequate time between injections should not be considered part of the primary series.

If you're exposed to hepatitis B during pregnancy, notify your doctor immediately. If you're not immune to the virus, the doctor may recommend an injection of hepatitis B immune globulin (HBIG -- a protein that can act as an antibody). HBIG should be given as soon as possible after exposure to the virus and be followed by a hepatitis B vaccination. HBIG provides immediate protection until the vaccine can stimulate the body to produce its own protective antibodies.

If you test positive for hepatitis B during pregnancy, your baby will receive the first dose of the hepatitis B vaccine series within 12 hours of birth. At the same time, your baby will receive HBIG for immediate protection. The second dose of the hepatitis B vaccine will be given at age 1 month and the third dose at age 6 months.

If you were not tested for hepatitis B before delivery, your baby will receive the first dose of the vaccine series within 12 hours of birth. At the same time, you will be tested for hepatitis B. If you're positive, your baby will receive a hepatitis B immune globulin injection (HBIG) as soon as possible (no later than one week of age). The second dose of hepatitis B vaccine will be given at age 1 month and the third dose at age 6 months.