Postpartum subsidence of hepatitis B viral replication in HBeAg-positive carrier mothers

Staging and clinical characteristics of pregnant women with chronic hepatitis B virus infection: A retrospective cohort study from Nanjing, China

AIM

To investigate the immune status of Chinese chronic hepatitis B (CHB) pregnant women and their clinical characteristics.

METHODS

About 1544 CHB pregnant women without antiviral therapy from 2013 to 2018 were selected from the hospital records. The definition of immune status is based on American Association for the Study of Liver Diseases (AASLD) 2018 Hepatitis B Guidance, and those who did not meet any criteria of the immune status were referred to in the gray zones (GZ).

RESULTS

There were 284 patients in the immune-tolerance phase, 72 patients in the HBeAg-positive immune active phase, 553 patients in the inactive phase, 61 patients in the HBeAg-negative immune active phase. Of note, 574 (37.18%) patients did not fit into any of the above phases were defined as the GZ. Patients with elevated ALT had a higher rate of intrahepatic cholestasis of pregnancy (ICP). Mother to child HBV transmission was rare (only two cases) and occurred in mothers in the immune-tolerant phase.

CONCLUSIONS

Our data showed that more than one-third of CHB pregnant women were classified into the GZ. In standard stages, advanced age is associated with HBeAg-negative and a higher cesarean rate in the inactive phase. The incidence of ICP was higher in immune active phases, including GB and GD. The probability of mother-to-child transmission in gray zones is low.

Postpartum hepatitis and host immunity in pregnant women with chronic HBV infection

In order to develop immune tolerant to the fetal, maternal immune system will have some modification comparing to the time before pregnancy. Immune tolerance starts and develops at the maternal placental interface. In innate immunity, decidual natural killer (dNK) cells, macrophages and dendritic cells play a key role in immue tolerance. In adaptive immunity, a moderate increase of number and immune inhibition function of regulatory T cells (Treg) are essential for immune tolerance. The trophoblast cells and immune cells expressing indoleamine 2,3-dioxygenase (IDO), the trophoblast cells expressing HLA-G, and Th1/Th2 shifting to Th2 dominant and Th17/Treg shifting to Treg domiant are in favor of maternal fetal immune tolerance. Steroids (estrogen and progesterone) and human chorionic gonadotropin (HCG) also participate in immune tolerance by inducing Treg cells or upregulating immunosuppressive cytokines. Most of the patients with chronic HBV infection are in the "HBV immune tolerance period" before pregnancy, and the liver disease is relatively stable during pregnancy. In chronic HBV infection women, after delivery, the relative immunosuppression in vivo is reversed, and Th1 is dominant in Th1/Th2 and Th17 is dominant in Th17/Treg balance. After delivery, the number of Treg decrease and NK cells increase in quantity and cytotoxicity in peripheral blood. Liver NK cells may cause liver inflammation through a non-antigen specific mechanism. After delivery, the number of CD8⁺ T cells will increase and HBV specific T cell response recovers from the disfunction in pregnancy. Under the background of postpartum inflammation, the rapid decrease of cortisol after delivery, and especially the enhancement of HBV specific T cell response induced by HBV DNA and cytokines, are the main reasons for postpartum hepatitis. HBeAg positive, especially HBeAg<700 S/CO, and HBV DNA>3-5Log₁₀IU/ml are risk factors for postpartum hepatitis. Antiviral treatment in late pregnancy can reduce the incidence of mother to child transmission (MTCT) in chronic HBV infection women. Chronic HBV infection women have hepatitis both during pregnancy and more often in 12 weeks postpartum. It is generally agreed that postpartum hepatitis is mild symptoms and self-limited. Delaying drug withdrawal to 48 weeks can increase the seroconversion rate of HBeAg in delivery women with elevated alanine aminotransferase (ALT) in pregnancy.

PgRNA kinetics predict HBsAg reduction in pregnant chronic hepatitis B carriers after treatment cessation

Background

Pregenomic RNA (pgRNA) and hepatitis B core-related antigen (HBcrAg) play significant roles in predicting discontinuing treatment outcomes. However, their role in pregnancy has rarely been reported. We aimed to evaluate the performance of pgRNA and HBcrAg kinetics in predicting HBeAg seroconversion and HBsAg reduction postpartum in HBeAg-positive pregnant women.

Methods

Pregnant HBeAg-positive patients receiving antiviral prophylaxis and ceasing treatment postpartum were included. PgRNA and HBcrAg levels were measured before treatment, at 32 weeks of gestation, and at treatment withdrawal postpartum. Other virological and biochemical parameters were regularly examined until 96 weeks postpartum.

Results

Of 76 pregnant chronic hepatitis B (CHB) carriers with a median treatment duration of 18.1 weeks, HBeAg seroconversion and HBsAg reduction >0.3 log₁₀ IU/mL at 96 weeks postpartum occurred in 8 (10.5%) and 13 (17.1%) patients, respectively. HBsAg correlated most strongly with pgRNA, while HBeAg correlated most strongly with HBcrAg. Multivariable regression analysis revealed that postpartum pgRNA decline and peak ALT levels were independent predictors of HBsAg reduction. The area under the curve of the regression model was 0.79 and reached as high as 0.76 through bootstrapping validation. The calibration plot showed that the nomogram had a performance similar to that of the ideal model. A decision tree was established to facilitate application of the nomogram. In addition, HBcrAg kinetics, as an independent predictor, performed poorly in predicting HBeAg seroconversion.

Conclusions

Postpartum pgRNA decline together with peak ALT levels may identify patients with a higher probability of HBsAg reduction after treatment cessation postpartum among pregnant CHB carriers receiving antiviral prophylaxis.

Tenofovir disoproxil fumarate therapy to prevent hepatitis B virus vertical transmission-A review of maternal and infant outcomes

Hepatitis B virus (HBV) is a global health problem. Vertical transmission of HBV from HBV surface antigen (HBsAg)-positive mothers to their infants is the most common cause of HBV infection worldwide. The use of passive-active immunoprophylaxis is >90% effective in reducing the risk of vertical transmission, but immunoprophylaxis failure can occur in infants born to mothers with high viraemia. Thus, it is recommended that pregnant women with HBV-DNA level >200 000 IU/ml receive nucleos(t)ide analogue (NA) treatment [i.e. tenofovir disoproxil fumarate (TDF), lamivudine or telbivudine] during third trimester to prevent infant immunoprophylaxis failure. TDF is recommended as the first-line therapy based on available data on efficacy, safety and resistance profile. However, maternal immunological reconstitution following parturition can increase immune-mediated flares to viral antigens that is potentially exacerbated following TDF withdrawal. In this article, we review available data on the efficacy and safety of TDF administration to prevent HBV mother-to-child transmission. We also discuss changes in maternal viral markers [i.e. HBV-DNA, HBV e antigen and HBsAg] and alanine aminotransferase during follow-up post-partum in mothers received NA to prevent HBV vertical transmission.

Clinical and Immunological Factors Associated with Postpartum Hepatic Flares in Immune-Tolerant Pregnant Women with Hepatitis B Virus Infection Treated with Telbivudine

Background/Aims

To investigate postpartum hepatic flares and associated factors in highly viremic pregnant patients in the immune tolerance phase who adopted telbivudine (LdT) treatment in the last trimester to reduce vertical transmission of hepatitis B virus.

Methods

Hepatitis B e antigen (HBeAg)-positive, highly viremic pregnant women were recruited for this prospective study. Treatment with LdT was started from 28 weeks of gestation. Virological and biochemical markers were examined before LdT treatment, antepartum and postpartum. Serial blood samples at the same time were collected to detect cytokines and cortisol (COR).

Results

Fifty-six of 153 patients (36.6%) had postpartum hepatic flares, defined as a 2-fold increase in alanine aminotransferase 6 weeks after delivery. Age and the antepartum alanine aminotransferase and postpartum HBeAg levels were independent influencing factors of postpartum hepatic flares. Cytokines showed no regularity during or after pregnancy. Compared with the patients with no postpartum flares, the patients with flares had lower baseline interferon γ and COR levels (p=0.022 and p=0.028) and higher postpartum interferon γ levels (p=0.026).

Conclusions

A high proportion of highly viremic and immune-tolerant pregnant patients treated with LdT in the last trimester had postpartum hepatic flares, which implied that these patients entered the immune clearance phase after delivery. Thus, this may create an appropriate opportunity for re-antiviral therapy.

Risk factors related to postpartum hepatic inflammation in pregnant women with chronic hepatitis B

OBJECTIVES

To investigate liver function after pregnancy in women with chronic hepatitis B virus (HBV) and factors related to postpartum abnormalities.

METHODS

A total of 317 pregnant women were included in this study and 138 had an HBV DNA level. In this trial, the highest number and proportion of hepatitis B surface antigen-positive mothers with postpartum hepatic inflammation were at 1 month after delivery.

RESULTS

Baseline liver function of postpartum women with hepatic inflammation was significantly higher than that in those before delivery. The rates of hepatitis B e-antigen (HBeAg)-positive status, baseline HBV DNA levels, gestational diabetes mellitus, and antiviral therapy during pregnancy were significantly higher in the hepatic inflammation group than in the control group. Among the 138 women who received antiviral therapy, 83 withdrew from antiviral therapy immediately after delivery and 55 continued antiviral therapy for at least 1 month after delivery. Multivariate logistic regression analysis showed that HBeAg-positivity and gestational diabetes mellitus were associated with hepatic inflammation after delivery. Postpartum hepatic inflammation occurred mostly at 1 month after delivery in pregnant women with HBV infection.

CONCLUSIONS

Close monitoring of women with HBV during pregnancy is required, especially for those who are HBeAg-positive and have gestational diabetes mellitus.

Viral hepatitis and pregnancy

The management of viral hepatitis in the setting of pregnancy requires special consideration. There are five liver-specific viruses (hepatitis A, B, C, D, E), each with unique epidemiology, tendency to chronicity, risk of liver complications and response to antiviral therapies. In the setting of pregnancy, the liver health of the mother, the influence of pregnancy on the clinical course of the viral infection and the effect of the virus or liver disease on the developing infant must be considered. Although all hepatitis viruses can harm the mother and the child, the greatest risk to maternal health and subsequently the fetus is seen with acute hepatitis A virus or hepatitis E virus infection during pregnancy. By contrast, the primary risks for hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis D virus are related to the severity of the underlying liver disease in the mother and the risk of mother-to-child transmission (MTCT) for HBV and HCV. The prevention of MTCT is key to reducing the global burden of chronic viral hepatitis, and prevention strategies must take into consideration local health-care and socioeconomic challenges. This Review presents the epidemiology of acute and chronic viral hepatitis infection in pregnancy, the effect of pregnancy on the course of viral infection and, conversely, the influence of the viral infection on maternal and infant outcomes, including MTCT.

Hepatitis B reactivation: diagnosis and management

INTRODUCTION

Hepatitis B virus (HBV) reactivation can be induced by treatments that attenuate the immunological control over HBV, leading to increased morbidity and mortality. The risk of HBV reactivation is determined by host immunity, viral factors, and the type and dose of treatments. Nevertheless, the risk of HBV reactivation for a growing number of novel therapies remains uncertain and needs to be carefully examined. Identification of patients at risk and administration of prophylactic antiviral agents are critical to prevent HBV reactivation. Early diagnosis and initiation of antiviral treatment are the keys to avoid devastating outcomes.

AREA COVERED

We summarized the latest evidence and recommendations for risk stratification, early diagnosis, prophylaxis, and management of HBV reactivation.

EXPERT OPINION

Universal screening, adequate prophylaxis, and close monitoring are essential for the prevention of HBV reactivation. Risk stratification of patients at risk with appropriate antiviral prophylaxis can prevent HBV reactivation effectively. Several emerging biomarkers have been proved to help determine the risk precisely. Early detection and timely administration of antiviral agents are crucial for management. Further studies on the precision of risk stratification as well as the optimal duration of prophylaxis and treatment are needed to establish an individualized strategy.

Serum alanine aminotransferase flares in chronic hepatitis B infection: the good and the bad

Chronic hepatitis B virus (HBV) infection follows a dynamic and variable course. At different stages in the disease, hepatitis flares might occur, which can be challenging to predict and manage. Flares are believed to be primarily immune-mediated and might mark transitions to inactive disease or clearance of infection, but in certain scenarios they might also lead to hepatic decompensation or death. As such, understanding of the clinical significance of flares in different patient populations and different scenarios is important for optimal management. In this Review, we summarise what is known about flares in different stages of chronic HBV infection; describe flares in the context of the natural history of chronic infection; summarise the immunological mechanisms underlying flares, and describe flares in different clinical scenarios. Each section reviews existing knowledge and highlights key unanswered questions that need to be addressed to improve the understanding of flares, hopefully providing insights into their pathogenesis that can be used to improve current clinical management and ideally to further develop new curative therapeutic approaches for HBV infection. We also propose a working definition of an ALT flare to facilitate future research.

High mutation prevalence of precore and basal core promoter in pregnant women who underwent spontaneous HBeAg seroconversion within one year postpartum

BACKGROUND

Seroconversion of hepatitis B e antigen (HBeAg) is a critical event in the natural course of hepatitis B virus (HBV) infection.

AIM

We herein characterize the virological factors associated with postpartum spontaneous HBeAg seroconversion.

METHODS

A total of 214 pregnant women positive for both hepatitis B surface antigen (HBsAg) and HBeAg were followed up at 7-12 months postpartum.

RESULTS

Of the subjects, 26 (12.1%) achieved spontaneous HBeAg seroconversion. Receiver operating curve analysis indicated that HBV DNA level <1.0 × 10⁷ IU/mL, HBsAg <1.0 × 10⁴ IU/mL and HBeAg <7.36 × 10² S/CO each independently predicted HBeAg seroconversion within 12 months postpartum. At delivery, 73.1% (19/26) women with postpartum HBeAg seroconversion had precore (PC) and/or basal core promoter (BCP) mutations, higher than that (5/36, 13.9%) in the women without postpartum seroconversion. Binary logistic regression analysis indicated that the presence of mutations in PC, BCP, and both PC and BCP at delivery was associated with an increased likelihood (OR = 13.286, 16. 238, and 22.143 respectively, all P < 0.05) to undergo postpartum spontaneous HBeAg seroconversion.

CONCLUSION

These results suggest that quantitative determination of virological markers and sequencing PC and BCP can predict spontaneous HBeAg seroconversion, which could be valuable in deciding antiviral therapy against HBV.

The Administration of Tenofovir Disoproxil Fumarate for Pregnant Japanese Women with Chronic Hepatitis B

The appropriate management of hepatitis B virus (HBV) infection during pregnancy has not been established in Japan. We herein report five HBV-infected pregnant Japanese women who received tenofovir disoproxil fumarate (TDF). Two of them had been born after the introduction of nationwide immunoprophylaxis and were vertically infected with HBV, highlighting the need to address mother-to-child transmission further. In both entecavir-experienced and nucleoside/nucleotide analog-naïve mothers, TDF suppressed HBV replication without serious adverse events. All five children were free from congenital disorders, growth impairment, and HBV infection. TDF showed safety and efficacy for pregnant woman with chronic hepatitis B and might have helped prevent mother-to-child transmission.

Baseline Hepatitis B Virus Titer Predicts Initial Postpartum Hepatic Flare: A Multicenter Prospective Study

BACKGROUND AND GOALS

A series of changes in the immune system occur during pregnancy and puerperium. Currently, we aim to characterize both the natural changes in liver inflammation and its association with hepatitis B viremia during this special period.

PATIENTS AND METHODS

Chronic hepatitis B (CHB) gravidas were recruited and followed up to 52 weeks postpartum. Virological and biochemical parameters were assessed throughout the period.

RESULTS

A total of 1097 CHB mothers had finished the entire follow-up including 451 accepting telbivudine, 178 accepting tenofovir, and 468 without antiviral therapy. Among the mothers, 11.94% went through hepatic flare in the first trimester and the rate decreased to 2.1% at the time of delivery. Nevertheless, a much higher frequency (19.78%) was observed in the early postpartum. Interestingly, alanine aminotransferase level decreased along with the development of pregnancy and then suddenly increased in the first month of puerperium. In addition, a downward trend was observed on the titer of HBsAg and HBeAg after delivery. Of note, an obvious higher frequency of alanine aminotransferase flare was revealed in mothers with high viremia (>6 log10 IU/mL). With multivariate analysis, only hepatitis B virus titer at baseline was strongly associated with hepatic flare during early postpartum (95% confidence interval, 1.012-3.049, P=0.045). The predictive rates of hepatic flare at baseline viral load of 6, 7, and 8 log10 IU/mL were 16.67%, 28.30%, and 30.60%, respectively.

CONCLUSIONS

CHB gravidas with high viremia should be monitored closely during entire pregnancy, and extended antiviral therapy is recommend to those mothers with baseline viremia >7 log10 IU/mL.

Serum Aminotransferase Flares in Pregnant and Postpartum Women With Current or Prior Treatment for Chronic Hepatitis B

BACKGROUND AND AIMS

Antiviral therapy is recommended for pregnant women with chronic hepatitis B (CHB) and hepatitis B virus (HBV) DNA>200,000 IU/mL, but there is less consensus on management of women who discontinue therapy in anticipation of pregnancy or who become pregnant while on therapy. The goal of this study was to describe flares in alanine aminotransferase (ALT) during pregnancy and postpartum in CHB women with current and/or prior treatment.

METHODS

This was a multicenter, retrospective study of 67 pregnancies in 56 CHB women treated before and/or during pregnancy. Main outcomes were frequency, severity, and resolution of ALT flare (≥5× upper limit of normal or ≥3× baseline, whichever was higher).

RESULTS

During pregnancy, ALT flares (95 to 1064 U/L) were observed in 16% (7/43) of women who stopped treatment before pregnancy and 31% (4/13) of women who discontinued treatment during first trimester, many of whom had high HBV DNA levels (4.9 to 8.0 log IU/mL). No flares (0/11) were observed in women who continued treatment. Postpartum ALT flares (104 to 1584 U/L) were observed in 0% (0/15) of women who were completely untreated during pregnancy, 29% (2/7) of women who discontinued treatment in first trimester, 33% (3/9) of women who stopped treatment at delivery, and 22% (4/18) of women who continued treatment postpartum.

CONCLUSIONS

In previously treated women with CHB, ALT flares were common during pregnancy and postpartum, especially if antiviral therapy was discontinued shortly before pregnancy, during first trimester, or at delivery. Thus, these pregnant women should be monitored closely throughout pregnancy and the early postpartum period; larger studies are needed to further characterize the natural history of HBV infection during pregnancy and postpartum.

Hepatitis B During Pregnancy in Endemic Areas: Screening, Treatment, and Prevention of Mother-to-Child Transmission

The proper management of pregnant women infected with hepatitis B virus (HBV) is necessary to prevent maternal and fetal morbidity and mortality and to protect the baby from HBV infection. In the majority of cases, vertical transmission can be prevented with a universal screening program, HBV vaccine immunoprophylaxis, and administration of hepatitis B immunoglobulin (HBIg) for babies born to mothers with HBV. However, in mothers with a high viral load (>200,000 or >1,000,000 IU/ml, depending on the guideline), the chance of immunoprophylaxis failure remains high. The standard recommendation is to give an antiviral agent during the third trimester in these patients. US FDA pregnancy category B agents such as tenofovir and telbivudine are allowed through all trimesters of pregnancy. Breastfeeding for patients who receive antiviral agents can be allowed after a risk-benefit discussion with the patient.

Peripartum cytokine flares in a multiethnic cohort of chronic hepatitis B carriers does not correlate with hepatitis B virus suppression or increased risk of liver disease

PROBLEM

In chronic hepatitis B (CHB) carriers, alanine transaminase (ALT) flares are common in the peripartum period. There are limited data on immunological changes of pregnancy in CHB. We hypothesize that in pregnant CHB carriers, the Th1/Th2 cytokine ratio is altered resulting in changes in biochemical/virological and liver fibrosis markers.

STUDY METHODS

Serum from 38 pregnant/post-partum CHB carriers (median age 32 years, 53% Asian, 8 HBeAg⁺ ) was tested for HBV DNA, quantitative HBV surface antigen, ALT and liver fibrosis by transient elastography (TE). Serum cytokines were analyzed using a Luminex assay.

RESULTS

Untreated CHB cases had mild ALT flares post-partum, but showed normal TE, and no change in viral markers despite increased Th1 cytokines compared to healthy controls (P<.05).

CONCLUSION

CHB carriers show increased Th1 cytokines in the peripartum period albeit with no effect on viral load or liver disease suggesting an aborted antiviral immune response.

Serum Alanine Aminotransferase and Hepatitis B DNA Flares in Pregnant and Postpartum Women with Chronic Hepatitis B

OBJECTIVES

Alterations in the immune system during pregnancy have been associated with reactivation of hepatitis B virus (HBV) in chronic hepatitis B (CHB) women. However, the effects of pregnancy on CHB remain not well understood. The goal of this study was to examine flares in HBV DNA and serum alanine aminotransferase (ALT) during pregnancy and postpartum in CHB women untreated prior to pregnancy.

METHODS

This was a multicenter retrospective study of 113 pregnancies in 101 CHB women who presented during pregnancy at two community gastroenterology clinics and two tertiary medical centers in the United States during 1997-2015. Outcomes analyzed included onset, severity, and resolution of flares in HBV and ALT that occurred prior to starting antiviral therapy, if antiviral therapy was subsequently initiated. Women who initiated antiviral therapy during pregnancy were not included in the analysis of postpartum flares.

RESULTS

HBV DNA flares were observed in 9% (8/90) of women during pregnancy and 4% (2/48) of women during postpartum. Flares in ALT (99-2522 U/l) were observed in 6% (7/112) of women during pregnancy and 10% (5/51) of women within the first 3 months of delivery. Age, HBeAg positivity, baseline HBV DNA, baseline ALT, gravida, and parity were not found to be significant predictors of flare.

CONCLUSIONS

Flares in HBV DNA and ALT can occur during late pregnancy and early postpartum in CHB women, and can be severe. Women with CHB should therefore be closely monitored during pregnancy and early postpartum.

Clinical and virological predictors of hepatic flares in pregnant women with chronic hepatitis B

BACKGROUND

Unique immunological changes occur during pregnancy; the impact of which, on virological and biochemical markers of hepatitis B infection is not well established. Rapid changes in the immunological profile post partum and consequent rebound of the inflammatory response may result in hepatic flares.

METHODS

Women with chronic hepatitis B were recruited during pregnancy into this observational study. Demographic and clinical data were collected together with virological and biochemical parameters at two time points during pregnancy (early and late) and two time points post partum (between 6 weeks and 12 weeks and at 12 months). Outcomes analysed included changes in HBV DNA, hepatitis B e antigen (HBeAg) status and flares of hepatitis.

RESULTS

One hundred and twenty-six women were recruited. Twenty-seven women out of 108 with postpartum bloods (25%) met our definition of a postpartum flare (ALT range 38-1654). Using univariate analysis HBeAg status, younger age, gravida and parity were associated with a flare. On multivariate analysis HBeAg positivity at baseline fell just outside of statistical significance in predicting a postpartum flare (p=0.051).

CONCLUSIONS

25% of women with chronic hepatitis B will demonstrate increased liver inflammation in the postpartum period. This is usually asymptomatic and resolves spontaneously. This is more likely if the woman is HBeAg-positive at baseline (2.56 times the risk), although flares also commonly occur in HBeAg-negative women.

Kinetic Changes of Viremia and Viral Antigens of Hepatitis B Virus During and After Pregnancy

Whether pregnancy may influence the replication of hepatitis B virus (HBV) remains unknown. The authors aimed to clarify this issue by observing the kinetics of HBV deoxyribonucleic acid (DNA) and viral antigens in women during and after pregnancy. Total, 371 pregnant women with positive hepatitis B surface antigen (HBsAg) were enrolled. Serial sera collected during and after pregnancy were quantitatively measured for HBV DNA, HBsAg, and hepatitis B e antigen (HBeAg). Total, 34 HBeAg-positive women underwent alanine aminotransferase (ALT) elevation during or after pregnancy; levels of HBV DNA and HBsAg in them showed no obvious change between second trimester or delivery and 7 to 12 months postpartum (P > 0.05). The 337 others had normal alanine aminotransferase levels during pregnancy and postpartum. In 147 HBeAg-positive women with follow-up 7 to 12 months postpartum, the average levels of HBV DNA (>7.0 log10 IU/mL), HBsAg (>4.0 log10 IU/mL), and HBeAg (>3.0 log10 S/CO) were longitudinally constant during pregnancy and postpartum, respectively. In 173 women with follow-up 4.8 years postpartum, neither HBV DNA levels nor antigen titers showed significant difference between second trimester and 4.8 years postpartum, regardless of the HBeAg status. In addition, levels of HBV DNA and viral antigens in second trimester, around delivery, 6 to 8 weeks and 7 to 12 months postpartum showed no marked fluctuations, respectively. Serum levels of HBV DNA and viral antigens in HBsAg-positive women are highly constant during pregnancy and postpartum, regardless of the HBeAg status and alanine aminotransferase levels. This demonstrates that pregnancy has little influence on the HBV replication and antigen expression.

Effect of Peg-interferon α-2a combined with Adefovir in HBV postpartum women with normal levels of ALT and high levels of HBV DNA

BACKGROUND & AIMS

Currently, routine antiviral treatment is not recommended for immune-tolerant subjects with chronic HBV infection. In this study, we assessed the treatment efficacy of combining Peg IFN α-2a with Adefovir (CPIA) in chronic HBV infected pregnant women with normal levels of ALT and high levels of HBV after delivery.

METHODS

Chronic hepatitis B pregnant women with normal levels of ALT and high levels of HBV DNA were treated with Telbivudine during the third trimester of their pregnancy. After childbirth, based on serological and virological parameters, the patients were either switched to CPIA treatment for 96 weeks or stopped Telbivudine treatment and followed for 48 weeks.

RESULTS

A total of 68 patients were enrolled in this study. Thirty (30/68) of them were switched to CPIA treatment after childbirth, 93.3% (28/30) of them achieved virological response, 56.7% (17/30) achieved HBeAg seroclearance and 26.7% (8/30) cleared HBsAg. The HBV DNA and HBeAg levels before CPIA treatment were negatively associated with HBeAg seroclearance. HBsAg and HBeAg levels in week 12 and week 24 after CPIA treatment were negatively associated with HBsAg seroclearance. Thirty-eight (38/68) patients did not receive antiviral treatment after childbirth, and none of them had HBeAg or HBsAg clearance.

CONCLUSION

High rates of viral response and clearance were achieved in chronic hepatitis B pregnant woman with normal levels of ALT and high levels of HBV DNA treated by CPIA after childbirth. (231 words).

Hepatitis B and C in pregnancy: a review and recommendations for care

Our objective was to provide a comprehensive review of the current knowledge regarding pregnancy and hepatitis B virus (HBV) or hepatitis C virus (HCV) infection as well as recent efforts to reduce the rate of mother-to-child transmission (MTCT). Maternal infection with either HBV or HCV has been linked to adverse pregnancy and birth outcomes, including MTCT. MTCT for HBV has been reduced to approximately 5% overall in countries including the US that have instituted postpartum neonatal HBV vaccination and immunoprophylaxis with hepatitis B immune globulin. However, the rate of transmission of HBV to newborns is nearly 30% when maternal HBV levels are greater than 200 000 IU ml(-1) (>6 log10 copies ml(-1)). For these patients, new guidelines from the European Association for the Study of the Liver (EASL) and the Asian Pacific Association for the Study of the Liver (APASL) indicate that, in addition to neonatal vaccination and immunoprophylaxis, treating with antiviral agents such as tenofovir disoproxil fumarate or telbivudine during pregnancy beginning at 32 weeks of gestation is safe and effective in preventing MTCT. In contrast to HBV, no therapeutic agents are yet available or recommended to further decrease the risk of MTCT of HCV, which remains 3 to 10%. HCV MTCT can be minimized by avoiding fetal scalp electrodes and birth trauma whenever possible. Young women with HCV should be referred for treatment post delivery, and neonates should be closely followed to rule out infection. New, better-tolerated treatment regimens for HCV are now available, which should improve outcomes for all infected individuals.

Anti-viral therapy for prevention of perinatal HBV transmission: extending therapy beyond birth does not protect against post-partum flare

BACKGROUND

Antepartum anti-viral therapy (AVT) is often administered to prevent perinatal transmission of hepatitis B virus (HBV) infection. Little is known about the effect of AVT on post-partum flare rates and severity.

AIM

To examine whether extending AVT beyond birth influences the post-partum course.

METHODS

One hundred and one pregnancies in 91 women with HBV DNA levels ≥log 7 IU/mL were included. AVT (initially lamivudine, later tenofovir disoproxil fumarate) was commenced from 32 weeks gestation and stopped soon after birth and at 12 weeks post-partum. Outcomes according to post-partum treatment duration were examined: Group 1 = AVT ≤4 weeks (n = 44), Group 2 = AVT >4 weeks (n = 43), Group 3 = no AVT (n = 14).

RESULTS

The majority of women were HBeAg+ (97%), median age 29 years, baseline HBV DNA log 8.0 IU/mL and follow-up 48 weeks post-partum. Post-partum treatment duration was 2 weeks for Group 1 and 12 weeks for Group 2, P < 0.01. Flare rates were not significantly different: Group 1 = 22/44 (50%), Group 2 = 17/43 (40%) and Group 3 = 4/14 (29%), P = 0.32. Onset of flare was similar at 8/10/9 weeks post-partum for Groups 1/2/3 respectively, P = 0.34. The majority of flares spontaneously resolved. HBeAg seroconversion (n = 1/5/1 in Groups 1/2/3, P = 0.27) was not associated with treatment duration or the occurrence of a post-partum flare.

CONCLUSIONS

Post-partum flares are common and usually arise early after delivery. They are often mild in severity and most spontaneously resolve. Extending anti-viral therapy does not protect against post-partum flares or affect HBeAg seroconversion rates.

Hepatic failure in pregnancy successfully treated by online hemodiafiltration: Chronic hepatitis B virus infection without viral genome mutation

A 23-year-old nulliparous woman, a hepatitis B virus (HBV) carrier with stable liver functions, presented with exacerbation of viral replication (HBV DNA level >9.0 log copies/mL) in gestational week 26. During the subsequent follow up without antiviral therapy, she was hospitalized with progression to hepatic failure in gestational week 35. Following initiation of antiviral therapy with lamivudine, emergent cesarean delivery was conducted for fetal safety. Liver atrophy and persistent hepatic encephalopathy (stage 2) necessitated artificial liver support (ALS) involving online hemodiafiltration (HDF) and plasma exchange. She regained full consciousness after the sixth online HDF session. ALS was terminated after the seventh online HDF session. On day 33 of hospitalization, she was discharged home without sequelae. Genetic analysis of the HBV strain isolated from her serum showed that this strain had genotype C. Direct full-length sequencing identified no known mutations associated with fulminant hepatitis B. HBV-related hepatic failure observed in the present case might have been related to perinatal changes in the host immune response.

Towards complete eradication of hepatitis B infection from perinatal transmission: review of the mechanisms of in utero infection and the use of antiviral treatment during pregnancy

Hepatitis B infection remains the most common form of chronic hepatitis. Mother to child transmission occurs despite immunoprophylaxis with vaccination and immunoglobulin. In utero infection is suggested to account for most of the cases with immunoprophylaxis failure. Infants who suffer from hepatitis B infection at birth have a higher risk of becoming chronic carriers and may develop liver cirrhosis or hepatocellular carcinoma in the future. Infected germ cells, transplacental infection, invasive prenatal diagnostic tests and various perinatal factors are possible factors leading to in utero infection and subsequent immunoprophylaxis failure. Hepatitis B e antigen positive status and high viral load increase the risk of immunoprophylaxis failure. Recent evidence shows promising results regarding the use of antiviral treatment in late gestation to suppress viral load, so as to decrease the risk of vertical transmission. This review discusses the possible mechanisms of in utero infection and the use of antiviral treatment during pregnancy.

Safety of lamivudine treatment for chronic hepatitis B in early pregnancy

AIM: To evaluate the safety of lamivudine (LAM) treatment for chronic hepatitis B in early pregnancy.

METHODS: A total of 92 pregnant women who received LAM treatment either before pregnancy or in early pregnancy were enrolled in this study. All of the pregnant women volunteered to take lamivudine during pregnancy and were not co-infected with hepatitis C virus, human immunodeficiency virus, cytomegalovirus, or other viruses. All infants received passive-active immunoprophylaxis with 200 IU hepatitis B immunoglobulin and three doses of 10 μg hepatitis B vaccines (0-1-6 mo) according to the guidelines for the prevention and treatment of chronic hepatitis B. Adverse events were observed throughout the entire pregnancy and perinatal period, and the effectiveness of lamivudine treatment for blocking mother-to-infant transmission of hepatitis B virus (HBV) was evaluated. All adverse events in mothers and infants during pregnancy and the perinatal period and the HBV mother-to-infant transmission blocking rate were compared with the literature.

RESULTS: Among the 92 pregnant women, spontaneous abortions occurred in 11 cases, while 3 mothers had a second pregnancy after the initial abortion; 72 mothers delivered 73 live infants, of whom 68 infants were followed up for no less than 6 mo, and 12 mothers were still pregnant. During pregnancy, the main maternal adverse events were vaginitis (12/72, 16.7%), spontaneous abortion (11/95, 11.6%), and gestational diabetes (6/72, 8.3%); only one case had 1-2 degree elevation of the creatine kinase level (195 U/L). During the perinatal period, the main maternal adverse events were premature rupture of the membranes (8/72, 11.1%), preterm delivery (5/72, 6.9%), and meconium staining of the amniotic fluid (4/72, 5.6%). In addition, 2 infants were found to have congenital abnormalities; 1 had a scalp hemangioma that did not change in size until 7 mo, and the other had early cerebral palsy, but with rehabilitation training, the infant’s motor functions became totally normal at 2 years of age. The incidence of adverse events among the mothers or abnormalities in the infants was not higher than that of normal mothers or HBV-infected mothers who did not receive lamivudine treatment. In only 2 cases, mother-to-infant transmission blocking failed; the blocking rate was 97.1% (66/68), which was higher than has been previously reported.

CONCLUSION: Lamivudine treatment is safe for chronic HBV-infected pregnant mothers and their fetuses with a gestational age of less than 12 wk or throughout the entire pregnancy.

Chronic hepatitis B virus infection and pregnancy

Planning of pregnancy and management of chronic hepatitis B virus during pregnancy includes recognition of maternal virological status, assessment of liver disease severity and minimization of risk for mother to infant transmission of infection. Decisions regarding the use of antivirals during pregnancy need to be individualized. Monitoring for infection and immunization in newborns is also important. For mothers on antiviral therapy, breastfeeding is not recommended.

Management of chronic hepatitis B in pregnancy

Pregnancy associated with chronic hepatitis B (CHB) is a common and important problem with unique challenges. Pregnant women infected with CHB are different from the general population, and their special problems need to be considered: such as the effect of hepatitis B virus (HBV) infection on the mother and fetus, the effect of pregnancy on replication of the HBV, whether mothers should take HBV antiviral therapy during pregnancy, the effect of these treatments on the mother and fetus, how to carry out immunization of neonates, whether it can induce hepatitis activity after delivery and other serious issues. At present, there are about 350 million individuals with HBV infection worldwide, of which 50% were infected during the perinatal or neonatal period, especially in HBV-endemic countries. Currently, the rate of HBV infection in the child-bearing age group is still at a high level, and the infection rate is as high as 8.16%. Effective prevention of mother-to-child transmission is an important means of reducing the global burden of chronic HBV infection. Even after adopting the combined immunization measures, there are still 5%-10% of babies born with HBV infection in hepatitis B e antigen positive pregnant women. As HBV perinatal transmission is the main cause of chronic HBV infection, we must consider how to prevent this transmission to reduce the burden of HBV infection. In this population of chronic HBV infected women of childbearing age, specific detection, intervention and follow-up measures are particularly worthy of attention and discussion.

HEPATITIS B AND PREGNANCY, THE SCIENTIFIC BASIS FOR PERINATAL PREVENTION

Hepatitis B and its complications are one of the major global health problems. Around 2 billion individuals are infected by hepatitis B virus (HBV) worldwide, more than 350 million are chronically infected, and approximately 15 to 40 percents of them will develop serious complications such as liver cirrhosis, hepatic failure, or hepatocellular carcinoma (HCC). The worldwide prevalence of chronic HBV infection ranges from 0.1 to 20 percent and varies widely in different geographic areas. According to the prevalence rate, WHO has classified countries into 3 levels: high areas (>8%) such as Africa, Asia, Western Pacific and Middle East; intermediate areas (2–8%) such as South America and Eastern Europe, and low areas (<2%) such as Western Europe, North America, and Australia.

Pregnancy and chronic hepatitis B virus infection

The combination of chronic hepatitis B virus (HBV) infection and pregnancy presents unique management questions. Aspects of care that need to be considered include effects of hepatitis B on pregnancy, effects of pregnancy itself on the course of hepatitis B infection, treatment of hepatitis B during pregnancy and prevention of mother-to-infant transmission. Chronic HBV infection is usually mild in pregnant women, but may flare shortly after delivery. Effect of HBV infection on pregnancy outcomes are generally favorable, but may depend on severity of liver disease. Mother-to-infant transmission can be minimized by current immunoprophylaxis strategies, however, high levels of viremia in mothers may be a factor in the small but reproducible failure rate of current immunoprophylaxis strategies. Use of antivirals during pregnancy needs to be individualized. Careful planning and management of pregnancy must be done among patients with chronic HBV infection.

Chronic hepatitis B in Asian women of childbearing age

Hepatitis B virus (HBV) infection is a serious clinical problem affecting approximately 2 billion people worldwide. An estimated 350 million live with chronic hepatitis B (CHB) infection and are at an increased risk for serious liver sequelae and death from acute or chronic consequences of CHB infection. Individuals with CHB have a 20-30% risk of early death from complications, including liver cirrhosis and hepatocellular carcinoma. In the Asia-Pacific region, half of the CHB burden results from vertical or mother-to-child transmission, with early childhood horizontal transmission accounting for the remaining half. Screening and vaccination are key factors in the successful prevention and control of HBV infection. Over the last 20 years, the implementation of screening programs and universal HBV vaccination for all individuals born in endemic areas have reduced the prevalence of HBV infection and HBV-related liver diseases among individuals younger than 30 years. Women of childbearing age are key stakeholders in preventing HBV infection and, as such, play a critical role in reducing the vertical and horizontal transmission of HBV. Further efforts are needed to implement screening and educational programs for women of childbearing age, particularly those with CHB, to prevent the transmission of HBV to newborns, spouses, other household members, and sexual partners. In addition, healthcare workers need to learn how to avoid iatrogenic transmission in the healthcare setting. This article reviews these issues and highlights areas in which their engagement with public health efforts serves to improve quality of life and society as a whole.

Clinical course of hepatitis B virus infection during pregnancy

BACKGROUND

For women with hepatitis B virus (HBV) infection, little is known about the natural progression of the disease during pregnancy or its impact on pregnancy outcomes.

OBJECTIVES

To investigate the natural progression of HBV infection during pregnancy or its impact on pregnancy outcomes.

METHODS

In this retrospective cohort study, we reviewed medical records of all patients who were pregnant and presented with HBsAg-positivity between 2000 and 2008 at a community gastroenterology practice and a university hepatology clinic. Maternal characteristics were analysed according to maternal and perinatal outcomes.

RESULTS

A total of 29 cases with at least 2 measurements of either HBV DNA or alanine aminotransferase (ALT) levels were included. Older age was the only predictor of a trend towards higher risk of an adverse clinical outcome [OR = 1.21 (0.97-1.51), P = 0.089], defined as either a negative foetal outcome (premature delivery, spontaneous abortion), or a negative maternal outcomes (gestational diabetes mellitus, pre-eclampsia, hepatic flare, liver failure). This trend for age remained even after adjusting for baseline ALT. Baseline serum HBV DNA, ALT, hepatitis B e antigen status, gravida and parity were not significant predictors for adverse clinical outcomes. Four patients developed liver failure.

CONCLUSIONS

Maternal and neonatal outcomes are highly variable in this clinic-based patient cohort. Severe complications due to HBV infection can occur during pregnancy in previously asymptomatic patients. It is unclear how generalizable the results observed in this cohort would be to the general population; therefore, further studies are needed to identify reliable predictors for significant adverse outcomes and until more data are available, pregnant patients with HBV infection should be monitored with periodic serum HBV DNA and ALT levels.

Hepatitis B and pregnancy: an underestimated issue

Hepatitis B infection during pregnancy presents a unique set of management issues. Aspects of care that must be considered include maternal and fetal effects of hepatitis B, effects of pregnancy itself on the course of hepatitis B infection and its complications, treatment of hepatitis B during pregnancy and prevention of perinatal infection. There are insufficient studies to date regarding these concerns; most are from the Far East, and many have important limitations, but some have yielded valuable data. Pregnant women with acute hepatitis B virus (HBV) infection typically have a course not very different from that in the general adult population, but the risk of transmission of HBV to neonates increases the later in gestation the acute infection occurs. Chronic HBV infection is usually mild in pregnant women, but may flare shortly after delivery. The risk of perinatal transmission is highest in women with high levels of viraemia; this may be a factor in the small but reproducible failure rate of current immunoprophylaxis strategies. Obstetrical policies must be assessed with respect to detection of maternal infection and liver disease, as well as with respect to perinatal transmission risk. In addition to the usual issues of drug efficacy and safety in the affected individuals, effects on the developing fetus must be considered. This paper reviews the current experience in each of these areas, and highlights the need for further investigation into this critical but often underestimated topic.

Chronic hepatitis B virus (HBV) infection in pregnancy

BACKGROUND

Hepatitis B is a considerable disease burden among Asians. Little is known about its disease behaviour in pregnant women.

METHODS

Clinical, laboratory and radiological data of pregnant and peri-partum females with chronic hepatitis B virus (HBV) infection who were seen between years 1999 and 2004 were studied. Their progress was documented up to 6 months post-partum. This was compared with the age-matched and HBe status-matched, non-pregnant, female patients with chronic HBV infection, who were consecutively selected from the department's registry as controls (ratio 1 mother: 4 non-pregnant controls), over the corresponding period.

RESULTS

A total of 35 mothers and 140 controls were studied. Mean age of patients was 30.7 +/- 3.6 years. Majority of mothers (74.3%) presented during pregnancy itself. 1st:2nd:3rd trimester presentation = 20.0%:48.6%:5.7%. Majority (65.7%) were positive for HBe antigen (HBeAg) at the time of presentation. About 57.1% mothers had a clinical event in the form of alanine transferase (ALT) elevation and/or loss of HBeAg vs 28.8% among controls (P = 0.002). Among HBeAg-positive subjects, more mothers (14.3%) than controls (2.2%) had resultant HBeAg loss (P = 0.02). Among HBeAg negative subjects, more mothers than controls had serum ALT elevations in the post-partum period (P = 0.007). Overall, more mothers had elevated ALT levels than controls, regardless of their HBeAg status. Neither mothers nor control subjects decompensated clinically, neither required liver transplantation nor died during the study period.

CONCLUSIONS

Pregnancy is associated with serum ALT elevation and HBeAg loss in patients with chronic HBV infection in the peri-partum period.

Hepatitis B in pregnancy

In countries with a high prevalence of chronic hepatitis B, perinatal transmission from mother to infant accounts for the majority of cases of chronic hepatitis B. Passive-active immunoprophylaxis with hepatitis B immunoglobulin and hepatitis B vaccine at birth is 95% efficacious in reducing the risk of HBV transmission but is less effective in HBeAg-positive mothers with very high serum HBV DNA levels. In the last 4 weeks of pregnancy lamivudine may provide additional protection in pregnant women who have high-level viremia. Further studies are needed to evaluate the use of nucleos(t)ide analogues to treat chronic hepatitis B during pregnancy.

Hepatitis B post-partum e antigen clearance in hepatitis B carrier mothers: Correlation with viral characteristics

BACKGROUND

The purpose of the present paper was to correlate hepatitis B virus (HBV) genotype, e antigen titer, HBV-DNA level and precore/basal core promoter mutations with post-partum e antigen clearance in hepatitis B e antigen (HBeAg)-positive carrier mothers.

METHODS

A total of 40 consecutive HBeAg-positive carrier mothers were studied from January 2002 to January 2003. The blood samples were taken at delivery, 3-4 months and at 1 year after delivery, and the follow-up period was until 1 year after delivery. All sera were assayed for HBeAg, HBV-DNA level, HBV genotype and precore/basal core promoter mutations. The correlation between HBV characteristics and post-partum e antigen clearance was analyzed by Mann-Whitney, Pearson chi2 and multiple logistic regression tests.

RESULTS

The mean age of the 40 HBeAg-positive carrier mothers was 29.9 +/- 5.3 years with a mean parity of 1.4 +/- 0.7. Five of them (group I) had post-partum e antigen clearance, which persisted thereafter, whereas the remaining 35 carrier mothers (group II) had persistent positivity of HBeAg during the follow-up period. The prepartum comparisons of HBV characteristics between groups I and II were comparable in terms of demographics and distributions of HBV genotype and precore/basal core promoter mutations. In contrast, group I carrier mothers had lower HBeAg titer and HBV-DNA level than group II carrier mothers (1:80 vs 1:4000, P = 0.02, and 3.75 x 10(5) vs 3 x 10(8) copies/mL, P = 0.028, respectively).

CONCLUSIONS

Post-partum e antigen clearance in HBeAg-positive carrier mothers is closely associated with prepartum low HBeAg titer or HBV-DNA level.

Severe autoimmune hepatitis first presenting in the early post partum period

BACKGROUND & AIMS

Autoimmune hepatitis (AIH) may run an aggressive clinical course if untreated. The influence of pregnancy on AIH is variable. Both flares in disease activity and remissions, often followed by a post partum flare, are well recognized. In contrast, definite AIH first presenting in the early post partum period has not been reported.

METHODS

We discuss a case series of 5 patients who developed severe AIH within 4 months post partum.

RESULTS

The diagnosis of AIH was definite based on internationally accepted criteria. Liver injury responded to conventional immunosuppressive therapy in all patients. Immune reactivation in the early post partum period may contribute to this entity.

CONCLUSIONS

AIH should be considered in the differential diagnosis of liver dysfunction first presenting in the early post partum period.

Hepatitis B virus DNA during pregnancy and post partum: aspects on vertical transmission

Little is known about how pregnancy influences viremia levels in women with chronic hepatitis B virus infection. In this study, we first retrospectively analysed changes in HBV DNA levels during and after 55 pregnancies in HBsAg-positive women, of whom 9 were HBeAg-positive. Secondly, HBV DNA levels in 3 HBeAg-positive mothers whose babies became chronic HBV carriers, were compared with levels in 18 mothers whose babies were not infected by HBV. We found that HBV DNA ranged from 10(8.1) to 10(9.5) copies/mL in HBeAg-positive, and from undetectable (< 100) to 10(6.8) copies/mL in HBeAg-negative mothers. HBV DNA increased by a mean of 0.4 log late in pregnancy or early post partum; in 4 out of 16 HBeAg negative mothers by > 1 log during pregnancy. Post partum ALT increased in both HBeAg-positive and negative women. HBV DNA was 10(9.4)-10(10.4) copies/mL in 3 HBeAg-positive mothers whose babies were, as compared to < 100-10(10.4) copies/mL in 18 whose babies were not, vertically infected. Although the majority of HBeAg-negative women had low and relatively stable HBV DNA during pregnancy, viremia was also relatively high in some HBeAg-negative mothers, and both viremia and ALT increased significantly late in pregnancy or shortly after delivery. Vertical transmission was only seen in HBeAg-positive mothers with very high levels of viremia. The value of measuring HBV DNA in the pregnant woman to modify immunoprophylaxis to her infant needs further study.

Loss of hepatitis C virus RNA after parturition in female patients with chronic HCV infection

It is unclear whether pregnancy has any influence on chronic hepatitis C virus (HCV) infection. The aim of this study was to investigate the relationship between pregnancy and parturition with HCV viremia levels and the natural resolution of HCV RNA. Twenty-two pregnant patients and 120 nonpregnant control female patients, both positive for anti-HCV and HCV RNA, were studied. The HCV core protein levels were quantified by enzyme immunoassay, and HCV RNA was detected by reverse transcription-polymerase chain reaction (RT-PCR). Of the pregnant group, two females whose HCV RNA was negative continuously for more than 6 months lost HCV RNA permanently after parturition, and one female whose level of HCV core protein was intermittently under the limit of detection level lost HCV RNA intermittently. In the control group, only one female lost HCV RNA persistently, and one lost HCV RNA intermittently after she developed liver cirrhosis. At 3 months after parturition, the HCV core protein level was <15 fmol/L in all patients who lost HCV RNA, while the HCV core protein level was >/=15 fmol/L in 81.3% of the patients who persistently had HCV RNA (P = 0.03). Significantly more pregnant patients lost HCV RNA than did nonpregnant controls. These findings suggest that pregnancy and parturition appear to influence the clinical course of HCV infection.

Secular trend of age-specific prevalence of hepatitis B surface and e antigenemia in pregnant women in Taiwan

To elucidate the impact of aging of hepatitis B carrier women on their viral replicative markers in a hepatitis B endemic area, all the parturients admitted to the Hospital were studied from 1985 to 2000. Serum hepatitis B surface (HBsAg) and hepatitis B e antigen (HBeAg) were tested by radioimmunoassay. Mann-Whitney U and Student's t-tests were used for statistical analysis. The results showed the yearly prevalence rate of HBsAg in pregnant women seemed stable with a mean of 12.0 +/- 1.1% during the period. The yearly positive rate of HBeAg among HBsAg-positive pregnant women varied between 30.4% and 42.6% from 1985 to 1992 and declined from 29.6% in 1993 to 18.1% in 2000. The mean ratio of HBeAg/HBsAg in carrier parturients was 24.7% [intraquantile range (IQR) 20.5-28.4] from 1993 to 2000, which was significantly lower than that of 32.4% (IQR 31.0-39.0) from 1985 to 1992 (P < 0.0001). The mean age of HBeAg-positive primiparas from 1993 to 2000 was 29.1 +/- 3.9 years and significantly higher than that of 28.0 +/- 3.7 years from 1985 to 1993 (P < 0.001), as well as in secundiparas 31.2 +/- 3.8 years vs. 30.1 +/- 3.4 years (P < 0.001) and in total parturients 30.3 +/- 4.2 years vs. 29.3 +/- 3.8 years (P < 0.001). Thus, no significant decrease of HBsAg carriage was observed in the past 16 years, whereas a decreased ratio of HBeAg/HBsAg was noted in carrier parturients in the past 8 years and the elderly HBeAg-positive parturients from 1993 to 2000 may be the cause.

Post-partum acute exacerbation of chronic hepatitis in a hepatitis C-carrier mother

Hepatitis C virus infection is a global health problem; however, the interaction between pregnancy and chronic hepatitis C remains controversial. A Taiwanese woman with chronic hepatitis C had an uncomplicated pregnancy and gave birth to a female baby through spontaneous vaginal delivery. The serum levels of alanine aminotransferase and hepatitis C virus (HCV) RNA were measured before pregnancy, in the first and third trimesters, 1 and 3 months after delivery, respectively. During her pregnancy, the serum aminotransferase levels became normalized, while the serum HCV-RNA levels declined significantly and consecutively with the lowest viral load in the third trimester. One month after delivery, she had an abrupt elevation of serum HCV-RNA level, paralleling a hepatitis flare with serum aminotransferase level more than 20-fold the upper normal limit. The serum HCV-RNA levels declined thereafter, and serum aminotransferase levels became normalized 3 months postdelivery. She was infected with HCV genotype 1a throughout the entire follow-up period, and other causes of hepatitis flare were excluded. In conclusion, post-partum acute exacerbation of chronic hepatitis may occur in HCV-carrier mothers, and an abrupt elevation of serum HCV-RNA level may be associated with the acute exacerbation.

Hepatitis C virus load during pregnancy and puerperium

OBJECTIVE

To assess whether pregnancy and delivery influence serum levels of hepatitis C virus (HCV) in carrier mothers.

DESIGN

A prospective study.

SETTING

University department of obstetrics and gynaecology.

PARTICIPANTS

Ten pregnant HCV carriers (group A) and 8 nonpregnant HCV carriers (group B).

METHODS

Serum samples were collected for group A at first and third trimesters, delivery, postpartum 1, 3, 6, 9 and 12 months, and at every three months for 1 year for group B.

MAIN OUTCOME MEASURES

Each serum sample was tested for serum alanine aminotransferase (ALT), anti-HCV titre and HCV-cDNA concentration by a competitive polymerase chain reaction (PCR) with a sensitivity of 250 copies/mL serum.

RESULTS

In group A, the HCV levels remained unremarkably changed during pregnancy and delivery. However, all women had decreased HCV levels 1 and 3 months after delivery. Two women had undetectable serum HCV level postpartum and thereafter. Serum ALT values in 3 women were sporadically elevated, but did not correlate with decreased serum HCV levels. Anti-HCV titres remained unchanged during the study period. In two women from group B, the serum HCV levels were undetectable during follow up. Other 6 women showed fluctuations in the serum HCV levels but all were above 250 copies/mL. Serum ALT values were normal and anti-HCV titres remained stationary in all 8 nonpregnant carriers.

CONCLUSION

Serum HCV levels are decreased 1 and 3 months after delivery. This fact might suggest that puerperium is an optimal time for antiviral therapy in HCV carrier mothers.

Age-specific prevalence of hepatitis B surface and e antigenemia in pregnant women in Taiwan

To investigate the age-specific prevalence of hepatitis B surface and e antigens (HBsAg and HBeAg) in pregnant women, we studied all the parturients encountered in National Taiwan University Hospital between 1985 and 1990. Serum HBsAg and HBeAg were checked by radioimmunoassay. The prevalence rate of HBsAg in pregnant women was 13.2%, 12.7%, 11.4%, 11.7%, 12.9% and 14.2%, respectively for each year. The figures seemed stable. The positive rate of HBeAg in HBsAg-positive pregnant women was 32.8%, 39.9%, 42.6%, 30.8%, 32.0% and 31.7%, respectively during the past 6 years. We also analyzed the results in different age-grouped pregnant women. The positive rate of HBsAg was 12.8%, 13.1%, 11.6% and 11.5% respectively in 21-25 year-old, 26-30 year-old, 31-35 year-old and 36-40 year-old groups. The positive rate of HBeAg in HBsAg-positive pregnant women was 49.4%, 36.5%, 31.5% and 20.0% respectively in these 4 age groups, with a prevalence declining with the advanced age. We conclude that HBsAg-positive rate was 11-14% in the pregnant women who visited our hospital, and their HBeAg-positive rate was 31-43%. No decrease of HBsAg carriage or HBeAg prevalence was seen in the past 6 years.

Low prevalence of hepatitis C virus and infrequent perinatal or spouse infections in pregnant women in Taiwan

To assess the prevalence of hepatitis C virus (HCV) infection in the pregnant women in Taiwan, we investigated two groups of pregnant women, 944 women without serum alanine aminotransferase (ALT) screening (group A) and 197 women with abnormal ALT (greater than 45 IU/L) (group B). They were checked for anti-HCV (anti-C100-3) with HCV EIA kit (Abbott Lab., North Chicago, IL). The results showed that 21 (2.2%) in group A and 5 (2.5%) in group B were anti-HCV-positive. However, 15 out of 21 in group A had an optical density (O.D.) of anti-HCV less than 1.0, were negative by recombinant immunoblot assay (RIBA), and were regarded as false-positive. Nine infants delivered by those 11 cases were negative for anti-HCV at 6 months of age, while none of the 8 husbands were anti-HCV-positive. It is concluded that the prevalence of anti-HCV in pregnant women in Taiwan is low (6/944, 0.63%), even in the cases with abnormal ALT (5/197, 2.5%). There was no serologic evidence for perinatal transmission or spouse infection.

The hepatitis B virus

Of all the hepatotropic viruses, HBV is associated with the greatest worldwide morbidity and mortality. This is because of the ease of transmission and the potential for progression to a chronic infective carrier state, with the complications of cirrhosis and hepatocellular carcinoma. The use of PCR has shown that some of the earlier concepts concerning the interpretation of serological data were inaccurate. Many patients with anti-HBe and anti-HBs have viral DNA detectable by PCR, and some hepatocellular carcinoma patients have detectable HBV DNA in their livers in the absence of all serological markers of HBV disease. The clearance of HBV infected cells from the liver is dependent on the interplay between the interferon system and the cellular limb of the host immune response. The importance of the nucleocapsid proteins as targets for sensitized cytotoxic T cells has been established for chronic HBV infection. The importance of pre-S sequences as inducers and targets of the virus-neutralizing humoral immune response is becoming established, but their precise role must await the development of in vitro models of hepadnavirus infection and a greater understanding of the mechanisms of viral uptake. The epidemiology and clinical course of the disease can be modified by immunization, immune stimulation and antiviral chemotherapy. For the developing world, a programme of immunization at birth would be the most effective way of eliminating this disease, but at present the cost is prohibitive. For the developed world, immunization is realistic for the at-risk population, and anti-viral and immunostimulatory therapy available for those already infected. In adult acquired chronic HBV infection alpha-interferon produces HBe antigen clearance in 40-60% of cases and is followed by resolution of the hepatic inflammation. Results in neonatally acquired infection are less impressive and prednisolone priming followed by interferon may be needed. The presence of a mutation in the pre-core region of some virus isolates has recently been described. Hepatocytes infected with this virus cannot produce HBe antigen and the course of the liver disease is fairly rapid. Whether this mutant causes liver damage in the same way as the wild virus or is directly cytopathic remains unclear, and its relationship to fulminant hepatitis is under investigation.