Maternal hepatitis B infection and gestational diabetes mellitus

Maternal infection with hepatitis B virus before pregnancy and risk of congenital malformations in offspring: a record-linkage study of a large national sample from China

BACKGROUND

Whether hepatitis B virus (HBV) infection of women prior to pregnancy can influence risk of congenital malformations in offspring remains controversial. We assessed the association between them by considering congenital malformations in the aggregate as well as risk of organs systems using a large national sample of Chinese women.

METHODS

We performed a record-linkage cohort study of women who participated in National Free Preconception Health Examination Project, between January 1, 2010, and December 31, 2019 for whom data on congenital malformations in their offspring were available from the National Population-Based Birth Defects Surveillance Network. A total of 498,968 linked records were obtained, of which 127,371 were excluded because HBV status before pregnancy was unknown, the records involved multiple pregnancies, or pre-pregnancy examinations were conducted after conception. Based on pre-pregnancy status, mothers were assigned to two categories of HBsAg- or HBsAg+ and, in certain analyses, to three categories of HBsAg-, HBsAg+/HBeAg- or HBsAg+/HBeAg+. Potential associations of serological status with risk of congenital malformations, considered separately or in aggregate, were explored using multilevel logistic regression. Factors that might influence such associations were also explored.

FINDINGS

Among the 371,597 women analyzed, 21,482 (5.78%) were HBsAg+ before pregnancy, and 8333 (2.24%) had a fetus or child diagnosed with congenital malformations, composed of 7744 HBsAg- women and 589 HBsAg+ women. HBsAg+ status was associated with increased risk of congenital malformations in the aggregate (OR 1.14, 95% CI 1.03-1.25) and of cardiovascular malformations specifically (OR 1.18, 95% CI 1.03-1.35). HBsAg+/HBeAg- status was associated with significantly higher risk of cardiovascular malformations (OR 1.19, 95% CI 1.01-1.39) as well as reproductive malformations (OR 1.51, 95% CI 1.02-2.23). Associations between HBsAg+ status before pregnancy and risk of congenital malformations was modified by alanine aminotransferase activity (P interaction < 0.05).

INTERPRETATION

Prepregnancy HBV infection might be associated with fetal malformations. This association needs further investigation to confirm whether it is a causal association, and assess whether antiviral therapy of women with HBsAg+ planning to conceive might reduce the risk of fetal malformations.

FUNDING

The National Health Commission of the People's Republic of China, China; Science and Technology Department of Sichuan Province, China; and the Ministry of Science and Technology of the People's Republic of China.

The effect of hepatitis B virus on the risk of pregnancy outcomes: a systematic review and meta-analysis of cohort studies

BACKGROUND

The effect of HBV on neonatal and maternal outcomes can create a basis for more accurate clinical decision-making. So, the aim of this meta-analysis is to detrmine the effect of chronic hepatitis B virus on the risk of pregnancy outcomes by combining cohort studies.

METHODS

International databases in this meta-analysis included the Cumulated Index to Nursing and Allied Health Literature (CINAHL), SPORT Discuss via the EBSCO interface, PubMed (Medline), Scopus, Web of Science, Embase, which were searched up to April 2023. All cohort studies reporting the risk ratio (RR) with a 95% confidence interval (CI) were included in the study. The quality assessment was done based on the Newcastle-Ottawa Scale (NOS).

RESULTS

Finally, thirty-five cohort studies were selected for meta-analysis. Outcomes of interest included pre-eclampsia, gestational diabetes, abortion, preterm birth, infant death, and other related outcomes. Results showed that the pooled RR for incident gestational diabetes in pregnant women with choronic hepatitis B infection was 1.16 (RR: 1.16; 95% CI 1.13-1.18; I-square: 92.89%; P value: 0.00). Similarly, the association between the presence of hepatitis B infection in pregnant women and the occurrence of pre-eclampsia was 1.10 (RR: 1.10; 95% CI 1.04-1.16; I-square: 92.06%; P value: 0.00). The risk of preterm delivery in pregnant women with hepatitis B infection was 1.17 times that of pregnant women without hepatitis B infection (RR: 1.17; 95% CI 1.14-1.20; I-squared: 94.32%; P value: 0.00).

CONCLUSION

This meta-analysis found that hepatitis B infection during pregnancy may be associated with an increased risk of gestational diabetes, preterm delivery, pre-eclampsia, and eclampsia. However, confirmation of this association, as well as the specific biological pathways involved in the association between HBV infection and pregnancy outcomes, requires further investigation.

Unravelling the mechanisms by which chronic hepatitis B infection is associated with an increased risk of gestational diabetes

An independent association between chronic hepatitis B virus (HBV) and the development of gestational diabetes (GDM) has been reported in the literature. Ethnic background and regional influences have been demonstrated to play a role in the reporting of incidence rates of GDM among women with chronic HBV. The mechanisms behind this association are poorly understood, but evidence suggests an inflammatory basis. Viral factors such as chronic HBV replication, quantifiable by HBV viral load, have been proposed to contribute to the increasing risk of insulin resistance in pregnancy. More research is needed to better characterise the association and determine if any interventions early in pregnancy for women infected with chronic HBV would mitigate the development of GDM.

Combined associations of family history and self-management with age at diagnosis and cardiometabolic risk in 86,931 patients with type 2 diabetes: Joint Asia Diabetes Evaluation (JADE) Register from 11 countries

BACKGROUND

Family history (FamH) of type 2 diabetes might indicate shared genotypes, environments, and/or behaviors. We hypothesize that FamH interacts with unhealthy behaviors to increase the risk of early onset of diabetes and poor cardiometabolic control.

METHODS

In a cross-sectional analysis of the prospective Joint Asia Diabetes Evaluation Register including patients from 427 clinics in 11 Asian countries/regions in 2007-2021, we defined positive FamH as affected parents/siblings and self-management as (1) healthy lifestyles (balanced diet, non-use of alcohol and tobacco, regular physical activity) and (2) regular self-monitoring of blood glucose (SMBG).

RESULTS

Among 86,931 patients with type 2 diabetes (mean±SD age: 56.6±11.6 years; age at diagnosis of diabetes: 49.8±10.5 years), the prevalence of FamH ranged from 39.1% to 85.3% in different areas with FamH affecting mother being most common (32.5%). The FamH group (n=51,705; 59.5%) was diagnosed 4.6 years earlier than the non-FamH group [mean (95% CI): 47.9 (47.8-48.0) vs. 52.5 (52.4-52.6), logrank p<0.001]. In the FamH group, patients with both parents affected had the earliest age at diagnosis [44.6 (44.5-44.8)], followed by affected single parent [47.7 (47.6-47.8)] and affected siblings only [51.5 (51.3-51.7), logrank p<0.001]. The FamH plus ≥2 healthy lifestyle group had similar age at diagnosis [48.2 (48.1-48.3)] as the non-FamH plus <2 healthy lifestyle group [50.1 (49.8-50.5)]. The FamH group with affected parents had higher odds of hyperglycemia, hypertension, and dyslipidemia than the FamH group with affected siblings, with the lowest odds in the non-FamH group. Self-management (healthy lifestyles plus SMBG) was associated with higher odds of attaining HbA_1c<7%, blood pressure<130/80mmHg, and LDL-C<2.6 mmol/L especially in the FamH group (FamH×self-management, p_interaction=0.050-0.001).

CONCLUSIONS

In Asia, FamH was common and associated with young age of diagnosis which might be delayed by healthy lifestyle while self management  was associated with better control of  cardiometabolic risk factors especially in those with FamH.

Integrated Management of Type 2 Diabetes and Gestational Diabetes in the Context of Multi-Morbidity in Africa: A Systematic Review

Introduction

Many adults diagnosed with gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) also have other known or unknown comorbid conditions. The rising prevalence of GDM and T2DM within a broader context of multimorbidity can best be addressed through an integrated management response, instead of stand-alone programs targeting specific infectious and/or chronic diseases.

Aim

To describe GDM and T2DM screening, care and cost-effectiveness outcomes in the context of multimorbidity through integrated interventions in Africa.

Methods

A systematic review of all published studies was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk Of Bias in Non-randomised Studies of Interventions (ROBINS-I) was used to assess risk of bias. Data synthesis was conducted using narrative synthesis of included studies.

Results

A total of 9 out of 13 included studies reported integrated diabetes mellitus (DM) screening, 7 included integrated care and 9 studies addressed cases of newly detected DM who were asymptomatic in pre-diabetes stage. Only 1 study clearly analysed cost-effectiveness in home-based care; another 5 did not evaluate cost-effectiveness but discussed potential cost benefits of an integrated approach to DM screening and care. Compared to partial integration, only 2 fully integrated interventions yielded tangible results regarding DM screening, care and early detection of cases despite many that reported barriers to its sustainability.

Conclusion

Though few, integrated interventions for screening and/or care of DM in the context of multimorbidity within available resources in health systems throughout Africa exist and suggest that this approach is possible and could improve health outcomes.

Relationship between viral load and pregnancy outcomes among hepatitis B carriers

OBJECTIVE

Pregnant hepatitis B carriers may have a higher risk of adverse pregnancy outcomes. Current evidences are conflicting regarding the relationship between hepatitis B virus (HBV) and various pregnancy complications, owing to the inclusion of women with different viral activity. This study is to evaluate the relationship between hepatitis B e antigen (HBeAg) status/HBV DNA level and pregnancy outcomes among pregnant hepatitis B carriers in Hong Kong.

MATERIALS AND METHODS

This was a retrospective analysis of a prospective multicenter observational study carried out in Hong Kong between 2014 and 2016. Pregnant HBV carriers were recruited. HBeAg was tested. HBV DNA level was quantified at 28-30 weeks of gestation. The rates of gestational diabetes mellitus (GDM), gestational hypertension, pre-eclampsia, preterm prelabour rupture of membranes (PPROM), preterm birth, low birth weight (LBW), macrosomia and mode of delivery were recorded.

RESULTS

679 pregnancies were analyzed. 23.3% of women were seropositive for HBeAg. The mean viral load (SD) at 28-30 weeks of gestation was 3.6 (2.5) log₁₀IU/ml. No statistically significant differences were found in the rates of GDM, gestational hypertension, pre-eclampsia, PPROM, preterm birth, LBW, macrosomia and mode of delivery among women with different viral load levels (≤2 log₁₀IU/ml, 2.01-6 log₁₀IU/ml and >6 log₁₀IU/ml). Positive maternal HBeAg status was not associated with pregnancy complications compared to seronegative women.

CONCLUSION

Seropositive HBeAg status or a higher level of HBV DNA during pregnancy did not pose a significant negative impact to the pregnancy outcomes.

Hepatitis C is associated with more adverse pregnancy outcomes than hepatitis B: A 7-year national inpatient sample study

Prior international studies have shown mixed results regarding the association of hepatitis B and hepatitis C with adverse pregnancy outcomes. We performed an updated evaluation of the prevalence of associated adverse pregnancy outcomes and evaluated trends over time of diagnosis of chronic hepatitis B (HBV) and chronic hepatitis C (HCV) in pregnant women in a national database. All pregnant women with HBV and HCV were identified from the National Inpatient Sample database 2012 to 2018. Multivariate logistic regression analyses were performed to compare pregnancy‐related complications, including rates of preeclampsia/eclampsia, gestational diabetes, intrauterine growth restriction, antepartum/intrapartum hemorrhage, preterm labor, and Cesarean section. We evaluated all‐cause in‐hospital mortality, length of stay, and total cost of hospitalizations. A total of 28.7 million pregnancy‐related hospitalizations that met our eligibility criteria were identified, including 51,200 with HBV and 131,695 with HCV. In comparison with the uninfected controls, the HBV group was significantly more likely to develop gestational diabetes (12.94% vs. 6.94%, p < 0.001). The HCV group was more likely to have preterm labor (9.63% vs. 6.27%, p < 0.001), intrauterine growth restriction (6.04% vs. 2.89%, p < 0.001), longer length of stay (3.4 days vs. 2.7 days, p < 0.001), and higher hospitalization cost (15,052 dollars vs. 14,258 dollars, p < 0.001). These findings should inform counseling of women who are found to have HBV or HCV during pregnancy regarding the risk of adverse pregnancy outcomes and support the need for an interdisciplinary approach to optimize maternal and neonatal outcomes.

Human cytomegalovirus infection and its association with gestational diabetes mellitus during pregnancy

BACKGROUND

Infection is an important risk factor for gestational diabetes mellitus (GDM), while infection of human cytomegalovirus (HCMV) with GDM remains unclear and rarely reported. This study aimed to investigate the association of HCMV infection and serum inflammatory factor levels in pregnancy with GDM.

METHODS

This prospective study included pregnant women who attended at Affiliated Hospital of Qingdao Hospital and Zibo Maternal and Child Health Hospital between December 2018 and August 2020. HCMV specific IgM and serum levels of inflammatory factors, including TNF-α, IL-6, and IL-1β, were analyzed.

RESULTS

A total of 5,316 pregnant women were included (415 with GDM (107 with HCMV+GDM+ and 308 with HCMV-GDM+) and 4901 GDM-free (759 with HCMV+GDM- and 4142 with HCMV-GDM-)). The prevalence of GDM was 7.81%. The rate of activation of HCMV was 16.29%. Specifically, 107 and 759 women in the GDM and control group exhibited HCMV infection, with positive rates of25.78% and 15.48%, respectively (P < 0.01). TNF-α, IL-6, and IL-1β at 24-28 weeks of gestation were significantly higher in women with GDM and HCMV infection than inthe other groups (all P < 0.01). Multivariable analysis showed that HCMV positive (OR = 1.851; 95% CI [1.425-2.403]; P < 0.001), IL-6 (OR = 1.010; 95% CI [1.002-1.018]; P = 0.013), and IL-1β (OR = 1.410; 95% CI [1.348-1.474]; P < 0.001) were all significantly correlated with GDM.

CONCLUSION

This study suggests HCMV infection during pregnancy is an independent risk factor of GDM and could significantly increase its incidence. Further studies are needed to elucidate possible mechanisms underlying associations between HCMV infection and GDM.

Obstetric implications of maternal chronic hepatitis B virus infection

Antenatal screening for hepatitis B surface antigen seropositivity is widely adopted to identify pregnant women with chronic hepatitis B virus (HBV) infection in order to target their newborn infants for combined passive-active neonatal immunization to prevent the maternal-to-child transmission of HBV. It is less certain whether the presence of chronic HBV infection in these largely asymptomatic women could impact their pregnancy outcome. There is now gathering information in the literature, though sometimes conflicting, on the obstetric implications of chronic HBV infection. The conflicting data is most probably related to confounding factors such as the immunological phase of chronic HBV infection, viral genotype and activity, presence of hepatic inflammation and other co-existing liver disorders such as non-alcoholic fatty liver disease, and coinfection with other virus such as hepatitis C virus and micro-organisms, which are usually not examined, but which could have made significant influence on the occurrence of many of the pregnancy complications and adverse fetal and neonatal outcome. For pregnancy complications, the evidence suggests association with increased gestational diabetes mellitus, preterm birth, intrahepatic cholestasis of pregnancy, caesarean delivery, and postpartum haemorrhage, probably increased placental abruption and prelabour rupture of the membranes, and no effect or a reduction in the hypertensive disorders of pregnancy, especially preeclampsia. For perinatal outcome, there may be increased miscarriage and fetal malformations, and increase in both low birthweight and large-for-gestational age/macrosomic infants, as well as increased intrauterine fetal demise/stillbirth and fetal distress. However, most studies have not elaborated on the mechanisms or explanations of many of the adverse outcomes. Taken together, maternal chronic HBV infection increases the risk of adverse obstetric outcome overall, but further prospective studies are warranted to elucidate the reasons and mechanisms of, and with a view to mitigate, these adverse obstetric outcomes.

Association between maternal hepatitis B virus carrier and gestational diabetes mellitus: a retrospective cohort analysis

INTRODUCTION

Given that many pregnant women have chronic hepatitis B virus (HBV) infection and that gestational diabetes mellitus (GDM) is linked to poor maternal and neonatal outcomes, we looked into the relationship between the hepatitis B surface antigen (HBsAg) and GDM to see if a high HBV DNA load is linked to a higher risk of GDM in chronic maternal HBsAg carriers.

MATERIALS AND METHODS

Our study included 39,539 pregnant women who gave birth at the Third Affiliated Hospital of Guangzhou Medical University in Guangzhou, China, between January 1, 2009, and December 31, 2019. The patients were divided into two groups: HBsAg negative (36,500) and positive (3039). The viral load levels of 1250 HBsAg-positive women who had tested their HBV DNA load during pregnancy were separated into three groups. We utilized univariate and multivariable logistical regression analysis to determine the relationship between maternal chronic HBsAg carrier and GDM.

RESULTS

Being HBsAg positive was discovered to be an independent risk factor for GDM.Pre-pregnancy Obesity and advanced age were linked to an increased incidence of GDM. Those with a high HBV DNA load (> 10⁶ IU/mL) had a higher risk of GDM than HBsAg-positive women with a low viral load (< 10³ IU/mL). Pre-eclampsia and intrahepatic cholestasis of pregnancy (ICP) appeared to be more common in HBsAg-positive women than in uninfected women.

CONCLUSIONS

Being HBsAg positive, advanced age, and pre-pregnancy obesity were all revealed to be independent risk factors for GDM in our study. In HBsAg carrier, pregnant women, a high HBV DNA burden was linked to a greater risk of GDM. Furthermore, being an HBsAg carrier during pregnancy raised the risk of ICP and pre-eclampsia.

Role of hepatitis A virus in diabetes mellitus

BACKGROUND

Although much information is available regarding hepatitis C virus infection and diabetes, less is known about the relationship between hepatitis A virus (HAV) infection and diabetes.

AIM

To examine the roles of HAV in diabetes risk.

METHODS

This cross-sectional study population included data from the National Health and Nutrition Examination Survey collected between 2005-2012. Adult subjects (≥ 20 years old) with available body mass index measurements, defined diabetes status, history of HAV vaccination, and HAV serology were included. HAV vaccination was based on self-reported history. Successful HAV immunization was defined as the presence of both vaccination and anti-HAV antibody. HAV infection was defined by the absence of vaccination but presence of anti-hepatitis A antibody. The odds ratio (OR) for diabetes with 95% confidence intervals (95%CI) was calculated for each HAV status and then adjusted for covariates. Sensitivity tests, based on different definitions of diabetes, were performed to verify the results.

RESULTS

Among 19942 subjects, 4229 subjects (21.21%) received HAV vaccination and HAV antibody was present in 9224 subjects (46.25%). Although HAV infection was associated with an increased risk of diabetes (OR: 1.13; 95%CI: 1.08-1.18), HAV vaccination was not associated with diabetes (OR: 1.06; 95%CI: 0.95-1.18), and successful HAV immunization had no impact on the risk of diabetes (OR: 1.11; 95%CI: 0.97-1.27). Thus, HAV infection was an unlikely cause of diabetes. Alternatively, in non-vaccinated subjects, diabetes increased the risk of HAV infection by 40% (OR: 1.40, 95%CI: 1.27-1.54).

CONCLUSION

An association between HAV infection and diabetes is observed which is best explained by an increased risk of HAV infection in diabetic patients. Diabetic subjects are more susceptible to HAV. Thus, HAV vaccination is highly recommended in diabetic patients.

Prevalence of Hepatitis B Carrier Status and Its Negative Association with Hypertensive Disorders in Pregnancy

Results

In a total cohort of 87889 deliveries over a period of 20 years, the prevalence rate of HBV fell from around 10-11% to around 6-7% in the last 5 years of the study. A negative association between chronic HBV carrier status and all gestational hypertensive disorders could be demonstrated. An apparent protective effect of HBV carrier status was apparently more robust against preeclampsia than gestational hypertension, as the negative association with preeclampsia was consistently observed throughout the study period. A logistic regression model showed that advanced maternal age, multiple pregnancies, obesity, and significant medical disorders were positively correlated with gestational hypertensive disorders, while multiparity and positive HBV carrier status were negatively correlated.

Conclusion

Chronic HBV carrier status appeared to have a protective effect against the development of preeclampsia and gestational hypertension in an endemic area with high HBV prevalence rates.

The effects of hepatitis B virus infection on natural and IVF pregnancy: A meta-analysis study

BACKGROUND

Hepatitis B virus (HBV) has been considered a significant cause of human reproductive failure in different studies; however, there is a considerable disagreement on the true impacts of HBV on female reproduction. This study has evaluated the impact of HBV infection on pregnancy complications in natural pregnancy and also on pregnancy outcomes in women undergoing in vitro fertilization (IVF) treatment.

METHOD

We searched Embase, Web of Science, PubMed and Google Scholar databases to identify the potentially relevant studies. Summary odds ratio (OR) or standardized mean difference (SMD) with 95% confidence interval (CI) was applied to assess the relationship. Heterogeneity testing, sensitivity analysis and publication bias testing were also performed.

RESULTS

A total of 42 studies concerning the effect of HBV infection on the natural and IVF pregnancy were included in this study. Our meta-analysis results revealed that HBV infection had a positive correlation to gestational diabetes mellitus (GDM) [OR = 1.32 (1.17-1.48) (p < 0.01)] and preterm birth [OR = 1.26 (1.14-1.40) (p < 0.01)] in natural pregnancy; however, HBV infection was not significantly associated with decreased fertility rates among the patients who underwent IVF.

CONCLUSION

This study revealed a strong association of GDM and preterm birth with higher rates of HBV infection in pregnant women. Also, our results suggested that HBV infection in patients undergoing IVF may not negatively influence the pregnancy outcome. It may be rational to conclude that IVF might be rather a safe and effective method for HBV+ females who desire to have children.

Chronic testicular Chlamydia muridarum infection impairs mouse fertility and offspring development†

With approximately 131 million new genital tract infections occurring each year, Chlamydia is the most common sexually transmitted bacterial pathogen worldwide. Male and female infections occur at similar rates and both cause serious pathological sequelae. Despite this, the impact of chlamydial infection on male fertility has long been debated, and the effects of paternal chlamydial infection on offspring development are unknown. Using a male mouse chronic infection model, we show that chlamydial infection persists in the testes, adversely affecting the testicular environment. Infection increased leukocyte infiltration, disrupted the blood:testis barrier and reduced spermiogenic cell numbers and seminiferous tubule volume. Sperm from infected mice had decreased motility, increased abnormal morphology, decreased zona-binding capacity, and increased DNA damage. Serum anti-sperm antibodies were also increased. When both acutely and chronically infected male mice were bred with healthy female mice, 16.7% of pups displayed developmental abnormalities. Female offspring of chronically infected sires had smaller reproductive tracts than offspring of noninfected sires. The male pups of infected sires displayed delayed testicular development, with abnormalities in sperm vitality, motility, and sperm-oocyte binding evident at sexual maturity. These data suggest that chronic testicular Chlamydia infection can contribute to male infertility, which may have an intergenerational impact on sperm quality.

Chronic hepatitis B in pregnant women: Current trends and approaches

Chronic hepatitis B (CHB) is a significant public health problem worldwide. The aim of the present review is to summarize the actual trends in the management of CHB in pregnant women. The prevalence of hepatitis B virus (HBV) infection in pregnant women is usually comparable to that in the general population in the corresponding geographic area. All women have to be screened for hepatitis B surface antigen (HBsAg) during pregnancy. Additional examinations of pregnant women with CHB may include maternal hepatitis B e antigen, HBV viral load, alanine aminotransferase level, and HBsAg level. The management of pregnancy depends on the phase of the HBV infection, which has to be determined before pregnancy. In women of childbearing age with CHB, antiviral therapy can pursue two main goals: Treatment of active CHB, and vertical transmission prevention. During pregnancy, tenofovir is the drug of choice in both cases. A combination of hepatitis B immunoglobulin and vaccine against hepatitis B should be administered within the first 12 h to all infants born to mothers with CHB. In such cases, there are no contraindications to breastfeeding.

Chronic maternal hepatitis B virus infection and pregnancy outcome- a single center study in Kunming, China

Background

Chinese population has a high prevalence of chronic hepatitis B virus (HBV) infection, the impact of which on pregnancy outcome remains controversial. A single-center retrospective cohort study was performed in Kunming, a multi-ethnic city in south-western China to examine this issue.

Methods

The singleton pregnancies delivering at ≥28 weeks gestation under our care in 2005–2017 constituted the study cohort. Maternal characteristics and pregnancy outcome were compared between mothers with and without seropositivity for hepatitis B surface antigen (HBsAg) determined at routine antenatal screening.

Results

Among the 49,479 gravidae in the cohort, the 1624 (3.3%) HBsAg seropositive gravidae had a lower incidence of nulliparity (RR 0.963, 95% CI 0.935–0.992) and having received tertiary education (RR 0.829, 95% CI 0.784–0.827). There was no significant difference in the medical history, pregnancy complications, or labor or perinatal outcome, except that HBV carriers had significantly lower incidence of labor induction (RR 0.827, 95% CI 0.714–0.958) and of small-for-gestational age (SGA) infants (RR 0.854, 95% CI 0.734–0.994). On regression analysis, maternal HBV carriage was independently associated with spontaneous labor (aRR 1.231, 95% CI 1.044–1.451) and reduced SGA infants (aRR 0.842, 95% CI 0.712–0.997).

Conclusions

Our 3.3% prevalence of maternal HBV infection was around the lower range determined in the Chinese population. The association with spontaneous labor and reduced SGA infants could have helped to promote the perpetuation of the infection through enhanced survival of the offspring infected at birth, thus explaining the high prevalence in the Chinese population.

Maternal HBV Viremia and Association With Adverse Infant Outcomes in Women Living With HIV and HBV

BACKGROUND

There is limited information on perinatal outcomes in HIV-hepatitis B virus (HBV) coinfection.

METHODS

HIV Prevention Trials Network (HPTN) 046 was a randomized double-blind placebo-controlled trial of perinatal transmission that evaluated 6 months of infant nevirapine versus placebo among breast-fed infants. Women living with HIV and their infants enrolled in sub-Saharan Africa from 2007 to 2010; 78% received antiretroviral therapy (ART). Maternal samples were tested for hepatitis B surface antigen (HBsAg). High and low HBV viral load (VL) was defined as ≥106 IU/mL and <106 IU/mL. The association between HIV-HBV coinfection and maternal and infant outcomes was assessed using multivariate (MV) logistic and Cox regression.

RESULTS

Among 2025 women, 88 (4.3%) had HBV. HIV-HBV women with high HBV VL had lower median CD4, versus HIV alone or HIV-HBV women with low HBV VL [320, 490 and 434 cells/mm3, respectively (P < 0.007)]. In MV analysis, adjusted for maternal CD4, age and maternal ART, infants born to women with high HBV VL were more likely to be low birth weight (LBW), versus HIV+/HBV- and low HBV VL women: [30% (3/10) vs. 10% (194/1953) vs. 6% (5/78), respectively, P = 0.03). High HBV VL was associated with HIV perinatal transmission [(hazard ratio 6.75 (95% confidence interval (CI): 1.86 - 24.50)]. There was no impact on infant mortality or maternal outcomes at 18 months.

CONCLUSIONS

In HIV-HBV women, high HBV viral loads increase the risk of LBW and potentially HIV perinatal transmission. Reduction of antepartum HBV viremia may have beneficial effects beyond the prevention of HBV perinatal transmission.

Maternal HBsAg carriers and pregnancy outcomes: a retrospective cohort analysis of 85,190 pregnancies

Background

Nowadays, a positive HBV carrier status is common among pregnant women, especially in endemic areas (such as China), little is known about the impact of maternal HBV infection on the risk of adverse pregnancy outcomes. Pregnant women with HBV infection often develop obstetric complications, such as pregnancy-induced hypertension (PIH) syndrome, postpartum hemorrhage, and gestational diabetes mellitus (GDM), and their infants often exhibit neonatal complications.

Methods

This study undertook a retrospective cohort analysis to explore the association of HBV carrier status with adverse pregnancy outcomes. A cohort of 85,190 women including 9699 HBsAg-positive and 73,076 HBsAg-negative pregnancies was retrospectively analyzed.

Results

It’s found that HBsAg-positive pregnancies may result in higher risk of various maternal outcomes such as ICP (OR 3.4,95%CI 2.80 to 4.13), postpartum hemorrhage (OR 1.16,95%CI 1.00 to 1.34). Interestingly, there was a decreased risk of Preeclampsia (OR 0.91,95%CI 0.87 to 0.96), premature rupture of membrane (OR 0.91,95%CI 0.87 to 0.96) and gestational hypertension (OR 0.828,95%CI 0.701 to 0.978). And in vaginal delivery subgroup analysis, It’s found that the HBsAg-positive group had a higher risk of placental abruption (OR, 1.44; 95% CI, 1.16–1.79).

Conclusions

The present results suggest that compared with HBV positive pregnancies were more likely to be ICP and postpartum hemorrhage. HBV-positive pregnant women underwent vaginal delivery were more likely to have placental abruption and premature birth compared with HBV-negative women. Obstetricians should be aware of ICP, postpartum hemorrhage, placental abruption and premature birth in HBV-positive pregnant women.

Maternal hepatitis B infection status and adverse pregnancy outcomes: a retrospective cohort analysis

PURPOSE

To investigate the association between maternal HBsAg-positive status and pregnancy outcomes.

METHODS

The study enrolled women with singleton pregnancies who delivered during January-December 2018. Data of maternal demographics and main adverse pregnancy outcomes were collected from the institutional medical records and analyzed by univariate and multivariate logistic regression models to determine the association between maternal HBV markers (HBsAg/HBeAg/HBV-DNA loads status) and adverse pregnancy outcomes.

RESULTS

Total 1146 HBsAg-positive and 18,354 HBsAg-negative pregnant women were included. After adjusting for potential confounding variables, maternal HBsAg-positive status was associated with a high risk of gestational diabetes mellitus (GDM) [adjusted odds ratio (aOR) = 1.24; 95% confidence interval (CI) 1.07-1.43], intrahepatic cholestasis of pregnancy (ICP) (aOR = 3.83; 95% CI 3.14-4.68), preterm birth (aOR = 1.42; 95% CI 1.17-1.72), and neonatal asphyxia (aOR = 2.20; 95% CI 1.34-3.63). Further, higher risks of ICP and neonatal asphyxia remained with either HBeAg-positive status (aOR = 1.64; 95% CI 1.10-2.44; aOR = 3.08; 95% CI 1.17-8.00) or high HBV-DNA load during the second trimester (aOR = 1.52; 95% CI 1.06-2.35; aOR = 4.20; 95% CI 4.20-15.83) among HBsAg-positive pregnant women.

CONCLUSION

Women with maternal HBsAg-positive status may have increased risks of GDM, ICP, preterm birth, and neonatal asphyxia; furthermore, the risks of ICP and neonatal asphyxia were higher in women with HBeAg-positive status and a high HBV-DNA load during the second trimester among the HBsAg-positive pregnant women, implying that careful surveillance for chronic HBV infection during pregnancy is warranted.

Hepatitis B - chronic carrier status and pregnancy outcomes: An obstetric perspective

Antenatal screening for hepatitis B surface antigen (HBsAg) only identifies women with hepatitis B virus (HBV) infection for neonatal immunoprophylaxis. It does not reflect the phase of chronic infection, viral genotype and activity, hepatic inflammation, or other co-existing liver disorders. Coinfection with other viruses and micro-organisms may also be present. These factors in various combinations can impact pregnancy outcomes, and they are probably responsible for the conflicting literature on this issue. Pregnancy complications may interact with maternal HBV infection and hepatitis flares, leading to serious and lethal complications. Hepatitis flares are common especially postpartum, and they are unpredictable and unpreventable with antiviral treatment. Evidence on the association between HBsAg seropositivity with gestational diabetes mellitus, preterm birth, increased foetal growth, and reduced pregnancy hypertensive disorders is stronger than other adverse pregnancy outcomes. Baseline assessment of liver function, and viral markers and activity, can delineate the truly high-risk pregnancies for close monitoring.

Placental infection of hepatitis B virus among Thai pregnant women: Clinical risk factors and its association with fetal infection

OBJECTIVES

To identify the risk factors of placental and fetal infections among HBsAg-positive women.

METHODS

A prospective cohort study involving HBsAg-positive pregnant women was conducted. Maternal risk factors, including serum HBeAg status, anti-HBcIgM, and HBV-DNA levels, were determined. Placental infection was identified by PCR and confirmed by DNA sequencing. Fetal infection was defined as a positive umbilical cord blood HBV-DNA at birth.

RESULTS

A total of 96 HBsAg-positive women were enrolled in the study. The prevalence of placental infection was high (44 of 96; 45.8%) among HBsAg-positive women. The major risk factors for placental infection were high maternal viral load and the presence of HBeAg. Fetal infection was detected in one quarter of HBsAg-positive women (25 of 95; 25.3%). The risk of fetal infection was strongly associated with placental infection (78.3%), high maternal viral load, and the presence of HBeAg. There was no significant difference in perinatal outcomes between the groups with and without placental infection. Data on rates of chronic HBV infection in infants after fetal infection were not available.

CONCLUSION

A significant association between maternal measures of viral replication and placental and fetal infection was demonstrated. These findings suggest that transplacental infection prior to birth may be a mechanism contributing to the higher rates of newborn prophylaxis failure in women with a high viral load.

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.

Effect of viral load on pregnancy outcomes in chronic hepatitis B infection

AIM

This study aimed to evaluate perinatal and neonatal outcomes in pregnant women with chronic hepatitis B virus infection based on infection status and to identify cut-off values based on hepatitis B virus DNA viral load to predict composite adverse perinatal/neonatal outcomes.

METHODS

Pregnant women with chronic hepatitis B virus who delivered at Hacettepe University between 2010 and 2018 were evaluated retrospectively. We included 95 patients. The patients were classified into two groups based on laboratory findings and viral load: group 1 (n = 63), immune inactive; and group 2 (n = 32), immune active. Maternal age, gravidity, parity, gestational week at birth, birth weight, 5th minute APGAR scores and composite perinatal and neonatal outcomes were compared between groups.

RESULTS

Gestational week at birth, birth weight and 5th minute APGAR score in group 2 were lower than those in group 1 (P < 0.001, P < 0.005 and P < 0.001, respectively). The rates of composite adverse perinatal/neonatal outcome, preterm birth, fetal growth restriction, oligohydramnios, pre-eclampsia, admission to the neonatal intensive care unit, small for gestational age and 5th minute APGAR score less than 7 were significantly higher in group 2 (P < 0.001). Hepatitis B virus DNA viral load of 17 515 IU/mL (72.7% sensitivity, 78.1% specificity) and 17 515 IU/mL (81.8% sensitivity, 80.8% specificity) were determined to be cut-off values for composite adverse perinatal and neonatal outcomes, respectively.

CONCLUSION

Care should be taken in patients with a viral load of greater than 17 515 IU/mL, and pregnancy should be postponed until the inactive phase of the disease for optimal results.

Maternal hepatitis B surface antigen carrier status increased the incidence of gestational diabetes mellitus

Background

The relationship between chronic hepatitis B virus (HBV) infection with gestational diabetes mellitus (GDM) remains unclear. This study aimed to identify the association between maternal HBsAg-positive status and GDM.

Methods

A retrospective cohort study was performed on the pregnant women who delivered from June 2012 to May 2016 at Wuhan Medical Care Center for Women and Children, Wuhan, China. We compared the incidence of GDM between HBsAg-positive pregnant women and HBsAg-negative controls. A multivariate regression model was used to measure the independent association between maternal HBsAg carrier and the risk of developing GDM.

Results

In total, 964 HBsAg-positive pregnant women and 964 HBsAg-negative women were included into the study. We observed maternal HBsAg carrier (OR 1.47, 95% CI 1.06–2.03), age (OR 1.05, 95% CI 1.00–1.10) and family history of diabetes (OR 3.97, 95% CI 2.05–7.67) had an independent risk for GDM in multivariable logistical regression model. However, no significant association was found between HBeAg carrier status, other HBV markers or viral load in pregnancy and the incidence of GDM.

Conclusions

Our results indicated that maternal HBsAg carriage is an independent risk factor for GDM, but viral activity indicated by HBeAg status and viral load is not the main reason for this phenomenon. Further studies are warranted to clarify the possible mechanisms behind such association of HBV infection and the additional risk of GDM.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3749-1) contains supplementary material, which is available to authorized users.

Hepatitis B surface antigen positivity during pregnancy and risk of gestational diabetes mellitus: A systematic review and meta-analysis

Chronic hepatitis B virus (HBV) infection is a prevalent public health issue worldwide. Its impact on important pregnancy outcomes, such as gestational diabetes mellitus (GDM), has not been clearly established. The findings from published studies are inconsistent. In this systematic review and meta-analysis, we aimed to clarify whether HBV infection manifested during pregnancy is associated with an increased risk of GDM. We searched MEDLINE and EMBASE for cohort studies and case-control studies that investigated the association between maternal hepatitis B surface antigen (HBsAg) positivity and GDM. We pooled adjusted odds ratio (aOR) and unadjusted OR, respectively, using the random-effect generic inverse variance method. We assessed risk of bias using the Quality in Prognosis Studies tool and conducted five pre-specified subgroup analyses. In total, 23 cohort studies involving 3 529 223 participants were included. The risk of GDM was 6.48% (1868/28 829) among HBsAg-positive pregnant women and 3.41% (119 283/3 500 394) among HBsAg-negative pregnant women. Meta-analyses of both unadjusted and adjusted effect estimates showed that HBsAg positivity during pregnancy was associated with higher risk of developing GDM (unadjusted OR 1.35, 95% CI: 1.17 to 1.56, I²  = 82.6%; adjusted OR 1.47, 1.22 to 1.76, I²  = 62%). Among pre-specified subgroup analysis, significant differences were found among studies with high vs low or moderate risk of bias. The results were robust to sensitivity analyses. In conclusion, HBsAg positivity during pregnancy has a moderate effect on an increased risk of GDM. Given the size of the population with HBV infection worldwide, however, this effect could have substantial impact on pregnancy. Further studies are warranted to investigate whether active infection with HBeAg positivity would further elevate the risk of adverse events during pregnancy.

Maternal Hepatitis B Infection and Pregnancy Outcomes in the United States: A Population-Based Cohort Study

Background

Hepatitis B virus (HBV) infection in pregnancy has been associated with risk of adverse maternal and infant outcomes in highly endemic settings, but this association is not well characterized in the United States.

Methods

We conducted a retrospective population-based cohort study in Washington State using linked birth certificate and hospital discharge records from 1992–2014. Among pregnant women with hepatitis B (n = 4391) and a hepatitis B–negative group (n = 22 410), we compared the risk of gestational diabetes, pre-eclampsia, eclampsia, placenta previa, preterm delivery, low birthweight, small for gestational age, and large for gestational age using multivariate logistic regression.

Results

Hepatitis B–infected pregnant women were more likely to be Asian (61% vs 8%, P < .001), foreign-born (76% vs 23%, P < .001), and older in age (77% vs 64% ≥26 years, P < .001). They were less commonly overweight or obese (33% vs 50%, P < .001). There was a lower risk of small for gestational age infants among HBV-infected women (adjusted RR [aRR], 0.79; 95% confidence interval [CI], 0.67–0.93). The risk of other adverse outcomes was not significantly different between hepatitis B–infected and –negative women (gestational diabetes: aRR, 1.11; 95% CI, 0.92–1.34; pre-eclampsia: aRR, 1.06; 95% CI, 0.82–1.35; eclampsia: aRR, 2.31; 95% CI, 0.90–5.91; placenta previa: aRR, 1.16; 95% CI, 0.35–3.84; preterm delivery: aRR, 1.15; 95% CI, 0.98–1.34; low birth weight: aRR, 1.08; 95% CI, 0.90–1.29; large for gestational age: aRR, 1.01; 95% CI, 0.82–1.24).

Conclusions

In a low-burden setting in the United States, hepatitis B infection was not associated with adverse pregnancy outcomes.

Three decades of neonatal vaccination has greatly reduced antenatal prevalence of hepatitis B virus infection among gravidae covered by the program

OBJECTIVES

To evaluate the impact of three decades of hepatitis B vaccination in infancy on antenatal prevalence of hepatitis B surface antigen (HBsAg) carriage in 93,134 Hong-Kong born gravidae managed in 1997-2015.

METHODS

Annual prevalence of HBsAg carriage on routine antenatal screening was examined with respect to maternal year of birth in three periods i.e. pre-1983 (before availability of vaccination), 1983-1988 (vaccination of infants born to HBsAg-carriers), and after 1988 (universal vaccination).

RESULTS

Overall HBsAg carriage was 8.3% (7737/93,134), decreasing from 10.5% in 1997 to 6.5% in 2015 (p < 0.001), and from 8.8%, 7.0% to 3.1%, respectively, for the three period-of-birth cohorts (p < 0.001). Annual prevalence decreased from 9.9% in 1997 to 7.5% in 2015 (p < 0.001) in the pre-1983 cohort, but showed neither difference nor trend in the other two cohorts. However, the annual prevalence showed significantly falling trends from the pre-1983 to the post-1988 cohorts for the years 2007-2008 and 2010-2015.

CONCLUSIONS

A progressive decline in overall annual prevalence of antenatal HBsAg carriage was found, with a consistently significant decline among the three cohorts for the years 2007-2008 and 2010-2015, providing evidence that universal hepatitis B vaccination in infancy has reduced significantly antenatal prevalence of HBsAg carriage in Hong Kong.

Maternal Hepatitis B Virus Infection and Pregnancy Outcomes: A Hospital-based Case-control Study in Wuhan, China

GOALS

To examine the impact of maternal hepatitis B virus infection on pregnancy outcomes.

BACKGROUND

Studies regarding hepatitis B virus infection and pregnancy outcomes are limited with inconsistent results, and none of them have evaluated the effect of maternal viral load in pregnancy on pregnancy outcomes.

STUDY

A hospital-based case-control study was conducted. In total, 1728 hepatitis B surface antigen (HBsAg)-positive women who delivered consecutively at Wuhan Women and Children Medical and Healthcare Center, Wuhan, China, from June 2008 to May 2015, were compared with 1497 HBsAg-negative women giving birth in the same hospital during the same period who were randomly identified and selected from the computerized medical record database in parallel. Univariate and multivariate logistic regression models were constructed.

RESULTS

After adjusting for confounding variables, maternal HBsAg carriage was associated with increased risk of pregnancy-induced hypertension [adjusted odds ratio (aOR)=2.20; 95% confidence interval (CI), 1.30-3.73], fetal distress (aOR=1.40; 95% CI, 1.09-1.78), cesarean delivery (aOR=1.70; 95% CI, 1.45-1.99), and macrosomia (aOR=1.68; 95% CI, 1.19-2.37). Moreover, maternal viral load in the second trimester was significantly associated with risk of preterm birth (aOR for each log10 copy/mL increase, 1.18; 95% CI, 1.01-1.39) among HBsAg carriers after adjustment for maternal age, employment, parity, history of abortion, and prenatal body mass index.

CONCLUSIONS

Maternal HBsAg carriage was associated with several adverse pregnancy outcomes. Furthermore, hepatitis B viral activity in pregnancy might have certain effects on pregnancy outcomes. Careful surveillance of maternal HBsAg status as well as viral activity in the second trimester among HBsAg carriers is warranted.

The impact of smoking on incident type 2 diabetes in a cohort with hepatitis B but not hepatitis C infection

Smoking may be a risk factor for diabetes, and it has been suggested that viral hepatitis may predispose to diabetes. We studied diabetes and smoking histories in people with viral hepatitis. From 1997 to 2004, we studied the risk of incident diabetes in a community cohort with hyperendemic HBV and HCV infection in southern Taiwan. The cohort involved 3539 people (40-70 years old) without diabetes. Four hundred and twenty-three individuals developed diabetes. Those who were ≥65 years old, frequently consumed alcohol, had a BMI ≥25, had <9 years of education, were anti-HCV⁺ or smoked ≥1 pack per day were more likely to develop diabetes (P < 0.05). A cumulative hazard function test showed that the higher the smoking levels, the greater the cumulative incidence rate of diabetes in HBsAg⁺ participants only (P = 0.03 by log-rank test). A multiple Cox proportional hazards model analysis in different hepatitis statuses showed smoking levels were strong predictors of diabetes with a dose-response relationship for type 2 diabetes in those with HBsAg⁺ : hazard ratio (HR) = 3.8, (95% CI: 1.2, 12.3) for light smokers (<1 pack per day) and HR = 4.4 (95% CI: 1.5, 13.3) for heavy smokers (≥1 pack per day). Increasing BMI was a common predictor in all people. Smoking is a strong predictor for diabetes with a dose-response relationship in HBsAg⁺ individuals and a mild predictor for seronegative individuals but not significant in anti-HCV⁺ individuals.

Lipopolysaccharide and double stranded viral RNA mediate insulin resistance and increase system a amino acid transport in human trophoblast cells in vitro

INTRODUCTION

Inflammation and underlying low-grade maternal infection can impair insulin signalling and upregulate nutrient transport in the placenta which contribute to fetal overgrowth associated with GDM and/or obese pregnancies. There are, however, no studies on the role of infection on placental nutrient transport in pregnancies complicated by GDM and/or obesity. Thus, the aims of this study were to determine the effect of the bacterial product lipopolysaccharide (LPS) or the viral dsRNA analogue polyinosinic:polycytidylic acid (poly(I:C)) on the insulin signalling pathway and amino acid transport in primary human trophoblast cells.

METHODS

Human primary villous trophoblast cells were treated with LPS or poly(I:C). Protein expression of insulin signalling pathway proteins, insulin receptor (IR)-β, insulin receptor substrate (IRS)-1 and protein kinase B (also known as Akt), and phosphatidylinositol-4,5-bisphosphate 3-kinase p85α subunit (PI3K-p85α) protein were assessed by Western blotting. Glucose and amino acid uptake were assessed by radiolabelled assay. Western blotting and qRT-PCR were used to determine amino acid transporter protein and mRNA expression, respectively.

RESULTS

LPS and poly(I:C) significantly decreased phosphorylation of IR-β, IRS-1, Akt, total PI3K-p85α protein expression and glucose uptake. LPS and poly(I:C) also significantly increased expression of System A amino acid transporters SNAT1 and SNAT2, and System A-mediated uptake of amino acids.

DISCUSSION

LPS and poly(I:C) induces insulin resistance and increases amino acid uptake in human primary trophoblast cells. This suggests that the presence of low-grade maternal infection can contribute to excess placental nutrient availability and promote fetal overgrowth in pregnancies complicated by GDM and/or obesity.

HBsAg positivity during pregnancy and adverse maternal outcomes: a retrospective cohort analysis

Hepatitis B virus infection characterized by HBsAg positivity during pregnancy is a well-recognized issue in developing countries, but the association between HBsAg positivity and adverse maternal outcomes remains uncertain. To examine the association between HBsAg positivity during pregnancy and adverse maternal outcomes, a retrospective cohort study was conducted in Sichuan province, China. Deliveries were recorded from six hospitals between 1 January 2009 and 31 December 2010. Pre-eclampsia, gestational diabetes mellitus (GDM), postpartum haemorrhage (PPH), intrahepatic cholestasis, Caesarean section and placenta previa were prespecified adverse maternal outcomes. We used two multivariate logistic regression models to assess the association between HBsAg positivity and adverse maternal outcomes. In total, 948 (4.2%) pregnant women were HBsAg positive from 22 374 deliveries. Pregnant women with positive HBsAg had higher risk of GDM (aOR1.41, 95%CI 1.15-1.74), PPH (1.44, 1.13-1.83), intrahepatic cholestasis (1.74, 1.40-2.16) and Caesarean section (1.24, 1.06-1.45). No statistical associations were found between HBsAg positivity and pre-eclampsia (1.36, 0.94-1.97), and placenta previa (1.21, 0.87-1.67). HBsAg positivity during pregnancy was associated with higher risk of multiple adverse maternal outcomes. Although the causality has yet to be established, efforts may be warranted in routine care, particularly in those with high risk for adverse maternal outcomes, given the volume population infected with HBsAg. Future studies are needed to establish causality and examine the impact of HBeAg on the adverse outcomes.

Hepatitis B Management in the Pregnant Patient: An Update

Chronic hepatitis B is a worldwide disease, with significant burden on health care systems. While universal vaccination programs have led to an overall decrease in incidence of transmission of hepatitis B, unfortunately, there remain large areas in the world where vaccination against hepatitis B is not practiced. In addition, vertical transmission of hepatitis B persists as a major concern. Hepatitis B treatment of the pregnant patient requires a thorough assessment of disease activity and close monitoring for flares, regardless of initiation of antiviral therapy. We discuss, in this article, the current and emergent strategies which aim to reduce the rate of transmission of hepatitis B from the pregnant mother to the infant and we review the updated guidelines regarding management of liver disease in pregnant women with hepatitis B.

Endoplasmic reticulum stress regulates inflammation and insulin resistance in skeletal muscle from pregnant women

Sterile inflammation and infection are key mediators of inflammation and peripheral insulin resistance associated with gestational diabetes mellitus (GDM). Studies have shown endoplasmic reticulum (ER) stress to induce inflammation and insulin resistance associated with obesity and type 2 diabetes, however is paucity of studies investigating the effects of ER stress in skeletal muscle on inflammation and insulin resistance associated with GDM. ER stress proteins IRE1α, GRP78 and XBP-1s were upregulated in skeletal muscle of obese pregnant women, whereas IRE1α was increased in GDM women. Suppression of ER stress, using ER stress inhibitor tauroursodeoxycholic acid (TUDCA) or siRNA knockdown of IRE1α and GRP78, significantly downregulated LPS-, poly(I:C)- or IL-1β-induced production of IL-6, IL-8, IL-1β and MCP-1. Furthermore, LPS-, poly(I:C)- or TNF-α-induced insulin resistance was improved following suppression of ER stress, by increasing insulin-stimulated phosphorylation of IR-β, IRS-1, GLUT-4 expression and glucose uptake. In summary, our inducible obesity and GDM-like models suggests that the development of GDM may be involved in activating ER stress-induced inflammation and insulin resistance in human skeletal muscle.

[Hepatitis B and pregnancy. Part 1. Thirteen practical issues in antenatal period]

In France, the prevalence of chronic hepatitis B is about 1% in pregnant women (usually asymptomatic carriers of HBsAg). The risk of maternal-fetal transmission of hepatitis B is particularly high when viral load measured by PCR is higher in mothers (above 7 log) or HBeAg is present. In case of maternal-fetal transmission of hepatitis B, the risk to the newborn of developing subsequent chronic hepatitis B is very high (90%), with long-term complications such as cirrhosis and hepatocellular carcinoma. The prevention of maternal-fetal transmission is based on systematic testing for hepatitis B during pregnancy, followed by serovaccination of the newborn at birth. If necessary, amniocentesis can be realised but will avoid the realization of a transplacental gesture. In case of high viral load, the establishment of a maternal antiviral treatment with lamivudine or tenofovir from 28SA can further reduce the risk of transmission. Given the low resistance it induces, tenofovir should be used preferentially.

Immune persistence after hepatitis B vaccination in infancy - Fact or fancy?

The hepatitis B vaccine has been introduced for more than 3 decades. In Hong Kong, excellent vaccine coverage through an efficient public health care system, together with supplemental programmes and easy availability of the vaccine, meant that most young pregnant women, and university students at entrance, should have been protected. Yet significant correlations in the prevalence of HBV infection with age were found in these groups of subjects, increasing from low to high endemicity rates from late teenage to the early twenties. This can only be attributed to vaccine failure, and there is cumulating evidence that several factors are involved, including the failure to respond to a primary series of hepatitis B vaccination in infancy, the waning of antibody titer with age, and loss of anamnestic response in a significant portion of the vaccinees. The duration of protection conferred by hepatitis B vaccination in infancy should be re-examined and remedial measures undertaken if its long term protection is found to be insufficient. Otherwise, the efforts to control HBV infection, especially in high endemicity regions, with universal vaccination in infancy would be rendered futile.

#38: Hepatitis B in pregnancy screening, treatment, and prevention of vertical transmission

Between 800,000-1.4 million people in the United States and more than 240 million people worldwide are infected with hepatitis B virus (HBV). Specific to pregnancy, an estimated prevalence of 0.7-0.9% for chronic hepatitis B infection among pregnant women in the United States has been reported, with >25,000 infants at risk for chronic infection born annually to these women. Vertical transmission of HBV from infected mothers to their fetuses or newborns, either in utero or peripartum, remains a major source of perpetuating the reservoir of chronically infected individuals globally. Universal screening for hepatitis B infection during pregnancy has been recommended for many years. Identification of pregnant women with chronic HBV infection through universal screening has had a major impact in decreasing the risk of neonatal infection. The purpose of this document is to aid clinicians in counseling their patients regarding perinatal risks and management options available to pregnant women with hepatitis B infection in the absence of coinfection with HIV. We recommend the following: (1) perform routine screening during pregnancy for HBV infection with maternal HBsAg testing (grade 1A); (2) administer hepatitis B vaccine and HBV immunoglobulin within 12 hours of birth to all newborns of HBsAg-positive mothers or those with unknown or undocumented HBsAg status, regardless of whether maternal antiviral therapy has been given during the pregnancy (grade 1A); (3) In pregnant women with HBV infection, we suggest HBV viral load testing in the third trimester (grade 2B); (4) in pregnant women with HBV infection and viral load >6-8 log 10 copies/mL, HBV-targeted maternal antiviral therapy should be considered for the purpose of decreasing the risk of intrauterine fetal infection (grade 2B); (5) in pregnant women with HBV infection who are candidates for maternal antiviral therapy, we suggest tenofovir as a first-line agent (grade 2B); (6) we recommend that women with HBV infection be encouraged to breast-feed as long as the infant receives immunoprophylaxis at birth (HBV vaccination and hepatitis B immunoglobulin) (grade 1C); (7) for HBV infected women who have an indication for genetic testing, invasive testing (eg amniocentesis or chorionic villus sampling) may be offered-counseling should include the fact that the risk for maternal-fetal transmission may increase with HBV viral load >7 log 10 IU/mL (grade 2C); and (8) we suggest cesarean delivery not be performed for the sole indication for reduction of vertical HBV transmission (grade 2C).

Positive hepatitis B surface antibody is associated with reduced risk of diabetes mellitus in retired female Chinese workers

BACKGROUND

To study the relationship between positivity for hepatitis B surface antibody (HBsAb) and the risk of diabetes mellitus in the retired Chinese population.

METHODS

A cross-sectional analysis was conducted in 900 retired Chinese workers attending a health check-up program. HBsAb, hepatitis B surface antigen, oral glucose tolerance test (OGTT), fasting plasma glucose (FBG), 2-h plasma glucose 2hBG, and insulin levels were collected.

RESULTS

Participants positive for HBsAb were younger, with lower blood pressure, lower FBG and 2hBG serum uric acid, and glutamic pyruvic transaminase than those who were HbsAb negative. There were 306 subjects with impaired glucose tolerance and 121 with type 2 diabetes (T2D) in the present cohort. Using Chi-squared analysis to assess the risk of diabetes, women positive for HBsAb had a lower prevalence of T2D than those negative for HBsAb (15.7% vs 26.5%, respectively; P < 0.01). Multivariate analysis revealed family history of diabetes, age, and waist circumference were independently associated with a higher prevalence of diabetes, and that HBsAb positivity was independently associated with a lower prevalence of diabetes (odds ratio 0.579; 95% confidence interval 0.388-0.918) when adjusted for sex, family history of hypertension and dyslipidemia, and body mass index.

CONCLUSIONS

An HBsAb-positive status is associated with a low rate of diabetes and better metabolic status. A prospective study of patients with known vaccination records is needed to investigate whether hepatitis B virus vaccination could protect against the development of diabetes.

The Impact of Hepatitis B Vaccination Status on the Risk of Diabetes, Implicating Diabetes Risk Reduction by Successful Vaccination

BACKGROUND

The liver plays a key role in fuel metabolism. It is well established that liver disease is associated with an increased risk for diabetes mellitus. Hepatitis C virus infection has been known to increase the risk of diabetes. However, much less is known about the role of hepatitis B virus (HBV) infection in diabetes. We examined the association of diabetes based on the vaccination status for HBV.

METHODS

In this cross-sectional study, we included adult subjects (≥20 y/o) with HBV serology available from the National Health and Nutrition Examination Survey 2005-2010. Diabetes was defined as established diabetes or fasting plasma glucose concentration ≥7.0 mmol/L, 2-hour plasma glucose concentration ≥11.1 mmol/L, or HbA1c ≥ 47.5 mmol/mol (6.5%). Vaccination was based on the reported history and immunization was determined by HBV serology. The odds ratio (OR) with 95% confidence intervals (95% CI) were calculated with consideration of the following covariates: age, gender, BMI, ethnic/racial group, current smoker, current alcohol consumption, family history of diabetes, poverty index, and education.

RESULTS

This study included 15,316 subjects. Among them, 2,320 subjects was immunized based the HBV serology. Among 4,063 subjects who received HBV vaccination, successful vaccination was only noted in 39% of subjects. The HBV vaccination was not associated with diabetes (OR: 1.08, 95%CI: 0.96-1.23). Serology evidence of HBV immunization was associated with a reduced OR of diabetes (0.75, 95%CI: 0.62-0.90). Successful HBV vaccination was also associated with a reduced OR of diabetes (0.67, 95%CI: 0.52-0.84).

CONCLUSIONS

Although our study shows the association of HBV vaccination with the reduced odds of diabetes by 33%, a prospective study is warranted to confirm and examine the impact of HBV vaccination in prevention of diabetes.

Effects of medical co-morbidities on severe maternal morbidities in China: a multicenter clinic register study

OBJECTIVE

To investigate the incidence of severe maternal morbidities (SMM) in China and explore effects of medical co-morbidities on SMM.

DESIGN

Proactive multicenter clinic register collaboration.

SETTING

Data on all deliveries at eight hospitals in Sichuan province, China, collected from 1 January 2009 to 12 December 2010.

POPULATION

33 993 delivering women and 34 547 live births.

METHODS

We defined SMM as a combination indicator of severe maternal complications, critical interventions, admission to the intensive care unit and maternal near-miss instances. We randomly selected 80% of the data from the entire database to build a logistic regression model. The remaining 20% were used to test the predictive power of the model.

MAIN OUTCOME MEASURES

SMM incidence, adjusted odds ratios (aORs), and area under a receiver operating characteristic (ROC) curve.

RESULTS

Severe maternal morbidities incidence was 43.4/1000 live births [confidence interval (CI) 41.24-45.56]. Fifteen variables were independent contributors to the model. Seven medical co-morbidities significantly affected the occurrence of SMM, including iron-deficiency anemia (aOR 3.07, CI 2.47-3.83) and other hematological diseases (aOR 5.82, CI 3.50-9.69), hepatitis-B virus infection (aOR 1.48, CI 1.12-1.97) and other hepatic diseases (aOR 3.81, CI 1.61-9.04), cardiopathy (aOR 3.59, CI 2.62-4.93), hypertension (aOR 5.23, CI 4.06-6.75), and respiratory diseases (aOR 2.10, CI 1.25-3.52). The area under the ROC curve was 0.8127.

CONCLUSIONS

The incidence of SMM was typical of a low resource area. There is a need to identify medical co-morbidities and to adopt prophylactic measures and interventions.

Double stranded viral RNA induces inflammation and insulin resistance in skeletal muscle from pregnant women in vitro

OBJECTIVE

Maternal peripheral insulin resistance and increased inflammation are two features of pregnancies complicated by pre-existing maternal obesity and gestational diabetes mellitus (GDM). There is now increasing evidence that activation of Toll-like receptor (TLR) signalling pathways by viral products may play a role in the pathophysiology of diabetes. Thus, the aim of this study was to assess the effect of the TLR3 ligand and viral dsRNA analogue polyinosinic polycytidilic acid (poly(I:C)) on inflammation and the insulin signalling pathway in skeletal muscle from pregnant women.

MATERIALS/METHODS

Human skeletal muscle tissue explants were performed to determine the effect of poly(I:C) on the expression and secretion of markers of inflammation, and the insulin signalling pathway and glucose uptake.

RESULTS

Poly(I:C) significantly increased the expression of a number of inflammatory markers in skeletal muscle from pregnant women. Specifically, there was an increase in the expression and/or secretion of the pro-inflammatory cytokines TNF-α, and IL-6 and the pro-inflammatory chemokines IL-8 and MCP-1. These effect of poly(I:C) appear to mediated via a number of signalling molecules including the pro-inflammatory transcription factor NF-κB, and the serine threonine kinases GSK3 and AMPKα. Additionally, poly(I:C) decreased insulin stimulated GLUT-4 expression and glucose uptake in skeletal muscle from pregnant women.

CONCLUSIONS

The in vitro data presented in this study suggests that viral infection may contribute to the pathophysiology of pregnancies complicated by pre-existing maternal obesity and/or GDM. It should be noted that the in vitro studies cannot be directly used to infer the same outcomes in the intact subject.

A nested case-control study indicating heavy metal residues in meconium associate with maternal gestational diabetes mellitus risk

BACKGROUND

Environmental pollutant exposure may play certain roles in the pathogenesis and progression of diabetes mellitus including gestational diabetes mellitus (GDM). We hypothesize that heavy metal exposure may trigger GDM during pregnancy. The objective of this study was to investigate the possible associations between selected heavy metal exposure and GDM risk.

METHODS

This investigation is a retrospective case-control study nested within a cohort of 1359 pregnant women. These participants were recruited in Xiamen Maternity and Child Care Hospital, China, during June to July, 2012. All their newborns' meconium samples were collected. By reviewing the antenatal care records, 166 GDM mothers were screened out from the 1359 participants; 137 of 166 GDM mothers offered their newborns' meconium samples for the metal analysis. Those 137 mothers were set as the case group. Similarly, 294 healthy mothers without any gestational complication were initially screened out from the rest 1193 non-GDM mothers. 190 of the 294 healthy mothers offered their newborns' meconium samples for the metal analysis. Those 190 mothers were set as the control group. Arsenic (As), mercury (Hg), lead (Pb), cadmium (Cd), and chromium (Cr) levels in these case-control meconium samples were measured by inductively coupled plasma mass spectrometry. The possible association between the metal levels and maternal GDM risk of studied subjects was assessed by binary logistic regression.

RESULTS

GDM prevalence of 12.21% was observed in the investigated 1359 participants. The concentrations of As, Hg, Cr and Cd in studied cases were significantly higher (p < 0.05) than those of controls. After adjustments for maternal age, pre-pregnant body mass index, gravidity, parity, hepatitis B virus infection, and newborn sex, As, Cd and Cr were found to be positively associated with GDM prevalence in dose-dependent manners. Among them, As was detected in all samples and its levels associated the maternal GDM with the adjusted odds ratios of 3.28 [95% CI 1.24, 8.71], 3.35 [95% CI 1.28, 8.75] and 5.25 [95% CI 1.99, 13.86] for the 2(nd), 3(rd) and 4(th) quartiles, respectively.

CONCLUSIONS

The present work implies that exposure to some of the selected metals (noticeably As) may contribute to maternal GDM risk during pregnancy.

Maternal chronic HBV infection would not increase the risk of pregnancy-induced hypertension--results from pregnancy cohort in Liuyang rural China

The relationship between maternal HBV (hepatitis B virus) infection and pregnancy-induced hypertension (PIH) is inconclusive. Few studies have been conducted in rural areas of China. In order to examine the association between maternal chronic HBV infection and risk of PIH in Liuyang rural area China, we enrolled 6,195 eligible pregnant women in 2010–2011 in selected 14 towns of Liuyang on their first prenatal visit to local maternity care unit. A total of 461 subjects (7.44% (95%CI: 6.79%, 8.10%)) were identified with positive HBsAg status (exposed group) and 5734 were non-HBV carriers (unexposed group). Multivariate log-binomial regression models were used to estimate the risk of PIH, gestational hypertension (GH), and preeclampsia (PE) in relation to maternal chronic HBV infection. There are total of 455 subjects diagnosed with PIH (7.34% (95%CI: 6.70%, 7.99%)), including 371 GH (5.99% (95%CI: 5.40%, 6.58%)) and 81 PE (1.31% (95%CI: 1.07%, 1.64%)). The crude risk ratio between PIH, GH, PE and maternal HBV infection were 1.20 (95%CI: 0.88, 1.64), 1.30(95%CI: 0.93, 1.81) and 0.79 (95%CI: 0.32, 1.93), respectively. After adjustment for gravidity history, abortion history, family history of Diabetes Mellitus (DM) and family history of hypertension, positive HBsAg status was still not significantly associated with PIH (RR = 1.18, 95%CI: 0.87, 1.62), GH (RR = 1.27, 95%CI: 0.91, 1.78) or PE (RR = 0.79, 95%CI: 0.32, 1.95). Additional adjustment for maternal age, marital status, parity history, family history of DM, Body Mass Index at first antenatal visit, folic acid supplementation, smoking status during pregnancy and economic status of living area, multivariate analysis provided similar results. In conclusion, our study found that maternal chronic HBV infection prevalence rate is 7.4% among Liuyang rural area and there is no significant association between maternal HBV infection and the risk of PIH, GH or PE.

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.

Minimal adverse influence of maternal hepatitis B carrier status on perinatal outcomes and child's growth

OBJECTIVE

To clarify whether maternal HBsAg positivity may add risk for adverse neonatal outcomes and even affect child's growth.

METHODS

The perinatal data and neonatal outcomes in 380 HBsAg-positive and 428 HBsAg-negative women delivered during 2002-2004 were investigated. Furthermore, 271 (71.3%) children of HBsAg-positive and 297 (69.4%) of HBsAg-negative mothers were followed at ages of 5-7 years. Child's growth including weight, height, and health conditions were evaluated.

RESULTS

The prevalence of preterm birth was relatively higher in HBsAg-positive group (2.9% versus 1.4%), but it failed to reach statistical significance (p = 0.140). There was no difference in other neonatal outcomes including stillbirth (0.5% versus 0.2%), neonatal death (0.5% versus 0.5%) and congenital malformation (0.8% versus 1.4%). Logistic regression analyses demonstrated maternal HBsAg positivity had no adverse influence on neonatal outcomes. Abnormal health conditions, other than adverse neonatal outcomes, was identified in one child (0.3%) of HBsAg-positive mother and four children (0.9%) of HBsAg-negative mothers at follow-up (p = 0.444). No maternal death occurred in HBsAg-positive or -negative mothers.

CONCLUSIONS

Maternal HBsAg carrier status does not add risk for adverse neonatal outcomes or child's growth; therefore, heightening surveillance for adverse neonatal complications in HBV-infected pregnant women may be unnecessary.

Maternal ABO and rhesus blood group phenotypes and hepatitis B surface antigen carriage

In view of a persistently high prevalence of hepatitis B surface antigen (HBsAg) carriage in our obstetric population, we examined the association between HBsAg carriage with maternal ABO and rhesus (Rh) blood group phenotypes determined at routine antenatal screening. In a retrospective study, the antenatal screening results of women booked for confinement between 1998 and 2011 in our hospital were examined for the relationship between HBsAg carriage with the ABO and rhesus blood groups, taking into account also the effects of advanced maternal age (≥ 35 years) and parity status (nulliparous or multiparous), and year of birth before or following the availability of the hepatitis B vaccine (1984). HBsAg carriage was found in 9.9%, 9.6%, 9.1% and 10.2% (P = 0.037) for group-A (n = 20 581 or 26.1%), -B (n = 20 744 or 26.4%), -AB (n = 5138 or 6.5%) and -O (n = 32 242 or 41.0%) among the 78705 women in the study cohort. Rhesus negativity was found in 0.6%, and HBsAg carriage was 12.3% and 9.8%, respectively, for the Rh-negative and Rh-positive women (P = 0.071). Carriage rate between group-O and non-O was influenced by nulliparity, age ≥ 35 years and Rh-positive status. Regression analysis indicated that group-B (P = 0.044, aOR = 1.062, 95% CI 1.002-1.127) and group-AB (P = 0.016, aOR = 1.134, 95% CI 1.024-1.256) were associated with HBsAg carriage. Blood groups-B and -AB are associated with increased hepatitis B virus (HBV) infection in our population, and further studies are warranted to elucidate the implications of this on the sequelae of HBV infection.