Advances in the Management of Viral Hepatitis during Pregnancy

Comprehensive Summary: Advances in the Management of Viral Hepatitis During Pregnancy

Lecture by Expert Speaker | Medical Education Series

1. Main Clinical Topics Discussed

• Overview of viral hepatitis (B, C, and E) complicating pregnancy
• Maternal-to-child transmission (MTCT) prevention strategies
• Antiviral therapy safety and timing in pregnancy
• Management of chronic liver disease (CLD) and cirrhosis in pregnant patients
• Infant vaccination protocols and immunoprophylaxis
• Safety of endoscopy during pregnancy

2. Key Learning Points, Guidelines, and Recommendations

General Principles

• Viral hepatitis in pregnancy represents a dual-life risk scenario requiring extreme vigilance
• The majority of cases are self-limiting; however, fulminant hepatic failure (FHF) remains a serious concern
• Timing of delivery is a critical multidisciplinary decision involving hepatologists, intensivists, and obstetricians
• Universal hepatitis B surface antigen (HBsAg) screening at least once during every pregnancy is endorsed by WHO, CDC, and all major gynecological societies

Physiological Considerations in Pregnancy

• Cardiac output increases by 40–45%, primarily benefiting renal, uterine, and skin circulation; hepatic blood flow changes minimally
• Largely unchanged in pregnancy: ALT, bilirubin, prothrombin time
• Altered in pregnancy: Albumin (decreased), alkaline phosphatase (elevated, placental origin), hemoglobin (decreased due to hemodilution), alpha-fetoprotein (elevated)
• Any abnormality in transaminases or bilirubin warrants further evaluation

Hepatitis B in Pregnancy — WHO Core Recommendations

• Elimination target: Reduce HBsAg prevalence to <0.1% in children ≤5 years of age
• Prevention of MTCT is central to the WHO global hepatitis B elimination strategy
• Birth dose vaccination within 24 hours is mandatory and critical
• Hepatitis B immunoglobulin (HBIG) should be given to infants born to HBsAg-positive and HBeAg-positive mothers where available
• Antiviral prophylaxis decision-making is guided by maternal viral load and HBeAg status:

• Postpartum monitoring is essential due to risk of hepatic flares
• Stopping antiviral prophylaxis after delivery in inactive HBV mothers remains debatable; close monitoring is mandatory

Antiviral Therapy Safety in Pregnancy

• Preferred agent: Tenofovir disoproxil fumarate (TDF) — Category B

- Minimal resistance profile

- High efficacy in preventing MTCT

- No significant adverse fetal effects reported

• Telbivudine: Category B but avoided due to resistance concerns
• Tenofovir alafenamide (TAF): Emerging data — a recent multicenter prospective trial (Chinese population, ~100 patients per arm, 2-year follow-up) published in *Clinical Gastroenterology and Hepatology* concluded TAF is "generally safe and effective" in pregnancy; further trials needed before routine recommendation
• Breastfeeding: Not contraindicated; antivirals are minimally excreted in breast milk and unlikely to cause significant toxicity

Pre-Conception Counseling Framework for Women with HBV

• Mild disease, low viremia: Monitor; pregnancy permissible before treatment
• Moderate disease, no cirrhosis: Treat before pregnancy; may continue or stop based on response
• Advanced/cirrhotic disease: Treat before and continue throughout pregnancy and postpartum
• Mild disease, high viremia: Init