Pregnant A review of review articles Bridget A Buyea Definition a disease of type A B C D or E you can get hepatitis if someone pees in your soup or you dont use a condom actually you can get hepatitis from spit so dont kiss anybody without using a dental dam or else you WILL die ID: 780153
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Hepatitis B……. Chronic…… Pregnant
A review of review articles
Bridget A. Buyea
Slide2Definition a disease of type A, B, C, D, or E. you can get hepatitis if someone pees in your soup or you don’t use a condom, actually, you can get hepatitis from spit, so don’t kiss anybody without using a dental dam or else you WILL die (1)
Chronic hepatitis represents a series of liver disorders of varying causes and severity in which hepatic inflammation and necrosis continue for at least 6 months (2)
Hepatitis. http://
www.urbandictionary.com/define.php?term
=hepatitis
Dienstag
, J. Chronic Hepatitis. Harrison’s
Prinicples
of Internal Medicine. pp 1955-1956 17t edition. Copyright 2008
Slide3Blast from the past: Step 1
HBsAg
: Antigen found on surface of HBV
HBsAb
: Antibody to
HBsAg
, provides immunity to hepatitis B
HBcAg: Antigen associated with core of HBVHBcAb: Antibody to HBcAg; IgM HbcAb is an indicator of recent disease; IgG HbcAb signifies chronic diseaseHBeAg: a second, different antigenic determinant in the HBV core. Important indicator of active viral replication and therefore transmissibility. High HBEAg level = high EnfectivityHBeAb: antibody to e antigen; indicates low transmissibility
Above info from: Hepatitis Serologic Markers. Pg 173. First Aid for Step 1
Slide4Diagnosis?
Above info from: Hepatitis Serologic Markers. Pg 173. First Aid for Step 1
Slide5So why do we care?
“infection at birth is associated with clinically silent acute infection but a 90% chance of chronic infection while infection in young adulthood in an
immunocompeta]ent
person is typically associated with clinically apparent acute hepatitis but a risk of
chronicity
of only approximately 1%” (2)
Remember, this is a disease people can die from. They have a shortened life expectancy depending on their viral load and
HBeAg + or –“Approximately 600,000 people DIE each year secondary to acute or chronic consequences of HBV” (3)3 Giles et al. Chronic Hepatitis B Infection and Pregnancy. CME Review Article. Obstetrical And Gynecological Survey. Volume 67. Number 1. Copyright 2012 Lippincott Williams and Wilkin
Slide6Chronic Hepatitis B + Pregnancy =No issues with fertility or conceptionNo difference in preterm delivery, birth weight, neonatal jaundice, congenital anomalies,
perinatal
mortality unless…
+cirrhosis: increased risk of SAB;
gHTN
, abruption, pp hemorrhage (versus general population)
Slide7MODES OF TRANSMISSION
VERTICAL
In
Utero
At Delivery
HORIZONTAL
Childhood
Slide8AT DELIVERY
MOST FREQUENT ROUTE OF TRANSMISSION (we think)
Based on diagnosis of +
HBsAg
at/after 1 month of life
All babies should get 2 interventions at birth if mom is
Hep
B +……………(I hope someone answered)“This strategy has been shown to reduce transmission by up to 90%”!!
Slide9IN UTERO
How is
Hep
B transmitted in general?
Ex. We know
Hep
A is transmitted fecal-oral
HOW is it transmitted in utero?WHEN is it transmitted in utero?Someone better have answered this one. Not sure: transplacental? Maternal blood leak?Not sure: but know that it can and DOES happen… and traditional regimen of treating AT delivery does not prevent this transmission
Slide10So what do we do?We want to prevent transmission regardless of route!
Slide11Not these things:Some +/- ideas that don’t have the evidence to back them up to make the experts recommend them
HBIG administration q4w starting at 24
wga
Some studies reported statistically significant findings to support this regimen, unfortunately there were significant methodological flaws in the studies
Cesarean delivery has shown a protective effect in preventing HVB transmission
…depending on which study you look at :\
Slide12New, Exciting, Alternatives!!
With the discovery that treating HIV in pregnant women can significantly reduce vertical transmission rates, that thought seems to have been carried over to the Hepatitis B world…and they are using some of the same drugs that were studied in HIV + moms
Slide13When antepartum treatment REALLY matters
HBeAg
+
Slide14ALSO:
HBV DNA levels >/= 6 log10 copies/ml
Slide15….But we still need “a properly designed, prospective, randomized, controlled trial to address the efficacy of antiviral therapy in the interruption of vertical transmission”….
Slide16NEVERTHELESS!
There are encouraging new studies showing the efficacy of
antepartum
treatment with antivirals
to decrease the rate of vertical transmission
It has been shown the tradition WHO regimen of HBIG +
Hep
B vaccine AT birth is LEAST effective with women who have a high viral load (>6/8/10 log10) and women with +HBeAg…..So, why don’t we DECREASE the viral load antepartum or attempt to seroconvert their HBeAg status?
Slide17STUDY SUPPORTLAMIVUDINE Studies with
n
= 3, 8, 12 showed decreased rates of transmission (also study of
n=114 but issues with intent-to-treat statistics)
TELBIVUDINE
Prospective, nonrandomized, open label study
Treatment arm 30% achieved undetectable viral load
vs 0% in no-treatment armAt delivery: 6.32% vs 30.43 %At 28weeks old: 2.11% vs 13.04%
Slide18TENOFOVIR!!!!!!
CLASS B
No Hepatitis B pregnancy studies BUT has been used in HIV + pregnancies and evidence from studies related to that illustrate no adverse effects during pregnancy (large
power)
Slide19Okay, so what about BREASTFEEDING??No Antivirals
+
immunoprophylaxis
Do it!
Antivirals
+
immunoprophylaxisDon’t unlessd/c antivirals 1 month post partum to “limit exposure of the infant to these drugs through breastmilk…need to monitor serial ALT and HBV DNA” in mom to detect Hepatitis flares that could occur 2/2 d/cing treatment..
Slide20Questions we are left withShould ALL Chronic Hepatitis B moms be treated with
antivirals
?
If so, when should it start?How often do we monitor ALT/HBV DNA/HBeAg
for people who are treated and for people who aren’t?
Do the benefits of breastfeeding outweigh the risks to the moms of
d/cing
treatment? (Especially in the HBeAg+ moms who should be on treatment for 48 months!)
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