What is Pregnancy and Viral Hepatitis?

In pregnancy, jaundice, a condition that turns the skin and eyes yellow, is often caused by acute viral hepatitis, an inflammation of the liver. Hepatitis can be triggered by diseases that are specifically related to pregnancy, as well as those that aren’t.

Diseases that are specifically related to pregnancy include acute fatty liver of pregnancy, hyperemesis gravidarum which is severe morning sickness, intrahepatic cholestasis of pregnancy which is a liver disorder, severe pre-eclampsia, and HELLP syndrome. HELLP syndrome includes symptoms of hemolysis which is the breakdown of red blood cells, elevated liver enzymes, and a low platelet count that can affect blood clotting.

The article provides a review of the most frequent types of viral hepatitis caused by Hepatitis A, B, C, D, and E viruses. It also discusses how these viruses are transmitted, potential pregnancy complications, immunization against them, and breastfeeding options for infected mothers and their newborns.

What Causes Pregnancy and Viral Hepatitis?

Hepatitis A is a type of virus that typically passes from person to person because of unhygienic conditions, including contaminated food or water. It can also be spread through intimate contact and in rare instances through blood during a transfusion. The virus is present in feces, blood and saliva. It takes about a month from exposure to the virus for someone to show symptoms. Pregnancy and childbirth rarely result in transmission of Hepatitis A.

Hepatitis B is a virus that belongs to the Hepadnavirus family. It’s linked with serious health conditions like cirrhosis and liver cancer. The virus doesn’t cross from mother to fetus unless there’s a breach in the protective barrier. Over 50% of cases result from transmission during birth. Infected mothers have a 90% chance of passing the virus to their child at birth. It can also be spread through sexual contact, body fluids, and blood transfusions.

Hepatitis C is a plus-sense RNA virus with various genotypes. If the virus is not cleared within six months of exposure, it can lead to chronic Hepatitis C and possibly cirrhosis and liver cancer. The main ways of spreading Hepatitis C include blood transfusions, shared drug needles, sexual contact, and from mother to baby. The risk is highest during the last month of pregnancy or delivery, and intrusive procedures such as amniocentesis can increase the chance of transmission.

Hepatitis D is caused by the hepatitis delta virus, which needs the help of the Hepatitis B virus to be infectious. It is mainly spread in the same ways as Hepatitis B, although it rarely passes from mother to baby during pregnancy. When Hepatitis D and Hepatitis B infect someone simultaneously, the Hepatitis D can become severe.

Hepatitis E is a type of virus from the Hepeviridae family. It is usually contracted by consuming contaminated food or water, especially in areas with poor sanitation. The chance of transmission from mother to baby can be between 23.3% to 50%. Cases have been reported in developed countries too which are generally caused by genotype 3, often linked to a suppressed immune system. Hepatitis E is infrequently passed on via sexual intercourse.

Risk Factors and Frequency for Pregnancy and Viral Hepatitis

Hepatitis is a common illness that affects millions of people worldwide. Each strain of the disease has its distinct characteristics and impact.

  • Hepatitis A: This type mainly affects developing countries, with about 1 in 1000 pregnant women contracting the virus. It usually resolves on its own and has a death rate of 0.3% to 0.6%.
  • Hepatitis B: It’s the leading cause of chronic hepatitis globally, affecting more than 250 million people. In the United States, there are about 800,000 to 1.4 million Hepatitis B virus carriers. The disease is prevalent in 0.7% to 0.9% of pregnant women in the United States.
  • Hepatitis C: This strain affects over 170 million people worldwide. Around 8% of pregnant women have Hepatitis C, with 1% to 2.5% of US expecting mothers affected by it.
  • Hepatitis D: This form affects 15 to 20 million people worldwide, mainly those already carrying the Hepatitis B virus. Recent studies suggest that up to 72 million might have the disease. In the United States, it ranges from affecting 2% to 50% of the population based on different demographics. In Pakistan, about 20.63% of pregnant women with Hepatitis B also have Hepatitis D.
  • Hepatitis E: It affects around 20.1 million people, particularly in developing countries. It’s responsible for about 70,000 deaths and 3,000 stillbirths annually. Pregnant women in the 2nd and 3rd trimesters are especially vulnerable to epidemics, with a death rate as high as 5% to 25%. Fatalities are higher for those who progress to severe hepatitis.

Signs and Symptoms of Pregnancy and Viral Hepatitis

Acute viral hepatitis (a liver disease caused by viruses) during pregnancy might not show any symptoms or could present with mild symptoms.

Women who have this condition might experience things like a yellowing of the skin and eyes (jaundice), feeling sick, loss of appetite, stomach pain or discomfort, fatigue, a general sense of not feeling well, muscle pain, and dark urine. However, it’s important to note that these symptoms can’t help distinguish between the different types of viral hepatitis.

If a pregnant woman has a long-term hepatitis B or C virus infection, her liver disease could get worse and lead to serious complications. These can include a build-up of fluid in the abdomen (ascites), confusion and other symptoms caused by a decline in brain function (hepatic encephalopathy), blood clotting disorders (coagulopathy), and bleeding from enlarged veins in the esophagus (esophageal variceal bleeding).

The most common sign of viral hepatitis is jaundice. Other general symptoms to watch out for include fever, muscle pain, abdominal pain, feeling sick, vomiting, among others.

  • Jaundice (yellowing of the skin and eyes)
  • Nausea (feeling sick)
  • Anorexia (loss of appetite)
  • Abdominal pain or discomfort
  • Fatigue (tiredness)
  • Malaise (general sense of not feeling well)
  • Myalgia (muscle pain)
  • Dark urine
  • Fever
  • Vomiting

Testing for Pregnancy and Viral Hepatitis

In simple terms, diagnosing acute viral hepatitis can involve tests that evaluate the condition of the liver, such as checking for high levels of liver enzymes (like ALT, AST, and ALP). Other tests related to the blood clotting process and protein and ammonia levels might also be carried out. The severity of the condition can move these readings up or down.

Acute Hepatitis A

If a pregnant woman has been in contact with someone suffering from acute Hepatitis A, it might be necessary to screen them for the disease. This screening involves checking for a specific type of antibody (anti-HAV IgM) that indicates a Hepatitis A viral infection in them and their unborn child or newborn.

Hepatitis B

If a pregnant mother has Hepatitis B, there’s a high chance (90%) it could be passed on to their fetus or newborn, especially if the mom is suffering from chronic Hepatitis B and tests positive for HBeAg, a specific hepatitis B virus antigen. Because of this, health experts in the U.S. suggest screening every pregnant woman for Hepatitis B, done through a test for the Hepatitis B surface antigen, at their first prenatal visit. This helps reduce the risk of passing the disease from the mother to the child.

Hepatitis C

In the case of Hepatitis C, high RNA levels among pregnant women suggest a greater chance of passing the virus to their child. As precautions, both ACOG and CDC advocate for targeted screenings among expectant mothers at risk. This involves checking for antibodies designed to fight off Hepatitis C.

Hepatitis D

For Hepatitis D—a unique case that only happens when one is already infected with Hepatitis B—the World Health Organization advises that pregnant women with Hepatitis B should also be screened for Hepatitis D. This can be done through testing for specific antibodies related to active Hepatitis D infection.

Hepatitis E

Pregnant women in their second and third trimesters are primarily at risk during Hepatitis E outbreaks, with death rates as high as 5-25%. The danger is much higher for expecting mothers who develop a severe form of Hepatitis. Antigens related to Hepatitis E infection are tested in expecting mothers suspected of having the disease.

Treatment Options for Pregnancy and Viral Hepatitis

For Hepatitis A, pregnant women who have been in contact with people suffering from acute Hepatitis A, and new-born babies infected during the third trimester, should receive Hepatitis A immunoglobulin. Babies should get this within 48 hours of birth, following advice from health authorities. Also, Hepatitis A doesn’t transfer via breast milk, so mothers with the infection can safely breastfeed their babies.

For Hepatitis B, it’s crucial to provide new-born babies with Hepatitis B immunoglobulin and vaccine within the first day after birth. This applies to all babies born to mothers with Hepatitis B or whose status is unknown. This approach reduces the risk of infection significantly. If a pregnant mother with Hepatitis B has a high viral load, some antiviral therapies can reduce the transmission risk to less than 3%. As with Hepatitis A, breastfeeding is encouraged as long as the baby has received immunization.

Concerning Hepatitis C, using a cesarean section to reduce transmission risks during pregnancy is discouraged. Antiviral treatments should be given before pregnancy because their safety during pregnancy is uncertain. Currently, no immunization is available for Hepatitis C, and breastfeeding is safe for infected mothers.

In terms of Hepatitis D, the infection is managed with long-term alpha interferon and PEGylated interferon, both of which should be avoided during pregnancy. The spread of Hepatitis D has largely decreased thanks to perinatal prevention and treatment of Hepatitis B.

Lastly, Hepatitis E can cause severe symptoms, but a recombinant protein vaccine has shown promise in reducing transmission in developing countries. However, this vaccine isn’t yet available in developed countries, and hasn’t been tested on pregnant women. Mothers infected with Hepatitis E also can breastfeed without any concerns.

When a pregnant woman has liver problems, doctors will consider several possible conditions. These include:

  • Acute Fatty Liver of Pregnancy: A serious liver condition that can occur in the third trimester, or sometimes earlier.
  • Hyperemesis Gravidarum: Severe nausea and vomiting during pregnancy that can lead to dehydration.
  • Intrahepatic Cholestasis of Pregnancy: A liver disorder that can cause severe itching, particularly on hands and feet, and can occur late in pregnancy.
  • Severe Preeclampsia: A potential life-threatening pregnancy complication characterized by high blood pressure.
  • HELLP Syndrome: A severe form of preeclampsia that involves low platelet count, high liver enzyme levels, and the breakdown of red blood cells.
  • Herpes Simplex Virus Hepatitis: A rare and severe condition where herpes simplex virus causes inflammation of the liver.
  • Epstein-Barr Viral Hepatitis: A condition where a common virus called Epstein-Barr causes the inflammation of the liver.

Determining the exact condition requires careful examination and tests by healthcare professionals.

What to expect with Pregnancy and Viral Hepatitis

People who have had a Hepatitis A infection do not suffer from long-term after-effects, according to available reports. However, in the case of Hepatitis E infection, the mortality rate appears to be higher during the 2nd and 3rd trimesters of pregnancy, between 5% and 25%. Pregnant women are also at a higher risk of developing severe, aggressive forms of hepatitis, known as fulminant hepatitis.

Possible Complications When Diagnosed with Pregnancy and Viral Hepatitis

Hepatitis A, B, C, D and E can all have different effects on pregnancy. Here is a rundown of the potential complications these various forms of hepatitis can cause during pregnancy:

Hepatitis A:

  • Premature contractions
  • Placental separation
  • Premature rupture of membranes
  • Vaginal bleeding
  • Fetal ascites and meconium peritonitis

Hepatitis B:

  • Increased maternal and perinatal death
  • Placenta abruption
  • Preterm birth
  • Gestational hypertension
  • Fetal growth restriction
  • Progression to cirrhosis

Hepatitis C:

  • Fetal growth restriction
  • Brachial plexus injury
  • Fetal distress
  • Cephalohematoma
  • Neonatal seizures
  • Intraventricular hemorrhage

Hepatitis D:

  • High risk of severe chronic liver disease

Hepatitis E:

  • Premature rupture of membranes
  • Antepartum and postpartum hemorrhage
  • Disseminated intravascular coagulation (DIC)
  • Intrauterine fetal deaths
  • Spontaneous abortions
  • Stillbirths
  • Complications of fulminant hepatitis
  • Preterm and low birth weights

Preventing Pregnancy and Viral Hepatitis

The U.S. Preventative Services, along with other medical organizations recommend that all pregnant women get screened for hepatitis B at their first prenatal appointment. This screening is done through a test called the Hepatitis B surface antigen (HBsAg).

Once a newborn, who may have been exposed to Hepatitis B, has been properly vaccinated, the major health organizations including the American College of Pediatrics and the Centers for Disease Control and Prevention, encourage breastfeeding.

At present, there’s no vaccine available to protect against the hepatitis C virus, both for pregnant women and their babies. However, mothers infected with hepatitis C can still breastfeed as there’s no risk linked to breastfeeding.

For pregnant women living in developed countries, medical advice usually discourages them from travelling to areas where there’s a high risk of catching the Hepatitis E virus.

Frequently asked questions

Pregnancy and viral hepatitis is a condition in which jaundice, characterized by yellowing of the skin and eyes, is often caused by acute viral hepatitis, an inflammation of the liver. Hepatitis can be triggered by diseases that are specifically related to pregnancy, as well as those that aren't.

Pregnancy and viral hepatitis are common, with different rates of prevalence depending on the specific strain of hepatitis.

Signs and symptoms of pregnancy and viral hepatitis include: - Jaundice (yellowing of the skin and eyes) - Nausea (feeling sick) - Anorexia (loss of appetite) - Abdominal pain or discomfort - Fatigue (tiredness) - Malaise (general sense of not feeling well) - Myalgia (muscle pain) - Dark urine - Fever - Vomiting It's important to note that these symptoms can't help distinguish between the different types of viral hepatitis. Additionally, if a pregnant woman has a long-term hepatitis B or C virus infection, her liver disease could get worse and lead to serious complications such as ascites (build-up of fluid in the abdomen), hepatic encephalopathy (confusion and other symptoms caused by a decline in brain function), coagulopathy (blood clotting disorders), and esophageal variceal bleeding (bleeding from enlarged veins in the esophagus).

Pregnancy and Viral Hepatitis can be transmitted through various ways, including mother-to-child transmission during birth, blood transfusions, and in some cases, intimate contact.

The doctor needs to rule out the following conditions when diagnosing Pregnancy and Viral Hepatitis: 1. Acute Fatty Liver of Pregnancy 2. Hyperemesis Gravidarum 3. Intrahepatic Cholestasis of Pregnancy 4. Severe Preeclampsia 5. HELLP Syndrome 6. Herpes Simplex Virus Hepatitis 7. Epstein-Barr Viral Hepatitis

For Pregnancy and Viral Hepatitis, the following tests are needed: - For Hepatitis A: Screening for anti-HAV IgM antibodies to detect a Hepatitis A viral infection in the pregnant woman and her unborn child or newborn. - For Hepatitis B: Testing for the Hepatitis B surface antigen to screen every pregnant woman for Hepatitis B and reduce the risk of transmission from mother to child. - For Hepatitis C: Screening for antibodies designed to fight off Hepatitis C to assess the risk of transmission from mother to child. - For Hepatitis D: Testing for specific antibodies related to active Hepatitis D infection in pregnant women with Hepatitis B. - For Hepatitis E: Testing for antigens related to Hepatitis E infection in pregnant women suspected of having the disease.

Pregnancy and viral hepatitis are treated differently depending on the specific type of hepatitis. For Hepatitis A, pregnant women who have been in contact with infected individuals and newborn babies infected during the third trimester should receive Hepatitis A immunoglobulin. For Hepatitis B, it is crucial to provide newborn babies with Hepatitis B immunoglobulin and vaccine within the first day after birth. Antiviral therapies can also be used to reduce transmission risk if the pregnant mother has a high viral load. For Hepatitis C, antiviral treatments should be given before pregnancy, and cesarean section is not recommended to reduce transmission risks. Hepatitis D is managed with long-term alpha interferon and PEGylated interferon, but these should be avoided during pregnancy. There is currently no immunization available for Hepatitis C. As for Hepatitis E, a recombinant protein vaccine has shown promise in reducing transmission in developing countries, but it has not been tested on pregnant women and is not yet available in developed countries. Breastfeeding is generally safe for mothers infected with viral hepatitis, as long as the baby has received immunization.

The side effects when treating Pregnancy and Viral Hepatitis can vary depending on the specific type of hepatitis. Here are the potential complications associated with each form of hepatitis during pregnancy: Hepatitis A: - Premature contractions - Placental separation - Premature rupture of membranes - Vaginal bleeding - Fetal ascites and meconium peritonitis Hepatitis B: - Increased maternal and perinatal death - Placenta abruption - Preterm birth - Gestational hypertension - Fetal growth restriction - Progression to cirrhosis Hepatitis C: - Fetal growth restriction - Brachial plexus injury - Fetal distress - Cephalohematoma - Neonatal seizures - Intraventricular hemorrhage Hepatitis D: - High risk of severe chronic liver disease Hepatitis E: - Premature rupture of membranes - Antepartum and postpartum hemorrhage - Disseminated intravascular coagulation (DIC) - Intrauterine fetal deaths - Spontaneous abortions - Stillbirths - Complications of fulminant hepatitis - Preterm and low birth weights

The prognosis for pregnancy and viral hepatitis varies depending on the specific strain of hepatitis. Here are the general prognoses for each type: - Hepatitis A: Usually resolves on its own with a death rate of 0.3% to 0.6%. - Hepatitis B: Can cause chronic hepatitis and affects 0.7% to 0.9% of pregnant women in the United States. - Hepatitis C: Affects around 1% to 2.5% of pregnant women in the United States. - Hepatitis D: Affects those already carrying the Hepatitis B virus and can range from 2% to 50% of the population based on different demographics. - Hepatitis E: Can be especially dangerous for pregnant women, with a death rate as high as 5% to 25% during the 2nd and 3rd trimesters.

An obstetrician or a maternal-fetal medicine specialist.

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