Management of Hepatitis B in Pregnancy
All pregnant women must be screened for HBsAg during early prenatal care, with HBV DNA testing for all HBsAg-positive women to guide antiviral therapy decisions. 1
Screening and Initial Management
- Screen all pregnant women for HBsAg during first trimester of each pregnancy, even if previously vaccinated or tested
- Test for HBsAg regardless of vaccination history or previous test results
- For women not tested prenatally, perform testing at admission for delivery
- For women with high-risk behaviors (multiple sex partners, STI treatment, injection drug use, HBsAg-positive partner), test at delivery even if previously negative
Management of HBsAg-Positive Pregnant Women
Maternal Assessment and Care
- Test HBV DNA levels to guide antiviral therapy decisions
- Consider antiviral therapy when maternal HBV DNA >200,000 IU/mL to prevent perinatal transmission 1
- Refer to Perinatal Hepatitis B Prevention Program (PHBPP) for case management
- Provide documentation of HBsAg status to delivery hospital and infant's healthcare provider
- Counsel on:
- Potential benefits of antiviral therapy
- Importance of infant prophylaxis
- Need for infant vaccination series completion
- Requirement for infant post-vaccination testing
Breastfeeding
- HBsAg-positive mothers may breastfeed immediately after birth if infant receives proper prophylaxis 1
- Breastfeeding does not increase transmission risk when prophylaxis is administered
Infant Management Based on Maternal HBsAg Status
Infants Born to HBsAg-Positive Mothers
- Administer within 12 hours of birth:
- Hepatitis B vaccine (first dose)
- Hepatitis B immune globulin (HBIG) 0.5 mL
- Complete vaccine series according to recommended schedule
- Perform post-vaccination serologic testing at 9-12 months of age (1-2 months after final dose):
- Test for HBsAg and anti-HBs
- Optimal timing is within 1-2 months after final dose to avoid unnecessary revaccination 2
Infants Born to Mothers with Unknown HBsAg Status
- Test mother for HBsAg immediately upon admission
- For infants ≥2,000 grams:
- Administer hepatitis B vaccine within 12 hours of birth
- If mother tests positive, administer HBIG as soon as possible (no later than 7 days of age)
- For infants <2,000 grams:
- Administer both hepatitis B vaccine AND HBIG within 12 hours of birth
- Birth dose should not count in the series (need 3 additional doses)
- Complete vaccine series based on maternal test results
Post-Vaccination Testing and Follow-up
- For infants born to HBsAg-positive mothers, perform testing 1-2 months after final vaccine dose:
- HBsAg-negative infants with anti-HBs ≥10 mIU/mL are protected and need no further management
- HBsAg-negative infants with anti-HBs <10 mIU/mL should receive one additional dose and be retested 1-2 months later
- If still <10 mIU/mL after single revaccination, complete a second 3-dose series
- HBsAg-positive infants should be referred for appropriate follow-up
Hospital Policies and Procedures
- Implement standing orders for:
- Review of maternal HBsAg results at delivery admission
- Testing mothers with unknown status
- Timely administration of prophylaxis to infants
- Documentation of maternal status and infant prophylaxis
- Ensure communication between facilities for transferred infants regarding vaccination status
Common Pitfalls to Avoid
- Delayed maternal screening - Screen at first prenatal visit
- Missing the birth dose window - Administer prophylaxis within 12 hours of birth
- Inadequate documentation - Ensure maternal HBsAg status is communicated to all providers
- Delayed post-vaccination testing - Testing too late (>6 months after final dose) may show falsely low antibody levels 2
- Forgetting HBV DNA testing - Essential for determining need for maternal antiviral therapy
- Discouraging breastfeeding - Safe with proper infant prophylaxis
By following these evidence-based guidelines, the risk of perinatal HBV transmission can be significantly reduced, improving long-term outcomes for infants born to HBsAg-positive mothers.