Management of Hepatitis E in Pregnancy
Delivery of the fetus (either preterm birth or therapeutic termination of pregnancy) should be considered to reduce maternal morbidity and mortality in mothers with acute severe hepatitis E and encephalopathy grade I-III. 1
Epidemiology and Clinical Significance
Hepatitis E virus (HEV) infection during pregnancy carries significant risks, particularly with genotype 1 in endemic regions. Unlike other viral hepatitis, HEV infection in pregnancy is associated with:
- High maternal mortality rates (median 26%, up to 30% in third trimester) 2
- High fetal/neonatal mortality (median 33% for fetal, 8% for neonatal) 2
- Increased risk of fulminant hepatic failure (median prevalence 45.3%) 2
- Vertical transmission rates of 33-100% 1
Diagnostic Approach
Perform HEV testing in pregnant women with:
- Acute hepatitis symptoms in endemic regions
- Unexplained liver enzyme elevations
- Recent travel to endemic areas
- Exposure to potential sources (contaminated water, undercooked pork)
Diagnostic tests should include:
- Anti-HEV IgM and IgG antibodies
- HEV RNA testing (PCR) for confirmation
- Liver function tests (ALT, AST, bilirubin, albumin, prothrombin time)
- Assessment for encephalopathy and other complications
Management Algorithm
1. Asymptomatic or Mild Disease
- Supportive care with close monitoring
- Regular assessment of liver function tests
- Adequate hydration and nutrition
- Vaginal delivery should not be discouraged 1
- Breastfeeding should not be discouraged in asymptomatic mothers 1
2. Moderate Disease
- Hospital admission for monitoring
- Supportive care with IV fluids
- Monitor for progression to severe disease
- Assess fetal wellbeing regularly
- Consider early delivery if maternal condition deteriorates
3. Severe Disease with Fulminant Hepatic Failure
- Immediate intensive care unit admission
- Close monitoring of liver function and encephalopathy
- Management of complications (coagulopathy, renal failure, cerebral edema)
- For patients with acute severe hepatitis E and encephalopathy grade I-III, delivery of the fetus (either preterm birth or therapeutic termination) should be considered to reduce maternal morbidity and mortality 1
- Early liver transplantation should be considered in eligible patients 3
Treatment Considerations
- Currently, no established treatment is available specifically for HEV in pregnant women 4
- Management is primarily supportive with diligent monitoring and intensive care 3
- Ribavirin, which is effective in chronic HEV infection, is contraindicated in pregnancy due to teratogenicity 5
- However, in life-threatening situations, the risk-benefit ratio may favor treatment despite teratogenicity risks 5
- Therapeutic termination of pregnancy cannot be routinely recommended based on available literature 3
Prevention Strategies
Primary prevention is critical:
- Ensure clean drinking water supply
- Proper sanitation and hygiene practices
- Avoid consumption of undercooked meat, particularly pork
- Avoid travel to endemic areas during pregnancy if possible
Vaccination:
- A Chinese HEV vaccine has shown protection in the general population
- Safety and efficacy in pregnant women remains to be fully established 4
- Not yet widely available outside China
Monitoring and Follow-up
- Regular liver function tests throughout pregnancy
- Close fetal monitoring with ultrasound assessments
- Vigilance for signs of deterioration (encephalopathy, coagulopathy)
- Postpartum monitoring for delayed complications
Key Pitfalls to Avoid
- Delaying delivery in cases of severe disease with encephalopathy
- Failing to recognize progression to fulminant hepatic failure
- Overlooking HEV as a diagnosis in endemic regions
- Assuming all viral hepatitis in pregnancy carries the same risk profile
- Underestimating the need for intensive monitoring and care
HEV infection in pregnancy, particularly in endemic regions, represents a serious condition with high maternal and fetal mortality rates. Early recognition, supportive care, and consideration of delivery in severe cases are crucial to improving outcomes.