Should a pregnant woman with Hepatitis B surface antigen (HBsAg) positive, Hepatitis B e-antigen (HBeAg) negative, and HBV DNA level of 750 IU/mL be treated with antiviral therapy?

Management of HBsAg-Positive Pregnant Woman with HBeAg-Negative Status and Low Viral Load

Antiviral therapy is not recommended for this pregnant woman with HBsAg-positive, HBeAg-negative status and HBV DNA level of 750 IU/mL, as her viral load is well below the threshold for treatment to prevent mother-to-child transmission. 1

Assessment of Risk for Mother-to-Child Transmission

• The HBV DNA level of 750 IU/mL is significantly below the threshold of 200,000 IU/mL (5.3 log10 IU/mL) at which antiviral prophylaxis is recommended during pregnancy 1
• HBeAg-negative status is associated with lower risk of perinatal transmission compared to HBeAg-positive status 2
• Multiple guidelines (AASLD, EASL, KASL, APASL) consistently recommend against antiviral therapy for pregnant women with HBV DNA levels below 200,000 IU/mL 1

Recommendations for Management

Standard Immunoprophylaxis

• Ensure the infant receives complete immunoprophylaxis including:
  • Hepatitis B vaccine within 12 hours of birth 1, 2
  • Hepatitis B immunoglobulin (HBIG) within 12 hours of birth 1, 2
  • Completion of the full HBV vaccine series according to the recommended schedule 2

Monitoring During Pregnancy

• Continue monitoring HBV DNA levels throughout pregnancy to detect any significant increases 2
• Monitor liver function tests (ALT/AST) during pregnancy to assess for any flares of hepatitis 1
• Refer to a hepatitis B prevention program for case management if available 2

Evidence Supporting Non-Treatment

• AASLD explicitly recommends against antiviral therapy to reduce perinatal transmission risk in HBsAg-positive pregnant women with HBV DNA levels ≤200,000 IU/mL (Quality of Evidence: Low) 1
• Studies have demonstrated that mother-to-child transmission is extremely rare when maternal viral load is <6 log10 IU/mL (<1,000 IU/mL) and proper infant immunoprophylaxis is administered 3
• Research shows that vaccine efficacy is 99.4% when maternal viral load is <6 log10 IU/mL, with zero transmission documented in this viral load range 3

Postpartum Considerations

• Breastfeeding is not contraindicated for HBsAg-positive mothers, regardless of treatment status 1, 4
• Monitor for postpartum ALT flares, which can occur in HBV-infected women 1
• Consider referral for evaluation of chronic hepatitis B management after delivery 2

Invasive Procedures During Pregnancy

• Non-invasive prenatal testing is preferred over invasive procedures like amniocentesis 1, 2
• If invasive procedures are necessary, they carry lower risk in women with low viral loads compared to those with high viral loads 2

Important Caveats

• If the viral load increases to >200,000 IU/mL during pregnancy monitoring, reassess the need for antiviral prophylaxis with tenofovir disoproxil fumarate (TDF) starting at 24-32 weeks gestation 1
• If the patient has evidence of advanced fibrosis or cirrhosis (regardless of viral load), treatment with tenofovir would be recommended and should be continued throughout pregnancy 1
• The threshold for treatment to prevent mother-to-child transmission is consistent across guidelines (>200,000 IU/mL), but some regional variations exist (APASL suggests >6-7 log10 IU/mL) 1