What are the management and treatment guidelines for hepatitis B in pregnancy?

Management of Hepatitis B in Pregnancy

All pregnant women with HBV DNA levels >200,000 IU/mL should receive tenofovir disoproxil fumarate starting at 24-32 weeks of gestation and continuing through 12 weeks postpartum to prevent mother-to-child transmission. 1

Screening and Initial Assessment

• Screen all pregnant women for HBsAg in the first trimester, as this is critical for recognizing and reducing mother-to-child transmission risk 1, 2
• Perform triple-panel testing (HBsAg, anti-HBs antibody, and total anti-HBc) at the initial prenatal visit if not previously documented 2
• For women with unknown HBsAg status at delivery, test immediately upon presentation to the birthing facility 2
• Measure HBV DNA and ALT levels at 26-28 weeks of gestation in all HBsAg-positive women to determine need for antiviral prophylaxis 1

Antiviral Therapy Indications and Timing

For Prevention of Vertical Transmission:

• Initiate tenofovir disoproxil fumarate (300 mg daily) at 24-32 weeks of gestation in pregnant women with HBV DNA >200,000 IU/mL (>5.3 log₁₀ IU/mL) 1, 2
• Continue therapy through 12 weeks postpartum 1
• The 2023 EASL guidelines provide the most recent evidence with 100% consensus on this threshold and timing 1

For Maternal Liver Disease:

• Continue tenofovir throughout pregnancy in women with chronic HBV infection and advanced fibrosis or cirrhosis 1
• Women already on entecavir should be switched to tenofovir before or during pregnancy 1
• Monitor HBV DNA and ALT every 12 weeks during pregnancy and at 4-6 weeks postpartum 1

Important caveat: Some guidelines suggest HBeAg-positive status alone as an indication for therapy, but the most recent 2023 EASL guidelines prioritize the viral load threshold of >200,000 IU/mL regardless of HBeAg status 1.

Drug Selection

• Tenofovir disoproxil fumarate is the first-line agent (pregnancy category B, now considered safe with extensive data) 1, 2
• Tenofovir alafenamide (25 mg daily) is an acceptable alternative 2
• Older guidelines mentioned telbivudine and lamivudine, but these are no longer preferred due to resistance concerns with lamivudine and superior safety data for tenofovir 1

Delivery Management

• Vaginal delivery is recommended; cesarean section should not be performed solely to reduce HBV transmission 1, 3, 2
• The exception: Some Asian guidelines suggest cesarean may be considered in HBeAg-positive Asian women with very high viral loads (>6.14 log₁₀ IU/mL) who did not receive antiviral therapy, though this is not universally endorsed 1
• Standard obstetric indications should guide mode of delivery 1, 2

Invasive Prenatal Testing

• Non-invasive prenatal testing is strongly preferred over amniocentesis in HBeAg-positive women or those with HBV DNA >5.3 log₁₀ IU/mL 1
• If amniocentesis is necessary, counsel patients that transmission risk increases with viral loads >7 log₁₀ IU/mL 1, 3
• Chorionic villus sampling should be avoided 1

Neonatal Management

• Administer both hepatitis B vaccine and HBIG within 12 hours of birth to all infants born to HBsAg-positive mothers, regardless of whether maternal antiviral therapy was given 1, 3, 2
• Complete the 3-dose vaccine series at 1 and 6 months 1, 3
• Test infant for HBsAg and anti-HBs at 9-12 months of age to confirm protection 4

Breastfeeding

• Breastfeeding is safe and should be encouraged in HBsAg-positive mothers, including those on tenofovir therapy 1, 5, 3, 2
• The 2023 EASL guidelines state with 100% consensus that breastfeeding should not be discouraged unless mothers have cracked nipples with detectable HBV DNA or the infant has oral ulcers 1
• This contradicts older 2015 US guidelines that recommended against breastfeeding during antiviral therapy—the more recent evidence supports breastfeeding safety 1, 5

Postpartum Monitoring

• Monitor for hepatitis flares after delivery and after stopping antiviral therapy 1, 4
• Check ALT every 1-3 months for 6 months postpartum in women who discontinue therapy 4
• Women who stop therapy postpartum require close monitoring for viral reactivation 1

Interventions NOT Recommended

• Do not administer hepatitis B immunoglobulin to pregnant women (antepartum maternal HBIG is ineffective at reducing transmission regardless of viral load) 1
• Do not delay breastfeeding initiation until after infant immunization 5
• Do not perform cesarean delivery solely for HBV transmission prevention 1, 3, 2

Common Pitfalls

• Failing to check viral load in the third trimester leads to missed opportunities for prophylaxis in high-risk women 1
• Using lamivudine for long-term therapy increases resistance risk; tenofovir is superior 1
• Continuing entecavir during pregnancy when tenofovir is the safer, evidence-based choice 1
• Discouraging breastfeeding based on outdated guidance contradicts current evidence showing safety with proper infant immunoprophylaxis 1, 5