What is the recommended management approach for a pregnant patient with chronic hepatitis, specifically hepatitis B or C?

Management of Chronic Hepatitis B and C in Pregnancy

Hepatitis B: Screening and Antiviral Prophylaxis

All pregnant women should be screened for HBsAg in the first trimester, with HBV DNA and ALT levels measured at 26-28 weeks gestation to determine the need for antiviral prophylaxis. 1

Third-Trimester Antiviral Therapy

• Initiate tenofovir disoproxil fumarate (TDF) at 24-32 weeks gestation in pregnant women with HBV DNA >200,000 IU/mL to prevent mother-to-child transmission 2, 1
• TDF is the first-line agent due to its superior safety profile and efficacy compared to other antivirals 1, 3
• Women already on entecavir should be switched to TDF before or during pregnancy, as entecavir is Category C (animal studies show teratogenic effects) while TDF is Category B 2, 1, 4
• Continue TDF throughout pregnancy in women with advanced fibrosis or cirrhosis regardless of viral load 1

Women Already on Antiviral Therapy

• For women on antivirals who desire pregnancy, continue therapy rather than stopping, particularly if they have cirrhosis or advanced fibrosis 1
• The risk of hepatic decompensation from stopping therapy outweighs theoretical fetal risks, especially with TDF 2

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
• This dual immunoprophylaxis is essential even when mothers received third-trimester antivirals 2, 3

Delivery and Postpartum

• Vaginal delivery is recommended; cesarean section should not be performed solely to reduce HBV transmission 1, 3
• Standard obstetric indications should guide mode of delivery 1
• Breastfeeding is safe and should be encouraged in HBsAg-positive mothers, including those on TDF therapy 1, 3
• The only contraindication is cracked nipples with detectable HBV DNA or infant oral ulcers 2, 1
• Monitor for hepatitis flares after delivery and after stopping antiviral therapy, as virologic relapse is common 2, 1

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 that transmission risk increases with higher viral loads 3

Hepatitis C: Surveillance Without Treatment

HCV treatment during pregnancy is not recommended; defer direct-acting antiviral therapy to the postpartum period. 2, 5

Screening and Monitoring

• Screen women at increased risk for HCV by testing for anti-HCV antibodies at the first prenatal visit 5
• If initial results are negative, repeat screening later in pregnancy for women with persistent risk factors (ongoing injection drug use) 5
• Universal prenatal HCV screening is recommended as part of the global elimination strategy and is cost-effective at prevalence as low as 0.07% 2

Why No Treatment During Pregnancy

• No large-scale published data exist on safety and efficacy of direct-acting antivirals (DAAs) in pregnant women, and none are licensed for pregnancy use 2
• A small phase I study of sofosbuvir/ledipasvir in 9 pregnant women showed all achieved SVR with low adverse events, but this is insufficient evidence for routine use 2
• Treatment can only be considered on a case-by-case basis after thorough discussion of risks and benefits, involving both hepatology and obstetric services 2

Delivery and Breastfeeding

• Cesarean delivery should not be performed solely for HCV transmission prevention 5
• Avoid internal fetal monitoring, prolonged rupture of membranes, and episiotomy during labor to minimize transmission risk 5
• Breastfeeding is not contraindicated and should be encouraged 2, 5
• HCV does not increase transmission risk through breastfeeding; only bleeding or cracked nipples warrant temporary cessation due to blood exposure risk 2

Postpartum Management

• Refer HCV-positive women to hepatology for DAA therapy postpartum 2
• Screen infants born to HCV-positive mothers for HCV RNA at 2-6 months of age 5
• Mother-to-child transmission occurs in approximately 5% of cases, higher with HIV coinfection 5

Common Pitfalls to Avoid

• Failing to check HBV DNA in the third trimester leads to missed opportunities for prophylaxis in high-risk women 1, 6
• Using lamivudine instead of TDF for pregnancy prophylaxis increases resistance risk and is less effective 1, 7
• Continuing entecavir during pregnancy when TDF is the evidence-based safer choice 1, 4
• Discouraging breastfeeding in HBV or HCV-positive mothers contradicts current evidence showing safety with proper infant immunoprophylaxis 2, 1, 5
• Performing cesarean delivery solely for viral hepatitis prevention, which provides no benefit 1, 3, 5