What is the recommended management for a pregnant woman who is susceptible to hepatitis B (negative hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis B core antibody)?

Management of Hepatitis B Susceptibility in Pregnancy

Pregnant women who are susceptible to hepatitis B (negative for HBsAg, anti-HBs, and anti-HBc) should receive hepatitis B vaccination during pregnancy, as the vaccine is safe, highly immunogenic, and provides protection against a preventable disease that poses significant risks if acquired during pregnancy. 1

Screening Recommendations

All pregnant women should undergo triple-panel testing (HBsAg, anti-HBs, and anti-HBc) at the initial prenatal visit if not previously documented. 1 This comprehensive approach identifies not only active infection but also immunity status and susceptibility. 1

• For subsequent pregnancies with previously documented negative triple-panel results, universal HBsAg screening alone is recommended at the initial prenatal visit. 1
• Women with unknown HBsAg status should be tested on any presentation for care during pregnancy. 1
• Those with clinical hepatitis or risk factors for acute HBV infection (injection drug use, multiple sex partners, HBsAg-positive partner, or recent STI evaluation) should be tested at admission to the birthing facility if not previously screened. 2

Vaccination Strategy for Susceptible Pregnant Women

The Society for Maternal-Fetal Medicine recommends hepatitis B vaccination in pregnancy for all individuals without serologic evidence of immunity or documented history of vaccination. 1

Safety and Efficacy Evidence

• Hepatitis B vaccine is safe during pregnancy with no increased risk of congenital abnormalities, adverse maternal outcomes, or developmental issues in infants. 3, 4
• The vaccine demonstrates 84-100% seroconversion rates when administered during pregnancy. 5, 4
• A three-dose schedule produces significantly higher maternal antibody levels at delivery compared to a two-dose schedule. 5
• Passive transfer of antibodies to newborns occurs in approximately 59% of cases, though these antibodies decline rapidly by 3 months postpartum. 4

Vaccination Schedule

Administer the standard three-dose series at 0,1, and 6 months. 6 The vaccine can be initiated at any trimester, though earlier initiation provides more complete protection during pregnancy. 3, 7

• Doses administered ≤4 days before the minimum interval are considered valid. 2
• For adolescents aged 11-15 years, a two-dose schedule of Recombivax adult formulation (10 μg) is licensed, but those >15 years at the second dose should switch to a three-dose series. 2

Rationale for Vaccination During Pregnancy

Hepatitis B infection acquired during pregnancy carries significant risks:

• Sixty percent of pregnant women who acquire acute HBV infection at or near delivery will transmit the virus to their offspring. 3
• While infection is rarely symptomatic in newborns, 70-90% will remain chronically infected into adulthood with increased risk of cirrhosis and hepatocellular carcinoma. 3
• Prematurity rates increase if hepatitis B is acquired in the last trimester. 3
• Vaccination during pregnancy provides protection before the infant can be vaccinated, though passive immunity is short-lived. 4

Common Pitfalls to Avoid

The most critical error is failing to identify susceptible pregnant women through inadequate screening. 1 Without triple-panel testing, susceptible women may be misclassified as immune or not assessed at all.

• Do not delay vaccination until after pregnancy based on unfounded safety concerns—the vaccine has been proven safe in all trimesters. 3, 7
• Do not assume that all pregnant women have been previously screened or vaccinated; universal screening at each pregnancy is essential. 2
• Do not rely solely on passive antibody transfer to protect infants; while it occurs, protection is transient and infants require their own vaccination series. 4

Additional Considerations

Pregnant women at high risk for HBV acquisition should be specifically targeted for vaccination. 7 Risk factors include:

• Healthcare workers with potential blood exposure 2
• Sex partners of HBsAg-positive persons 2
• Injection drug users 2
• Women with multiple sex partners or recent STI diagnosis 2
• International travelers to endemic areas 2

Vaccination is recognized as the first anti-cancer vaccine because it prevents primary liver cancer by preventing chronic HBV infection. 6 Universal childhood immunization has been shown to decrease hepatocellular carcinoma incidence in both children and adults. 6