What are the recommended screening and management protocols for hepatitis B, hepatitis C, and hepatitis A in pregnant women, including antiviral therapy, newborn immunoglobulin and vaccination, delivery mode, and breastfeeding guidance?

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Hepatitis in Pregnancy: Screening and Management

Hepatitis B Screening

All pregnant women must be screened for hepatitis B surface antigen (HBsAg) at the first prenatal visit, regardless of prior vaccination status or previous negative tests. 1, 2, 3, 4

  • Repeat HBsAg testing at hospital admission if maternal status is unknown or if new risk factors emerge (injection drug use, recent STI diagnosis). 1, 2
  • Measure HBV DNA and ALT at 26–28 weeks gestation in every HBsAg-positive woman to determine need for antiviral prophylaxis. 2, 5, 3

Hepatitis B Antiviral Therapy

Initiate tenofovir disoproxil fumarate (TDF) 300 mg daily at 28–32 weeks gestation when maternal HBV DNA exceeds 200,000 IU/mL (≈5.3 log₁₀ IU/mL) or when the mother is HBeAg-positive. 2, 5, 3

  • TDF is the sole first-line agent for HBV treatment in pregnancy, with FDA safety data from >3,300 first-trimester exposures showing no increased birth defect risk. 2
  • Continue TDF through 12 weeks postpartum for women who started prophylaxis during pregnancy to prevent hepatitis flares. 2, 5
  • Women with advanced fibrosis, cirrhosis, or active hepatitis should continue TDF throughout pregnancy regardless of viral load. 2, 5
  • Monitor ALT every 1–3 months for 6 months postpartum after TDF discontinuation, as hepatic flares occur in 3.5–25% of women. 2, 5

Hepatitis B Delivery Management

Vaginal delivery is the preferred mode for all HBsAg-positive mothers; cesarean section should follow standard obstetric indications only, not for HBV prevention. 2, 5, 3

  • Exception: In Asian, HBeAg-positive women with very high viral loads (>7 log₁₀ copies/mL or >6.14 log₁₀ IU/mL) who have not received antiviral therapy, elective cesarean may be considered (pooled OR 0.42 for transmission reduction). 2
  • This exception does not apply when antiviral prophylaxis has been given. 2

Hepatitis B Neonatal Immunoprophylaxis

All infants born to HBsAg-positive mothers must receive both hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth. 1, 2, 5, 3, 4

  • This dual prophylaxis reduces mother-to-child transmission from >90% to 5–10% in high-risk mothers. 2, 5
  • If maternal HBsAg status is unknown at delivery, give the infant hepatitis B vaccine within 12 hours; add HBIG as soon as possible (no later than 7 days) if the mother tests positive. 1, 2
  • Complete the vaccine series at 1 month and 6 months, then test for anti-HBs at 9–12 months to confirm immunity. 2, 5
  • Never administer HBIG to the mother antepartum—it provides no benefit for preventing transmission. 2

Hepatitis B Breastfeeding Guidance

Breastfeeding is safe and should be encouraged for all HBV-infected mothers, including those receiving TDF. 2, 5, 3

  • Tenofovir concentrations in breast milk are <0.01% and do not increase infant risk. 2
  • Contraindications are limited to: cracked or bleeding nipples in mothers with detectable HBV DNA, or infants with oral ulcers. 2

Hepatitis B Invasive Prenatal Testing

Prefer non-invasive prenatal testing (NIPT) over amniocentesis in HBeAg-positive women or those with HBV DNA >5.3 log₁₀ IU/mL, as invasive procedures increase transmission risk. 2

  • Avoid chorionic villus sampling in high-risk HBV pregnancies. 2
  • If invasive testing is unavoidable, obtain informed consent outlining transmission risks. 2

Hepatitis C Screening

Screen all pregnant patients for hepatitis C virus by testing for anti-HCV antibodies in every pregnancy. 1, 6

  • Universal screening is now recommended by the CDC and USPSTF, endorsed by SMFM. 1
  • Screen HCV-positive pregnant patients for other STIs (HIV, syphilis, gonorrhea, chlamydia, hepatitis B). 1, 6
  • Vaccinate against hepatitis A and B if not immune. 1

Hepatitis C Antiviral Therapy

Direct-acting antiviral regimens should only be initiated during pregnancy in the setting of a clinical trial. 1, 6

  • Women who become pregnant while taking direct-acting antivirals should be counseled through shared decision-making about risks and benefits of continuation. 1
  • Defer antiviral treatment to the postpartum period in most cases. 6

Hepatitis C Delivery and Intrapartum Management

Cesarean delivery is not recommended solely for hepatitis C prevention. 1, 6

  • Avoid internal fetal monitors and early artificial rupture of membranes unless necessary for clinical management (e.g., inability to trace fetal heart rate externally). 1, 6
  • Delivery mode should follow standard obstetric indications. 1

Hepatitis C Breastfeeding Guidance

Hepatitis C status should not alter standard breastfeeding counseling unless nipples are cracked or bleeding. 1, 6

  • There is no evidence of HCV transmission through breast milk. 6

Hepatitis C Prenatal Testing

If invasive prenatal diagnostic testing is requested, counsel patients that data on vertical transmission risk are reassuring but limited. 1, 6

  • Amniocentesis is preferred over chorionic villus sampling given the lack of data on the latter. 6

Hepatitis C Fetal Surveillance

Third-trimester assessment of fetal growth may be performed, but antenatal testing is not indicated for HCV diagnosis alone. 1

  • HCV infection during pregnancy is associated with increased risk of fetal growth restriction and low birthweight. 1

Hepatitis A Screening and Management

A reactive hepatitis A total antibody test indicates past infection or vaccination and represents immunity, requiring no treatment. 7

  • If acute hepatitis A is suspected clinically, order HAV IgM specifically—only IgM indicates acute or recent infection. 7
  • If HAV IgM is positive, provide supportive care only; hepatitis A is self-limiting with no specific antiviral treatment. 7, 8
  • Mother-to-child transmission of hepatitis A is extremely rare. 7, 8
  • Breastfeeding should not be discouraged; there is no evidence of HAV transmission through breast milk. 7, 8
  • Cesarean section is not recommended unless there is a specific obstetric indication. 7, 8

Hepatitis A Vaccination in Pregnancy

Hepatitis A vaccine is safe during pregnancy and should be offered to at-risk pregnant individuals without immunity. 7, 8

  • Both hepatitis A vaccine and immunoglobulin for postexposure prophylaxis can be used safely in pregnancy. 7, 8

Common Pitfalls to Avoid

  • Omitting third-trimester HBV DNA testing fails to identify candidates for antiviral prophylaxis. 2
  • Administering HBIG to the mother antepartum provides no benefit. 2
  • Discouraging breastfeeding in HBV or HCV infection contradicts current evidence supporting its safety with proper infant immunoprophylaxis. 1, 2
  • Performing elective cesarean solely for HBV or HCV prevention offers no advantage and conflicts with guideline recommendations. 1, 2, 3
  • Misinterpreting a reactive hepatitis A total antibody as active infection—total antibody positivity indicates immunity, not active disease. 7
  • Failing to screen for HBsAg in every pregnancy, even if previously vaccinated or tested negative. 1, 2, 3

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Management of Hepatitis B in Pregnancy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Research

Hepatitis C in pregnancy: screening, treatment, and management.

American journal of obstetrics and gynecology, 2017

7
Guideline

Interpretation and Management of Reactive Hepatitis A Total Antibody

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

8
Guideline

Hepatitis A Infection in Pregnancy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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