Update on viral hepatitis in pregnancy

Author and Disclosure Information


Pregnant women with acute viral hepatitis are at higher risk of morbidity and death than pregnant women with chronic viral hepatitis. The risk of death is highest with acute viral hepatitis E, and the rate of transmission to the baby may be highest with hepatitis B virus (HBV) infection. Managing viral hepatitis in pregnancy requires assessing the risk of transmission to the baby, determining the gestational age at the time of infection and the mother’s risk of decompensation, and understanding the side effects of antiviral drugs.


  • Preventing vertical transmission of HBV infection in pregnancy is key to decreasing the global burden of this infection. Universal maternal screening and passive-active immunoprophylaxis of newborns have reduced transmission of HBV, but the addition of antiviral therapy is necessary to further decrease immunoprophylaxis failure.
  • Tenofovir, telbivudine, and lamivudine can be used safely in pregnancy without apparent teratogenicity or other harmful effects on mother or baby. But optimal outcome requires discussion of safety and the plan of care with the patient, obstetrician, and hepatologist.
  • Most pregnant women with hepatitis C virus (HCV) infection have chronic disease, with no effects on the pregnancy or baby, but 3% to 5% transmit HCV to their child at the time of birth. All pregnant women at risk should be screened at the first prenatal visit. The safety and efficacy of treating pregnant women to prevent transmission to the fetus are not established; thus, treatment is not recommended for pregnant women.



Viral hepatitis affects mother and child, and pregnancy can exacerbate the disease. Vertical transmission contributes significantly to the high prevalence of viral hepatitis and compromises the well-being and the prognosis in the newborn. The indications for therapy in pregnant women may differ from those in the general population, and new therapies are available.


Hepatitis A virus (HAV) infection is associated with significant morbidity and death around the world, as 1.4 million cases are reported every year worldwide.1 However, in the United States, the prevalence has declined by 95% since HAV vaccination was introduced in 1995, and in 2013, the prevalence was 0.6 per 100,000 population.2 Acute HAV infection during pregnancy is rare. As a result, the incidence during pregnancy is difficult to ascertain.3

HAV is transmitted by the fecal-oral route from person to person contact and from contamination of food and water. Vertical transmission from pregnant mother to fetus has not been reported.4

Clinical outcomes of HAV in pregnancy

Acute HAV infection during pregnancy is rare, and teratogenicity associated with HAV has not been reported.3 The course of the disease during pregnancy is generally similar to that in nonpregnant patients, with excellent maternal and fetal outcomes in developed nations. There have been reports in developing nations of premature contractions and labor, placental separation, premature rupture of the membranes, and vaginal bleeding.5,6


Routine screening for HAV is not recommended, but serologic testing by detection of anti-HAV immunoglobulin M (IgM) antibodies is done in high-risk patients suspected of having acute HAV infection.


Prevention includes adherence to sanitary practices and active and passive immunoprophylaxis.3 Universal vaccination for pregnant mothers is not recommended,1,2,6 but vaccination is recommended for high-risk patients and mothers—those with chronic liver disease, those receiving clotting factors, those who use illegal drugs, and travelers to areas where HAV is endemic. Immune globulin is also available for postexposure prophylaxis. HAV vaccines and immune globulin are safe in pregnancy.3,6,7


Treatment of acute HAV in pregnancy is supportive because of its benign nature; few patients require hospitalization.3

Pregnant patients with HAV can deliver vaginally, and breastfeeding is not contraindicated.8


Hepatitis B virus (HBV) infection is a major global health problem. About 240 million people worldwide have chronic HBV infection, and more than 780,000 die every year from acute and chronic consequences.9

Vertical transmission is responsible for about half of chronic HBV infections worldwide. Thus, interruption of mother-to-child transmission is important. Universal maternal screening and passive-active immunoprophylaxis of newborns have lowered the transmission rates to between 5% and 10%. The 10% failure rate is unacceptably high and has been attributed to seropositivity for hepatitis B e antigen and a high viral load in the mother (ie, HBV DNA > 106 copies/mL). High viral load is an independent risk factor for failure of immunoprophylaxis.10 Therefore, antiviral therapy is suggested in pregnant women who have a high HBV viral load to further decrease the chance of mother-to-child transmission and to prevent failure of immunoprophylaxis.11

Clinical outcomes of HBV in pregnancy

Acute HBV infection during pregnancy is usually benign and is not associated with increased risk of death or teratogenicity.12 Symptomatic disease in the mother with acute hepatitis B includes nausea, vomiting, abdominal pain, fatigue, and jaundice.3 For the newborn, there is increased risk of low birth weight and prematurity.13

When acute HBV infection occurs early in pregnancy, the rate of perinatal transmission is about 10%, increasing to 60% if it occurs near delivery.12,13

Chronic HBV infection does not usually affect the outcome of pregnancy, but it may if the woman has cirrhosis or advanced liver disease14; however, pregnancy is very rare in women with HBV cirrhosis due to anovulation, and acute HBV flares have been described during pregnancy and postpartum.15

Pregnant patients with cirrhosis and portal hypertension are at risk of hepatic decompensation, variceal bleeding, and death.16 Risk is high with a score of 10 or more on the Model for End-stage Liver Disease scale, and is low with a score of 6 or less.17 Like nonpregnant patients, pregnant patients with cirrhosis should be monitored, and upper endoscopy should be performed in the 2nd trimester to assess for varices. A beta-blocker should be given or banding of varices should be done to avoid rupture. Rates of fetal demise, premature labor, spontaneous abortion, and stillbirth are high with portal hypertension.16

Next Article:

Bleeding esophageal varices: Who should receive a shunt?

Related Articles