The common cause of jaundice in pregnancy is acute viral hepatitis. Hepatitis could be caused by diseases distinctively associated with pregnancy and those not distinctively associated with pregnancy.
Diseases uniquely associated with pregnancy include acute fatty liver of pregnancy, hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, severe pre-eclampsia, and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)
EPIDEMIOLOGY
- Hepatitis A
Hepatitis A is most prevalent in developing countries. 1:1000 pregnant women are infected with acute Hepatitis A virus. The disease is mostly self-limited, with mortality of 0.3% to 0.6% - Hepatitis B
Hepatitis B affects more than 250 million individuals worldwide and is the most common cause of chronic hepatitis worldwide. Sixty-five million women of childbearing age are infected with chronic hepatitis B virus.There is a 0.7% to 0.9% prevalence of chronic hepatitis B infection among pregnant women in the United States. - Hepatitis C
Hepatitis C virus affects more than 170 million people worldwide. About 8% of pregnant women are infected with HCV. - Hepatitis D
Hepatitis D virus affects 15 to 20 million people worldwide with hepatitis B virus carriers. New studies estimate the prevalence of Hepatitis D to be closer to 62 to 72 million - Hepatitis E
Hepatitis E virus affects about 20.1 million new infections. Hepatitis E viral infection is prevalent in developing countries. Hepatitis E viral infection accounts for 70,000 deaths and 3000 stillbirths yearly. Pregnant women in the second and third trimesters are mostly affected during epidemics. The mortality rate as high as 5% to 25%. There is a higher mortality rate in pregnant women who progressed to fulminant hepatitis.
SYMPTOMS
Acute viral hepatitis in pregnancy could be asymptomatic or have mild clinical disease.
Patients may present with nonspecific symptoms such as jaundice, nausea, anorexia, abdominal pain or discomfort, fatigue, malaise, myalgia, and dark urine. Clinical symptoms are unable to differentiate the various viral hepatitides.
Pregnant women with chronic hepatitis B and C viral infection may progress to decompensated cirrhosis and develop ascites, hepatic encephalopathy, coagulopathy, and esophageal variceal bleeding.
The most common presentation of viral hepatitis is jaundice. Other nonspecific symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and to mention a few
EVALUATION
- Hepatitis A
Pregnant women who had contact with persons with acute hepatitis A should be screened for acute hepatitis A virus infection. Hepatitis A viral infection is diagnosed by detecting the immunoglobulin M antibody to the hepatitis A (anti-HAV IgM) virus in pregnant women and the fetus/newborn. - Hepatitis B
Vertical transmission of Hepatitis B virus from infected mothers to their fetuses or newborns results in a 90% likelihood of the newborn getting infected if the pregnant woman has chronic hepatitis B and positive for Hepatitis B virus E antigen (HBeAg).
Thus every pregnant woman should be screened for the hepatitis B surface antigen at the initial visit. This is to decrease the mother-to-child transmission of the hepatitis B virus. - Hepatitis C
Transmission is associated with pregnant women with higher levels of HCV RNA.
American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) recommend risk-based screening for HCV in pregnant women. The anti-HCV antibody is tested as the screening tool during pregnancy - Hepatitis D
World Health Organization (WHO) recommends screening pregnant women infected with Hepatitis B virus for Hepatitis D virus. Serum immunoglobulin M anti-HDAg is detected during active infection.. - Hepatitis E
Pregnant women in the second and third trimesters are mostly affected during epidemics. The mortality rate as high as 5% to 25%. There is a higher mortality rate in pregnant women who progressed to fulminant hepatitis. Anti-HEV IgM is tested during pregnancy for suspected cases
TREATMENT (notes)
* Please refer to the health professional to acquire in depth information regarding treatment through public and private health facilities in Indonesia.
- Hepatitis A: There is a minimal risk of transmission of Hepatitis A virus via breastmilk. The benefit of breastfeeding greatly outweighs stopping breastfeeding. There is no contraindication to breastfeeding for mothers infected with hepatitis A.
- Hepatitis B : Fetal exposure risk has not been increased with the use of these antiviral medications during pregnancy. Breastfeeding is encouraged after newborns receive the appropriate immunoprophylaxis
- Hepatitis C : Currently, there is no immunization for hepatitis C virus-infected mothers and infants. There is no contraindication for breastfeeding in hepatitis C virus-infected mothers and infants
- Hepatitis D : Transmission of the Hepatitis D virus has largely decreased due to perinatal prevention and treatment of Hepatitis B virus infection.
- Hepatitis E : There is no contraindication to breastfeeding in mothers infected with the hepatitis E virus.
COMPLICATIONS
- Hepatitis A : Hepatitis A has been associated with gestational complications, including premature contractions, placental separation, premature rupture of membranes, and vaginal bleeding.
- Hepatitis B : The adverse effect of the Hepatitis B virus on pregnancy is rare in patients with acute or chronic HBV infection. Chronic HBV in pregnancy increases the risk of progression to cirrhosis.
- Hepatitis C : Fetal growth restriction, brachial plexus injury, fetal distress, cephalohematoma, neonatal seizures, and intraventricular hemorrhage are gestational complications observed in HCV-infected pregnant women.
- Hepatitis D : Chronic hepatitis D is associated with a high risk of severe chronic liver disease in pregnant women.
- Hepatitis E : Fetal complications from Hepatitis E virus include preterm and low birth weights.
Viral hepatitis is the most common cause of jaundice in pregnancy. Viral hepatitis in pregnancy is associated with significant gestational and fetal complications. Adhering to screening guidelines is key to reduce mother-to-child transmission of viral hepatitis. An interprofessional team including obstetric care provides, internists, gastroenterologists, nurses, midwives, and pediatricians is important in providing a holistic and integrated approach to pregnant women with exposure or infected with viral hepatitis to achieve the best possible outcomes..
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