COMMENTARY

Updated Advice on Managing Liver Disease During Pregnancy

Rowen K. Zetterman, MD

Disclosures

September 15, 2017

In This Article

Viral Infection

ACG recommendation: "Pregnant women presenting with acute hepatitis should be tested for...hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis E virus (HEV), and herpes simplex virus (HSV)."[1]

HAV. Infection with HAV may not alter the course of pregnancy, although it has been associated with preterm labor.[29] Mothers with acute HAV infection at delivery can transmit the virus to their newborn, and outbreaks of hepatitis A in neonatology units have been described.[30]

HBV. Maternal infection with HBV is identified in approximately 85 of every 100,000 deliveries annually.[31] Rates of HBV infection and disease are higher in women with concurrent HIV infection and those who use alcohol or abuse drugs during pregnancy. Vertical transmission of HBV to children born to HBV-positive mothers remains a frequent worldwide cause of chronic HBV infection in humans. Administration of the vaccine series and hepatitis B immune globulin to children born to HBV-infected mothers can reduce the risk for chronic HBV infection in the child.[32]

ACG recommendation: "Active-passive immunoprophylaxis with hepatitis B immune globulin and the HBV vaccination series should be administered to all infants born to HBV-infected mothers to prevent vertical transmission."[1]

Mothers with very high levels of circulating HBV DNA carry the highest risk for HBV transmission to their offspring.[33] Standard postdelivery immunoprophylaxis may fail to prevent vertical transmission of HBV in these mothers with very high levels of circulating HBV.[32] Tenofovir[34] and telbivudine[35] are safe antiviral agents for use during pregnancy, and these treatments can reduce the risk for vertical transmission of HBV to the newborn during pregnancy.[36]

ACG recommendation: "Women chronically infected with HBV and high viral load (>200,000 U/mL or >106 log copies HBV/mL and higher) should be offered antiviral medication with tenofovir or telbivudine in the third trimester to reduce perinatal transmission of HBV."[1]

Although cesarean section (C-section) may reduce vertical transmission of HBV, it is not recommended as primary therapy to prevent vertical transmission in HBV-infected women.[32]

ACG recommendations: "C-section should not be performed electively in HBV-positive mothers to prevent fetal infection."

"Women chronically infected with HBV should be allowed to breastfeed as recommended for infant health."[1]

HCV. Chronic HCV infection is present in approximately 3 million Americans.[37] Recent increases in drug abuse in the United States may also be increasing the number of reproductive-aged women with chronic HCV infection.[38] Approximately 120 cases of chronic HCV infection are identified for every 100,000 deliveries annually in the United States.[31] Higher rates of chronic HCV infection occur in HIV-positive mothers, those who abuse drugs or alcohol, and smokers. Chronic HCV infection in the absence of hepatic complications may not have an adverse effect on pregnancy for the mother[39] but may result in low birthweight, a small for gestational age newborn, and a greater need for newborn care in the neonatal intensive care unit.[40] Vertical transmission of HCV occurs in approximately 6% of children born to mothers with detectable circulating HCV RNA.[41] Pregnant women with evidence of chronic HCV infection should be referred to a gastroenterologist or hepatologist to establish long-term follow-up care.

ACG recommendations: "All pregnant women with risk factors for HCV should be screened for anti-HCV antibody."

"Hepatitis C therapy should not be offered to pregnant women to either treat HCV or decrease the risk for vertical transmission."[1]

HEV. HEV types 1 and 2 infections, more commonly seen in other countries, can be associated with significant maternal mortality during pregnancy.[42] HEV types 3 and 4 are more common in the United States. The risk for maternal mortality from these genotypes during pregnancy is less clear but probably less than for HEV types 1 and 2.

HSV. Acute hepatitis from HSV is rare but can occur during pregnancy, with significant mortality.[43] Empirical administration of acyclovir is recommended if HSV is suspected during pregnancy.

ACG recommendation: "Pregnant women with acute hepatitis suspected from HSV should be initiated on acyclovir."[1]

Summary

Liver disease during pregnancy can be either directly related to pregnancy or to a liver injury that happens to be present or develop during pregnancy. A pregnant woman should be carefully evaluated for the cause of abnormal liver tests if they develop. Ensuring that a high-risk obstetrician and a gastroenterologist or hepatologist are involved in the care seems appropriate.

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