Hepatitis B in pregnant women

What is hepatitis B in pregnant women -

Hepatitis B, despite the effectiveness of prevention, is a public health problem worldwide. This is due to the continuously growing incidence and the frequent development of adverse outcomes - chronic persistent and active hepatitis, cirrhosis of the liver and hepatocellular carcinoma. More than 1 million people die every year from these diseases. Hepatitis B is of great importance because of the potential for vertical transmission. Babies usually become infected from HBsAg-positive mothers during childbirth due to exposure to blood and infected vaginal secretions and are at high risk of becoming chronic carriers of hepatitis B.

What provokes / Causes of Hepatitis B in pregnant women:

The hepatitis B virus is a DNA-containing virus, its replication occurs by reverse transcription within the host hepatocytes. The virus has a complex structure, including the Dane DNA particle and 4 antigens - surface (HBsAg), heart-shaped (HBcAg), infectivity antigen (HBeAg) and HBxAg - a protein responsible for replication. Due to the fact that the hepatitis B virus (HBV) genome integrates into the DNA of the host hepatocytes and liver tumor cells contain multiple copies of it, it is assumed that HBV is an oncogenic virus.

HBV is resistant to many physical and chemical factors and survives for several days in various body secretions (saliva, urine, feces, blood).

HBV is highly infectious. The source of infection are patients with acute and chronic hepatitis and virus carriers. The virus is transmitted parenterally, through sexual contact, transplacental, intrapartum, through breast milk. Infection is also possible through close household contacts (sharing toothbrushes, combs, handkerchiefs) and using poorly treated medical instruments.

Hepatitis B infection is high worldwide, especially in countries with low socioeconomic levels and high rates of drug abuse. In pregnant women, 1-2 cases of acute hepatitis B and 5-15 cases of chronic hepatitis B are recorded per 1000 pregnancies.

Symptoms of Hepatitis B in pregnant women:

The incubation period ranges from 6 weeks to 6 months, after which acute viral hepatitis may develop, although asymptomatic infection is more common. After acute viral hepatitis (more often with anicteric course of the disease), 5-10% of individuals may develop chronic carriage of the virus. Symptoms of acute hepatitis are fever, weakness, anorexia, vomiting, pain in the right hypochondrium and epigastric region. Hepatomegaly and jaundice are pathognomonic features of the disease. Urine becomes dark (beer color) due to bilirubinuria, and feces become light (acholic). Due to impaired liver function in the blood, an increase in liver enzymes is detected and coagulopathy develops. With the development of liver failure, symptoms of hepatic encephalopathy and hepatic coma may be observed. Mortality from acute hepatitis B is 1%. However, 85% of patients have a good prognosis with the achievement of complete remission of the disease and the acquisition of lifelong immunity.

With the chronicization of the process and the development of cirrhosis, a characteristic clinical picture develops in the form of jaundice, ascites, the appearance of spider veins on the skin and erythema of the palms. Mortality from chronic hepatitis B and its consequences is 25-30%. However, in immunocompetent individuals, the disease may regress as a result of HBeAg seroreversion (in 40% of cases), and active cirrhosis may become inactive (in 30% of cases). And therefore, in general, the prognosis of chronic hepatitis B depends on the stage of the disease and the phase of virus replication.

Carriers of hepatitis B usually do not have any clinical symptoms of the disease. However, they are the main reservoir and spreaders of the infection.

The course of chronic hepatitis B in combination with hepatitis D is more aggressive.

The course of acute hepatitis B during pregnancy may differ in particular severity with the occurrence of so-called fulminant forms of the disease. However, in most cases, the course of acute hepatitis B does not differ between pregnant and non-pregnant patients, and the mortality rate in pregnant women is not higher than in the general population.

Outcomes for the fetus and newborn. Infection of the fetus occurs in 85-95% intranatally due to contact with blood, infected secretions of the birth canal, or ingestion of infected secretions. In 2-10% of cases, transplacental infection is possible, especially in the presence of various lesions of the fetoplacental complex (fetoplacental insufficiency, placental abruption), and infection through contaminated mother's milk. In the postnatal period, contact-household infection of the child from the mother is also possible. The severity of the disease in newborns is determined by the presence of certain serological markers in the mother's bloodstream and the gestational age at which the mother was first infected with HBV. So, if the infection occurred in the I or II trimester of pregnancy, the child is rarely infected (10%). If the acute phase of the disease occurred in the third trimester, the risk of vertical transmission is 70%.

If the mother is a carrier of HBsAg, the risk of infection of the fetus is 20-40%, while being positive for HBeAg, indicating active persistence of the virus, the risk increases to 70-90%. The number of malformations, abortions and cases of stillbirth with hepatitis B does not increase, the number of premature births triples. Most infected children have mild acute hepatitis B. In 90% of cases, a state of chronic carriage develops with the risk of new horizontal and vertical transmission of infection and the occurrence of primary carcinoma or cirrhosis of the liver. A possible reason for such a high percentage of the development of chronic forms of infection in newborns is the immaturity of their immune system. It is assumed that during the transplacental transition of HBV antigens to the fetus, immunological tolerance to the virus develops due to inhibition of natural defense mechanisms.

Diagnosis of Hepatitis B in pregnant women:

Serological diagnosis is based on the detection of various antigens and antibodies to HBV. Patients with acute hepatitis B, in whom HBsAg is detected 6 months after the onset of infection, are considered as chronic carriers of hepatitis B. At the same time, the percentage of patients in whom the infection becomes chronic varies from 5 in healthy adults to 20-50 in persons with impaired immunity. In contrast, 90% of newborns infected with hepatitis B virus antenatal and intrapartum develop chronic hepatitis B.

Treatment of hepatitis B in pregnant women:

With the development of acute hepatitis B during pregnancy, therapy consists of supportive treatment (diet, correction of water and electrolyte balance, bed rest). With the development of coagulopathy, fresh frozen plasma, cryoprecipitate, is transfused.

Patients with various forms of hepatitis B should limit indications for invasive procedures during pregnancy and childbirth. You should also try to reduce the duration of the anhydrous period and childbirth in general. Since the transmission of hepatitis B virus to a newborn from a mother positive for HBeAg antigen and HBV DNA is recognized in almost all cases, in developed countries, caesarean section in combination with simultaneous passive and active immunoprophylaxis is considered the best method of prevention. In the Russian Federation, the presence of hepatitis B is not an indication for delivery by caesarean section, since it also does not exclude the possibility of infection (contact with infected blood).

In the postnatal period, if the newborn is intact, horizontal transmission of the virus from mother to newborn should be avoided. All newborns born to mothers carrying HBV, as well as to women who were not screened for hepatitis B during pregnancy, are subject to vaccination. Newborns are also shown the introduction of protective immunoglobulin "Hepatect" in the first 12 hours of life. The effectiveness of administration reaches 85-95% in preventing neonatal HBV infection. Failures in immunization (active and passive) are associated with the presence of intrauterine infection with the development of the s-gene mutation and impaired immune response of the newborn.

If vaccinated immediately after birth, breastfeeding should not be avoided, although the detection of HBsAg in the milk of infected women is about 50%.

After childbirth, it is necessary to examine cord blood for various markers of hepatitis B. If HBsAg is detected in cord blood, a newborn has a 40% risk of chronicity of the process. Then, for 6 months, the child's blood is examined monthly for viral markers until a final diagnosis is established.

Prevention of Hepatitis B in pregnant women:

The main method of preventing neonatal viral hepatitis is a 3-fold examination of pregnant women for the presence of HBsAg. If a seronegative woman is at risk of infection during pregnancy, a 3x HBV vaccination with a recombinant vaccine is indicated without risk to the child and mother.

All newborns whose mothers are positive for HBsAg should immediately after birth, no later than 12 hours, simultaneously undergo immunoprophylaxis with immunoglobulin against hepatitis B hepatectome and hepatitis B vaccine. After 1 month, it is advisable to test for antibodies to HBsAg, since only the level of above 10 U / ml. Revaccination should be carried out when the anti-HBsAg titer is below 10 IU/L.

To prevent hepatitis B in a seronegative pregnant woman after contact with HBV, immunoglobulin against hepatitis B is used at a dose of 0.05-0.07 ml/kg. The drug is administered twice: the first time within 7 days after contact, the second - after 25-30 days.

Thus, the main measures to prevent vertical transmission of HBV are as follows.

• Screening for HBV during pregnancy (at first visit and in the third trimester).
• Upon contact of a seronegative pregnant woman with HBV, passive prophylaxis of hepatectomas is carried out (in the first 7 days after contact and after 25-30 days).
• In developed countries, seronegative pregnant women are given active prophylaxis with a recombinant hepatitis vaccine.
• All newborns from HBsAg-positive mothers undergo passive prophylaxis of hepatectomas at a dose of 20 IU/kg intravenously during the first 12 hours of a child's life.
• All newborns from HBsAg-positive mothers receive active prophylaxis with a recombinant hepatitis B vaccine.
• Prevention of intrapartum transmission - in developed countries, HBeAg-positive and HBV-DNA-positive pregnant women are given caesarean section.
• Prevention of postnatal transmission - refusal to breastfeed unvaccinated newborns.

Which doctors should you contact if you have Hepatitis B in pregnant women:

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Other diseases from the group Pregnancy, childbirth and the postpartum period:

This is a group of infectious diseases with predominant damage to the liver tissue caused by hepatotropic viruses and detected during gestation. Manifested by severe intoxication, jaundice, dyspepsia, discoloration of urine and feces, enlargement of the liver. They are diagnosed using ELISA, RIF, PCR, laboratory studies of enzyme systems, pigment, protein, fat metabolism, supplemented by a general blood test and the results of ultrasound of the liver. For treatment, infusion therapy, hepatoprotectors, choleretic drugs are used in combination with a therapeutic and protective regimen and diet therapy.

ICD-10

O98.4 Viral hepatitis complicating pregnancy, childbirth, or the puerperium

General information

Diagnostics

In the presence of epidemiological prerequisites and classical symptoms, the diagnosis does not present any particular difficulties. Diagnostic difficulties are possible with an atypical low-symptomatic course, reactivation of a chronic process. Taking into account the high risk of infection of the fetus with virus carriers and the chronic course of blood-borne hepatitis, all pregnant women undergo laboratory screening. The examination plan usually includes methods aimed at detecting the virus and signs of liver dysfunction:

• Analyzes for pathogen verification. Specific ELISA markers of disorders are the corresponding total Ig antibodies (M + G), antibodies to non-structural proteins (for hepatitis C). DNA and RNA of viruses can be detected using PCR diagnostics. RIF allows you to detect virus particles in the liver tissue and other biological materials. In chronic hepatitis B and carriage, HBSAg is determined.
• Liver tests. A key marker of hepatocyte cytolysis is at least a 10-fold increase in ALT activity. The indicator begins to increase from the end of the prodrome, reaches its maximum value during the peak period and gradually decreases to normal during convalescence. An increase in the concentration of alkaline phosphatase (AP) and gamma-glutamyl transferase (GGT) indicates cholestasis.
• Study of protein metabolism. In case of inflammatory damage to the liver parenchyma, the values ​​of the sublimate test decrease, while those of the thymol test increase. The severity of changes directly correlates with the severity of the infectious process. Reduced levels of total protein, albumin. There is dysproteinemia. Due to a violation of protein synthesis in the liver, the indicators of the hemostasis system worsen.
• Study of pigment and lipid metabolism. Functional failure of the liver is manifested by hyperbilirubinemia with a predominant increase in the concentration of direct bilirubin, the presence of bile pigments and urobilinogen in the urine. Violation of cholesterol synthesis by hepatocytes damaged in acute and chronic forms of viral hepatitis is accompanied by a drop in its level in the blood.

In the general blood test, the number of leukocytes and neutrophils is reduced, the relative content of monocytes and lymphocytes is increased, ESR is often within the normal range, but can reach 23 mm / h. Ultrasound of the liver usually reveals an increase in the size of the organ, with different variants of the course, hypoechogenicity, hyperechogenicity, and heterogeneity of the structure are possible. Differential diagnosis is carried out between different types of hepatitis. The infectious viral process also needs to be differentiated from damage to the hepatic parenchyma in benign lymphoblastosis, yersiniosis, leptospirosis, Far East scarlet fever, drug-induced hepatitis, severe early toxicosis, cholestasis of pregnancy, preeclampsia, acute fatty hepatosis of pregnancy, HELLP syndrome. In addition to the infectious diseases specialist, the patient is consulted by a therapist, hepatologist, dermatologist, neuropathologist, toxicologist according to indications.

Treatment of VH in pregnant women

A woman with a confirmed diagnosis is hospitalized in the infectious diseases department with obstetric wards. Interruption of gestation with an abortion is possible only in the early stages during the convalescence period. A pregnant woman is shown a sparing regimen with limited motor activity. Diet correction provides for the exclusion of alcohol, fatty, fried foods, eating dietary meat (chicken, turkey, rabbit), low-fat boiled, baked, steamed fish, cereals, dairy products, fresh vegetables and fruits. The volume of fluid consumed is recommended to be increased to 2 l / day or more. It is advisable to drink alkaline mineral waters. In the convalescent period, restriction of physical activity, a sparing diet are shown.

Special etiotropic treatment of parenteral variants of hepatitis during gestation is not carried out. Pregnant women with a severe course of the disease, severe intoxication, and significant impairment of hepatic functions are recommended medications with pathogenetic and symptomatic effects. Taking into account the symptoms, the treatment regimen may include the following groups of drugs:

• Detoxification agents. To remove toxic metabolites, both colloidal and crystalloid infusion solutions are used. Their appointment makes it possible to stop the intoxication syndrome, reduce the intensity of itching in cholestasis, and improve the rheological parameters of the blood.
• Hepatoprotectors. The use of phospholipids, herbal remedies, amino acids, multivitamin complexes is aimed at stabilizing cell membranes, protecting hepatocytes from necrosis, tissue regeneration, and improving biochemical parameters. Usually they are prescribed for convalescence.
• Choleretics and cholekinetics. Cholagogue drugs are indicated for the threat or occurrence of cholestasis. They can reduce the load on hepatocytes, facilitate the outflow of bile, eliminate its stagnation in the gallbladder, and reduce the severity of mesenchymal-inflammatory changes in the liver.

With changes in the blood coagulation system, the treatment regimen is supplemented with drugs that affect hemostasis. Pregnant women with an extremely severe fulminant course, increasing liver failure are transferred to the intensive care unit for intensive care. The recommended method of delivery is natural childbirth at physiological time. Cesarean section is performed only in the presence of obstetric or extragenital indications (placenta previa, clinically and anatomically narrow pelvis, transverse position of the fetus, tight entanglement of the umbilical cord, preeclampsia).

Forecast and prevention

With timely diagnosis of acute viral hepatitis in a pregnant woman and the correct choice of medical tactics, the outcome of pregnancy is usually favorable. The level of maternal mortality does not exceed 0.4%, mortality is due to severe extragenital pathology. The prognosis becomes more serious when infected with the causative agent of viral hepatitis E in the 2nd half of pregnancy. In such cases, the risk of death of a pregnant woman reaches 50%, in almost all cases the fetus dies. Chronic variants of the disorder during gestation are activated extremely rarely. Preventive measures are aimed at preventing infection, include personal hygiene and food hygiene, especially when living and visiting epidemiologically dangerous regions, avoiding unprotected sex, frequent change of sexual partners, injecting drug use, careful examination of donor materials, processing of medical instruments.

To the viruses that cause hepatitis A, E, B, a stable lifelong immunity is formed. For prophylactic purposes outside of gestation, vaccination against hepatitis A, B and emergency immunization with immunoglobulins against HAV are possible. Pregnant women are prescribed vaccines and serums with caution after studying all possible indications and contraindications. Active-passive prevention of infection of newborns with blood-borne hepatitis can reduce the risk of infection by 5-10%. With viremia over 200 thousand IU / ml, women suffering from hepatitis B are prescribed antiviral treatment with nucleoside reverse transcriptase inhibitors, followed by active and passive immunization of the newborn.

Inflammation of the liver tissue is called hepatitis and it can be acute or chronic. There are many causes of hepatitis (viruses, bacteria, alcohol, autoimmune diseases, and others). For expectant mothers, inflammation of the liver caused by viruses is of interest, since under certain conditions these viruses can be dangerous for the unborn child and newborn.

Exists 5 main types of viral hepatitis, depending on the type of virus that causes inflammation of the liver: hepatitis A, B, C, D, and E. Although these viruses are called hepatitis viruses, some of them can affect other organs and organ systems. Hepatitis can also be caused by other viruses: adenoviruses, Epstein-Barr viruses, cytomegalovirus, and even in rare cases, herpes simplex viruses. Up to 95% of all acute cases of viral hepatitis are due to infection with hepatitis viruses. Each virus is transmitted in a different way, so not all viruses can be transmitted from mother to fetus. Hepatitis B, D and C viruses are transmitted sexually and through the placenta to the child - most often the hepatitis B virus is transmitted.

In the last century, more than half of the population of many countries, especially adolescents and young people, became infected with the hepatitis A virus. Almost everyone knows such a disease as jaundice or Botkin's disease. Although jaundice can occur for various reasons, in people under 20 years of age, the cause of jaundice was viral hepatitis A. With the improvement in sanitary and hygienic living conditions for most people, cases of hepatitis A have become less and less common. The hepatitis A virus is most commonly transmitted through dirty hands and contaminated food and water. In most cases, hepatitis A heals on its own within a few weeks and is not dangerous to humans. After the first contact with the hepatitis A virus, a person develops lifelong immune protection. Medicine knows only one registered case of acute hepatitis A in a pregnant woman, when the child was also infected with hepatitis A viruses.
The hepatitis B virus poses a great danger to expectant mothers., which is often referred to as the Australian antigen. Until 1965, doctors knew nothing about this virus. The problem is that this type of virus can be transmitted sexually, and the risk of transmission from an infected partner to a healthy one is almost 25%. It was believed that the hepatitis B virus was mainly infected by homosexuals and drug addicts, however, despite the high incidence of hepatitis B among this contingent of people, a huge number of carriers of the virus are observed among adults of traditional sexual orientation, as well as among children. This virus can be transmitted from mother to child, and in the dominant majority of cases during childbirth, as well as through blood products (intravenous infusions of plasma, blood, etc.), the use of reusable injection needles, and instruments.
In 90-95% of people infected with the hepatitis B virus, there is a complete recovery without the risk of serious complications, but if the infection occurred during childbirth, then only 5% of newborns will recover. Therefore, in many countries of the world, pregnant women are tested for the carriage of the hepatitis B virus.
Only about 2–5% of adults may have a longer period of infection with periodic reactivations, and 15–40% of these patients are at risk for developing cirrhosis and liver cancer.
Thanks to intensive vaccination against this type of viral disease, especially in areas of its pronounced distribution (Asia and Africa), new cases of hepatitis B have become very rare. However, in developed countries, 1-3 pregnant women per 1000 will be infected with the hepatitis B virus.
Although you will find a lot of information in the literature that the hepatitis B virus is transmitted from mother to child, it is important to understand that in most cases we are talking about transmission during childbirth. With a "silent" carriage of the virus, when it is not detected in the blood, in 10-20% of cases, the child can become infected during childbirth. When a viral infection is reactivated in chronic carriers of the virus, the transmission of hepatitis B virus to a child during childbirth or in the first days after childbirth (through kissing, breast milk, close contact) is observed in almost 90% of cases. The same high level of infection occurs when a primary infection occurs in a woman, especially closer to childbirth.
Fortunately, the transmission of hepatitis B virus from mother to fetus is only theoretically high, but isolated cases of hepatitis B virus infection of the fetus have been practically registered. The placenta performs an excellent barrier role in protecting the child from this type of infection. Therefore, the main attention of doctors is aimed at preventing infection of the child during childbirth.

All pregnant women are encouraged to be tested for hepatitis B virus carriage, which is carried out in many clinics. But most often, neither doctors nor women themselves know what exactly needs to be determined in the blood when it comes to hepatitis B. The hepatitis B virus is called an antigen (Australian antigen), but its structure is complex, therefore, surface antigen HBsAg and nuclear HBcAg are isolated . These antigens can be detected in the blood serum, but not during all periods of infection. There is also the HBeAg antigen, but it does not always appear in the blood of an infected person. Antibodies (immunoglobulins) are produced for all types of antigens to neutralize the virus.
IgManti-HBc appear first. Then there are immunoglobulins of the IgG class: anti-HBc and anti-HBs. Since there are several subclasses of IgG, different antibodies (IgG 1, IgG 2, IgG 3, IgG 4) can be produced in infected hepatitis viruses, which makes diagnosis difficult to some extent. Some people can detect anti-Hbe, but since not all viruses contain this type of antigen, not all people can detect these antibodies.
Most often, when one type of antibody is detected, a woman is prescribed a whole arsenal of medications that are not related to the treatment of viral hepatitis. Since this branch of infectious disease is very new in medicine, and viral hepatitis has received more attention in the last 10-15 years (in fact, with the development of an entire branch of medicine in relation to HIV and AIDS), many doctors have a superficial knowledge of viral hepatitis. Therefore, in any case of detecting any antibodies, it is advisable to consult a highly qualified infectious disease specialist.
The most optimal and rational type of testing will be to answer the questions whether a woman is infected with the hepatitis B virus and whether the infection is active. To do this, you need to know if the hepatitis virus is present in the blood serum, and therefore, to determine the presence of the HBsAg antigen. This is important to know in order to prevent infection of the newborn, as well as people who are in close contact with the woman.
If the result is negative in the first half of pregnancy, then such a test is usually repeated in the second half of pregnancy. If the result is positive, then the woman is offered the so-called hepatitis B test panel. It usually includes the determination of other types of hepatitis B virus antigens and antibodies to these antigens: HBsAg, anti-HBc, IgManti-HBc, anti-HBs. The problem is that many doctors do not know what exactly to determine in a woman's serum and how to interpret the results. What a woman is advised to undergo, especially with regard to treatment, often does not fit into any framework of modern medicine.

The table below provides combinations of results and an explanation of how to correctly interpret the meaning of these results. I include this table because I receive so many letters from anxious women who go into shock after they are found to have something in the form of an "Australian antigen", and doctors immediately frighten the woman with extremely dire consequences. When I clarify what exactly they were determined, what indicators, how the survey was conducted, then in 99% of cases - a dense forest: the survey was carried out incorrectly, of poor quality and very superficially. But the conclusions are very horrifying, as is the arsenal of treatment, which I call the "explosive mixture".
Modern “hepatitis B virus diagnostic panels” include a number of classes and subclasses of antibodies, so most often this is not specified in the referral and results. For example, some commercial anti-HBc tests may include several IgG subclasses (IgG 1, IgG 3) and even other antibody classes (IgM, IgA 1). Therefore, the sensitivity of such diagnostic methods is lower than the specific speed tests that have already been developed, are being tested and are gradually being introduced into practice. So, let's look at what is determined in relation to the diagnosis of the hepatitis B virus, and what the results mean: a table of the correct interpretation of the results of the panel of tests for hepatitis B.

For the first time, a person fell ill with the hepatitis C virus 300 years ago. Today in the world about 200 million people (3% of the total population of the Earth) are infected with this virus. Most people are not even aware of the presence of the disease, because they are latent carriers. In some people, the virus multiplies in the body for several decades, in such cases they talk about the chronic course of the disease. This form of the disease is the most dangerous, as it often leads to cirrhosis or liver cancer. As a rule, infection with viral hepatitis C in most cases occurs at a young age (15-25 years).

Of all known forms, viral hepatitis C is the most severe.

The method of transmission occurs from person to person through the blood. Often, infection occurs in medical institutions: during surgical operations, during blood transfusions. In some cases, it is possible to become infected by household means, for example, through syringes from drug addicts. Sexual transmission is not excluded, as well as from an infected pregnant woman to the fetus.

Hepatitis C Symptoms

In many infected people, the disease does not make itself felt at all for a long period of time. At the same time, irreversible processes take place in the body, leading to cirrhosis or liver cancer. For such insidiousness, hepatitis C is also called the “gentle killer”.

20% of people still notice a deterioration in their health. They feel weakness, decreased performance, drowsiness, nausea, loss of appetite. Many of them are losing weight. There may also be discomfort in the right hypochondrium. Sometimes the disease manifests itself only with joint pains or various skin manifestations.

Detection of the hepatitis C virus in a blood test does not present any difficulties.

Hepatitis C treatment

There is currently no vaccine for hepatitis C, but it is possible to cure it. Note that the earlier a virus is detected, the greater the chance of success.

If a pregnant woman is infected with the hepatitis C virus, she must be examined for the presence of characteristic signs of chronic liver disease. After the baby is born, a more detailed hepatological examination is performed.

Treatment of hepatitis C is complex, and the main drugs used in the treatment are antiviral.

Fetal infection

In most cases, the hepatitis C virus does not have any negative effect on the course of pregnancy. In fact, the possibility of infecting a child with hepatitis C exists only in 2-5% of the total number of infected expectant mothers. If a woman is also a carrier of HIV, the risk of infection increases to 15%. In addition, there are a number of conditions and conditions under which it is possible to infect a child. Among them, first of all, hypovitaminosis, poor nutrition are distinguished. The bulk of cases when there is infection of the fetus with hepatitis C occurs at the time of delivery or the immediate postpartum period.

How to give birth?

It has been proven that the frequency with which the hepatitis C virus is transmitted from mother to child does not depend on whether the baby was born naturally or by caesarean section. There is a category of medical workers who claim that during a caesarean section, the risk of infection is less. Which way of delivery to choose in a particular case is up to the woman and her attending physician. In some cases, when the patient is also infected with other viruses (for example, hepatitis B or human immunodeficiency), a planned cesarean is recommended.

Child

During pregnancy, antibodies to hepatitis C are transmitted to the baby through the placenta. After birth, they can circulate in the blood for a year and a half, and this is not a sign that the baby was infected from the mother.

Examination of the child for possible infection during childbirth should be carried out at 6 months after birth (blood test for HCV RNA) and at 1.5 years (blood test for anti-HCV and HCV RNA).

Immediately after birth, doctors closely monitor the health of the newborn.

Breast-feeding

It is not forbidden, but it is necessary to ensure that the baby does not injure the mother's nipples, otherwise the risk of infection increases. It is believed that the benefits to the child's body from breastfeeding far outweigh the risk of contracting the virus. Mothers need to carefully monitor that sores and aphthae do not form in the child's mouth, since infection can occur through them during breastfeeding. If a woman is also infected with the human immunodeficiency virus, then breastfeeding is contraindicated.

Prevention of hepatitis C

In order not to get infected with the hepatitis C virus, you need to remember the following. In no case should you use other people's things: razors, toothbrushes, nippers for manicure and pedicure, nail files or other items that may come into contact with blood. If you have to use the services of a tattoo artist, make sure that the tools are properly sterilized. It is better if disposable needles are used for these purposes.

During sexual intercourse (especially promiscuity), you can reduce the risk of infection by using condoms.

Especially for- Elena Kichak

From Guest

Found antibodies to hepatitis C for 5 weeks. How many experiences were words beyond words. From ZhK they gave a referral to an infectious disease specialist. He laughed, made a diagnosis of "carrier of hepatitis C" and said "don't worry, you will give birth - then come." In LCD appointed analysis again. Negative.

From Guest

Today at the turnout they said that they might have found Hepatitis C ... there are signs that have not yet been fully identified. On December 30, they said they would say for sure .... here I sit and torture myself ... where did I get this from ... and I'm very nervous ... pregnancy 27 weeks

Hepatitis A is an acute cyclic viral infection with fecal-oral transmission of the pathogen, characterized by impaired liver function.

Synonyms
Hepatitis a.
ICD-10 CODE
B15 Acute hepatitis A.

EPIDEMIOLOGY

Hepatitis A - intestinal infection, severe anthroponosis. The source of infection is patients with inapparent and manifest forms of hepatitis A. Persons with subclinical, obliterated and anicteric forms of the disease have the greatest epidemiological significance, the number of which can many times exceed the number of patients with icteric forms of hepatitis A. Infection of contact persons is possible already from the end of the incubation period, most intensively continues during the prodromal (preicteric) period and persists in the first days of the height of the disease (jaundice). The total duration of virus isolation with faeces usually does not exceed 2-3 weeks. In recent years, it has been shown that viremia in hepatitis A can be longer (78–300 days or more).

The fecal-oral mechanism of transmission of the pathogen is realized by the water, food and contact-household route with the absolute predominance of the water route, which provides outbreaks and epidemics of hepatitis A. The possibility of the blood-contact (parenteral) route of transmission of the hepatitis A virus (about 5%) from patients with manifest and inapparent forms of infection (post-transfusion infection with hepatitis A in patients with hemophilia, infection of intravenous drug users).

The sexual route of transmission of the pathogen is not excluded, which is facilitated by promiscuity, the presence of other STIs, non-traditional sexual intercourse (primarily oral-anal contacts).

It occurs predominantly in children and young adults; In recent years, cases of hepatitis A in people older than 30 years and even 40 years have become noticeably more frequent. The disease is characterized by seasonality (mainly summer-autumn period).

The frequency of ups and downs of the disease ranges from 5 to 20 years.

Susceptibility to hepatitis A is high.

CLASSIFICATION

Allocate inapparent (subclinical) and manifest forms of hepatitis A. The latter includes erased, anicteric and icteric forms. According to the severity of the course, mild, moderate and severe forms are distinguished, along the course - acute and protracted. Chronic forms of hepatitis A are not observed.

ETIOLOGY (CAUSES) OF HEPATITIS A

The causative agent - Hepatitis A virus (HAV) - belongs to the family Picornaviridae, the genus Hepatovirus. Opened in 1973 by S. Feinstone. HAV is a small virus containing ribonucleic acid (RNA), has one specific Ag (HAAg), which is highly immunogenic. There are four known HAV genotypes that belong to the same serotype, which is the reason for the development of cross-immunity. Anti-HAV IgM circulate in the blood from the first days of illness for a short time (2–4 months), and HAV IgG appearing later remain in the body for a long time.

The hepatitis A virus is very stable in the environment, but is sensitive to ultraviolet irradiation and boiling (it dies after 5 minutes).

PATHOGENESIS

The entrance gate is the mucous membranes of the gastrointestinal tract. In the vascular endothelium of the small intestine and mesenteric lymph nodes, the primary replication of the virus occurs. This is followed by viremia (in the clinical picture it manifests itself as an intoxication syndrome), followed by dissemination of the pathogen into the liver (a consequence of the hepatotropy of the virus). HAV replication in hepatocytes leads to dysfunction of cell membranes and intracellular metabolism with the development of cytolysis and dystrophy of liver cells. Simultaneously with the cytopathic effect of the virus (leading in hepatitis A), a certain role is assigned to immune damaging mechanisms. As a result, clinical biochemical syndromes characteristic of hepatitis develop - cytolytic, mesenchymal inflammatory, cholestatic.

The pathogenesis of complications of gestation

The pathogenesis of complications of gestation in hepatitis A has not been studied enough, including because of their great rarity.

CLINICAL PICTURE (SYMPTOMS) OF HEPATITIS A IN PREGNANT WOMEN

Hepatitis A is characterized by polymorphism of clinical manifestations and self-limiting nature with reversible structural and functional changes in the liver.

The inapparent form prevails in frequency, its diagnosis is possible only with the help of ELISA when examining contact and sick persons (in epidemic foci).

Manifest forms proceed with a successive change of periods: incubation, prodromal (preicteric in the icteric form of the disease), peak (icteric in the presence of jaundice), convalescence. Infrequently, but relapses and complications of infection are possible.

The average incubation period is 15–45 days. The prodromal period lasts 5–7 days, proceeds with a variety of clinical symptoms. According to the leading syndrome, it is customary to distinguish influenza-like (feverish), dyspeptic, asthenovegetative, and the most frequently observed mixed variant of the prodrome with the corresponding clinical manifestations.

1-4 days after the first signs of the disease, the color of the urine changes (to brown of varying intensity), the feces (acholia) become discolored, acquiring the consistency and color of white (gray) clay. Already in the prodromal period, hepatomegaly is possible with liver tenderness on palpation. Sometimes the spleen is slightly enlarged.

The peak period lasts an average of 2-3 weeks (with fluctuations from 1 week to 1.5-2 months, with the development of relapse - up to 6 months or more). The beginning of this period in the icteric form is marked by icteric staining of the visible mucous membranes and skin. At the same time, the well-being of patients noticeably improves, the signs of the prodromal period soften or disappear altogether. At the same time, the enlargement of the liver may continue - patients are concerned about heaviness and fullness in the epigastric region, moderate pain in the right hypochondrium. In 1/3 of cases during this period, splenomegaly is noted.

With the disappearance of jaundice, the restoration of the normal color of urine and feces, a period of convalescence begins. Its duration ranges from 1–2 to 8–12 months (depending on the presence or absence of relapses, exacerbations, and the course of the disease).

Erased and anicteric forms of hepatitis A usually proceed easily, with few symptoms, with a quick recovery.

The frequency of protracted manifest forms does not exceed 5–10%; in these cases, an increase in either the peak period or the convalescence period (with or without relapses, exacerbations) is noted, followed by clinical and laboratory recovery.

Hepatitis A in pregnant women proceeds in the same way as in non-pregnant women. There is no risk of antenatal transmission of the pathogen.

Complications of gestation

With rare severe and prolonged forms of hepatitis A, premature birth is possible, in isolated cases - spontaneous miscarriages. There may be a threat of abortion, premature or early outflow of OB. In pregnant women with hepatitis A, as in other extragenital diseases, somewhat more often than in the population, early toxicosis, preeclampsia develop (including during childbirth).

DIAGNOSTICS OF HEPATITIS A IN PREGNANCY

Anamnesis

The diagnosis of hepatitis is established on the basis of epidemiological conditions (contact with a patient with hepatitis A), anamnestic data (symptom complexes of the prodromal period), indications of dark urine and fecal acholia.

Physical examination

During an objective examination, the main symptoms are icterus of the visible mucous membranes (the frenulum of the tongue, sclera), skin, slight or moderate enlargement and sensitivity / tenderness of the liver on palpation, much less often - slight splenomegaly.

Laboratory research

The most constant and diagnostically significant biochemical sign of hepatitis is an increase in the activity of the hepatocellular enzyme ALT by 10 times or more compared to the norm. Hypertransferasemia is the main marker of cytolysis syndrome. The increase in ALT activity begins already at the end of the prodromal period, reaches a maximum during the height of hepatitis, gradually decreases and normalizes during the convalescence period, indicating recovery. Hyperfermentemia is characteristic not only of icteric, but also anicteric forms of hepatitis. Violation of pigment metabolism is marked by the appearance of urobilinogen and bile pigments in the urine, an increase in the content of bilirubin in the blood, mainly conjugated (bound, direct bilirubin). Mesenchymal-inflammatory syndrome is detected by the determination of protein sediment samples. In hepatitis, the thymol test rises, and the sublimate titer decreases. The degree of their deviation from the norm is proportional to the severity of the infection. In many cases, hypocholesterolemia is noted due to a decrease in its synthesis by damaged hepatocytes. Hepatitis occurring without bacterial layers is characterized by leukopenia, neutropenia, relative and absolute lymphocytosis and monocytosis, normal ESR (often 2-3 mm/h).

Verification of hepatitis A is achieved using ELISA. The diagnosis of hepatitis A is considered confirmed by the determination of anti-HAV IgM in the blood serum during the prodromal period and during the peak period. Anti-HAV IgG is usually detected already during the convalescence period.

Instrumental Research

When conducting an ultrasound scan, diffuse changes in the liver and an increase in its echogenicity are sometimes determined. There are no characteristic signs of hepatitis on ultrasound.

Differential Diagnosis

Hepatitis A is differentiated primarily from other etiological forms of hepatitis (B and C, mixed hepatitis), since in 40-70% of cases of jaundice in pregnant women are of a viral nature. The basis of their differentiation is the use and correct interpretation of the results of the ELISA. Sometimes it becomes necessary to differentiate viral hepatitis, including hepatitis A, from the so-called satellite hepatitis (with infectious mononucleosis, pseudotuberculosis, intestinal yersiniosis, leptospirosis, etc.). In these cases, the basis for distinguishing liver damage is the correct assessment of symptoms that are not just associated with satellite hepatitis, but determine the clinical appearance of diseases. The final solution to the problem of differentiation of viral hepatitis and other infectious lesions of the liver is the use of appropriate specific bacteriological and serological research methods.

In some cases, the differential diagnosis of viral hepatitis and jaundice directly related to pregnancy is more difficult. With CGD, pruritus of varying intensity comes to the fore with usually mild jaundice. There is no hepatosplenomegaly in CGD, as well as intoxication. Hepatosis is characterized by leukocytosis and an increase in ESR. The content of conjugated bilirubin in serum increases slightly, there is no hyperenzymemia (ALT) in most cases. However, in some pregnant women, ALT activity is still elevated - such options are the most difficult for differential diagnosis. The cholesterol content is usually elevated. Finally, there are no markers of viral hepatitis in CGD (exceptions to this rule are possible if CGD develops against the background of chronic hepatitis B and C, i.e. with comorbidity, the frequency of which has been increasing everywhere in recent years).

The greatest difficulties arise when distinguishing between severe forms of hepatitis (usually hepatitis B) and Sheehan's syndrome - acute fatty preeclampsia in pregnant women. Their clinical similarity can be very significant.

A detailed biochemical study contributes most of all to the correct differentiation of hepatitis and acute fatty gestosis of pregnant women, especially with indications for the treatment of a pregnant woman with tetracycline antibiotics in large doses in the third trimester of gestation. The liver in acute fatty gestosis of pregnant women is usually not enlarged, signs of DIC, hypoproteinemia (often with ascites), azotemia, and high leukocytosis are noted. The content of direct (conjugated) bilirubin increases moderately or slightly, the activity of cytolysis markers (ALT, AST) is low. The activity of alkaline phosphatase is increased, the sublimate test is reduced, however, these indicators have no differential diagnostic value, since they are also characteristic of hepatitis, as well as a decrease in prothrombin. On the contrary, hypoglycemia, which is almost not amenable to correction, and decompensated metabolic acidosis, which are characteristic of acute fatty gestosis of pregnant women and are uncharacteristic of hepatitis, are highly informative. Markers of hepatitis are absent, if we are not talking about comorbidity.

Currently, a rare variant of differential diagnosis is hepatitis and preeclampsia with liver damage. The latter is the extreme severity of preeclampsia with all its manifestations, steadily increasing over time with inadequate therapy for severe nephropathy. Biochemical signs of cytolysis, pigmentary disorders are moderately or slightly expressed in preeclampsia and do not correlate with the severity of other manifestations of pregnancy complications and the general condition of the patient.

Occasionally, errors in the diagnosis of viral hepatitis, primarily hepatitis A, occur in pregnant women with jaundice that occurs with severe early toxicosis. In this case, repeated "excessive" vomiting and dehydration come to the fore. The course of the complication, unlike hepatitis, does not have a cycle, jaundice is mild, the intoxication syndrome is insignificant, the liver and spleen remain within normal sizes. The content of bilirubin rarely exceeds the norm by more than 2 times and usually increases due to the non-conjugated (indirect, unbound) fraction. There is usually no increase in ALT activity, as well as no DIC. Often, toxicosis develops acetonuria, which does not happen with hepatitis. Finally, with early toxicosis, immunoserological markers of hepatitis are not determined.

When differentiating hepatitis A (and other hepatitis) with HELLP syndrome, the reference points are the presence of hemolytic anemia, thrombocytopenia, and an increase in the level of unconjugated (indirect, free) bilirubin in the latter. Hypertension can help in the differential diagnosis, since hepatitis A tends to hypotension (if the patient does not suffer from hypertension or renal pathology).

Hepatitis A does not aggravate the course of the HELLP syndrome.

Indications for consulting other specialists

With the appearance of jaundice syndrome (icteric staining of visible mucous membranes and skin, darkening of urine, fecal acholia, elevated bilirubin), hepatomegaly, splenomegaly, intoxication syndrome and fever, increased activity of hepatocellular enzymes (ALT) against the background of leukopenia and normal / reduced ESR, consultation of an infectious disease specialist and his joint observation of a pregnant woman with an obstetrician.

Diagnosis example

Viral hepatitis A, icteric form, severe course. Relapse from 05.05.2007. Pregnancy 32–34 weeks.

TREATMENT OF HEPATITIS A DURING PREGNANCY

Non-drug treatment

Most patients with hepatitis A, including pregnant women, do not need active drug therapy. The basis of the treatment of patients is considered a sparing regimen and a rational diet. During the height of the infection, bed rest is indicated. The volume of fluid consumed (preferably alkaline mineral) is important - at least 2-3 liters per day. Within 6 months after recovery, physical activity is limited and a sparing (mechanically and thermally) diet is recommended with the exception of spicy, fatty foods and alcohol.

Medical treatment

With severe intoxication, intravenous detoxification is carried out (saline solutions, 5% glucose solution, dextrans, albumin). A good effect is given by detoxifiers for oral administration: polyphepan ©, povidone, rehydron ©, etc.

During the period of convalescence, multivitamins, hepatoprotectors (silibinin, Essentiale©, etc.) are prescribed to restore disturbed metabolism. With posthepatitis biliary dyskinesia, antispasmodics are prescribed (better than atropine, including belladonna, belladonna) and choleretic agents.

Surgery

Surgical treatment of hepatitis A is not carried out. Termination of pregnancy in hepatitis is not indicated, as it can worsen the prognosis of the disease. Exceptions - the occurrence of placental abruption with bleeding, the threat of uterine rupture.

Prevention and prediction of complications of gestation

In the last 10-15 years hospitalization of patients with hepatitis A is optional. Patients can stay at home under the supervision of an outpatient service doctor (with the exception of persons living in hostels, which is dictated by anti-epidemic considerations).

As for pregnant women with hepatitis A, they should be hospitalized in an infectious diseases hospital for control and timely detection of the threat of complications of gestation and prevention of adverse pregnancy outcomes. In the hospital, the pregnant woman should be observed by two attending physicians - an infectious disease specialist and an obstetrician.

Features of the treatment of complications of gestation

Complications of gestation that have arisen in a patient with hepatitis A in any trimester are corrected according to the principles adopted in obstetrics by appropriate methods and means. This also applies to complications during childbirth and the postpartum period.

Indications for hospitalization

Pregnant women with hepatitis, including hepatitis A, are hospitalized in an infectious diseases hospital according to clinical indications (to monitor the progress of gestation, prevent and timely correct possible complications of pregnancy).

TREATMENT EFFECTIVENESS ASSESSMENT

Therapy for hepatitis A is well developed, most patients recover completely. Mortality does not exceed 0.2–0.4% and is associated with severe concomitant pathology.

With adequate management of a pregnant woman and proper joint supervision of an obstetrician and an infectious disease specialist, pregnancy outcomes in women with hepatitis A are also favorable (for the mother, fetus and newborn).

CHOICE OF DATE AND METHOD OF DELIVERY

The best tactic in relation to delivery of a patient with hepatitis A is considered urgent delivery per vias naturalis.

INFORMATION FOR THE PATIENT

Hepatitis A is an acute intestinal infection, therefore, one of the main conditions for one's own protection against it is strict observance of personal hygiene rules. In order to avoid sexual infection (very rare), it is necessary to exclude oral-anal sexual intercourse. With the development of the disease in a pregnant woman, hospitalization is mandatory. Determination of anti-HAV IgM in a newborn for 3-6 months does not indicate infection, since they are transmitted from the mother. Breastfeeding is permitted provided that all hygiene rules (nipple care, etc.) are observed. The use of hormonal contraceptives is permissible no earlier than 8-12 months after the disease. There are no contraindications for other contraceptives. Re-pregnancy is possible 1-2 years after hepatitis.