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Hepatitis during Pregnancy

September 1, 2007 on 8:55 pm | In Antenatal |

The word ‘hepatitis’ means an infection or inflammation of the liver. If the liver becomes inflamed due to an infection with a virus it is called ‘viral hepatitis’. However, the liver can also become inflamed through excessive alcohol intake or by taking certain medications or being exposed to certain chemicals.

Some viral hepatitis infections only cause a temporary dysfunction of the liver, while others can cause permanent liver damage (called ‘cirrhosis’). In some cases, a small number of people with cirrhosis may eventually experience liver failure or liver cancer later in life. However, this will depend on the type of hepatitis involved.

There are 3 main types of viral hepatitis. These are:

Hepatitis A virus (HAV). Hepatitis A or ‘hep A’ is the most common type of hepatitis. It is transmitted by coming in contact with contaminated faeces (bowel motions) through water supplies, foods washed in contaminated water or eating utensils handled by the unwashed hands of an infected person. Some people become infected with the virus through occupational exposure by working with sewerage, handling the faeces of patients in hostels or hospitals or changing babies in childcare settings. Hepatitis A does not cause long term liver problems and there are vaccinations available if you feel you are at risk of coming in contact with the virus. Many people are vaccinated as a precaution before travelling overseas (especially to developing countries).

Hepatitis B virus (HBV). Hepatitis B or ‘hep B’ is transmitted by coming in contact with infected blood of another person. This can be through the sharing of injecting equipment, tattooing or body piercing with non-sterile equipment or occupational needle stick injuries. It can also be transmitted through their saliva or having unprotected sex with an infected person. The hepatitis B virus can cause long term liver problems for some people. Vaccinations are now available to protect against hepatitis B and the vaccination of babies during the first 6 months after birth is now offered routinely in Australia. You can read more about this in Hepatitis B vaccination.

Hepatitis C virus (HCV). Hepatitis C or ‘hep C’ (previously known as ‘non A - non B hepatitis’) is transmitted by coming into contact with the blood of an infected person. Hepatitis C is not transmitted through saliva and very rarely through sexual contact. Infection with the hepatitis C virus can happen by sharing injecting equipment, tattooing or body piercing with non-sterile equipment or occupational needle stick injuries. At present there is no vaccine available to protect against hepatitis C.

In recent years there have been additional types of viral hepatitis identified. These are relatively rare so far but can include hepatitis E or ‘HEV’ (which is similar to hepatitis A), Hepatitis D (HDV) and hepatitis G (HGV). At present these types of hepatitis are not routinely tested for during pregnancy.

NOTE:Be aware that even though all types of viral hepatitis infect and inflame the liver, not all hepatitis infections produce obvious physical signs. There are many people who are ‘carriers’ of a hepatitis virus, meaning they are infected with the virus and are capable of infecting others but are not aware they have the infection themselves. Also each type of hepatitis can be transmitted from one person to another in different ways.

Effects on the pregnancy

If a woman knows she has hepatitis or discovers she has it during her pregnancy, the most common concerns are how this will affect her pregnancy and her unborn baby. In most cases the pregnancy itself will not affect the severity of the hepatitis infection for the woman, or the long term course of the hepatitis disease. (Unless it is found to be the rarer type of hepatitis E or ‘HEV’, which can become worse during pregnancy. This type of hepatitis is similar to hepatitis A.)

The unborn baby does not tend to have any health concerns if their mother has hepatitis. However, it is sometimes possible for the baby to become infected with the virus around the time of birth or during their early childhood years. Transmission of the virus during pregnancy does not usually happen, but the risk for this can be increased if the mother first becomes infected just before she conceives or during her pregnancy (this mainly relates to hepatitis C).

Most women with hepatitis will have a normal pregnancy, but the physical process of pregnancy can put added strain on a woman’s liver. For a few women this may lead to complications or health concerns during pregnancy and can include:

Gallstones or ‘cholelithiasis’. About 6% of women with hepatitis can develop gallstones (or ‘cholelithiasis’) during their pregnancy. This may present as abdominal pain and sometimes jaundice. Cholelithiasis may need to be treated with an operation to remove the gallstones if they do not pass naturally into the woman’s bowel. The timing of this will depend on the severity of the condition, weighing up the risks of miscarriage or premature birth.

Cholestasis. A few women may be at increased risk of developing cholestasis of pregnancy. This condition is characterised by itching of the skin, especially the hands and feet. You can read more in cholestasis.

Acute fatty liver of pregnancy. Although rare, hepatitis can predispose a few women to a condition called ‘acute fatty liver of pregnancy’. This is a life-threatening condition for the woman that may require delivering her baby prematurely and possible treatment for the woman in an intensive care facility. However, most women normally recover quickly after the baby is born. If a pregnant woman becomes very unwell before the birth of her baby, the baby may also be unwell and can in some cases be stillborn.

Pregnant women who have (or carry) the hepatitis virus require regular blood tests during their pregnancy to check the functioning of their liver. These are called ‘Liver Function Tests’ or ‘LFT’s’. Depending on the results of the tests, these may be done every few months, monthly or perhaps weekly if the levels appear to be rising. Be aware that it is normal for pregnant women to have increased alkaline phosphatase levels (3 to 4 times higher than normal) because the placenta creates alkaline phosphatase. However, ALT levels (or ‘alanine aminotransferase serum’) increase if the woman is ill from hepatitis or if liver damage is occurring. (The normal ALT range for women is 10 - 32 U/L.)

NOTE:Women with hepatitis should not be treated any differently by their healthcare professionals during the pregnancy, labour, birth or postnatal recovery. All caregivers handling blood products and performing medical procedures involving blood exposures treat every person in the same way. This is known as ‘universal precautions’ and means the caregiver will wear gloves when taking blood and gloves gowns and goggles or glasses when caring for women giving birth or having a Caesarean operation, regardless of whether they are positive for hepatitis or not. However, women who are infectious with hepatitis A do need to be isolated from other women and babies when being cared for in a hospital setting.

Support

Finding out you have hepatitis can come as quite a shock and bring up a range of emotions. Your caregiver should discuss at length the implications of having the virus and any effects on your pregnancy, family, relationships and overall health as well as any health concerns for your baby. Usually your close personal contacts (such as your partner) will need to be tested for the virus. But you are not obliged to tell other members of the family, friends or work colleagues and the results of your test should be kept confidential.

Obtaining up to date information and counselling with people who understand your situation can provide immediate and ongoing support. These are usually provided by volunteer and health department organisations that specialise in hepatitis. At present in Australia there is no central organisation that provides national services. Most are state based and funded and usually have local numbers in capital cities and toll free numbers for rural residents. Ask your caregiver about what is available in your area or use the phone book or a search of the Internet to locate these organisations.
Hepatitis A virus (HAV or ‘hep A’) is the most common type of hepatitis worldwide, being most prevalent in developing countries. Hepatitis A was first identified in human faeces in 1973 and later identified in blood tests. Hepatitis A is a notifiable disease within Australia and is reported by health professionals to the Department of Health’s National Centre for Disease Control (NCDC). These reports do not contain information that identifies an individual person. In the year 2000 there were 812 cases of hepatitis A reported in Australia. The rates of hepatitis A infections have dropped from 16.4 per 100,000 (0.0164%) in 1997 to 2.8 per 100,000 (0.0028%) in 2001.

The hepatitis A virus is transmitted by coming into contact with:

Water contaminated with infected faeces (or bowel motions).
Food, drinks, eating utensils and cigarettes handled by an infected person.
Touching nappies, linen or towels soiled with the faeces of an infected person.
Eating oysters and shellfish contaminated with sewerage.
Anal or oral sex with an infected person.

Physical signs

The ‘incubation period’ of hepatitis A, or the time it takes between coming in contact with the virus and showing physical signs of illness, varies between 2 and 7 weeks, with an average of 4 weeks. The physical signs of hepatitis A can include:

Nausea, vomiting, loss of appetite and weight loss.
Abdominal pain, diarrhoea, mild fever, aching joints, headaches.
Jaundice, darker coloured urine, pale bowel motions and an enlarged liver.

The jaundice can last anywhere from 1 to 6 weeks, after which a person generally makes a full recovery. The bowel motions of a person are infectious for 2 weeks before the physical signs become apparent until 1 to 2 weeks after the Jaundicefirst becomes visible (3 to 4 weeks in total). Hepatitis A does NOT cause long term liver problems and once a person has experienced an infection, they have lifelong immunity.

Tests and treatments

Hepatitis A can be diagnosed with a blood test showing ‘anti-HAV IgM’, but this is only detectable during the 2 weeks before the illness becomes apparent or during the actual illness (i.e. 2 to 5 weeks after being exposed to the virus). Therefore, it is not possible to test for the hepatitis A virus within 2 weeks of being exposed to hepatitis A. The anti-HAV IgM can be present in the person’s blood for several months after the person recovers from the illness (long after they stop being infectious). However, if your blood test shows positive for ‘anti-HAV IgG’, this means you have had a hepatitis A infection in the past and are immune to the virus. Hepatitis A is not something that is routinely tested for during pregnancy, but a test will be done if you or your caregiver suspects you may be infected.

The treatments for hepatitis A are rest and fluids and a nutritious diet. You should avoid alcohol and taking medications that rely on being broken down and excreted by the liver, or that could possibly inflame the liver. Some people will also use natural therapies to help boost their immune system to the combat virus.

The hepatitis A virus is able to survive in water for up to 14 weeks and on contaminated objects for several hours to several weeks if the objects are not thoroughly washed or treated. People known to be infected with hepatitis A should wash their hands thoroughly with soap and water after going to the toilet and/or handling a baby’s nappies.

Ideally, a person infected with hepatitis A should not prepare food for others (including baby bottles). However, if this is not possible, they should wash their hands thoroughly with warm water and soap before handling food, or wear clean (preferably disposable) gloves. People who handle food as part of their job or who work in close personal contact with others (hospitals, childcare and hostel facilities) should not work while they are infectious. This is for at least 1 week after the onset of Jaundice.

While a person is infectious they should not share their eating and drinking utensils or cigarettes with others and they should not share linen and towels. All linen and towels need to be washed separately in warm soapy water in a washing machine (not hand washed).

Pregnancy and vaccinations

If a pregnant woman becomes infected with hepatitis A, generally her unborn baby is not affected. However, pregnant women who plan to travel to countries that are thought to have high risks for being infected with the hepatitis A virus are usually advised to have a hepatitis A vaccination. At present it is thought to be safe to give pregnant women the hepatitis A vaccine. The vaccination should be given at least 2 weeks before travelling and can last for up to 12 months after a single dose, and up to 20 years after a second dose.

Pregnant women (and others) who think they may have been exposed to hepatitis A may be given an injection of normal human immunoglobulin (NIGH) against the virus, as well as the hepatitis A vaccine. Immunoglobulin is a blood product derived from human blood donations. It aims to provide temporary immunity to the virus while the vaccine takes effect and may reduce the physical signs of the illness if it is given within 2 weeks of being in contact with the virus.

Babies

Most newborn babies and young children who become infected with the hepatitis A virus remain well or only have very mild physical signs. If they do become infected they will usually have lifelong immunity. The age of a person will usually determine how unwell they become with hepatitis A. As a general guide:

About 75% of adults and children over the age of six will become unwell.
About 10% of children from 4 to 6 years will become unwell.
About 5% of newborn babies and children under 4 years will become unwell.

Be aware that a baby or young child may be infectious and capable of passing the hepatitis A virus onto others, even though they show no physical signs of being ill.

Breastfeeding

Breastfeeding women infected with the hepatitis A virus are encouraged to breastfeed. Make sure you wash your hands thoroughly with warm water and soap before touching your breasts and nipples, especially after changing the baby’s nappy or going to the toilet.

Hepatitis B virus (HBV or ‘hep B’) can cause an infection of the liver that may lead to long term health problems. Hepatitis B is a notifiable disease within Australia and is reported by health professionals to the Department of Health’s National Centre for Disease Control (NCDC). These reports do not contain information that identifies an individual person. In 2000, there were 8,303 cases of Hepatitis B reported in Australia.

Hepatitis B can be passed onto others by coming in contact with the blood, semen, vaginal fluid (and to a lesser degree saliva) of an infected person. This can be through contact with someone who is carrying or incubating the virus or when they are actually suffering from an acute hepatitis B illness. Hepatitis B can be transmitted through:

Unsafe heterosexual or homosexual sex (no condoms or dams) with that person.
Sharing needles when injecting drugs.
Sharing equipment and dyes with amateur tattooing and body piercing.
Professional dealings with infected blood (for example needle stick injuries or blood splashes).
Sharing toothbrushes or razors of an infected person in the same household, or touching open wounds.
From mother to baby at birth and through breastfeeding (if the baby is not vaccinated soon after birth).
Child to child transmission through open sores or wounds.
Contact with another’s blood through sporting activities.

Australia has screened all blood and organ donations for hepatitis B since the 1980’s. This has virtually eliminated contracting the hepatitis B virus through a blood transfusion, or by receiving other blood or body products.

Physical signs

The ‘incubation period’ of hepatitis B, or the time it takes between coming in contact with the virus and showing physical signs of illness varies between 6 and 25 weeks. However, when adults become infected with the hepatitis B virus only about 50% will show any physical signs of illness, while the remaining 50% will become infected and are capable of infecting others but not experience any ill health (and are therefore not aware they have the virus). If a person does become unwell, they are said to have ‘acute hepatitis’.

The physical signs of acute hepatitis B can include:

Tiredness and fatigue that can persist for weeks after the person has recovered.
Abdominal pain, a fever, aching joints and muscles.
Skin rashes, nausea and vomiting.
Jaundice, darker coloured urine, pale bowel motions and an enlarged liver.

Of all adults who become infected with the hepatitis B virus (whether they are ill or not) about 1 to 12 % (average 5%) will continue to carry the virus in their bodies for years. They are described as ‘carriers’ of hepatitis B virus. ‘Carriers’ can pass the virus onto others and are at increased risk of having long term liver disease (about 25% chance) and liver cancer (15 to 25% chance) later in life, often by the time they reach middle age.

Tests and treatments

Testing for the hepatitis B virus is generally a standard, routine test performed on all pregnant women at or before their first pregnancy visit, (usually before about 12 to 14 weeks of the pregnancy). If the woman is carrying the hepatitis B virus, her blood test result will show as being ‘positive’ for the ‘hepatitis B surface antigen’ (or ‘HbsAg positive’). However, if the blood test shows positive for ‘anti-HBs’ or ‘HBsAb’, this means you are immune to the hepatitis B virus. This can be after a hepatitis B vaccination or because of a past infection.

A blood test for hepatitis B will not show as being positive if it has been less than 3 months since you were exposed to the virus. This 3 month period of being infected but not showing up on a blood test is known as a ‘window period’.

The treatments for acute hepatitis B infections are rest and fluids and a nutritious diet. You should avoid alcohol and not take any medications that rely on being broken down and excreted by the liver, or that can inflame the liver. Some people will also use natural therapies to help boost their immune system to combat the virus.

Carriers of the hepatitis B virus need to practise safe sex with their partners (using condoms or dams) and not share needles. They should also not share toothbrushes, razors or other personal items that may transmit blood or saliva to another person.

Pregnancy and vaccinations

Pregnant women (and others) who think they may have been exposed to hepatitis B may be given and injection of hepatitis B immunoglobulin (HBIG) against the virus (ideally within 72 hours of exposure), as well as the hepatitis B vaccine (within 7 days of exposure). Immunoglobulin is a blood product derived from human blood donations. It aims to provide temporary immunity to the virus while the hepatitis B vaccine takes effect. A second hepatitis B vaccination needs to be given about 1 month later with a 3rd injection at around 6 months after the first vaccination (or 5 months after the second vaccination).

At present it is thought that giving the hepatitis B vaccine to pregnant women is relatively safe, even though there is not sufficient research evidence to completely confirm its safety for the unborn baby. However, the risks of a woman becoming infected with the hepatitis B virus and possibly infecting her baby are thought to outweigh the possible small risks from the vaccination.

Babies

If a pregnant woman is a carrier of the hepatitis B virus her unborn baby will generally not be affected. However, the baby can become infected at birth (through either a vaginal or Caesarean birth), or through breastfeeding or contact with carriers during the first 1 to 2 years of their life (unless the baby is vaccinated). If a young baby becomes infected with the hepatitis B virus, they will usually not show any physical signs of being ill.

An unvaccinated baby whose mother is a hepatitis B carrier has up to a 40% chance of becoming infected with the virus during the first 18 months of their life, of which up to 90% can become a long term carrier and be infectious to others, as well as being at risk of liver disease and liver cancer in later life. Hepatitis B can also be passed through breast milk. The transmission of the hepatitis B virus from child to child (for example in a day care setting) is believed to be very low risk, but possible through contact with open sores or the wounds of an infected child.

Mothers who are carriers of the hepatitis B virus are strongly recommended to allow caregivers to give their baby an injection of the Hepatitis B Immunoglobulin (HBIG) soon after of the birth (within 12 hours) and before they have their first breastfeed, as well as their first hepatitis B vaccination (HBV) within 7 days of birth. The immunoglobulin is a blood product derived from human blood donations and is aimed at providing temporary immunity to the hepatitis B virus while the vaccine takes effect. A second hepatitis B vaccination needs to be given about 1 month later with a 3rd injection at 6 months after the first vaccination (or 5 months after the second vaccination). You can read more in hepatitis B vaccination for the baby.

Breastfeeding

Mothers who carry the hepatitis B virus are encouraged to breastfeed their baby. It is recommended that the baby breastfeeds after the administration of the Hepatitis B Immunoglobulin (HBIG) but not necessarily before the first hepatitis B vaccination (HBV). The hepatitis B vaccination can be delayed more than 24 hours after the baby’s birth but definitely needs to be given before the baby is 7 days old.

Hepatitis C virus (HCV or ‘hep C’) can cause an infection of the liver that may lead to long term health problems. Hepatitis C used to be called ‘non A - non B’ hepatitis and caregivers were aware of its presence as early as the 1970’s, but it was not specifically identified until 1987. A blood test to detect hepatitis C was first developed in 1990. Australia has screened all blood and organ donations for hepatitis C since February 1990. This has virtually eliminated contracting the hepatitis C virus through a blood transfusion, or by receiving other blood or body products.

There are different strains of hepatitis C and a person may be infected (or re-infected) by the different strains. Hepatitis C is a notifiable disease within Australia and is reported by health professionals to the Department of Health’s National Centre for Disease Control (NCDC). These reports do not contain information that identifies an individual person. With the increased testing for hepatitis C, more and more cases are being discovered each year. In 2000, there were 20, 010 cases of Hepatitis C reported in Australia. It is thought that between 1 and 4% of pregnant women could carry the hepatitis C virus.

Hepatitis C can be passed onto others by coming in contact with the blood of an infected person. Hepatitis C can be transmitted through:

Sharing needles when injecting drugs.
Sharing equipment and dyes with amateur tattooing and body piercing.
Professional dealings with infected blood (for example needle stick injuries or blood splashes).
Sharing toothbrushes or razors of an infected person in the same household, or touching open wounds.
Child to child transmission through open sores or wounds.
Contact with another’s blood through sporting activities.
Having received a blood donation or blood products before February 1990 in Australia.

The transmission of hepatitis C through sex is very uncommon. If it happens, it is believed to be as a result of blood-to-blood contact during sex, for example if the woman is menstruating. However, the risk of transmitting hepatitis C sexually is possibly increased during the initial acute phase of infection, which can last for up to six months after catching the virus.

Transmission from mother to baby during pregnancy and at birth is thought to be very low risk (about 5 to 10%) and there is no evidence that a baby can be infected with hepatitis C through breast milk.

Hepatitis C is NOT spread by ordinary social contact such as hugging, kissing, shaking hands, sharing food, plates, cups and glasses, using the same shower and toilet facilities or using the same washing machine.

NOTE:Be aware that up to 50% of people who find out they have hepatitis C cannot identify any risk factors or reasons as to why they have become infected.

Physical signs

The ‘incubation period’ of hepatitis C, or the time it takes between coming in contact with the virus and showing physical signs of illness varies between 3 and 20 weeks, but is on average 6 to 10 weeks. However, when adults become infected with the hepatitis C virus most do not show any physical signs of being ill and some people will carry the virus for up to 10 to 20 years before they develop any physical signs (unless they have a blood test for hepatitis C).

Only about 25% of people actually become unwell with hepatitis C and the physical signs are usually very mild including feeling tired, having a mild fever and a loss of appetite. However, for some people they experience a milder form of hepatitis illness such as nausea, vomiting, diarrhoea, muscular aches and possibly a mild body rash. Only a few people will experience jaundice.

Of all adults who become infected with the hepatitis C virus (whether they are ill or not) about 15 to 20% will clear the virus within 2 to 6 months and about 80 to 85% will continue to carry the virus in their bodies for years. They are referred to as being ‘carriers’ of hepatitis C virus and are infectious and can pass the virus onto others. About 60 to 65% of carriers will have long term liver damage (on average after 15 years) and about 20 to 25% will develop liver cirrhosis (after about 20 to 40 years. In a minority of cases, people who develop liver cirrhosis may go on to have liver failure or liver cancer. Only about 20% of people will not develop any liver damage or symptoms form hepatitis C.

Tests and treatments

In recent years, the testing for Hepatitis C during pregnancy has become increasingly accepted as ‘routine’ by many maternity caregivers, along with testing for hepatitis B. In some places, only women considered ‘at risk’ are tested. For example, women with a history of using IV drugs or who have tattoos or body piercings. However, testing for hepatitis C is not compulsory and some women do decline it if they do not wish to be tested.

Ideally, pregnant women being offered a hepatitis C test should be counselled before they have the test and given an opportunity to discuss the social, physical and emotional implications of receiving a possible ‘positive’ result. Your test result should also be kept confidential. If you do have a blood test for the hepatitis C virus, this will be done at or before your first pregnancy visit, (usually before about 12 to 14 weeks of the pregnancy).

If a woman is carrying the hepatitis C virus, her blood test result will show as being ‘antibody positive’ for the hepatitis C virus. However, if your blood test shows you are ‘antibody negative’ you do not have the virus. A blood test will not show as being ‘positive’ unless it has been more than 3 months since you were exposed to the virus. This 3 month period of being infected but not showing up on a blood test is known as a ‘window period’.

There is currently no cure for hepatitis C and no vaccine available to prevent a person from becoming infected. Carriers need to look after their bodies with good nutrition and regular exercise and avoid alcohol and medications that rely on being broken down and excreted by the liver, or that can inflame the liver. They also need to be aware of activities that can expose their blood to others by not sharing toothbrushes, razors or other personal items that may transmit blood, using condoms for sex during menstruation and anal sex and covering sores and open wounds.

The treatments available to boost the body’s immune system to fight the hepatitis C virus include:

Interferon alpha. This is a synthetic drug similar to natural substances produced by the body in response to viral infections. The effect of Interferon on the unborn baby is unknown and pregnant women are usually advised to stop taking it during their pregnancy.

Ribavirin (or Rebetron). This is a medication used sometimes in combination with Interferon. Ribavirin has a high risk of causing birth defects in the unborn baby and women are advised not to conceive for at least 6 months after stopping the Ribavirin medication and should not breastfeed if taking Ribavirin.

Some people will also use natural therapies to help boost their immune system to combat the virus.

Babies

The transmission of the hepatitis C virus from a mother to her baby during pregnancy or at birth is thought to be relatively low, with only about 5 to 10% of babies becoming infected. However, this may be increased if the woman first becomes infected just before she conceives her baby or at some stage during the pregnancy. At present there is no vaccination or immunoglobulin available that can be given to the newborn baby to prevent them being infected with the hepatitis C virus.

If the baby’s blood is tested soon after the birth for hepatitis C antibodies, the test will show as being ‘antibody positive’. This is because the baby is carrying their mother’s antibodies, passed on to them through the placenta. These clear naturally over a period of months (up to 18 months in some cases). However, there is a special blood test called a ‘PCR test’, which is capable of detecting or measuring the actual hepatitis C virus in the blood. If this blood test is used on the baby when they are about 6 to 8 weeks old, it will usually show if the baby has been infected or not. If a baby is infected, the outlook for their health is believed to be similar to adults with the hepatitis C virus.