No. 342-Hepatitis B and Pregnancy

ObjectiveTo review the epidemiology, natural history, evaluation, and treatment of hepatitis B virus (HBV) infection during pregnancy. This will aid obstetric care providers in counseling their patients regarding perinatal risks and management options available to pregnant women with hepatitis B.OutcomesOutcomes evaluated include thresholds for HBV anti-viral treatment for prevention of perinatal transmission and for invasive procedures during pregnancy for women with hepatitis B infection.EvidenceMedline, EMBASE, and CINAHL were searched for articles in English on subjects related to HBV infection, pregnancy, and perinatal transmission from 1966 to March 2016. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Other (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical speciality societies.Validation methodsThe quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Recommendations for practice are ranked according to the method described in this Report.Guideline updateThe guideline will be reviewed 5 years after publication to decide if an update is required. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.SponsorsThis guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada.Recommendations1.Pregnant women should be offered screening for hepatitis B virus infection in early pregnancy by determination of their hepatitis B surface antigen (I-A).2.If status of hepatitis B surface antigen is unknown at time of maternal admission to hospital, this should be done immediately to inform infant management1,2 (III-A).3.Hepatitis B surface antigen-positive pregnant women require testing for hepatitis B envelope antigen, hepatitis B virus (HBV) DNA level, alanine aminotransferase (I-A) and ultrasound of the liver (III-B) during pregnancy for the purposes of maternal health and perinatal HBV transmission risk stratification. A specialist referral is recommended (III-L).4.Hepatitis B surface antigen-positive pregnant women should receive counseling on prevention of hepatitis B virus transmission to sexual partners and household contacts (II-2A).5.If hepatitis B surface antigen is negative but there is an ongoing risk of infection (e.g., born in country where hepatitis B virus is endemic, illicit drug use, multiple sexual partners, multiple transfusions, immunosuppression, hepatitis B positive partner, health care workers, incarceration, or abnormal alanine aminotransferase), screening should be repeated in late pregnancy3 (II-3A).6.Women at high risk for acquiring hepatitis B infection who are hepatitis B surface antigen-negative and have not been vaccinated for hepatitis B must be counseled on risk factor modification and should be offered recombinant hepatitis B vaccine series: pregnancy is not a contraindication for immunization to hepatitis B virus (II-2A).7.Encourage non-invasive screening techniques for aneuploidy prior to invasive testing for women who are hepatitis B surface antigen-positive and counsel women that risk of transmission in utero increases if maternal hepatitis B virus DNA is >200 000 IU/mL (>106 copies/mL) at the time of amniocentesis (II-2B).8.If possible, avoid intrapartum invasive procedures (e.g., fetal electrocardiogram, scalp lactate) that may increase the infant's risk of percutaneous hepatitis B virus exposure (III-L).9.Cesarean section is not recommended for the sole purpose of reducing the risk of perinatal transmission of hepatitis B virus (II-2C).10.Vaccinate the neonate for hepatitis B and give hepatitis B immunoglobulin within the first 12 hours of life to all neonates born to women who are hepatitis B surface antigen-positive (I-A).11.Breastfeeding does not pose an additional risk of hepatitis B virus infection, even without neonatal vaccination, hence mothers with chronic hepatitis B infection who wish to breastfeed should be encouraged to do so (II-2A).12.Encourage families to complete the infant immunization series for hepatitis B virus according to local infant vaccination schedule and obtain serological confirmation of protection after completion of hepatitis B vaccination series, no sooner than 9 to 12 months of age (I-A).13.In collaboration with an adult infectious diseases/gastroenterology or hepatology specialist, consider antiviral treatment for viral suppression for prevention of perinatal transmission in women with hepatitis B DNA viral loads level >200 000 IU/mL (>106 copies/mL), starting at 28 to 32 weeks' GA and continuing until delivery (II-B).