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Viral hepatitis and pregnancy

Abstract

The management of viral hepatitis in the setting of pregnancy requires special consideration. There are five liver-specific viruses (hepatitis A, B, C, D, E), each with unique epidemiology, tendency to chronicity, risk of liver complications and response to antiviral therapies. In the setting of pregnancy, the liver health of the mother, the influence of pregnancy on the clinical course of the viral infection and the effect of the virus or liver disease on the developing infant must be considered. Although all hepatitis viruses can harm the mother and the child, the greatest risk to maternal health and subsequently the fetus is seen with acute hepatitis A virus or hepatitis E virus infection during pregnancy. By contrast, the primary risks for hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis D virus are related to the severity of the underlying liver disease in the mother and the risk of mother-to-child transmission (MTCT) for HBV and HCV. The prevention of MTCT is key to reducing the global burden of chronic viral hepatitis, and prevention strategies must take into consideration local health-care and socioeconomic challenges. This Review presents the epidemiology of acute and chronic viral hepatitis infection in pregnancy, the effect of pregnancy on the course of viral infection and, conversely, the influence of the viral infection on maternal and infant outcomes, including MTCT.

Key points

  • Acute hepatitis A virus (HAV) infection during pregnancy might increase the rates of adverse pregnancy outcomes; cases leading to fetal liver injury and mother-to-child transmission (MTCT) of HAV have been reported.

  • Pregnant women with chronic hepatitis B virus (HBV) infection might have an increased risk of preterm delivery and gestational diabetes.

  • There is risk of MTCT of HBV, especially in mothers with high levels of HBV DNA, but this risk is reduced with the use of maternal antiviral therapy and prompt administration of infant immunoprophylaxis.

  • Pregnant women with chronic hepatitis C virus (HCV) infection have increased rates of adverse pregnancy outcomes; MTCT occurs in 5% and is linked with invasive fetal monitoring and prolonged rupture of membranes.

  • Risks related to underlying cirrhosis can be more frequent in pregnant women with hepatitis D virus (HDV) infection; MTCT of HDV is rare and management is the same as HBV monoinfection.

  • Acute hepatitis E virus (HEV) infection in pregnancy is associated with an increased risk of maternal death and infant mortality, including higher rates of preterm delivery and stillbirths; MTCT of HEV can occur.

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Fig. 1: Mother-to-child transmission of virus in women with chronic viral hepatitis.
Fig. 2: Suggested management algorithm for women positive for HBV.

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N.A.T. has received institutional grant support unrelated to this work from Gilead Sciences and Roche/Genentech. M.T.L. is an adviser or has received research grants from AbbVie, Gilead Sciences, Merck/MSD and Bayer. G.J. owns equities in Sanofi and has received grants from Gilead. K.W.C. has no competing interests.

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Terrault, N.A., Levy, M.T., Cheung, K.W. et al. Viral hepatitis and pregnancy. Nat Rev Gastroenterol Hepatol 18, 117–130 (2021). https://doi.org/10.1038/s41575-020-00361-w

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