HEPATITIS and PREGNANCY

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 babyprematurely 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 emotionsYour 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.

Reviewed by Bambang Widjanarko Obstetrician & Gynecologist

Juni 2009