| disease | Pregnancy Complicated by Viral Hepatitis |
Pregnancy complicated with viral hepatitis is a common obstetric pestilence, which has a significant impact on both mother and child, and is receiving increasing attention. Particularly in recent years, with the in-depth progress of research on viral hepatitis both domestically and internationally, the effects of the disease on mother and child, such as vertical transmission, maternal and infant mortality, and breastfeeding, have garnered more attention. The incidence of pregnancy complicated with viral hepatitis is approximately 0.025% to 0.08%, with a higher incidence in the advanced stages of pregnancy.
bubble_chart Clinical Manifestations
Pregnancy Complicated with Hepatitis A
The impact of hepatitis A on perinatal infants: According to data from the First Maternity and Infant Hospital in Shanghai, the perinatal mortality rates for pregnant women with hepatitis A during the intermediate stage [second stage] and advanced stage of pregnancy were 42.3% and 125%, respectively, indicating a significant increase in perinatal mortality during the advanced stage of pregnancy. Compared to the perinatal mortality rate of 14.1% for normal pregnant women in Shanghai in the same year, there is a highly significant difference. Although there were no deaths among pregnant women with hepatitis A, the high perinatal mortality rate is an issue that cannot be ignored.
Pregnancy Complicated with Hepatitis B
The impact of hepatitis B on pregnancy: Pregnant women with hepatitis B have significantly higher rates of late abortion, premature labor, dead fetus, stillbirth, neonatal asphyxia, and neonatal mortality. This is related to acute jaundice hepatitis, especially severe or fulminant hepatitis, during the advanced stage of pregnancy. The mortality rate of fulminant hepatitis is higher in pregnant women than in non-pregnant women. Pregnancy, especially during the late stage [third stage], is particularly prone to fulminant hepatitis.
The impact of pregnancy on viral hepatitis: Some believe that pregnancy is more likely to produce non-specific hypersensitivity reactions, and pregnancy is in a state of preparation for non-specific hypersensitivity reactions, so the probability of grade III or fulminant hepatitis during pregnancy is significantly increased. Animal experiments have shown that acute liver necrosis in pregnant rabbits is more severe before and after delivery, so in recent years, it has been advocated that artificial late abortion can be performed in the early stages of pregnancy if the HBsAg titer is high and HBeAg is positive. In the advanced stage of pregnancy, due to the relative insufficiency of liver blood flow, and after the complication of hepatitis, the liver blood flow is relatively reduced, which can exacerbate the hepatitis condition and even lead to severe hepatitis.Pregnancy combined with hepatitis A
The symptoms are the same as those in non-pregnant women, with a more acute onset. In addition to gastrointestinal symptoms and jaundice, a positive anti-HAV-IgM in serological tests can confirm the diagnosis.
Pregnancy combined with hepatitis B
(1) There are digestive system symptoms (nausea, vomiting) and lack of strength, jaundice, etc., with an acute onset and elevated serum ALT.
(2) Serological test indicators
1) Hepatitis B surface antigen (HBsAg): the most commonly used indicator of hepatitis B infection. During the incubation period of infection, HBsAg can be positive before serum ALT rises; when HBsAg is at a high titer, the e antigen (HBeAg) is also positive. Clinically, using HBsAg alone as an infection indicator is insufficient; it should be judged in combination with clinical manifestations and other indicators.
3) Hepatitis B e antigen (HBeAg): a degradation product of HBcAg, appearing slightly later than HBsAg in acute infection. The subtypes e1 and e2 more reflect the activity of hepatitis B virus replication.
4) Hepatitis B e antibody (anti-HBe): generally, when HBeAg disappears in the blood, anti-HBe appears, indicating reduced virus replication, decreased pestilence, and the condition tends to stabilize.
5) Core antibody (anti-HBc): in acute infection, it can be detected 2-4 weeks after the appearance of HBsAg, before clinical symptoms appear. Therefore, anti-HBC-IgM is mostly seen in the early stages of infection or the active phase of chronic infection.
6) Hepatitis B virus DNA (HBV-DNA): positive HBV-DNA is direct evidence of hepatitis B virus replication and a pestilence indicator. HBV-DNA is in balance with HBeAg and DNA polymerase. In all HBeAg-positive blood, 86-100% can detect HBV-DNA.
Based on clinical symptoms, signs, liver function tests, and serological indicators, the diagnosis of pregnancy combined with hepatitis B can be quickly clarified.
When using serological diagnosis for intrauterine infection of hepatitis B virus, the following three bases should be noted:
(1) Positive HBsAg in neonatal umbilical blood can be a reference indicator.
(2) Positive HBcAb-IgM in neonatal umbilical blood can confirm intrauterine infection.
(3) If conditions permit, positive hepatitis B virus DNA in umbilical blood can further confirm the diagnosis, but this indicator is not yet widely applicable domestically.
Diagnostic criteria: acute onset, obvious toxic symptoms, severe jaundice.
(1) Serum bilirubin ≧171μmol/L (10mg/dl) within one week, or daily increase ≧17.1μmol/L (1mg/dl).
(2) Prothrombin time is significantly prolonged, 0.5-1 times longer than normal or even longer.
(3) There are varying degrees of hepatic unconsciousness, and severe cases may present with hepatic odor.
(4) Ascites may appear or the liver dullness area may shrink.
bubble_chart Treatment Measures
Pregnancy complicated with Hepatitis A
Currently, there is no specific treatment for Hepatitis A, and the following comprehensive measures are generally adopted:
(1) Rest and liver-supportive therapy. Commonly used are Virgate Wormwood infusion granule, stringy stonecrop herb infusion granule, as well as vitamin C and complex vitamin B, or intravenous glucose infusion.
(2) Since the Hepatitis A virus does not cross the placental barrier and does not transmit to the fetus, there is no need for artificial late abortion or intermediate stage [second stage] pregnancy induction. Since liver function impairment can affect maternal metabolism, causing hypoxia, etc., leading to a higher likelihood of premature labor, it is necessary to strengthen self-monitoring such as fetal movement counting in the advanced stage of pregnancy. Those with signs of premature labor should be hospitalized early for treatment, and non-stress tests (NST) and B-ultrasound biophysical indicators should be monitored. During labor, attention should be paid to shortening the second stage of labor, preventing postpartum metrorrhagia, and puerperium infection.
(3) Regarding breastfeeding. Those who have recovered from Hepatitis A after childbirth can breastfeed, but breastfeeding should be prohibited during the acute phase, not only to prevent vertical transmission from mother to child but also to facilitate the mother's recovery.
Pregnancy complicated with Hepatitis B
(1) General treatment: In addition to isolation and bed rest during the acute phase of hepatitis, a light and low-fat diet should be provided, with sufficient daily energy supply. If gastrointestinal symptoms are severe, glucose infusion should be administered intravenously.
(2) Application of liver-protective drugs: A large amount of vitamin C, vitamin K1, and vitamin B1, B6, B12 should be given daily. Vitamin C is an important substance involved in the body's redox process, enhancing anti-infection ability, promoting liver cell regeneration, and improving liver function; vitamin K1 can promote the synthesis of prothrombin, fibrinogen, and certain clotting factors (factors VII, X). Generally, 3g of vitamin C and 40mg of vitamin K1 are added to 500ml of 5% or 10% glucose solution for intravenous infusion once daily. At the same time, an energy mixture is given, such as 250-500ml of 25% glucose solution with 100u of coenzyme A and 3g of vitamin C. Intramuscular injection of 50mg of vitamin E is also beneficial for preventing liver cell necrosis. For those with high ALT, 80ml of Stronger Neo-Minophagen C and 20ml of potassium magnesium aspartate can be added to glucose solution for intravenous infusion. If there is anemia or hypoproteinemia, an appropriate amount of fresh blood, human albumin, or plasma can be transfused.
(3) Chinese herbal medicine treatment: Mainly focusing on clearing heat and draining dampness, commonly using modified Virgate Wormwood decoction. Formula: Virgate Wormwood 30g, Gardenia 12-15g, raw Astragalus Root 15-20g, Skullcap Root 12g, Coptis 6g, Poria 15g, Chinese Angelica 12g, Patrinia 12-15g, Bupleurum 9g, Dried Tangerine Peel 9g. One dose per day, decocted and taken, beneficial for reducing jaundice, improving liver function, and clinical symptoms.
(4) Obstetric management
1) Early pregnancy: If HBsAg titer is high and HBeAg is positive with clinical manifestations, artificial late abortion can be performed under active treatment. Because pregnancy and hepatitis B have adverse effects on each other. However, patients in the advanced stage of pregnancy should focus on liver-protective treatment and should not rashly undergo induction to avoid adverse consequences caused by induction.
2) Childbirth and puerperium period: The following three aspects must be noted: ① Preventing bleeding; ② Preventing infection: Antibiotics that do not adversely affect the liver and kidneys should be used postpartum to prevent infection; ③ Closely monitoring clinical symptoms and liver function test results to prevent disease progression.
From an obstetric perspective, observe whether the fetus has cephalopelvic disproportion. Even if labor progresses well, the second stage of labor should be appropriately shortened with forceps-assisted delivery, which is beneficial for reducing maternal physical exertion and neonatal asphyxia. Postpartum, umbilical bleeding should be routinely tested for liver function and hepatitis serological indicators.
(5) Handling of newborns: In recent years, it has been advocated that infants born to HBsAg-positive pregnant women should receive an intradermal injection of 30μg of hepatitis B vaccine within 24 hours after birth, at 1 month, and at 6 months. This generally blocks 90% of mother-to-child transmission. If conditions permit, an additional intramuscular injection of human HBs immunoglobulin (HBIG) after birth is more beneficial in preventing vertical mother-to-child transmission. The effectiveness of the hepatitis B vaccine in our country can last for about 5 years, so a booster immunization should be administered before entering elementary school.
Pregnancy complicated with severe hepatitis
(1) General management: ① Specialized nursing care is required, accurately recording blood pressure, respiration, pulse, and fluid intake and output; ② Provide a low-fat, low-protein, high-carbohydrate liquid or semi-liquid diet, ensuring an energy intake of 6276 kJ/d (1500 kcal/d), and administer large amounts of vitamins.
(2) Transfuse 600-800 ml of warm fresh blood to increase clotting factors, and also transfuse human albumin or freeze-dried plasma, which helps prevent liver cell necrosis and reduce the occurrence of cerebral edema.
(3) Administer 1 mg of glucagon plus 8 units of regular insulin, and 10-20 ml of 10% potassium chloride in 500-1000 ml of 10% glucose solution, intravenously.
(4) Interferon can be used at 3 million units daily, intramuscularly for 7-14 consecutive days, or 1 million units three times daily, intramuscularly.
(5) Fetal liver cell suspension 200 ml, intravenously, once daily or every other day, for 3-5 times, can achieve excellent results. This can also be referred to as fetal liver cell transplantation.
(6) 14-amino acid-800 250 ml or compound formula branched-chain amino acids 250 ml, intravenously, once or twice daily, can promote improvement in liver condition.
(7) 40 ml of 10% potassium magnesium aspartate dissolved in 250 ml of 10% glucose solution, slow intravenous drip.
(8) Regardless of the presence of infection signs, broad-spectrum antibiotics with the least impact on liver and kidney function should be administered.
Management of disseminated intravascular coagulation (DIC)
(1) Diagnostic criteria for DIC complicating pregnancy with severe hepatitis: ① Platelet count ≤50×109/L (50,000/mm3); ② Prothrombin time prolonged more than twice the normal; ③ Fibrinogen ≤1.25 g/L (125 mg/dl); ④ Positive protamine paracoagulation (3P) test or ethanol gel test.
(2) Management of DIC: Based on obstetric characteristics, in the absence of labor signs and occurrence of DIC, heparin can be used, with an initial dose of 25 mg (3125 IU) in 100 ml of 5% glucose solution, intravenously (usually completed in about 30 minutes), followed by 25 mg in 200 ml of 5% glucose solution, slow intravenous drip. Subsequent doses of heparin should be determined based on laboratory results. If DIC occurs during labor or within 24 hours postpartum, transfusion of warm fresh blood and freeze-dried plasma should be prioritized, and heparin should not be used rashly. Due to severe clotting factor deficiency and the open uterine sinuses postpartum, which are prone to bleeding, inappropriate use of heparin can exacerbate bleeding.
Obstetric management: Upon admission, emergency management must be implemented, starting with transfusion of warm fresh blood, human albumin, freeze-dried plasma, and for patients with hepatic coma, active treatment for 24 hours followed by prompt termination of childbirth. According to 1990 data from the Obstetrics and Gynecology Hospital of Shanghai Medical University, among 22 cases of pregnancy complicated with severe hepatitis, 9 cases underwent timely and appropriate use of fresh blood, albumin, plasma, and heparin, followed by seasonal epidemic cesarean section or even hysterectomy, with 8 cases surviving; 1 case died post-cesarean section due to DIC. Among 13 cases managed conservatively awaiting vaginal childbirth, 2 cases died without childbirth; of the remaining 11 cases who gave birth, only 4 survived, including 3 multiparas with premature labor and 1 primipara whose hepatic coma worsened postpartum and was ultimately saved by fetal liver cell transplantation.
The above data illustrate the obstetric management principles for such patients as follows:
(1) Multiparas with premature labor can undergo vaginal childbirth under the aforementioned active treatment conditions.
(2) For all primiparas who are at term or near term, a cesarean section under local anesthesia should be performed after 1-2 days of the aforementioned active treatment. However, postoperative use of analgesics such as pethidine (Dolantin) is prohibited to avoid increasing the burden on the liver, exacerbating the condition, or even leading to death.
(3) Postoperative continuation of supportive therapy and administration of broad-spectrum antibiotics to prevent infection.
(1) Hepatitis A is a benign self-limiting disease. The hepatitis A virus is transmitted through fecal contamination and oral pestilence, with particular attention needed for foods like clams.
(2) Strengthen public health education on dietary hygiene, pay attention to utensil disinfection, and especially ensure the hygiene of raw or cold dishes.
(3) If a pregnant woman has been in contact with a hepatitis A patient, strive to administer an intramuscular injection of gamma globulin within 2 weeks, with a dose generally ranging from 0.02 to 0.05 mg/kg. Lerman et al. (1993) noted that using immune serum globulin (ISG) at 0.02 ml/kg can provide 2 months of protection; if the dose is increased to 0.06 ml/kg, the protection period can be extended to 6 months. They suggested that for short-term prevention of hepatitis A infection, an injection of 2 ml of immune serum globulin is sufficient. If 5 ml of immune serum globulin is administered, passive immunity can be maintained for 5 to 12 months.
