Deteksi Dini

Hepatitis B dalam
Kehamilan

Ali Sungkar
Divisi Fetomaternal, Departemen Obstetri & Ginekologi FKUI / RCM - PB POGI
 Background Information

1991 hepatitis B screening of pregnant

women recommended by ACOG, AAP, ACIP
Risk of perinatal transmission
HBsAg and HBeAg + at delivery - 70-90%
HBsAg + only 5-20%
90% of infants infected perinatally will
become chronic carriers of hepatitis B
25% of those infected will die of HBV-related
disease
Hepatitis B: Global Health Problem
Indonesia
Epidemiology of hepatitis B infection
Worldwide - 300 million chronic carriers
Epidemiology varies around the world
Characteristics Hepatitis A Hepatitis B Hepatitis C
Virus type RNA DNA RNA
Virus size 27 nm 42 nm 30-60 nm
Incubation period 15 50 days 30 180 days 30 160 days
Transmission Fecal oral Parentral or body fluid Parentral sporadic
Vertical transmission
Not observed Common Uncommon
to fetus
HBs Ag, HBs Ab, IgM, and
Hepatitis A antibody IgG types Hepatitis C antibody
Serologic diagnosis
IgM and IgG types HBe Ag, Ab, Hepatitis B RNA by PCR
virus DNA

Prodrome or HBe Ag
Maximum infectivity Prodrome HIV co- infected
Positive
Carrier state None 5 10% 50 85%
Asymptomatic to Asymptomatic to
Acute clinical forms Asymptomatic to fulminant
fulminant sever relapsing

Chronic persistent
Chronic persistent hepatitis
hepatitis
Chronic clinical Chronic active hepatitis
None Chronic active
forms Cirrhosis
hepatitis
Cirrhosis
Patogenisitas Virus Hepatitis Pathogens!
 Possible
Possible Outcomes
Outcomes of of
Hepatitis B Infection
Hepatitis B Infection

Acute HBV Chronic HBV Chronic hepatitis B

infection infection HBeAg-positive

Fulminant HBsAg Reactivation

Recovery hepatitis carrier

Chronic hepatitis B
HBeAg-positive
Cirrhosis
HDV
Chronic hepatitis B superinfection
HCC HBeAg-positive
 Hepatitis B Lab Markers
Marker Abbreviation Use
Hepatitis B surface HBsAg Detection of acutely or chronically
antigen infected persons; antigen used in
hepatitis B vaccine
M class immunoglobulin IgM Anti-HBc Identification of acute or recent HBV
antibody to hepatitis B Anti-HBc, IgM infections (including those in HBsAg-
core antigen HBcAb, IgM negative persons during the window
phase of infection)
Antibody to hepatitis B Anti-HBc Identification of persons with acute,
core antigen HBcAb resolved, or chronic HBV infection
(not present after vaccination)
Antibody to Hepatitis B Anti-HBs Identification of persons who have
surface antibody HBsAb resolved infection with HBV;
determination of immunity after
immunization
Hepatitis B e antigen HBeAg Identification of infected persons at
increased risk for transmitting HBV
Antibody to Hepatitis B e Anti-HBe Identification of infected person with
antigen HBeAb lower risk for transmitting HBV
 Differential Diagnosis of Liver
Disease in Pregnancy
Serum Bilirubin Coagulo Histology Other Features
Transaminases pathy

Acute >1000 >5 - Hepatocellular Potential for

Hepatitis B necrosis perinatal
transmission

Acute <500 <5 + Fatty infiltration Coma,

Fatty Liver renal failure,
hypoglycemia
Intrahepatic <300 <5, - Dilated bile Pruritis, increased
Cholestasis mostly canaliculi bile acids
direct
HELLP >500 <5 + Variable HTN, edema,
periportal thrombocytopenia
necrosis
Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course

Symptoms
HBeAg anti-HBe
Total anti-HBc
Titer
IgM anti-HBc
HBV DNA

HBsAg anti-HBs

Window
Period

0 4 8 12 16 20 24 28 32 36 52 100
Weeks after Exposure
Progression to Chronic Hepatitis B Virus Infection
Typical Serologic Course
Acute Chronic
(6 months) (Years)
HBeAg anti-HBe
HBsAg
Total anti-HBc
Titer

IgM anti-HBc

0 4 8 12 16 20 24 28 32 36 52 Years
Weeks after Exposure
 Acute vs. Chronic HBV Infection

Acute Chronic
HBsAg+ < 6 months. HBsAg + for at least 6
IgM anti-HBc + positive months
Infection will resolve and Also known as a carrier
person will have lifelong Infection does not resolve
immunity and the person remains
HBsAb+ and HBcAb+ infectious
HBsAb- and HBcAB+
 What do these HBV results mean?
Hepatitis B surface antigen POSITIVE
vThis is a screening result which needs to be confirmed
by other tests before we know her true HBV status
vShe could be currently infected with hepatitis B virus
vThis could transmit to her baby at birth
vNeed to test for other hepatitis B markers:
vConfirmation second hepatitis B surface antigen test
vHepatitis B e antigen and antibody
vHepatitis B core IgM antibody
What do these HBV confirmatory results mean?
(Hepatitis B surface antigen POSITIVE)
Confirmation second Hepatitis B surface antigen test
Strongly Positive She IS Infected with HBV
Hepatitis B e antigen and antibody
Hepatitis B e antigen Positive She is very infectious
Hepatitis B core IgM antibody
Negative she has not been infected in the last few
months and so is likely to be a Persistently infected
carrier of HBV
How is Hepatitis B spread?

By having unprotected sex?

By kissing?
By using a public toilet?
By standing next to an infected
person on a bus?
By sharing mobile phones?
 How is Hepatitis B spread?

By having unprotected sex? YES

By kissing? NO NO
By using a public toilet? NO
By standing next to an infected person
on a bus? NO
By sharing mobile phones? NO
Management of Hepatitis B
Infection in Pregnancy
Management of Hepatitis B in Pregnancy

Confirm Hepatitis B surface antigen (HBsAg) status

of the mother
Confirm Hepatitis B e status
She is HBe Antigen positive HIGHLY INFECTIOUS
Confirm if this is an acute case of HBV in pregnancy
She is anti-HBc IgM negative so she has not acquired
HBV infection in the last few months and during this
pregnancy
Management of Hepatitis B in Pregnancy
Hepatitis B e status
HBe Antigen positive means the woman is highly
infectious and has a high risk of transmitting HBV
to the baby at birth
HBe Antigen positive people also have a high risk
of transmitting infection to others via unprotected
sex or through blood contact
Anti-HBe positivity status implies people are much
less infectious
Management of Hepatitis B in Pregnancy
If a pregnant woman has confirmed HBV infection in
pregnancy there is a risk of transmission to her baby
If she has anti HBe antibody, the baby is given HBV
vaccine soon after birth and then at months 1,2 and 12
If she has no anti-HBe antibody or the mother
acquired HBV infection during pregnancy, the baby
should receive HBV vaccine as above PLUS hepatitis
B immunoglobulin as soon after birth as possible
 Management of Hepatitis B in Pregnancy
vMother to be referred to a liver doctor or infectious disease
physician for clinical review she may benefit from antiviral
treatment
vMother to be informed that baby will need immunisation at
birth and at 1, 2 and 12 months old the addition of hepatitis
B immune globulin (ready made antibody) might also be
required at birth based on the following criteria:
Mother HBeAg positive
Mother negative for both HBeAg and Anti-HBe
Mother positive for anti-HBc IgM (indicating an acute infection in
pregnancy)
Mother had high level of virus DNA (>1,000,000IU/ml)
vBaby will need a blood test at 12 months to ensure that he/she
has not become infected
 Effect of hepatitis B vaccination
on Perinatal transmission

o Without intervention 70% - 90% of the babies born

to HBeAg mothers would become persistently
infected
o With vaccination started just after birth 30% may
become infected (70% are protected)
o With vaccination after birth with immune globulin
less than 10% become infected (over 90%
protection)
Strategies to Reduce HBV Disease

Continue and enhance vaccination efforts

School and childcare requirements
HCW
Adults (20-44 years)
Birth dose
Surveillance
Early detection
Education
Perinatal hepatitis B prevention program
Rationale for the screening programme
Hepatitis B
Is a viral infection of the liver resulting in acute and
chronic liver disease which is potentially life threatening
Is transmitted through blood and other body fluids with
the risk of vertical transmission to an unborn fetus
Infants who contract hepatitis B from their mother during
pregnancy or childbirth have a poor prognosis from
developing chronic liver disease at a young age
Targeted immunisation of these infants will provide them
with 95% protection from the disease
 Perinatal transmission
Transmission can occur in utero but is mainly around the
time of delivery.
Approximately 1 in 4 mothers with chronic hepatitis B
infection will infect their baby
82% if HBeAg positive
9% if HBsAg positive only
Breastfeeding not contraindicate
If a baby is infected perinatally, 90% chance of them
becoming a chronic carrier
Infectious to others
Risk of developing chronic liver disease

Giving hepatitis B vaccine + Hepatitis B immunoglobulin

(HBIG) to babies will prevent 90-95% of babies becoming
chronic hepatitis B carriers
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Requirement for HBIG
Six Responsibilities of Perinatal
Hepatitis B Prevention Program
Assure identification Assure all exposed
of ALL HBsAg infants receive HBIG
positive women and and 1st dose of hep.
their infants B vaccine w/in 12
Prevention
hours of birth
of
Perinatal
Hepatitis B
Transmission
Assure
Assure that all
completion of 3

susceptible
household and doses of hepatitis
sexual contacts B vaccine and post
are vaccinated vaccination testing
of exposed infants

Conduct active
surveillance, quality
assurance, and outreach to
improve program
 Ibu hamil yang ANC di RSCM
trimester satu

Skrining Hepa;;s B
HBsAg

HBsAg (+) HBsAg(-)

Cek HBV-DNA Risiko ;nggi

Vaksinasi HBV
Cek ulang + infeksi -
HBV-DNA HBV-DNA HBsAg
> 108 kopi/ml < 108 kopi/ml sebelum Risiko ;nggi:
-> 2 pasangan seks dalam 6
persalinan bulan
Konsul minimal 30 -IMS
hepatologi hari setelah -Pengguna IVDU
terapi ARV -Pasangan HBsAg (+)
vaksin terakhir -Pasien secara klinis hepa;;s

Neonatus
menerima
vaksin HBV HBsAg (-) Edukasi
dan HBIG saat pen;ngnya
lahir vaksinasi HBV
 Ibu hamil ANC

Skrining Hepa;;s B
HBsAg, an; Hbs

HBsAg (+)
HBsAg(-)

Cek HBsAg
Keluarkan dari
ulang 1 bulan
peneli;an
lagi

HbsAg (-) HbsAg(+)

Keluarkan dari Cek HbeAg, an; Hbe, an; Hbc, HBV Protokol Penelitian
peneli;an DNA, SGOT, SGPT Profile Hepatitis B

Profil hepatitis B di Indonesia

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