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PREGNANCY
DR shams rehan
THREE PATHOLOGICAL
PROCEDURES LEADS TO JAUNDICE
HAEMOLYSIS
CONGENITAL HYPERBILIRUBINEMIA
CONJUGATED
UNCONJUGATED
CHOLESTASIS
INTRAHEPATIC
EXTRAHEPATIC
VIRAL HEPATITIS
HEPATITIS A VIRUS
HEPATITIS A VIRUS
Global distribution
Outbreaks in areas with crowded
conditions , inadequate water supply,
poor hygiene & sanitation
Highly contagious virus with fecal-oral
route of transmission& exposure to
contaminated food & water
Parenteral transmission is rare b/c
virus is present only transiently in
serum
HEPATITIS A VIRUS
DIAGNOSIS
INITIAL CLINICAL SYMPTOMS
Fatigue , malaise, fever , nausea , anorexia
Significant weight loss may be presenting
symptom in pregnant women
THE CLASSICAL ICTERIC ILLNESS become
apparent with in 10 days of generalized
symptoms & is usually preceded by
palpable hepatosplenomegaly
FULMINANT HEPATITIS resulting in death in
<1% of cases
HEPATITIS A VIRUS
MATERNAL & FETAL EFFECTS
HEPATITIS A VIRUS
MANAGEMENT OPTIONS
HEPATITIS B IN GENERAL
HBV , a major global health problem with
600,000 ANNUAL DEATHS attributable to
consequences of HBV infection
IN AREAS OF ASIA, 8-10 % of the adult
population is chronically infected with HBV
The earlier in life a person is infected, the
higher the risk of being a chronic carrier,
so the risk of chronic HBV infection for a
child infected in the newborn period, in the
absence of prophylactic therapy is 70-90 %
TRANSMISSION OF HBV
1. BLOOD & BLOOD PRODUCTS are the most
thoroughly established sources of HBV
infection
2. BODY FLIUDS like Serum ,saliva & semen
have been associated consistently with
transmission
3. PER-CUTANEOUS TRANSFER of the virus is the
most obvious route of transmission in the
medical settings , through needle stick
injuries
4. Contact of infectious material with BROKEN
SKIN or mucous membranes
TRANSMISSION OF HBV
HBV is fairly stable virus & remains
infectious on household surfaces up to 7
days
Although transmission in households is
more common through sexual contacts
NONSEXUAL HOUSEHOLD TRANSMISSION
(fomite contacts) has been established as a
route for HBV infection
Therefore , any surfaces potentially
contaminated with infectious blood should
be cleaned with 1:10 of bleach solution
TRANSMISSION OF HBV
Vertical transmission is a major
source & 40-50 % 0f HBsAg
carriers become infected in
perinatal period
Children born to carrier mothers
who escapes the neonatal period
without evidence of infection are
still
at
risk
of
childhood
acquisition of HBV
DIAGNOSIS
DISTINGUISHING FEATURES OF
HEPATITIS B VIRUS
LONG INCUBATION PERIOD ( 1-6
MONTHS)
By the presence of extra hepatic
symptoms in 20% of
patients( arthralgia , rash , myalgia)
Detection of HBV specific serum
markers
There are three distinct antigen-
more than
DISAAPEARANCE OF HB s Ag &
THE APPEARANCE OF
ANTI
HBsAb SIGNALS
1. RECOVERY FROM HBV
INFECTION
2. NONINFECTIVITY
3. IMMUNITY
WINDOW PERIOD
A WINDOW OF TIME has been described
In which a patient still with clinical hepatitis
is negative for both HB s Ag & HBsAb.
During this time ,HBV infection still can be
diagnosed by the detection of hepatitis B core
antibody ( HBcAb), which begins to appear 3-5
weeks after HBsAg does
HBcAb titers may drop off in the first 1-2 years
after infection , although the antibody is still
detectable years after acute disease in most
patients
Anti Hbc
HBcAg alone doest appear in serum
IgM anti-HBc appears shortly after HBsAg is detected
IgM anti-HBc indicates a diagnosis of acute hepatitis
B, and it fills the serologic gap in rare patients who
have cleared HBsAg but dot yet have detectable
antiHBs.
IgM anti-HBc may also reappear during flares of
previously inactive chronic heptitis B
IgG antiHBc also appear during acute hepatitis B but
persits
indefinitely;
whether
the
patient
recovers( with appearance of anti HBs) or chronic
HBV develop( with persistence of HBsAg)
HBeAg
It appears in serum during the incubation
period shortly after detection of Hb s Ag
IT INDICATES VIRAL REPLICATION &
INFECTIVITY
Persistence of Hbe Ag beyond three months
indicates increased likely hood of chronic
hepatitis B
Its disappearance is often followed by the
appearance of anti Hbe, signifying diminished
viral replication & decreased infectivity
Ig +
M
IgG +
*
IgG -
ACUTE HEPATITIS B
IgG +
or
_
+
-
0r
MANAGEMENT
TREATMENT DURING PREGNANCY IS MAINLY
SUPPORTIVE AS IN NON-PREGNANT STATE
HOSPITALIZATION SHOULD BE CONSIDERED
FOR PREGNANT WOMEN WITH ACUTE HBV
INFECTION IF
ENCEPHALOPATHY
COAGULOPATHY
SEVERE NUTRITIONAL & FLUID IMBALANCE
NO TERATOGENIC ASSOCIATION HAS BEEN
ESTABLISHED
MANAGEMENT
VERTICAL TRANMISSION
The rate of vertical transmission
during
acute
maternal
HBV
infections
depends
on
the
gestational age of fetus
DURING FIRST TRIMESTER --- up
to 10 % of neonates will be
infected
-DURING THIRD TRIMESTER -- up
to 80-90 % of neonates will be
HBs Ag positive.
HEPATITIS B SCREENING IN
PREGNANCY
POST EXPOSURE
TREATMENT
Single dose of HBIG administered
as
temporally as possible immediate to the
exposure
A series of HBV vaccination should also be
initiated ,if the exposure was within a setting
of ongoing risk e.g health care.
The regimen consists of injections at 0,1,6
months
Administration
of
HBV
vaccine
simultaneously with HBIG doest diminish the
immunologic response to the vaccine
PREVENTING
TRANSMISSION
PERINATAL
HEPATITIS VACCINATION IN
PREGNANCY
PREGNANCY IS NOT A
CONTRAINDICATION TO VACCINATION.
Limited data suggest that developing
fetuses are not at risk for adverse
events when hepatitis B vaccine is
administered to pregnant women.
Available
vaccines
contain
noninfectious
HBsAg
and
should
cause no risk of
infection to the
fetus.
HEPATITIS B SEROLOGY
HBs
Ag
ACUTE
HBs Ab HBc Ig
M
HBc
IgG
HBeAg
HBeAb
HBV
DNA
+
RESOLVE
D ACUTE
INFECTIO
N
CH
CARRIER
STATE
CH
ACTIVE
HEPATITI
S
VACCINAT
ED
+/_
+
+
+/_
RESULT
HBsAg
Anti- HBc
Anti- HBs
HBsAg
Anti- HBc
Anti- HBs
HBsAg
Anti- HBc
Anti- HBs
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
POSITIVE
POSITIVE
NEGATIVE
NEGATIVE
INTERPRETATIO
N
SUSCEPTIBLE
IMMUNE DUE
TO NATURAL
INFECTION
IMMUNE DUE
TO HEPATITIS
B
VACCINATION
POSITIVE
RESULT
HBsAg
Anti- HBc
IgM Anti- HBc
Anti- HBs
POSITIVE
POSITIVE
POSITIVE
NEGATIVE
INTERPRETATIO
N
ACUTELY
INFECTED
CHRONICALLY HBsAg
POSITIVE
INFECTED
Anti- HBc
POSITIVE
IgM Anti- HBc NEGATIVE
Anti- HBs
NEGATIVE
TESTS
HBsAg
Anti- HBc
Anti- HBs
RESULTS
NEGATIVE
POSITIVE
NEGATIVE