Hepatitis B dalam Kehamilan

Noroyono WibowoFetomaternal Division

Department of Obstetrics & GynecologyFaculty of Medicine University of IndonesiaDr. Cipto Mangunkusumo General Hospital

Jakarta

Viral Hepatitis - OverviewViral Hepatitis - Overview

Type of HepatitisType of Hepatitis

AA BB CC DD EESource ofvirus

feces blood/blood-derived

body fluids

blood/blood-derived

body fluids

blood/blood-derived

body fluids

feces

Route oftransmission

fecal-oral percutaneouspermucosal

percutaneouspermucosal

percutaneouspermucosal

fecal-oral

Chronicinfection

no yes yes yes no

Prevention pre/post-exposure

immunization

pre/post-exposure

immunization

blood donorscreening;

risk behaviormodification

pre/post-exposure

immunization;risk behaviormodification

ensure safedrinkingwater

Estimates of Acute and Chronic DiseaseBurden for Viral Hepatitis, United States

HAV HBV HCV HDVAcute infections(x 1000)/year* 125-200 140-320 35-180 6-13

Fulminant deaths/year 100 150 ? 35

Chronicinfections

0 1-1.25 million

3.5million 70,000

Chronic liver disease deaths/year 0 5,000 8-10,000 1,000

* Range based on estimated annual incidence, 1984-1994.

Outcome of Hepatitis B Virus InfectionOutcome of Hepatitis B Virus Infectionby Age at Infectionby Age at Infection

Symptomatic Infection

Chronic Infection

Age at Infection

Chr

onic

Infe

ctio

n (%

)

Sym

ptom

atic

Infe

ctio

n (%

)

Birth 1-6 months 7-12 months 1-4 years Older Childrenand Adults

0

20

40

60

80

100100

80

60

40

20

0

• Prevent perinatal HBV transmission• Routine vaccination of all infants• Vaccination of children in high-risk groups• Vaccination of adolescents

– all unvaccinated children at 11-12 years of age– “high-risk” adolescents at all ages

• Vaccination of adults in high-risk groups

Elimination of Hepatitis B Virus Elimination of Hepatitis B Virus Transmission in the United StatesTransmission in the United States

StrategyStrategy

Interpretation of the Hepatitis B PanelTests Results InterpretationHBsAganti-HBcanti-HBs

negativenegativenegative

Susceptible

HBsAganti-HBcanti-HBs

negativepositivepositive

Immune due to natural infection

HBsAganti-HBcanti-HBs

negativenegativepositive

Immune due to hepatitis B vaccination

HBsAganti-HBcIgM anti-HBcanti-HBs

positivepositivepositivenegative

Acutelyinfected

HBsAganti-HBcIgM anti-HBcanti-HBs

positivepositivenegativenegative

Chronicallyinfected

HBsAganti-HBcanti-HBs

negativepositivenegative

1. Might be recovering from acute HBV infection.2. Might be distantly immune and test not sensitive enough to detect very low level of anti-HBs in serum.3. Might be susceptible with a false positive anti-HBc.4. Might be undetectable level of HBsAg present in the serum and the person is actually chronically infected

Definitions• Hepatitis B Surface Antigen (HBsAg): A serologic

marker on the surface of HBV. It can be detected in high levels in serum during acute or chronic hepatitis. The presence of HBsAg indicates that the person is infectious. The body normally produces antibodies to HBsAg as part of the normal immune response to infection.

• Hepatitis B Surface Antibody (anti-HBs): The presence of anti-HBs is generally interpreted as indicating recovery and immunity from HBV infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B.

Definitions• Total Hepatitis B Core Antibody (anti-HBc):

Appears at the onset of symptoms in acute hepatitis B and persists for life. The presence of anti-HBc indicates previous or ongoing infection with hepatitis B virus (HBV) in an undefined time frame.

• IgM Antibody to Hepatits B Core Antigen (IgM anti-HBc): This antibody appears during acute or recent HBV infection and is present for about 6 months.

• Transmissibility 100 times greater than HIV1 • Vertical

– Infected mother-to-infant during first year of life• Earlier age at exposure increases the risk of

developing chronic HBV infection2

Transmission of HBV

1. WHO-CSR

2. WHO and CDC fact sheets, available at www.who.int and www.cdc.gov

INTRAUTERINE INFECTION OF HBV

• HBsAg Seropositive Rate at Birth : 2.4% (16/665) Among Neonates of HBeAg

Positive, HBsAg Positive Mothers

• Chronicity : 100%

Tang JR et al. J Pediatr 1998 ; 133: 374

Lamivudine Therapy During Pregnancy to Prevent Perinatal Transmission of HBV Infection

8 Highly Viraemic (HBV-DNA>1.2 x 109 geq/mL) Mothers Treated With 150 mg of lamivudine Daily Since 34 Wks of Gestation.

HBV-DNA, HBsAg, Anti-HBs, Anti-HBc of their Infants were Measured at 0, 3, 6, 12 Months.

• Historical Control : 24 Children , born to untreated HBsAg-positive mothers with HBV-DNA levels >1.2 x 109 geq/mL

• All children received passive-active immunization at birth .

van Zonneveld M, et al. ( J Viral Hepatitis 2003; 10: 294-7)

Lamivudine Treatment During Pregnancy to Prevent Perinatal Transmission of HBV Infection

• Lamivudine Group : 1/8 Children (12.5%) was HBsAg and HBV-DNA positive at age 12 months.

• Untreated Historical Control Group, Perinatal Transmission Occurred in 7/25 children (28%).

M. van Zonneveld M, et al. ( J Viral Hepatitis 2003; 10: 294-7)