My first baptism with hepatitis in pregnancy was an encounter with a patient that had bleeding post delivery, which generally is referred to as Post Partum Haemorrhage PPH. I had actually been called. It was a crazy experience: blood was just coming from the uterus, sutured episiotomy site and even the nose!
The standard procedure of making the uterus to contract and packing the vaginal introitus was religiously followed. Every time we did, the sanitary pads got soaked so fast that you wondered whether you did the right thing. Unfortunately, before she could receive adequate blood transfusion, she succumbed.
We were all stunned and devastated. Well, it was time to ask questions. She wasn’t a haemophliac, neither did she have any known bleeding disorder. The only thing I got to know was that her ante-natal viral screening confirmed that she was Hepatitis B positive. I almost went out of my mind; in the process reviewing whether the protective gear I wore was adequate. I immediately cursed the risks and hazards surgeons are exposed in the cause of their job.
Lately, I was invited to perform a caesarian section on a woman whose expected day of delivery had passed and the baby’s weight was low for that gestational age. Her first delivery was through a Caesar for which she also received blood transfusion. On seeing her on the operating table, I noticed that the colour of her was very dark. I had no doubt in my mind that the concentration of BILIRUBIN and UROBILINOGEN in the urine was high. When I asked whether she had malaria: or was actively haemolysing; that is destroying the red blood cells in her. The doctor told me that she had hepatitis. I froze. He, however, assured me that her bleeding and PROTHROMBIN times were normal. We proceeded and everything went well with the delivery of a low birth weight baby. There was no abnormal bleeding.
For definitions, HEPATITIS is the inflammation of the Liver as a result of infection by the hepatitis virus. In his acute form the infection is easily noticed from the yellow discoloration of the skin and the white part of the eye known as the sclera. This is as result of high level of bilirubin in the circulation. The known variants of the virus include A, B, C, D, E, F and G. The most prevalent in our environment that cause most scourges are hepatitis A and B. Hepatitis A infection is the second commonest among the lot. It has an acute course with full recovery within eight to 12 weeks. The virus is transmitted by faeco-oral route; in other words by eating food contaminated by faeces. The virus only replicates in the cytoplasm of Liver cells. The resultant inflammation and Liver cell death or necrosis is not as a direct effect of the virus populating the hepatocytes but the effect of the immune response from the infection. This is largely thought to be mediated by the T-Lymphocytes. The inflammation, which results in the swelling of the liver cells leads to the obstruction of the biliary canaliculi with resultant appearance of bilirubin in the blood and urine. This virus can also be transmitted through sexual contact; but poor hygiene and sanitation is the rule.
During pregnancy, mother-to-child is almost impossible as the anti-hepatitis A immunoglobulin antibodies present during the early stages of the infection crosses the placenta barrier to protect the baby after delivery. To date, no evidence of congenital hepatitis A infection has been reported. Thus in pregnancy, no intervention is recommended in hepatitis A infection.
Hepatitis B infection is caused by the similarly named virus, which has a double stranded DNA core surrounded by a lipoprotein. This is where the hepatitis B antigen HBsAg is located. The lipoprotein is excessively produced and leaks into the blood circulation. The virus itself does not kill liver cells. It merely interferes with the functions of the liver while replicating and it is the immune response to this that leads to the inflammation resulting in cell death and scarring of the Liver. It is a chronic condition such that those infected would have started transmitting the virus without exhibiting any symptoms. It is transmitted through blood, body fluid and sexual intercourse. A break in the skin and mucosa is needed for an effective and successful transmission.
The hepatitis virus cannot cross the placenta because of its size; so while in the womb the foetus cannot be infected. Infection can only occur if there is a break in the mother-baby barrier, such as you have when the water bag breaks. Procedure done by a care giver it is known as AMNIOCENTESIS. During labour and delivery, a period referred to as perinatal, transmission from mother to the newborn is most important mode of infection. The infection rate is very high and that makes it mandatory that as the patient’s expected day of delivery draws near, IMMUNOGLOBULIN must be available in readiness to be administered to the baby on arrival. The whole concept is to quickly neutralize the virions that must have crossed to the baby during delivery.
The diagnosis of hepatitis is made by estimating the level liver enzymes in the blood like Alanin Aminotransferases (ALP), Aspartate Aminotransferases (ASP) and Alkaline Phosphatase (ALP). The most diagnostic is Alanin aminotransferases. For those involved in obstetrics, Prothrombin Time is absolutely necessary as the day of delivery approaches. This is because most of the clotting factors in the blood are produced in the liver. With regards to hepatitis B infection the specific test involves the evaluation of the antigens and anti bodies. These include the SURFACE antigen and antibodies (HBsAg and anti-HBs), CORE antigen and anti-bodies (HBcAg and anti-HBc) and PRECORE antigen and antibodies (HBeAg and anti-HBe). The presence of precore antigen and antibodies is indicative of severe disease and high infectivity.
Having said much, it must be borne in mind that during pregnancy viral hepatitis is associated with the lowest risk of complications when compared with other liver diseases like acute fatty liver of pregnancy, severe preeclampsia and Haemolysis Elevated Liver Enzymes and Low Platelet (HELLP) syndrome. In most cases no special treatment is required during the acute phase of the infection. Bed rest is not mandatory. In our environment it should be recalled that some of these patients are picked up during routine ante-natal screening.
There are good antiviral drugs now in use if need be and the indication for their use must be apt. They include drugs like LAMIVUDINE, ANTECAVIR and Interferon, which is an immunomodulatory drug. The challenge to drug therapy remains mutation of the virus and resistance.