Hepatitis may predate pregnancy or may occur coincidentally during or after pregnancy. The diagnosis of acute viral hepatitis is made from the history and from blood tests of liver function (increased conjugated bilirubin, markedly increased transaminases, and slightly increased alkaline phosphatase). Chronic hepatitis (active, persistent, drug- or alcohol- induced) also causes abnormality of liver function tests, but definitive diagnosis is made by liver biopsy.
Problems and special considerations
Viral hepatitis
Viral hepatitis accounts for 40% of all liver disease associated with pregnancy, and in its acute form is the most common cause of jaundice in pregnant women. The disease may be caused by the hepatitis viruses, cytomegalovirus, Epstein-Barr virus or herpes simplex virus. It is thought that pregnant women might be more susceptible to viral hepatitis because of their relatively immunosuppressed state.
Hepatitis A is highly contagious and spread by the faecal-oral route. The incidence in pregnancy is unknown, since many infections are mild, but is thought to be low in the UK. The disease course is similar to that in non-pregnant patients, although infection may carry an increased risk of fetal morbidity and preterm labour.
Hepatitis B is thought to infect up to 1 in 50 pregnant women in UK inner cities, in which there is a large immigrant population. It is readily spread by contact with blood and body fluids. Women who are intravenous drug users and those who have had multiple sexual partners or are sex workers should be assumed to be at high risk of having hepatitis B, and appropriate precautions should be taken. There is a ~10% risk of developing chronic liver disease; this may be increased by co-infection with hepatitis D. The risk of transmission to the fetus is 10-20% if the mother is positive for the hepatitis B surface antigen (HbsAg) and around 90% if she is positive for the hepatitis B envelope antigen (HBeAg), and so pregnant women have been screened for hepatitis B in the UK since 2000. Measures to reduce maternofetal transmission of infection include administration of hepatitis B immunoglobulin to the mother during pregnancy and to the baby at birth, and vaccination of the baby at birth, 1 month, 2 months and 12 months of age. Some women with high viral loads may require additional treatment with antivirals in late pregnancy.
Hepatitis C is unusual in pregnancy in the UK; its prevalence in inner-city parturients is thought to be 0.5-1%. It is spread mainly by contact with blood, although sexual transmission may also occur. There is a 50-80% risk of developing chronic liver disease, and a ~5% risk of transmission to the baby during pregnancy and delivery. There is currently no preventive treatment to decrease the risk of transmission to the fetus.
Hepatitis E is similar to hepatitis A, but is unusual in the UK. Infections occurring during the last trimester may have a fulminant course with a maternal mortality up to 50%.
Symptoms of viral hepatitis are non-specific, and include fatigue, general malaise, loss of appetite, nausea, vomiting, headache and pyrexia. There may be some abdominal discomfort. Overt jaundice only occurs in about a quarter of cases. Treatment is symptomatic, and in the majority of cases there is complete resolution of all signs and symptoms over the course of a few weeks. Women with significantly impaired liver function may be thrombocytopenic or have abnormal clotting studies. Renal function may also be impaired. In endstage hepatitis, alteration in mental state may occur as a result of hepatic encephalopathy. There is no evidence that pregnancy affects the course of the disease, nor that hepatitis has any significant effect on pregnancy in the majority of cases. For the small number of pregnant women who develop hepatitis C, it has been suggested that maternal morbidity and mortality is higher than in non-pregnant women. However, this increased risk may be apparent, due to misdiagnosis of conditions such as fatty liver of pregnancy, rather than a genuine risk.
Chronic hepatitis
Chronic persistent hepatitis is usually unaffected by pregnancy. Chronic active hepatitis is associated with impaired fertility; if pregnancy does occur it may be associated with accelerated deterioration in liver function. Treatment includes corticosteroids and antiviral drugs including interferon. The risk of interferon to the fetus is unknown. Lupus antibodies may occur in up to 20% of women with chronic active hepatitis. Chronic active hepatitis may be complicated by arthritis, impaired renal function, myocarditis and neuropathies. Diabetes, hypertension and osteoporosis may also occur as a result of long-term steroid therapy.
Management options
Regional analgesia and anaesthesia are not contraindicated if coagulation studies are normal. If there is chronic impairment of liver function, invasive venous pressure monitoring may assist fluid management, especially if regional anaesthesia is performed. Although fluid overload must be avoided, hypotension will aggravate any reduction in liver blood flow. There may be impaired clearance of lidocaine; dose reduction is advisable.
Patients with severe liver disease often have severely impaired liver function and coagulopathy. Women who have oesophageal varices are at an increased risk of suffering a bleed during pregnancy. Avoidance of pushing during vaginal delivery is recommended, but superimposed obstetric complications (pre-eclampsia, fetal growth restriction) will frequently necessitate operative delivery.
Rapid-sequence induction of general anaesthesia for caesarean section should be used. Suxamethonium can be used safely, despite the greater than normal reduction in plasma cholinesterase levels that is likely to be present. Use of a peripheral nerve stimulator is mandatory, since the action of non-depolarising neuromuscular blockers may be prolonged, and blood glucose levels must be monitored. Opioid analgesia should be used with caution in women with severe hepatic dysfunction.
Standard infection control precautions should be used if women with viral hepatitis are hospitalised.
Key points
• Viral hepatitis is highly contagious.
• Regional analgesia and anaesthesia are not contraindicated, but impaired liver function may be associated with disorders of coagulation.
Further reading
Tran TT. Hepatitis B in pregnancy. Clin Infect Dis 2016; 62 (Suppl 4): S314-17.
Westbrook RH, Dusheiko G, Williamson C. Pregnancy and liver disease. J Hepatol 2016; 64: 933-45.