The combination of chronic hepatitis B (CHB) in pregnancy is an important issue that is both common and uniquely challenging. HBV infection in pregnant women is different from the general population and requires thinking about a number of special issues: such as the impact of HBV infection on the mother and fetus, the effect of pregnancy on HBV replication, whether HBV antiviral therapy should be administered during pregnancy, the impact of these treatments on the mother and fetus, how newborns are immunized, and whether hepatitis activity can be induced in the postpartum period, among a host of other issues. This article provides a review of the management of pregnant CHB patients from clinical practice. Pregnancy combined with chronic hepatitis B (CHB) is an important issue that is both common and uniquely challenging. HBV infection in pregnant women is different from the general population and requires thinking about a number of special issues: such as the impact of HBV infection on the mother and fetus, the effect of pregnancy on HBV replication, whether HBV antiviral therapy should be administered during pregnancy, the impact of these treatments on the mother and fetus, how to immunize the newborn, and whether hepatitis activity can be induced in the postpartum period, among a host of other issues. This article provides a review of the management of pregnant CHB patients from a clinical practice perspective. Pregnancy and chronic hepatitis B interact with each other A series of physiological changes occur in the mother during pregnancy, such as high maternal metabolism and high nutrient consumption; a large amount of sex hormones produced by the mother during pregnancy need to be metabolized and inactivated in the liver, and the metabolism and detoxification of the fetus also depend on the maternal liver to complete. HBV infection can increase the burden of existing liver disease and worsen liver damage. There is a tendency for ALT to increase in late pregnancy and postpartum, but there is no significant difference in HBV replication during pregnancy. A proportion of women experience immune activation for HBeAg seroconversion in the initial months after delivery, and studies have found a seroconversion rate of 12.5% to 17% during this period, which may be related to the marked decline in adrenocorticotropic hormones after delivery. Overall, chronic HBV infection in women of childbearing age has no serious impact on the course of pregnancy. Some studies have reported that chronic HBV infection is associated with gestational diabetes, antepartum hemorrhage, preterm delivery, and reduced fetal Apgar score. If the mother has severe liver function abnormalities, she is prone to postpartum hemorrhage, increased chance of puerperal infection, and susceptibility to fetal low birth weight, fetal distress, preterm delivery, stillbirth, and neonatal asphyxia. Although HBV infection is often tolerated during pregnancy, there are still perinatal hepatitis outbreaks leading to severe hepatic failure and poor prognosis for mother and child. Perinatal management of patients with chronic hepatitis B Perinatal screening for HBV has become an integral part of standard perinatal care due to the emergence of relatively safe and effective treatment protocols for HBV. Screening for maternal HBV infection identifies newborns who require primary-passive immunization with hepatitis B vaccine and hepatitis B immune globulin (HBIG) and pregnant women who require antiviral medication during pregnancy, and allows for guidance on sexual and family contact for HBV-infected individuals. HBV-infected women should do plan their pregnancies. Baseline assessment is recommended before pregnancy: HBsAg, HBeAg, anti-HBe, HBV DNA, severity of liver disease, and whether other viral infections are co-infected. Assess their tolerance for pregnancy and the risk of mother-to-child transmission. All pregnant women must be screened for HBV at the first antenatal visit during early pregnancy; all those screened positive for HBsAg should be referred to a hospital with experience in managing pregnant women with hepatitis B. This will facilitate monitoring of the mother during pregnancy, delivery, postpartum and the newborn, as well as access to appropriate mother-to-child blockade treatment on an individual basis. Treatment of Chronic HBV Infection in Pregnancy The goals of treatment for CHB in pregnancy are: stable maternal liver function during pregnancy and no HBV infection in the newborn. the mother needs regular monitoring of liver function and HBV DNA levels throughout pregnancy to assess whether the mother has progressive liver disease and whether antiviral therapy is needed. 1. If the baseline HBV DNA level is low (HBV DNA < 106 copies/mL for HBeAg positive; HBV DNA < 105 copies/mL for HBeAg negative) and there is no significant fibrosis, antiviral therapy will be withheld and monitoring will be performed during pregnancy. If HBV DNA > 107 copies/mL or HBV DNA > 106 copies/mL in the third trimester of pregnancy with a previous history of HBV-positive infant delivery, antiviral therapy should be given; otherwise, antiviral therapy can be withheld. 2. If the baseline HBV DNA level is high and there is significant liver fibrosis but no cirrhosis, it is recommended that antiviral therapy be administered first. If the response can be sustained after drug discontinuation, pregnancy can be carried out and monitored during pregnancy, and the treatment is the same as ①; if the response cannot be maintained after drug discontinuation, the treatment is the same as ③. 3. If cirrhosis existed before pregnancy, it is recommended to administer antiviral therapy before pregnancy and choose lamivudine (LAM) or tenofovir (TDF) or telbivudine (LdT), and continue antiviral therapy with one of the above drugs during pregnancy, and monitor throughout pregnancy. Issues related to antiviral therapy in pregnancy There is a clear correlation between intrauterine and perinatal transmission of HBV and maternal HBV DNA levels, with high levels of HBV DNA being an independent risk factor for the occurrence of intrauterine transmission. The more studied method of blocking mother-to-child transmission is the treatment of pregnant women with oral antiviral drugs in late pregnancy, which reduces HBV transmission from mother to child by lowering the peripheral blood HBV DNA titer before delivery. 1, the choice of antiviral drugs. Interferon has a proliferation inhibiting effect and is prohibited for use during pregnancy, and those who apply it can only become pregnant after six months of discontinuation. So far the FDA certified pregnancy B antiviral drugs are LdT and TDF, in view of the increasing safety data of LAM in clinical applications, the National Institutes of Health (NIH) to LAM to pregnancy B drugs. 2. Indications for antiviral therapy. All pregnant women who screen positive for HBsAg are recommended to undergo baseline evaluation during early pregnancy for: HBsAg, HBeAg, anti-HBe, HBV DNA, hepatitis activity, liver fibrosis or degree of cirrhosis. If HBV DNA levels are high and hepatitis activity (ALT > 2 x ULN, HBV DNA > 105 copies/mL) or cirrhosis is present in early pregnancy, antiviral therapy is administered in early pregnancy. In pregnant women with normal liver function, ALT and HBV DNA are re-evaluated at mid-pregnancy (26-28 weeks); those with HBV DNA >107 copies/mL or HBV DNA >106 copies/mL and a history of previous births of HBV-positive infants should be given LAM, TDF or LdT antiviral therapy at 28-30 weeks and continued until 4 weeks postpartum. The decision to continue will be based on the condition; otherwise, antiviral therapy may be withheld. If cirrhosis existed before pregnancy, it is recommended to administer antiviral therapy before pregnancy and choose LAM, TDF or LdT, and continue antiviral therapy with one of the above drugs during pregnancy, and monitor throughout pregnancy (Figure 1). 3. Women with unintended pregnancy during anti-HBV treatment need to be individualized for each case. There are two options: one is to temporarily discontinue the drug, monitor HBV DNA and ALT levels throughout the pregnancy, and then decide whether or not to administer antiviral therapy based on the specific situation, which is suitable for patients with mild hepatitis and less risk of severe rebound or disease progression; the other is to continue antiviral therapy throughout the pregnancy, but should be changed to LAM, TDF or LdT. although all HBsAg-positive pregnant women’s neonates require combined primary-passive immunization and breastfeeding does not increase the risk of HBV infection in neonates, evidence of the safety of these drugs in neonates exposed during breastfeeding has not been obtained for pregnant women who have received antiviral therapy whether or not to breastfeed. Management of HBV-infected pregnant women during and after delivery To interrupt HBV infection in infants, the mode of delivery has also been considered a potential risk factor for the occurrence of mother-to-child transmission. However, to date, there is no reliable evidence-based medical evidence to confirm the impact of mode of delivery on reducing mother-to-child transmission of HBV. All newborns of HBsAg-positive mothers should be immunized with combined primary-passive immunization on schedule after birth, and blood should be drawn for HBsAg, HBeAg, anti-HBe and HBV DNA at birth and at 7 months of age. hepatitis B vaccination and combined HBIG immediately after birth are effective in blocking infection during delivery and postpartum, but not for intrauterine infections that have already occurred. This is the main cause of immunization failure in infants after birth. All HBsAg-positive pregnant women should be monitored for ALT and HBV DNA at 1, 3, and 6 months postpartum, and observed for serologic conversion and anti-HBe positive conversion if hepatitis activity is present. In summary, perinatal transmission of HBV is a major cause of chronic HBV infection, and to reduce the burden of HBV it is necessary to consider how to interrupt this mode of transmission. Specific testing, interventions, and follow-up measures for this special population of chronically HBV-infected women of childbearing age deserve particular attention and exploration.