Recently, I have seen many lesbians of childbearing age struggling with mother-to-child transmission. In fact, there are many articles on this subject, only that our scientific activities are not well done, so that the articles sleep in the magazines, and those who need them are at a loss. The following is part of the manuscript “Recommendations for the interruption of mother-to-child transmission of hepatitis B virus infection” that I myself once wrote, and I hope it will help you.
First of all, let’s understand the pregnancy classification of anti-HBV drugs
(i) Prenatal blockade
1.Anti-viral treatment
Treatment for women with HBV infection who wish to become pregnant depends on the severity of the disease and the level of HBV DNA, and needs to be individualized and can be based on the following roadmap for choosing an antiviral treatment regimen.
If HBV DNA levels are low, i.e., HBV DNA <5 log copies/mL (HBeAg positive) or HBV DNA <4 log copies/mL (HBeAg negative), and there is no clear liver fibrosis, treatment can be delayed until after delivery to avoid fetal exposure to therapeutic agents, but HBV DNA levels should be monitored repeatedly for 3 months before delivery. DNA levels, if the patient has very high viremia (HBV DNA >7 log copies/mL), reasonable treatment with “B” drugs can be used in the 3 months before delivery, and the regular treatment regimen can be used after delivery.
If HBV DNA level is very high, i.e. HBV DNA >5 log copies/mL (HBeAg positive) or HBV DNA >4 log copies/mL (HBeAg negative), or if there is definite liver fibrosis but no cirrhosis, treatment should be started before pregnancy, and if there is a durable response to treatment, treatment can be considered to be stopped before pregnancy, but after stopping the drug , it should be strictly monitored during pregnancy to prevent recurrence of hepatitis. If you already have cirrhosis, you should receive antiviral therapy before pregnancy and continue antiviral therapy during pregnancy and postpartum, and you should be treated with class “B” drugs during pregnancy.
In case of unplanned pregnancy while on anti-HBV therapy, individualized treatment is recommended as follows.
① For patients with hepatitis B who have an unplanned pregnancy during treatment with LAM or “B” drugs, one option is to discontinue treatment, monitor serum HBV DNA levels and ALT activity throughout pregnancy, and restart treatment after delivery, which is only appropriate for patients with mild liver inflammation, severe flare-ups, and low risk of disease progression. The other option is to continue LAM or a “B” drug therapy. Asymptomatic HBsAg carriers with chronic hepatitis B and HBV DNA positivity who have no indication for treatment may be considered for LAM or a class “B” drug in late pregnancy to reduce mother-to-child transmission.
For hepatitis B patients with unplanned pregnancy during ETV and ADV treatment, it is recommended to terminate the pregnancy with full communication with the patient and family members. It is not clear whether ETV and ADV can reduce mother-to-child transmission; therefore, the use of ETV or ADV is not recommended for the prevention of mother-to-child transmission in asymptomatic carriers of HBsAg with chronic hepatitis B and HBV DNA positivity without treatment indications.
(iii) In patients with hepatitis B who have unintended pregnancy during treatment with interferon analogues, termination of pregnancy is recommended and interferon analogues are contraindicated in the treatment of hepatitis B during pregnancy or in the interruption of mother-to-child transmission.
(ii) Delivery interruption
Whether different modes of delivery (mainly cesarean section and vaginal delivery) affect the risk of mother-to-child transmission of HBV remains controversial. The majority of incidents of mother-to-child transmission of HBV occur during labor, and the mechanisms involved may include infusion of maternal blood into the fetus due to labor contractions, infection after rupture of the amniotic membrane, and direct exposure of the fetus to infected blood or secretions in the mother’s birth canal. Recent Meta-analyses strongly support the effectiveness of cesarean delivery in reducing mother-to-child transmission of HBV compared with vaginal delivery (cesarean delivery, 10.5%; vaginal delivery, 28.0%), with statistically significant comparisons between the two groups (RR 0.41, 95% CI 0.28C0.60, P < 0.000001), but the lack of randomization and blinding in methodology makes the prevention of mother-to-child transmission of HBV by cesarean delivery transmission is uncertain, and higher quality randomized controlled studies are still needed to assess the advantages of cesarean delivery versus vaginal delivery for the prevention of mother-to-child transmission of HBV.
(iii) Postnatal interruption
1. Blocking mother-to-child transmission of HBV through immunoprophylaxis.
(1) Immunoprophylaxis for newborns of HBsAg-positive mothers – combined active and passive immunization
All newborns of HBsAg-positive mothers should receive one injection of single antigen HBV vaccine and HBIG 100IU at different sites within 12 hours after birth, the second HBV vaccine at 1 to 2 months of age, the third at 6 to 8 months of age, and the last vaccine should not be given before 24 weeks of age (164 days) (i.e., 0, 1, 6 months). For premature infants weighing less than 2000 g, the first vaccine dose (birth dose) should not be counted as part of the vaccine series because these infants may have reduced immunogenicity of HBV vaccine. The other 3 vaccine doses (4 in total) should be initiated when the infant reaches 1 month of age (i.e., 0, 1, 2, and 7 months).
Monitoring for anti-HBs and HBsAg should be done as late as possible after completion of the HBV vaccination series (9 to 18 months of age) and not before 9 months of age, avoiding detection of anti-HBs in infancy after HBIG administration. infants who are HBsAg negative with anti-HBs levels ≥10 mIU/mL indicate protection and do not require further vaccination. For infants who are HBsAg negative with anti-HBs levels <10 mIU/mL, they should receive 3 additional doses of HBV vaccine and be retested 1 to 2 months after the last vaccination. Infants who are HBsAg positive should receive appropriate follow-up and treatment.
(2) Immunoprophylaxis for infants born to mothers with unknown HBsAg status
For pregnant women who are hospitalized for delivery but do not have HBsAg test results, blood should be drawn and tested immediately after hospitalization. In the case of delivery before the test result is announced, all newborns should receive the first dose of single antigen HBV vaccine (without HBIG) within 12 h after birth. If the mother tests positive for HBsAg, her infant should receive HBIG 100 IU intramuscularly if possible, but no later than 7 days of age, and the vaccination should be completed within the recommended timeframe. If the mother tests negative for HBsAg, the HBV vaccine series should also be completed within the recommended timeframe, and HBIG is not necessary for these infants.
Because preterm infants weighing less than 2000 g may have reduced vaccine immunogenicity, if the mother’s HBsAg status is unknown within 12 h of delivery, these infants should receive single antigen HBV vaccine and HBIG (0.5 mL) injections. Three additional doses of vaccine should be given within the recommended time frame (4 doses in total) based on the mother’s HBsAg test results. In addition, regarding breastfeeding, HBsAg can be detected in the milk of most HBV-infected mothers, and there may be concerns regarding the risk of breastfeeding after the infant has been immunized. In China, it has been reported that the rate of colostrum infection in pregnant women with hepatitis B is related to the degree of infection, and the highest rate of HBV infection in colostrum was 84.85% in HBsAg, HBeAg and HBcAb-positive mothers, followed by 19.05% in HBsAg, HBeAb and HBcAb-positive mothers, and the lowest rate of infection in single HBsAg-positive mothers was 9.52%. hBeAg-positive pregnant women Breast milk, the rate of HBV DNA positivity in saliva was as high as 77.77%, indicating that close contact between mothers and infants and breastfeeding is a non-negligible route of HBV transmission from mother to child. However, numerous studies have confirmed that there is no significant difference in perinatal infection rates between breastfed and formula-fed vaccinated infants. Therefore, it is believed that breastfeeding is not a contraindication to HBV infection in infants receiving HBIG and HBV vaccine and that breastfeeding does not interfere with the infant’s immune response to HBV vaccine, therefore, infants born to HBsAg-positive mothers can begin breastfeeding immediately after birth provided they have received HBIG and HBV vaccine.
However, for lactating mothers on antiviral therapy, it is clear that lamivudine is excreted in breast milk at similar concentrations to plasma; animal studies have shown that telbivudine, entecavir, and tenofovir are excreted in breast milk, but in humans, it is unclear whether these three drugs are excreted in breast milk; it is unclear whether interferon analogs and adefovir are excreted in breast milk. To avoid possible harm from exposure of newborns to anti-HBV drugs, breastfeeding mothers are advised to avoid anti-HBV drugs, and maternal patients who are using them are advised to avoid breastfeeding.