in one article I have found mothers with hepatitis are encouraged to breastfeed. "Hepatitis B antibodies have been detected in breastmilk from women who test positive for Hepatitis B. However, studies from Taiwan and England have shown that breastfeeding by Hepatitis B positive women does not significantly increase the risk of infection among their infants. Infants born to known Hepatitis B positive women should receive Hepatitis B immune globulin (HBIG) and Hepatitis B vaccine (HBV), effectively eliminating any theoretical risk of transmission through breastfeeding. "

Source: http://www.childrensspecialists.com/body.cfm?id=388

According to the Center for
Disease Control and Prevention (CDC) and the World Health Organization (WHO), it is safe for an infected
woman to breastfeed her child. All women with hepatitis B are encouraged to breastfeed their
babies since the benefits of breastfeeding outweigh the potential risk of transmitting the virus through
breast milk. In addition, since all newborns should receive the hepatitis B vaccine at birth, the risk of
transmission is reduced even further.

Breastfeeding is acceptable and does not pose a risk of transmitting hepatitis B virus (HBV) to infants who have begun prophylaxis.

Management of pregnant woman with hepatitis

Management of pregnant women with chronic HBV infection should be aimed: at counseling on maternal risk of infection,
rates of vertical transmission, and
preparation for neonatal vaccination.

Limited data suggest that intrauterine infection may occur at higher rates in mothers with high serum HBV DNA levels, leading to failure of standard passive-active immunoprophylaxis with HBIG and vaccine. Thus, treatment of these individuals with an oral HBV antiviral agent in the third trimester may be considered after discussion with the mother regarding the risks and benefits of therapy.

(Tran, 2008)

Antiviral Therapy

•alpha-interferon or lamivudine
•Interferon does not appear to adversely affect the embryo or fetus.
•Initial data do not suggest that Lamivudine is teratogenic. Lamivudine has been used in the latter half of pregnancy in attempt to prevent perinatal transmission of hepatitis B virus infection with mixed success.


In one study: In highly viraemic HBsAg-positive mothers, reduction of viraemia by lamivudine therapy in the last month of pregnancy may be an effective and safe measure to reduce the risk of child vaccination breakthrough.

With regards as to whether mother can safely breatfeed the infant..

HBV-infected mothers can safely breastfeed their infants,
according to the CDC. While the surface antigen – the
outer coating of the virus – is found in breastmilk, there
are no intact viruses in breastmilk that can infect infants.
Studies have shown that breast-fed infants who were
immunized immediately after birth were not at increased
risk of HBV infection when compared to infants who were
not breast-fed.

http://www.hcvadvocate.org/hepatitis/factsheets_pdf/HBV_mother.pdf

TYPE OF DELIVERY and BREASTFEEDING during hepatitis infection

infection of the infant can occur despite by delivery of cesarean section and in unimmunized infants the HBsAg carrier rate is not affected by the route of delivery. However in ecent study, infants of HeAg positive mothers given HB vaccine in the first week of life were less likely to become HBsAg carriers if they had been delivered by cesarean section (10%) than if they had been delivered vaginally (25%). The overall carrier rates were lower in a subgroup who recieved passive as well as active immunization bu tstill differed significantly according to route of delivery (6% = CS, 20%=vaginally).

However, these findings suggest that CS may offer additional protection for infants of highly infectious HbsAg carrier mothers. a higher dose of HBIG and/or a more immunogenic vaccine given after vaginal delivery probably would be equally effective and safer than CS.


In unimmunized infants the incidence of HBV transmission is not affected by breast feeding although HBsAg can be detected in breast milk of about 70% of carriers. However, in small proportion of infants in whom immunization fails, breast milk is a conitnuiing potential source of infection.

(Gilbert, 1991)

according to some literatures, the risk of transmission of the virus via breastfeeding is still a topic of debate.

According to the WHO, breastfeeding has been suggested as an additional mechanism by which
infants may acquire HBV infection, because small amounts of Hepatitis B surface antigen (HBsAg) have been detected in some samples of breastmilk. However, there is no evidence that breastfeeding increases the risk of mother to child transmission.

• A follow up study of 147 infants born to mothers known to be carriers of HBV in Taiwan found
  similar rates of HBV infection in 92 children who were breastfed compared to 55 who were bottle fed.
  
• A study in Britain, involving 126 subjects, also showed no additional risk for breastfed versus non
  breastfed infants of carrier mothers. This study included the measurement of HBeAg status of the mothers, but found no association between maternal e-antigen status and transmission rates.
  

These findings suggest strongly that any risk of transmission associated with breastmilk is negligible compared to the high risk of exposure to maternal blood and body fluids at birth. Experts on hepatitis, however, do have concerns that breast pathology such as cracked or bleeding nipples or lesions with serous exudates could expose the infant to infectious doses of HBV.

Reference: Hepatitis and Breastfeeding (WHO doc) available at http://www.medguide.org.zm/whodocs/hepbrest.htm

classmates do you still have other answers for the type of delivery aside for what Ara posted?

another consideration during the intrapartal management would be the choice of birthing...

as what thea posted, the mode of delivery does not appear to have an effect on the interruption of transmission. but caesarean delivery is still preferred.

Share lang...

* Failure to screen a pregnant mother or a mother who presents in labor without having received prenatal care and whose hepatitis B status remains unknown could lead to physician liability because the baby may not have received optimal prophylaxis and is at risk for chronic hepatitis B.
* Failure of the physician to either notify an infected person identified with blood screening or other tests or provide appropriate counsel regarding transmission (eg, sexual contact, needle sharing) may lead to the exposure of additional people to hepatitis B.

* Hepatitis B is one of the major diseases that can be prevented with vaccination. Two types of recombinant hepatitis B vaccines are licensed for use in the United States; both are effective and safe.
* Universal vaccination refers to the administration of HBV vaccine to all infants as a part of the routine childhood immunization schedule and to all children younger than 11 or 12 years who have not previously received a vaccine. Rapid (0-, 1-, and 2-mo) and standard (0-, 1-, 6-mo) schedules have identical efficacy.
* Passive immunization refers to the administration of preformed human or animal antibody, in the form of hepatitis B immunoglobulin (HBIG), to patients after or just before exposure.
o The current recommendation for neonates of mothers who are HB s Ag positive is to administer HBIG 0.5 mL intramuscularly with the first dose of recombinant HBV vaccine within 12 hours of birth.
o After immunization, serology should be tested for HB s Ag and anti-HB s at age 9-18 months.
o In infants of infected mothers, combined treatment with the vaccine and HBIG has 79-98% efficacy in preventing chronic HBV infection.
* Patients on dialysis and those who are immunocompromised need to be evaluated annually for hepatitis B; if the anti HB s Ab level is less than 10 mIU/mL, a booster dose is recommended.
* Testing of hepatitis serology for immune response is recommended for high-risk groups such as homosexuals and bisexuals, patients on dialysis, sexual and household contacts of hepatitis B carriers and patients with human immunodeficiency virus (HIV) infection.
* After 3 primary doses of the vaccine, if no serologic response with anti-HB s of 10 mIU/ml is noted, reimmunization with a 3-dose series is recommended. If the response if still negative, they are unlikely to mount antibody with additional doses.
* Twinrix is a combination of hepatitis B (Engerix-B, 20 mcg) and hepatitis A (Havrix, 720 ELU) vaccine approved for people aged 18 years or older in a 3-dose schedule administered at 0 months, 1 month, and 6 or more months later.
* For preterm infants who weigh less than 2000 g and are born to mothers with unknown HB s Ag status, 0.5 ml HBIG should be given within 12 hours. The birth dose should not be counted, and 3 additional doses are given according to recommendations.

Hepatitis B

Author: Poonam Sharma, MD, Assistant Professor, Department of Pathology, Creighton University Medical Center and Veterans Affairs Medical Center; Director of Pathology Course, School of Pharmacy and Health Professions, Creighton University Medical Center
Coauthor(s): Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine; Alexander T Kessler, MD, Consulting Staff, Northside Medical Specialties, LLC; Athena P Kourtis, MD, PhD, Assistant Professor, Department of Pediatrics, Divisions of Infectious Diseases and Epidemiology, Emory University School of Medicine


Updated: May 1, 2008

yes.. all of you are correct... when handling vaccination like Hepa B we should try to consider cold chain, because Hep B vaccine is least heat sensitive.

>> i think it will be adherence to the contact precaution...

considerations in giving it to the infant:
1) follow the schedule of immunization. give 3 doses, 1st dose at birth, 2nd dose after 6 weeks, 3rd dose after 8 weeks. It is given IM in the upper outer portion of the infant's thigh.
2)contraindication in giving it is severe sensitivity to the drug/its component.

Antepartum
Pregnant Hepatitis B carriers should be advised to
• Obtain vaccination against hepatitis viruses A as indicated.
• Abstain form alcohol use
• Avoid hepatotoxic drugs such as acetaminophen (Tylenol) that may worsen liver damage.
• Not donate blood, body organs, other tissue, or semen.
• Not share any personal items that may have blood on them (e.g., toothbrushes and razors).
• Inform the infant’s pediatrician, OB/GYN, and labor staff that they are a hepatitis B carrier.
• Make sure their baby receives hepatitis B vaccine at birth, one month, and six months of age as well as H-BIG at birth.
• Be seen at least annualy by their regular medical doctor.
• Discuss the risk for transmission with their partner and discuss the need for counseling and testing
b. Liver function testing is recommended for women who test positive for HBsAg [1]

The following recommendations from The Society of Obstetricians and Gynecologists of Canada may be helpful in counseling women considering amniocentesis.

SOGC Recommendations [14]

• “The risk of fetal hepatitis B infection through amniocentesis is low. However, knowledge of the maternal hepatitis B e antigen status is valuable in the counselling of risks associated with amniocentesis.
• For women infected with hepatitis B, hepatitis C, or HIV, the addition of noninvasive methods of prenatal risk screening, such as nuchal translucency, triple screening, and anatomic ultrasound, may help in reducing the age-related risk to a level below the threshold for genetic amniocentesis.
• For those women infected with hepatitis B, hepatitis C, or HIV who insist on amniocentesis, every effort should be made to avoid inserting the needle through the placenta. “


Although cesarean delivery has been proposed as a means of reducing mother to child transmission (MCT) of HBV. The mode of delivery does not appear to have a significant effect on the interruption of HBV maternal-baby transmission by immunoprophylaxis. Delivery by cesarean section for the purpose of reducing MCT of HBV is note presently recommended by either the CDC or the ACOG.

Breast feeding.
With appropriate hepatitis B immunoprophylaxis, breast-feeding poses no additional risk for transmission from infected hepatitis B virus carriers

Reference:

Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines --- 2002 .MMWR May 10, 2002 / 51(RR06);1-80
2. ACOG educational bulletin. Viral hepatitis in pregnancy. Number 248, July 1998 . American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1998 ;63:195-202. MEDLINE

http://www.perinatology.com/exposures/Infection/HepatitisB.htm