Case #4
1. What risk/s does an infant born to a mother positive for HBsAg have?

The risk for an infant born to a mother positive for HBsAg is there’s a possibility that a newborn can acquire that virus from her mother which is transmitted during pregnancy or delivery. Almost 90% of these babies will become chronically infected with hepatitis B at birth if there is no prevention.


2. In the case, the mother was not immediately tested fro HBaAg. Ideally, when should pregnant women be tested for HBsAg?

Ideally, HBsAg testing should be done early in pregnancy and when other routine prenatal testing is done.

3. What is the correct medical management for this woman, having known that she was positive for HBsAg? If a pregnant woman tests positive for hepatitis B, then she should be referred to a liver specialist for further evaluation. Although most women do not have any pregnancy complications as a result of HBV infection, it is still a good idea to be seen by a specialist.

What is a possible adverse effect of treatment on the fetus? What happens to the baby if the vaccine is not received on time?

Women who present for delivery without prenatal care or without medical records documenting the results of HBsAg screening should have the HBsAg test done as soon as possible after admission, since delay in administration of HBIG to infants of carrier mothers will decrease the efficacy of therapy. In the studies that demonstrated the highest efficacy (85%-95%) of combined HBIG and HB vaccine prophylaxis, HBIG was administered within 2-12 hours after birth (2,4-6). In one study in which only HBIG was used for prophylaxis, no efficacy was found if HBIG was given more than 7 days after birth, and a significant decrease in efficacy was observed if it was given more than 48 hours after birth (16). Only one-third of U.S. hospitals currently perform the HBsAg test as an in-house procedure, and many of these have technicians who are trained to do the test available on only one shift. Hospitals that cannot rapidly test for HBsAg should either develop this capability or arrange for testing to be done at a local laboratory or blood bank where test results can be obtained within 24 hours.
1. Stevens CE, Beasley RP, Tsui J, Lee W-C. Vertical transmission of hepatitis B antigen in Taiwan. N Engl J Med 1975;292:771-4.
2. Stevens CE, Toy PT, Tong MJ, et al. Perinatal hepatitis B virus transmission in the United States: prevention by passive-active immunization. JAMA 1985;253:1740-5.
3. Beasley RP, Hwang L-Y. Epidemiology of hepatocellular carcinoma. In: Vyas GN, Dienstag JL, Hoofnagle JH, eds. Viral hepatitis and liver disease. Orlando, Florida: Grune & Stratton, 1984:209-24.


4. What are important considerations in handling and administration of hepatitis B vaccines.

Infants born to HBsAg-positive mothers should receive HBIG (0.5 mL) intramuscularly (IM) once they are physiologically stable, preferably within 12 hours after birth. HB vaccine, either plasma-derived (10 *gmg per dose) or recombinant (5 *gmg per dose), should be administered IM in three doses of 0.5 mL each. The first dose should be given concurrently with HBIG but at a different site. If vaccine is not immediately available, the first dose can be given within 7 days after birth. The second and third doses should be given 1 month and 6 months after the first. Testing the infant for HBsAg and its antibody (anti-HBs) is recommended at 12-15 months of age to monitor the effectiveness of therapy. If HBsAg is not detectable and anti-HBs is present, the child can be considered protected.

1. Stevens CE, Beasley RP, Tsui J, Lee W-C. Vertical transmission of hepatitis B antigen in Taiwan. N Engl J Med 1975;292:771-4.
2. Stevens CE, Toy PT, Tong MJ, et al. Perinatal hepatitis B virus transmission in the United States: prevention by passive-active immunization. JAMA 1985;253:1740-5.
1. Beasley RP, Hwang L-Y. Epidemiology of hepatocellular carcinoma. In: Vyas GN, Dienstag JL, Hoofnagle JH, eds. Viral hepatitis and liver disease. Orlando, Florida: Grune & Stratton, 1984:209-24.
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5. Upon knowing that a mother is positive for HBsAg, how will you care for her during the intrapartal period?
-I think we have to assist her for an appropriate counseling and medical management.
- Provide Health teaching about the mode of transmission, any perinatal concerns like breastfeeding, prevention of HBV transmission, including the importance of postexposure prophylaxis for the newborn infant and hepatitis B vaccination for household contacts and sex partners

6. What is the preferred method of delivery in pregnant women found positive for HBsAg? Why?
I think any method of delivery will do either nsd or cesarean section because there is still possibility of transmitting that virus to the baby.

7. Should breastfeeding be encouraged?
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.

For Case #3

1. What were the underlying causes of Jyotsana’a death?
-The underlying causes of Jyotsana’s death, were lack of assessment skills on the part of the doctor, delayed decision making on both parties, and the infection brought by the dead fetus.

2. What should she have done differently?
- I think Jyotsana should have monitored well the movement of her baby inside her womb and should have consulted the doctor immediately when she noticed something different, and maybe through this, her death could have been prevented and one more thing since she came from a well-to do family maybe she could have sought for second opinion if she was not satisfied with the service of the first consultant/doctor.

3. What should her family have done differently?
- I think the family should have explored more and insisted to the doctor to tell the real condition of Jyotsana and the possible options or treatment that could have been done and the family should have suggested or accompanied Jyotsana to seek for second opinion, maybe through Jyotsana’s death could have been prevented.

4. What should the doctors have done differently?
- I think the doctor should have a thorough assessment about Jyotsana’s condition to confirm the diagnosis he had in his mind and if his diagnosis was confirmed with the results of the procedure that were supposed to be perform, then he should not hold back or suppress the information to Jyotsana and her family, even if that is too painful on the part of Jyotsana. If in case the doctor was not that competent to handle such case I think he/she could have referred Jyotsana to the other doctor/consultant who is competent enough to handle such case.

1. What risk/s does an infant born to a mother positive for HBsAg have?

The precise mechanism of HBV transmission remains unclear, but it appears that infection may occur intrapartum or, rarely, in utero. Hepatitis B viral DNA and HBsAg have been detected in amniotic fluid, placental cells, and vaginal secretions of HBsAg-positive women during pregnancy and in cord blood of their neonates

Three possibilities of transmission of HBV from carrier mothers to newborns are suggested: (a) transplacental transmission in utero - it was estimated that such transmission occurred in 5-15% of newborns; (b) transmission during delivery, which is considered the main mode of perinatal transmission; (c) postnatal transmission from mother to newborn, which is not common.

The overall rate of transmission of HBV from an infected HBsAg-positive mother to her neonate during the perinatal period ranges from 5-90% in the absence of immunoprophylaxis [2,4-7]. This risk depends on whether the mother also has a positive hepatitis B e antigen (HBeAg) test; those with a positive HBeAg test have a transmission rate of 70-90%, whereas those with a negative HBeAg test have a rate of transmission less than 10% [2]. In these mothers with HBeAg, the risk of HBV perinatal transmission is reduced from 70-90% to approximately 5-15% when the infant receives postnatal immunoprophylaxis with both hepatitis B immune globulin (HBIG) and hepatitis B vaccine series [5,6]; the risk is reduced to approximately 20% with regimens that use multiple doses of HBIG only or the vaccine series alone [1,2, 4-6]. Although controlled trials have not been performed with HBeAg-negative women, postexposure prophylaxis with HBIG and vaccination would presumably further minimize the risk of transmission.

Most neonates with HBV infection are asymptomatic but develop chronic, subclinical hepatitis characterized by persistent HBsAg antigenemia and variably elevated transaminase activity. Many born to women with acute hepatitis B during pregnancy are of low birth weight, regardless of whether they are infected.

Infrequently, infected neonates develop acute hepatitis B, which is usually mild and self-limited. They develop jaundice, lethargy, failure to thrive, abdominal distention, and clay-colored stools. Occasionally, severe infection with hepatomegaly, ascites, and hyperbilirubinemia (primarily conjugated bilirubin) occurs. Rarely the disease is fulminant and even fatal. Fulminant disease occurs more often in neonates whose mothers are chronic carriers of hepatitis B.

2. In the case, the mother was not immediately tested fro HBaAg. Ideally, when should pregnant women be tested for HBsAg?

* Test all pregnant women at the first prenatal visit for hepatitis B surface antigen (HBsAg).
* Women admitted for delivery who have not had prenatal HBsAg testing should have blood drawn for testing [5].
* Send a copy of the original lab report to the hospital.
* “More than 90% of women found to be HBsAg-positive on routine screening will be HBV carriers, routine follow-up testing later in pregnancy is not necessary for the purpose of screening. In special situations, such as when the mother is thought to have acute hepatitis, when there has been a history of exposure to hepatitis, or when particularly high-risk behavior such as parenteral drug abuse has occurred during the pregnancy, an additional HBsAg test can be ordered during the third trimester” [6]
* Test all susceptible contacts (including all family members) with hepatitis B panel (HBsAg, antiHBc, antiHBs).
* Screening and vaccination of susceptible contacts should be done by the family's pediatrician, primary health-care provider, or the physician evaluating the clinical status of the HBsAg-positive pregnant women.
• Health-care providers should test all pregnant women for HBsAg during each pregnancy.
• HBsAg testing should be incorporated into standard prenatal testing panels (e.g., blood type, HIV infection, Rh factor, rubella antibody titer, syphilis infection) used by all practitioners caring for pregnant women.
• Women who test negative for HBsAg but have risk factors (>1 sex partner in past 6 months, evaluation or treatment for a sexually transmitted disease, recent or current injection-drug use, HBsAg-positive sex partner) should be vaccinated against hepatitis B and should be retested in the third trimester.

3. What is the correct medical management for this woman, having known that she was positive for HBsAg?

What is a possible adverse effect of treatment on the fetus? What happens to the baby if the vaccine is not received on time?


The treatment of acute HBV infection is supportive.Persons with chronic hepatitis B should be referred to health-care professionals with experience in the treatment of hepatitis B for treatment with alpha-interferon or lamivudine [1]. Interferon does not appear to adversely affect the embryo or fetus. However, the data is limited, and the potential benefits of interferon use during pregnancy should clearly outweigh possible hazards [7-9]. Initial data do not suggest that Lamivudine is teratogenic [10]. Lamivudine has been used in the latter half of pregnancy in attempt to prevent perinatal transmission of hepatitis B virus infection with mixed success [11,12]


There is a certain risk that if a child at danger is not immunised, it may develop into a chronic carrier and eventually produce liver damage.

Some sources proved that delayed vaccination schedules are not less effective than immunization beginning right after birth. A 1993 article (18) states that "late active immunization starting at 3 months of age appears to provide similar protective efficacy as active immunization starting at birth when combined with hepatitis B immune globulin at 0 and 3 months of age." Passively acquired antibodies at birth (immune globulines) remained present for about five months in most infants (19). 18. Am J Dis Child, 1993; 147/12:1316-20 19. Vaccine, 1994; 12/12:1059-63



4. What are important considerations in handling and administration of hepatitis B vaccines.

Administer 0.5 mL hepatitis B vaccine intramuscularly in the anterolateral thigh muscle for infants
Choose needle length appropriate to the child’s
age and body mass: newborns (first 28 days of life) and premature infants: e"; infants younger than age 12 mos: 1"; toddlers
1–2 yrs: 1–13" (anterolateral thigh) or e–1" (deltoid muscle);
It is necessary to give 4 doses of HepB when Comvax or Pediarix vaccines are given after the
birth dose.

5. Upon knowing that a mother is positive for HBsAg, how will you care for her during the intrapartal period?

AT THE TIME OF ADMISSION
• Review the hepatitis B surface antigen (HBsAg) status of all pregnant women admitted for labor and delivery.
• Accept only laboratory reports as documentation of hepatitis B status.
• Perform HBsAg testing as soon as possible if there is no documentation of the woman’s HBsAg status or if she has clinical hepatitis.
• Retest women who are known to have engaged in behaviors that put them at risk for acquiring hepatitis B infection during pregnancy (e.g., recent intravenous drug use, an HBsAg-positive sex partner, more than one sex partner in the past 6 months, or treatment for a sexually transmitted disease).

Pregnant women who present at delivery with unknown HBsAg status should have blood drawn at that time for HBsAg testing. In most states, hepatitis B infection in pregnancy is a reportable condition, and state and local public health departments have programs to provide education and follow-up for HBsAg positive women and their children. Mothers who have a positive HBsAg test should undergo evaluation to determine if they have evidence of chronic liver disease. To facilitate immunoprophylaxis of a woman who is HBsAg seropositive, provide a copy of her laboratory report to her delivery hospital and/or the obstetrical provider that will attend her devlivery, as well as the healthcare provider who will care for her neonate.

6. What is the preferred method of delivery in pregnant women found positive for HBsAg? Why?

The mode of delivery (vaginal versus caesarean) does not appear to have an impact on the risk for perinatal HBV infection. 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.


7. Should breastfeeding be encouraged?
Transmission of HBV through breast milk is not a significant source of infection, as demonstrated by several small studies performed before the era of routine neonatal prophylaxis [12,13]. With appropriate hepatitis B immunoprophylaxis, breast-feeding poses no additional risk for transmission from infected hepatitis B virus carriers [17,18] However, if a mother has cracked nipples, abscesses, or other breast pathology, breastfeeding could potentially transmit HBV.



References:
J Virol Methods. 1987 Aug;17(1-2):69-79. Perinatal transmission of hepatitis B virus in high-incidence countries. Ghendon Y. World Health Organization, Geneva, Switzerland.

Neonatal Hepatitis B Virus Infection

Labor and Delivery Unit and Nursery Unit Guildelines to Prevent Hepatitis B Virus Transmission

Components of Case Management Programs to Prevent Perinatal Hepatitis B Virus (HBV) Infection


Hepatitis B Infection

Hepatitis-B vaccination in newborns Kris Gaublomme, MD


A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States

Standing Orders for Administering Hepatitis B Vaccine to Children & Teens

Preventing Perinatal Hepatitis B Guidelines for Labor and Delivery Units

Recommendations of the Immunization Practices Advisory Committee Prevention of Perinatal Transmission of Hepatitis B Virus: Prenatal Screening of all Pregnant Women for Hepatitis B Surface Antigen

Case Study: Treating Complications in Pregnancy

Jyotsana’s Story

Jyotsana
was 20 years old and had been married for one year. She came from a
well-to do family, and now lived in a small village with her husband.
This was her first pregnancy. She had regular antenatal check- ups at a
private clinic, and her pregnancy had been uneventful. When she was
eight months pregnant, however, she suddenly developed a fever and a
pain in her abdomen. She was taken to a private doctor, who admitted
her for observation, but he was soon called away and did not examine
her very well. The doctor did not tell Jyotsana or her family what he
thought her diagnosis was or discuss any treatment options with them.
The next day her condition became worse, and her relatives were told to
take her to the hospital, which was located more than 40 km away.

By
then, Jyotsana could not speak and was unresponsive. By the time they
arrived at the hospital, she had already died. The doctor examined her
and told the relatives that the baby had died earlier in her abdomen
and might have poisoned her body, leading to her death.

Questions for Students
1. What were the underlying causes of Jyotsana’a death?

Physiologic piont-of-view:
Fever
and pain are very general symptoms. Fever could either represent an
underlying inflammatory condition/infection or fluid loss. In this case
fever is more likely to have been caused by fluid loss, i.e. bleeding.
The bleeding that have occurred perhaps could have been a concealed one
as in the case of abruptio placenta, where the placenta has been
completely torn from the uterus. The pain the pain she felt is also one
sign of the said condition. With the placenta no longer attached there
was no source of oxygen and nutrients for the fetus, hence, fetal death
would be imminent unless delivery would be done.


2. What should she have done differently?

It was good that the client sought consultation at the time she felt there was something wrong with her condition.

To
my some of you who said that she should have asserted being examined
more carefully, well, I believe it was more of her family's
responsibility to insist that since at that time her condition may be
deteriorating and she needs to rest. She is not fit to argue.

3. What should her family have done differently?

It was mentioned in the case and i quote,
"She
was taken to a private doctor, who admitted her for observation, but he
was soon called away and did not examine her very well. The doctor did
not tell Jyotsana or her family what he thought her diagnosis was or
discuss any treatment options with them. " Her family should have been
more assertive of their rights to full disclosure of her condition. To
me it seems that the family were not even so attentive to her
deteriorating condition because even if the doctor was not there, they
would see how her condition is worsening. All they need to do was call
the doctor. They did not have to wait for the next day.

4. What should the doctors have done differently?

I
agree with everyone, the doctor should have diclosed to the patient and
the family his remarks on the condition. Perhaps, he was still unsure
of the diagnosis that was why he did not tell them immediately. Of
course, observation would be very helpful. But he should have at least
made a careful examination of the client before attending to something
else. He should have also left somebody in charge of the patient in his
absence (a nurse perhaps), but he did not. If there was no nurse, then
may be he could have told the family to monitor the condition of the
client and call him when they observe that the condition is getting
worse.



Other views on the case:

Poverty is not an
issue in this case. The client had the access to the routine prenatal
checkups during the course of her pregnancy. However, lack of proper
assessment and monitoring of the patients condition has caused a delay
in giving the proper treatment for her condition and also accessibility
to a higher level medical facility can be highlighted as a problem here.

The
case did not present whether the client belonged to a high risk
pregnancy category prior to the appearance of her symptoms which led
her to seek consultation. The pregnancy had been pretty much normal.

although i cam on and off in this discussion...i would like to share this journal review that i fpound as supplemental reading...

kindly check this out


http://www.hbvadvocate.org/news/NewsUpdates_pdf/News_Review_2009/HBJ-6.6.pdf

just a reading that i found that i believe answers most of the inquiries in this discussion...

kindly chech this out...

okie...thanks guys...
nytie!

thank you for the learnings today. see you again tomorrow. good night.

Thank you ladies for that fruitful discussion. Goodnight!

Goodnight!

pahabol lng...

according to CDC also...proper breast hygeine should be observed by these mothers to avoid cracking and possible bleeding...but, the initiation of brestfeeding should not be hindered...

thank god!at last!

thank you. goodnight:D

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 (4) 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 (5). 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. (WHO, 1996)

Thank you also Yogi for your wonderful insights.. Good Night!

Ladies I think we have the same themes that breastfeeding is not yet proven to cause an infection to the infant.

I think we have all reached the saturation point of tonight's discussion.
Thank you Tina, Ara, Thea and Raiza for sharing your researches and insights on the case studies given.

Good Night and Good Luck!!

angel