Department of Obstetrics & Gynecology
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Protocols

 
Subject : Hepatitis B and C
Hepatitis B
Screening and Diagnosis: Hepatitis B virus infects the liver and causes varying degrees of inflammation and illness. Infected patients may respond in several ways: The acute hepatitis may resolve and the patient develop immunity. The patient’s hepatitis  may progress quickly and they may be at risk for acute hepatic failure. Or  they may become chronic carriers with a long-term risk for cirrhosis and hepatic cancer .   Because women infected with hepatitis B are at risk for acute and chronic liver problems and may transmit the infection to their sexual partners and neonates, North Carolina recommends routine screening of all pregnant women for Hepatits B Surface antigen as part of their initial prenatal labwork.  Neonatal vaccination and administration of hepatitis B immune globulin (HBIg) can interrupt 90% of vertical transmission of Hepatitis B. Vaccination of sexual partners may prevent sexual transmission. Most children born in the US are now vaccinated for hepatitis B, but older mothers and immigrants may be at risk for infection.
 
Recommendations:
 
If the patient’s hepatitis B surface antigen is positive:
  1. Counsel the patient about the test results and the need for further testing. The patient should be informed that the neonate will need injections after birth to help prevent transmission.  If the patient appears jaundiced or acutely ill refer for immediate medical attention.
  2. Document result on the lab screen and problem list “Positive Hepatitis B”
  3. Send patient to the lab for the following tests:
    1. Liver function tests-AST, ALT, Tbili, ABC (thrombocytopenia may indicate more severe disease) PT/PTT
    2. Hepatitis B core antibody IgM (reflects recent infection and merits  monitoring to evaluate for the development of chronic hepatitis or infection resolution)
    3. Hepatits e antigen (if positive patient is at higher risk of transmission of infection)
    4. Hepatitis C antibody (co-infection is common)
    5. Confirm HIV result (co-infection is common)
  4. Vaccinate the patient for hepatitis A (two injections one month apart) and document in chart.
  5. Provide results of the above tests to CNM/MD
  6. Patient may plan to breastfeed after the neonate receives hepB Immune globulin and hepatitis B vaccine
  7. Patient should be referred for a one visit consult to the high risk OB clinic but may continue their care at their original prenatal clinic. At the High risk Ob consult visit, patient will be informed of the option for liver specialty care after delivery.
 
 
Hepatitis C
Screening and Diagnosis: Patients with a history of liver disease/hepatitis, illicit drug use, sex partner with hepatitis C or transfusion prior to 1992 should undergo screening with a hepatitis C antibody.
Hepatitis C may be transmitted vertically to the fetus/neonate or to a sex partner.
Hepatitis C is not an indication for cesarean. Hepatitis C infected individuals may lactate.
If Hepatitis C antibody is positive:
1.  Counsel the patient about the test results (that she has been exposed to hepatitis C and the need for further testing to see if she has ongoing infection).
  1. Document on the lab screen and problem list : “Positive hepatitis C antibody”
  2. Send patient to the lab for the following tests:
    1. Liver function tests-AST, ALT, Tbili
    2. Confirm HIV test results
 
  1. Patient should be referred for a one visit consult to the high risk OB clinic but may continue their care at their original prenatal clinic. At the High risk Ob consult visit, patient will be tested for hep C RNA  and informed of the option for liver specialty care after delivery.
  2. Vaccinate for hepatitis A and B.
 
 
 
The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.
 
These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions.  We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.
The protocols remain the intellectual property of the Duke University Health System.  They cannot be reproduced in whole or part without the expressed permission of the Health System.
 
These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia.  Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.
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