Quirino Memorial Medical Center Quezon City, National Capital Region, Philippines
Imnas Marie Carina G. Arquillo, Quirino Memorial Medical Center, Quezon City, National Capital Region, Philippines
Introduction: Viral hepatitis is a systemic infection affecting the liver predominantly, caused by one of five viral agents: hepatitis A virus, hepatitis B virus, hepatitis C virus , hepatitis D virus, and hepatitis E virus. In Asia and Africa, hepatitis viruses’ B and E are the leading etiologies for fulminant viral hepatitis . Fulminant hepatitis in pregnancy often occurs in the late stages of pregnancy. In pregnant patients with fulminant hepatitis, the ultimate question and dilemma is when to deliver the baby and when to start anti-viral agents.
Case Description/Methods: A case of a 35-year old female 35 weeks pregnant G4P3 (3003) presented at the emergency room with vaginal bleeding and hypogastric pain. She was diagnosed with chronic hepatitis B infection 2 years ago, and underwent treatment and was lost to follow up. Patient was admitted and noted changes in behavior during the hospitalization. Noted high levels of liver enzymes and HBV DNA levels. Patient was managed as a case of hepatic encephalopathy secondary to fulminant hepatitis B infection. Patient was given tenofovir 300mg/tab 1 tab once a day and underwent emergency caesarian section and delivered to a live baby. There was noted improvement on signs and symptoms and was discharged apparently well, and breastfeeding was encouraged.
Discussion: Hepatic encephalopathy, fulminant hepatitis is an emergency that should be recognized early. The incidence of fulminant hepatitis in pregnancy is 66x that of non-pregnant patients. Early clinical manifestations of fulminant hepatitis includes decrease in appetite, deep jaundice, nausea, vomiting and abdominal distention, and the major dilemma is the timing of delivery. The mode of delivery should still be guided by obstetric indications rather than HBV infection status. The indications for delivering the baby includes: after the patient has been supportively treated and clinical symptoms and signs have been in a steady state for 24 to 48 hours or fetal distress is detected and the fetus is viable or after medication treatment yields no improvement in clinical conditions. If a pregnant patient is diagnosed with hepatitis, one should be evaluated for treatment (figure 1), however reactivation of HBV can occur during pregnancy and postpartum periods as observed in our patient. Patients with history of hepatitis should be educated regarding its long-term sequela. The initiation of treatment of antivirals depends on both obstetrical condition and of the disease course.
Figure: FIGURE 1. Algorithm from the Hepatology Society of the Philippines Management of Hepatitis B in Special Populations. Management of hepatitis B infection in a pregnant patient.
Imnas Marie Carina Arquillo indicated no relevant financial relationships.
Imnas Marie Carina G. Arquillo, . P2942 - Hepatic Encephalopathy in Pregnancy: A Flare of Hepatitis B Infection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.