June 2018 Updates from NJPA
In this newsletter…
- Perinatal Hepatitis B Prevention
- Genetics Corner
- Meet our Perinatologist
Perinatal Hepatitis B Prevention
Between 800,000-1.4 million people in the United States and more than 240 million people worldwide are infected with hepatitis B virus (HBV). Specific to pregnancy, an estimated prevalence of 0.7-0.9% for chronic HBV infection among pregnant women in the US has been reported, with >25,000 infants at risk for chronic infection born annually to these women. While there are many risk factors for hepatitis B infection, vertical transmission of HBV from infected mothers to their fetuses or newborns, either in utero or peripartum, remains the major source of chronically infected individuals worldwide. From a global health perspective, chronic HBV infection is the major cause of hepatocellular carcinoma.
Earlier this year, the American College of Obstetrics and Gynecology (ACOG) issued a practice advisory in response to the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) updated guidance on preventing the transmission of hepatitis B virus. In the advisory, it is acknowledged that a critical element of the strategy to eliminate HBV infection in the US is the prevention of perinatal transmission. ACOG endorses the CDC recommendations regarding the use of HBV viral load testing to guide the use of antiviral medication to prevent perinatal transmission and encourages practicing physicians to adopt these strategies into practice.
In this newsletter, the guidelines for the management of HBV infected mothers are reviewed.
Practice Guidelines for Prevention of Perinatal HBV Infection
- Universal screening for HBV infection during pregnancy is recommended
- Universal HBV vaccination is recommended within 24 hours of birth for medically stable infants
- Administer HBV vaccine and HBV immunoglobulin within 12 hours of birth to all newborns of HBV infected mothers or those with unknown HBV status, regardless of whether maternal antiviral treatment was given during the pregnancy
- HBV viral load testing is recommended in the third trimester of pregnancy in those that are chronically infected
- In pregnant women with an HBV viral load of >200,000 IU/mL, HBV targeted maternal antiviral therapy should be considered for the purpose of decreasing the risk of intrauterine fetal infection
- Women with HBV infection should be encouraged to breastfeed as long as the infant receives the recommended immunoprophylaxis at birth
- Invasive fetal testing during pregnancy, such as chorionic villous sampling and amniocentesis, can be performed. Counseling should include the fact that the risk for maternal-fetal transmission may increase with increasing HBV viral load
- Maternal HBV infection alone is not an indication for cesarean delivery as this has not been shown to decrease the risk of intrapartum transmission of HBV to fetuses/neonates.
- All HBV positive pregnant women should be referred to their local Perinatal Hepatitis B Prevention Program for case management to ensure that their infants receive timely prophylaxis and follow up.
Please note that New Jersey Perinatal Associates (NJPA) has developed these best practice recommendations based on a review of current literature and expert opinion. They are not intended to establish standards or absolute requirements and these recommendations do not guarantee a specific outcome. All recommendations and best practices should be considered in the context of each patient’s individual circumstances and clinical evaluation.
Direct to Consumer Genetic Screening
Over the past decade or so, genealogy tests have become quite common. In these tests, customers send a DNA sample (saliva) to a company and for a reasonable fee, they receive a report about their genetic heritage and whether or not they carry genetic variants, all without the involvement of a doctor or similar medical professional. These tests have traditionally been restricted to genealogical heritage, but one company by the name of 23andMe (founded in 2006) has received approval from the FDA to run tests to report medical health risks.
Even though these direct-to-consumer tests have been approved, for the purposes of reproductive genetic risk, 23andMe states that their carrier reports are not intended to tell consumers anything about their risk for developing a disease in the future, the health of their fetus, or their unborn child’s risk of developing a particular disease later in life.
The American College of Obstetrics and Gynecology (ACOG) recommends genetic carrier screening be offered to all women considering pregnancy or who are pregnant. 23andMe does not include carrier screening for Spinal Muscular Atrophy, which is recommended by ACOG for all women who are considering pregnancy or are pregnant. 23andMe also only includes 22 out of the minimum 23 cystic fibrosis mutations that are recommended by ACOG. 23andMe and other direct to consumer tests, do not replace counseling from a physician or genetic counselor and are not alone sufficient for genetic screening when it comes to reproductive risks.
If you have any questions, please feel free to call any one of our genetic counselors at 973-535-8012.
Meet Our Perinatologist
Edward Wolf, MD
Dr. Wolf graduated from Georgetown University School of Medicine in Washington, DC, prior to completing his residency at the National Naval Hospital in San Diego, California. He completed his fellowship in maternal-fetal medicine at the University of Connecticut.
He then served as the Associate Director of the Division of Maternal-Fetal Medicine at the National Naval Medical Center in Bethesda, Maryland and Assistant Residency Director at the Uniformed
Services University of the Health Sciences and the National Institutes of Health.
Dr. Wolf’s research interests include multiple gestations and preterm birth.
- Society for Maternal-Fetal Medicine Consult Series #38: Hepatitis B in pregnancy screening, treatment, and prevention of vertical transmission. J. Dionne-Odom, et al. AJOG, January 2016.
- Practice Advisory: Hepatitis B Prevention, ACOG, January, 2018.
- Prevention of HBV infection in the US: Recommendations of the Advisory Committee on Immunization Practices. S. Schillie, et al. MMWR, January 12, 2018.
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