[CG] Hepatitis B positive - Management of women identified through antenatal screening

Warning

exp date isn't null, but text field is

Please report any inaccuracies or issues with this guideline using our online form

Antenatal screening for three communicable diseases – hepatitis B, HIV, and syphilis - is offered to all pregnant women. The uptake is over 99% across Greater Glasgow and Clyde for all three diseases. The primary aim of screening for hepatitis B is to ensure a plan for treatment and management for affected individuals and their babies. This allows treatment to be given, which can reduce the risk of mother to child transmission, improves the long-term outcome and development of affected children, and ensures that women, their partners and families are offered appropriate referral, testing and treatment.

Approximately 70 mothers are identified by West of Scotland Specialist Virology Centre (WoSSVC) every year in NHS GGC as being hepatitis B surface antigen positive during antenatal screening.

  1. Following identification of an HBsAg positive test from the booking blood sample, the WoSSVC writes to the clinician in charge of the patient and the nominated obstetrician at the referring unit in GGC as below:
    Princess Royal Maternity Dr Victoria Brace 
    QEUH Dr Marianne Ledingham
    Royal Alexandra Hospital Dr Andrew Quinn
    The result is copied to Sandyford Shared Care Support Service – Tel: 0141 211 8639 and the GP (if patient registered).
    The Public Health Protection Unit (PHPU) is notified electronically on a weekly basis.

  2. This letter will inform the obstetrician of the diagnosis of hepatitis B in the mother and will indicate, depending on available viral markers, if the baby requires immunoglobulin AND vaccine OR vaccine alone at birth (as per current Green Book recommendations, see below). This letter will also contain a section to be completed by the obstetrician once the 26 week gestation hepatitis B DNA levels are know, along with instructions on how this will affect the recommendations for neonatal treatment.

    The WoSSVC also writes to the GP at this point to invite the GP to continue the vaccination programme which will be started in the maternity unit. Public health coordinate the response and follow up programme for the baby.

  3. The letter sent to the Obstetrician is placed in the mother’s notes for the attention of the neonatal paediatrician. The letter advises the paediatricians to inform the NHS GGC Screening Dept at Templeton by email of the birth of the baby - HepB.Screening@ggc.scot.nhs.uk

  4. The nominated obstetrician will:
    1. Immediately refer the patient to the local hepatitis service for clinical review and advice
    2. Send a letter to the patient informing them of the hepatitis B result
    3. Offer to refer the patient to the Counselling and Support Team (CAST) at the Brownlee  Centre  where  screening  of  family  members  and contract tracing will be carried out
    4. Give the patient an appointment to attend for review at 26 weeks
    5. Ensure the hepatitis B status and management plan is clearly documented in the Neonatal section of the Yellow Alert Sheet which starts every inpatient maternity record.

  5. At the 26 week review the nominated obstetrician will have a sample taken for the HBV DNA viral load, liver function tests, prothrombin time and anti hepatitis C.

  6. If the HBV DNA viral load at booking is >200,000 IU/mL (≥ log 5.3 or 10 5 . 3 IU/ml1) then urgent referral to the hepatitis service should be made and antiviral therapy during the third trimester (from week 28 to delivery) will be considered, to reduce viral load and risk of transmission to the infant.

  7. If the HBV DNA viral load is >200,000 IU/mL (≥ log 5.3 or 10 5 . 3 IU/ml1) at any point during pregnancy then urgent referral to the hepatitis service should be made AND hepatitis B immunoglobulin (HBIg) and hepatitis B vaccine should be given to the infant at birth.

  8. The HBV DNA viral load should be documented clearly by the responsible obstetrician in the relevant section of the letter from the WoSSVC. The neonatal section of the Yellow Alert Sheet should also be amended with this level and the implications for neonatal management.

  9. If HBV DNA viral load is ≤200,000 IU/mL (< log 5.3 or 10 5 . 3 IU/ml1), then the woman would be monitored as normal during pregnancy. Again the HBV DNA viral load should be documented clearly by the responsible obstetrician in the relevant section of the letter from the WoSSVC. The neonatal section of the Yellow Alert Sheet should also be amended with this level and the implications for neonatal management.

  10. When the woman is in labour, the obstetrician/midwife informs the paediatric team that the baby will require vaccination +/- immunoglobulin at birth as per letter from WoSSVC and the Green Book criteria.

  11. Neonatal paediatrician gives first dose of vaccine (and immunoglobulin if required) and informs the NHS GGC Screening Dept by email (HepB.Screening@ggc.scot.nhs.uk)

  12. HBV vaccine and HBIg must be administered within 24 hours of birth, ideally as soon as possible (i.e. within 4 hours). HBV vaccine – Engerix B 10 mcg (0.5ml) or HBvaxPRO 5 mcg (0.5ml) given IM into anterolateral thigh (not into buttock). HBIg - 200IU (2 ml) given IM into upper outer quadrant of the buttock or anterolateral thigh of the opposite leg from site of HBV vaccination. Routine postnatal care, including breast feeding, is appropriate.

  13. Before discharge from the maternity unit a check should be made that mothers have already attended the hepatitis service and if not a further appointment at 2 months is made.

  14. The NHS GGC Screening Dept arrange call/recall for subsequent vaccination of the infant to complete the course. Invitation letters and reminder letters are sent to the mother, health visitor and GP of baby.

  15. Following the 12 month dose of hepatitis B vaccine, the infant must be checked for response by assay for HBsAg and anti-HBs. The GP is asked by public health to refer the baby to the Paediatric Infectious Disease service at Royal Hospital for Children for this assay.

  16. The PHPU monitors uptake of all babies receiving hepatitis B vaccination from data supplied by Screening Dept. PHPU liaises with the health visitor to promote uptake of vaccine in babies who have not completed the course. PHPU produces regular uptake figures to feedback to all involved. PHPU  carries out a yearly audit of all HBV notifications in pregnancy.

Hepatitis B status of mother

Baby should receive:-  

Hepatitis B vaccine

HBIG

HBsAg positive and HBeAg positive

yes

yes

 HBsAg positive, HBeAg negative and anti-HBe negative

 yes

yes

Acute hepatitis B during pregnancy

yes

yes

HBsAg positive, anti-HBe positive

yes

no

 HBsAg positive and a baby birthweight of 1500g or less

 yes

 yes

 Woman is HBsAg seropositive and known to have an HBV DNA level above 200,000 IU/mL (≥log 5.3)** in an antenatal sample (regardless of HBeAg and anti-HBe status)

yes

yes

** Note, the ‘Green Book’ (Immunisation against Infectious Disease, Public Health England, 2013) states ‘equal or above 1x106IUs/ml’.  

References
  1. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. Journal of Hepatology 2017 vol. 67 370–398

Last reviewed: 30 October 2021

Next review: 30 November 2024

Author(s): Hepatitis B in Pregnancy and Newborn Guideline Group; Gillian Penrice; David Bell