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South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
Department for Health and Wellbeing, Government of South Australia. All rights reserved.
INFORMAL COPY WHEN PRINTED Page 1 of 18
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Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of published
evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the patient s
medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
The use of interpreter services where necessary,
Advising consumers of their choice and ensuring informed consent is obtained,
Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
Documenting all care in accordance with mandatory and local requirements
Explanation of the aboriginal artwork:
The Aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the Aboriginal culture. The horse shoe shape design
shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant woman. The smaller horse shoe shape in this instance represents
the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in unison.
Purpose and Scope of Perinatal Practice Guideline (PPG)
This guideline provides clinicians with information on Hepatitis B virus in pregnancy. It includes
details of risk groups, screening and interpreting tests and ongoing management. Newborn
management is also described.
Australian Aboriginal Culture is the oldest living culture in the world yet
Aboriginal people continue to experience the poorest health outcomes when
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to
be of low birth weight. The accumulative effects of stress, low socio economic
status, exposure to violence, historical trauma, culturally unsafe and discriminatory
health services and health systems are all major contributors to the disparities in
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics
the birth of an Aboriginal baby is a celebration of life and an important cultural
event bringing family together in celebration, obligation and responsibility. The
diversity between Aboriginal cultures, language and practices differ greatly and so
it is imperative that perinatal services prepare to respectfully manage Aboriginal
protocol and provide a culturally positive health care experience for Aboriginal
people to ensure the best maternal, neonatal and child health outcomes.
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Flowchart 1: Routine screening in pregnancy and reducing risk of
maternal to child transmission of hepatitis B virus
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Flowchart 2: Screening for women from at risk groups in pregnancy
and reducing risk of maternal to child transmission of hepatitis B virus
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Flowchart 3: Follow-up of infants whose mothers are HBV positive
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Table of Contents
Purpose and Scope of Perinatal Practice Guideline (PPG) ...................................................... 1
Flowchart 1: Routine screening in pregnancy and reducing risk of maternal to child transmission
of hepatitis B virus ..................................................................................................................... 2
Flowchart 2: Screening for women from at risk groups in pregnancy and reducing risk of
maternal to child transmission of hepatitis B virus .................................................................... 3
Flowchart 3: Follow-up of infants whose mothers are HBV positive ......................................... 4
Summary of Practice Recommendations .................................................................................. 6
Abbreviations ............................................................................................................................. 6
Hepatitis B Virus (HBV) ............................................................................................................. 7
Transmission of HBV ................................................................................................................. 7
At risk groups ......................................................................................................................... 8
Antenatal screening ................................................................................................................... 8
Routine screening for all pregnant women (see flowchart 1) ................................................ 8
Screening women from at risk groups (see flowchart 2) ..................................................... 8
Interpretation of results .......................................................................................................... 9
Women who are HBsAg and anti-HBs negative (non-infected and non-immune) ................ 9
Notification and counselling of women who are HBsAg positive............................................... 9
Notification to the Communicable Disease Control Branch (CDCB) ..................................... 9
Post-test counselling ............................................................................................................. 9
Available support services: .................................................................................................. 10
Women who are HBsAg positive OR HBsAg negative, anti-HBs negative and anti-HBc positive
................................................................................................................................................. 11
When to refer ....................................................................................................................... 11
Additional investigations ...................................................................................................... 11
Women with high antenatal viral loads (HBV DNA viral load ? 200,000IU/mL) .................. 11
Women with antenatal HBV DNA viral load < 200,000IU/mL.............................................. 12
Women already taking anti-viral treatment / women with cirrhosis ..................................... 12
Risk of vertical transmission during invasive procedures in pregnancy .............................. 12
Infection control measures ...................................................................................................... 12
Intrapartum management ........................................................................................................ 12
Care of the newborn baby ....................................................................................................... 13
Breastfeeding....................................................................................................................... 13
Newborn Immunoglobulin and Vaccination ............................................................................. 13
Hepatitis B immunoglobulin: ................................................................................................ 13
Hepatitis B vaccine: ............................................................................................................. 13
Low birth weight (LBW) and/or preterm newborn ................................................................ 14
Universal recommendation for vaccination ......................................................................... 14
Follow up ................................................................................................................................. 14
Infants .................................................................................................................................. 14
Woman ................................................................................................................................ 14
Exposure to HBV during pregnancy ........................................................................................ 15
References .............................................................................................................................. 16
Useful web sites ...................................................................................................................... 16
Acknowledgements ................................................................................................................. 17
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Summary of Practice Recommendations
Routine antenatal screening for hepatitis B surface antigen (HBsAg) and hepatitis B surface
antibody (anti-HBs) is recommended for ALL pregnant women at their first antenatal appointment,
unless they are in an at risk group.
For women in at risk groups, antenatal screening for hepatitis B surface antigen (HBsAg),
hepatitis B surface antibody (anti-HBs) and hepatitis B core antibody (anti-HBc) is recommended
at their first antenatal appointment.
Each interaction that a pregnant woman who is positive for hepatitis B virus (HBV) has with health
practitioners should be used as an opportunity to provide education about disease management,
plan ongoing care and test family and close contacts.
For HBsAg positive women with high viral loads (> 200,000 IU/mL), specialist (hepatologist or
infectious diseases consultant) referral should be undertaken for consideration of antiviral therapy
to commence between 28 and 32 weeks gestation to further reduce the risk of perinatal
transmission.
Women who are HBsAg positive should be encouraged to breastfeed as there is no evidence of
HBV transmission through breastfeeding.
Infants of HBsAg positive women should be given both hepatitis B immunoglobulin (HBIG) and the
first dose of the hepatitis B vaccine within 12 hours of birth, followed by a full course of hepatitis B
vaccine, offered as part of the routine childhood immunisation schedule.
Infants of HBsAg positive women should be tested for HBsAg and anti-HBs at 9-12 months of age
(at least 3months after final dose of hepatitis B vaccine). Do not test the infant before 9 months of
age, to avoid detecting anti-HBs from the HBIG given at birth.
Follow up advice should be provided in the hospital discharge summary of infants born to women
who are HBV positive to ensure appropriate vaccination and testing.
Follow up advice should be provided to women who are HBV positive in the hospital discharge
summary following birth.
Women with chronic hepatitis B infection should be referred for regular, lifelong monitoring by
infectious diseases or liver specialist, or with a suitably experienced GP.
Abbreviations
CDCB Communicable Disease Control Branch
DNA Deoxyribonucleic acid
e.g. For example
GP General practitioner
HB Hepatitis B
anti-HBc Hepatitis B core antibody (previously HBcAb)
HBeAg Hepatitis B e antigen
anti-HBe Hepatitis B e antibody (previously HBeAb)
HBIG Hepatitis B immunoglobulin
anti-HBs Hepatitis B surface antibody (previously HBsAb)
HBsAg Hepatitis B surface antigen
HBV Hepatitis B virus
HBV DNA Hepatitis B virus deoxyribonucleic acid
INR International normalised ratio
IU International units
IgM anti-HBc IgM antibody to the hepatitis core antigen
IM Intramuscular
LBW Low birth weight
mL Millilitre/s
NHMRC National Health and Medical Research Council
PCR Polymerase chain reaction
PT Prothrombin time
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Hepatitis B Virus (HBV)
HBV is an infection that causes both acute and chronic liver disease. It is excreted in various
body fluids (e.g. blood, saliva, vaginal fluid and breastmilk), that may be highly infectious. Adults
with chronic infection may have no symptoms.1
People with chronic hepatitis B should receive regular, lifelong monitoring of disease progression
by a general practitioner (GP), infectious diseases or liver specialist. Routine monitoring
(biannually) even when there are no symptoms, can prevent severe liver disease including liver
cancer.3
Worldwide, transmission of infection from mother to infant around the time of birth is one of the
most important causes of chronic HBV infection in underdeveloped countries. The risk of perinatal
transmission is associated with the presence and level of hepatitis B e antigen (HBeAg) in
maternal serum. The HBeAg-seropositive status in a person with chronic HBV infection is
associated with high levels of viral replication. Without the use of postpartum hepatitis B
vaccination and immunoprophylaxis (hepatitis B immunoglobulin (HBIG) up to 95% of infants of
HBeAg-positive mothers will become chronically infected. By administering HBIG and the
hepatitis B vaccine soon after birth, the risk of vertical transmission is reduced to 5-10%.4
In pregnancies of women with chronic HBV infection, where the maternal viral load is high
(>200,000 IU/ml), there remains a risk of viral transmission despite use of vaccination and
immunoprophylaxis. This risk is minimised by the use of tenofovir antiviral treatment in the third
trimester of pregnancy to reduce maternal viral load.5
There are no data to justify a recommendation on the mode of birth in HBV infection. There is
insufficient evidence that offering caesarean section provides additional protection against
perinatal hepatitis B virus transmission over the recommended neonatal regimen of hepatitis B
immunoglobulin and vaccination.6
It is vital to ensure babies born to hepatitis B surface antigen (HBsAg) positive mothers receive
hepatitis B vaccine plus HBIG at birth. The hepatitis B vaccine course must be completed with
doses at 6-8 weeks, 4 and 6 months of age.2,6
Transmission of HBV
Hepatitis B virus infection may result from transmission through broken or penetrated skin, or by
mucosal contact with blood or other body fluids (mainly vaginal fluids and semen) from an
infectious person. The risk of spread is increased when there are higher levels of virus in the
blood. The level of virus varies considerably between people infected with hepatitis B.
Women with acute hepatitis caused by HBV and those with chronic hepatitis B viral infection
(HBsAg positive) may transmit HBV to their infants.2
Newly acquired cases of HBV infection in Australia mostly occur in young adults through
injecting drug use, skin penetration procedures and sexual contact. There are
approximately 12,000 notifications in Australia per year.
Acute hepatitis B diagnosed in the first or second trimester carries a perinatal
transmission risk of about 10%, increasing to about 75% in the third trimester. Although
not routinely recommended, maternal vaccination has been shown to be safe and
effective in pregnancy.2,6
Most perinatal transmission can be prevented with antiviral prophylaxis during pregnancy
for women with high viral loads and appropriate prophylaxis given to the infant at the time
of birth
In Australia the most likely ways young children become infected are:
Mother-to-baby transmission at or around the time of birth, particularly for people born
outside Australia in countries where hepatitis B is common, in women from remote
Aboriginal and Torres Strait Island communities, in women who inject drugs and in
women who participate in unprotected sex with individuals that are HBV positive.
From child-to-child usually through contact between open sores or wounds, particularly
for people born outside Australia in countries where hepatitis B is common, and in remote
Aboriginal and Torres Strait Island communities.
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Other ways of contracting hepatitis B include:
sharing equipment used for injecting drugs
unprotected sex (anal and vaginal)
tattooing, body piercing and other skin penetration procedures with unsterilised
equipment
household contact, including sharing razors, hair clippers and toothbrushes
accidental needle stick or blood splash to broken skin or mucous membrane.
At risk groups
Women from areas of high prevalence (more than 2%)2,7
Australian Aboriginal and Torres Strait Islanders
New Zealand Maoris
Pacific Islands: Melanesia, Micronesia, Polynesia
South Asia: India, Bangladesh, Pakistan, Sri Lanka
South East Asia: Cambodia, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand,
Vietnam
East Asia: China, Hong Kong, Korea, Taiwan
Africa (except white South African)
South America: Chile
Mediterranean: Crete, Cyprus, Greece, Italy, Malta
Middle East: Egypt, Iran, Jordan, Lebanon, Turkey
Central Europe: Romania, countries of former Yugoslavia.
Women who are non-immune or whose immunity status is unknown with a history of:
Household / intimate contact with an individual that is HBV positive
Multiple sexual partners
Injecting drugs
Tattoos / body piercing
Jaundice or other clinical or biochemical features of acute hepatitis
Incarceration
Hepatitis C infection.
Antenatal screening
Hepatitis B virus infection is diagnosed by serological testing. Hepatitis B serology allows
clinicians to determine susceptibility, active infection, or immunity through vaccination or past
infection.
Routine screening for all pregnant women (see flowchart 1)
In South Australia, routine antenatal screening for HBsAg is recommended for pregnant women
at their first antenatal appointment.
Screening women from at risk groups (see flowchart 2)
In women from at risk groups, the initial screening should include HBsAg, hepatitis B surface
antibody (anti-HBs / HBsAb) and hepatitis B core antibody (anti-HBc / HBcAb)6. Interpretation of
these results allows categorisation of most women either as non-immune, immune, or chronically
infected with HBV.6,7
Note: To be able to order all 3 diagnostic tests simultaneously and retain Medicare
eligibility, the requesting doctor should write ? Chronic hepatitis B on the request form.
In women from at risk groups, ensure household contacts have been screened (by their general
practitioner) for HBV and vaccinated if non-immune.
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Interpretation of results
HBsAg positivity implies infection with hepatitis B
If HBsAg is negative and anti-HBs is positive, the woman is considered not infected and
immune.
If HBsAg, anti-HBs and anti-HBc are all negative this indicates that the woman is not
infected and non-immune to hepatitis B infection. She should be vaccinated post-birth
unless there is a significant risk of exposure to hepatitis B during pregnancy. See section
on Exposure to HBV in pregnancy .
If anti-HBc is positive then hepatitis B viral load (HBV DNA viral load) and additional
testing (HBeAg and hepatitis B e antibody [anti-HBe]) should be requested.
Note: Viral mutations in the HBsAg can result in a false negative test (detectable hepatitis B DNA
with negative HBsAg). This is not apparent if anti-HBc is excluded in hepatitis B screening.
Therefore HBsAg, anti-HBs and anti-HBc should be requested for women at risk of HBV.
Further information on interpretation of results in women with suspected HBV is available via the
Australasian Society for HIV Medicine, Viral Hepatitis and Sexual Health Medicine (ASHM)
Testing Portal8 at: http://www.testingportal.ashm.org.au/hbv.
Women who are HBsAg and anti-HBs negative (non-infected and non-immune)
Women who are non-infected and non-immune are susceptible to HBV infection if there is a
significant exposure to HBV during pregnancy. Women should be informed of their non-immune
status with the following recommendations:
Post-birth vaccination with HBV-containing vaccine OR
Vaccination with HBV-containing vaccine during pregnancy if at high risk (e.g. household
member or partner is HBV positive)
Further testing and administration of HBIG and HBV-containing vaccine may be required
as part of post-exposure prophylaxis if significant exposure occurs during pregnancy. If
women are concerned they should contact their maternity care provider as soon as
practicable following exposure. For further details, refer to Exposure to HBV during
pregnancy below.
Note: Women who have had prior HBV vaccination but anti-HBs is undetectable may be immune.
Women with immune memory should respond to a single booster dose of the HBV vaccination.
See https://immunisationhandbook.health.gov.au/ for further detail.
Notification and counselling of women who are HBsAg positive
Notification to the Communicable Disease Control Branch (CDCB)
Hepatitis B is a notifiable condition9 and must be reported to the CDCB within 3 days of
suspecting or confirming a diagnosis
The medical officer should either
Telephone CDCB on 1300 232 272, Monday to Friday (8.30 am to 5.00 pm) with patient
details including risk factor information OR
Complete the 'Report of Notifiable Condition: Hepatitis B virus or Related Death' form
upon receipt of a positive laboratory result. The form is available online via the following
link: http://www.sahealth.sa.gov.au/NotifiableDiseaseReporting
Fax form to the CDCB on (08) 8226 7187
This form is NOT to be sent by email for reasons of confidentiality.
Post-test counselling
The attending medical officer should inform the woman of her chronic hepatitis B infection,
explaining the associated risk to baby, household members and caregivers. Consider use of an
interpreter as appropriate to ensure understanding.
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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The woman should be provided with8:
Her HBsAg result early in the consultation, using clear language (e.g. You have hepatitis
B )
An explanation that hepatitis B is a notifiable disease
Methods of transmission risk including current and subsequent pregnancies
Requirement for lifelong monitoring of liver health
The need to test +/- vaccinate sexual and household contacts
Verbal and written information about:
o Course of the illness
o Preventing transmission
o Need for further serology and monitoring throughout pregnancy and beyond
o Issues around disclosure and stigmatisation.
It is important for the woman to understand her condition so that she can make informed
decisions about:
Her baby s care during the perinatal period
Care in any subsequent pregnancies
Her own health by embarking on a program of lifelong monitoring of liver health including
screening for the need for possible treatment and hepatocellular carcinoma.
A positive diagnosis is often a shock. Aim to minimise the psychological impact at this time.
Reassure the woman about confidentiality and offer information about available sources of
support.
It is important to assess how much information the woman can process. There may be a need to
arrange a number of consultations to discuss implications for the woman and her unborn baby.
The woman s GP should be informed to facilitate ongoing care (e.g. contact tracing other family
members, vaccinating household contacts if susceptible).
Aboriginal women should be referred to their nominated aboriginal health professional.
Available support services:
Hepatitis SA
Hepatitis SA is a non-government organisation providing hepatitis B and hepatitis C information,
education and support services to all South Australians. The Hepatitis SA Helpline Information
and Support Service offer free and confidential telephone information and support about hepatitis
B and C to people affected and their families and health and community workforces.
Face to face appointments can be arranged.
The Helpline operates Monday Friday 9am 5pm, by calling 1800 437 222.
Further information on the range of services offered by Hepatitis SA is available at
www.hepsa.asn.au
Viral hepatitis nurses:
Viral Hepatitis Nurses are Nurse Consultants who work with people affected by hepatitis B and C
in the community, general practice and tertiary hospitals. They provide specialised education and
care coordination to patients as well as support and advice to GPs and healthcare staff.
Located at all metropolitan Local Health Networks
Women may contact Nurses directly
Support is also available for people in country areas
For contact details, see
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clini
cal+resources/clinical+programs+and+practice+guidelines/infectious+disease+control/vir
al+hepatitis+nursing+support/viral+hepatitis+nursing+support
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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PEACE Multicultural Services at Relationships Australia:
This service employs workers with a long experience of working with people with chronic hepatitis
B who are from a country other than Australia. They have a well-developed understanding of
cultural issues and can be contacted to:
Provide women with further information and support to deal with chronic hepatitis B
Guide and refer to other services as indicated
Accompany women to medical appointments or other relevant services
Telephone contact: (08) 8245 8100
For further resources follow link to Chronic Hepatitis B the four stages .
http://www.youtube.com/watch?v=ZhL92VZtMHw
Health care workers can contact the AMIC worker or aboriginal health professional (e.g.
Aboriginal Liaison officer) in their local area to provide support for Aboriginal and
Torres Strait Islander women.
Women who are HBsAg positive OR HBsAg negative, anti-HBs
negative and anti-HBc positive
When to refer
Refer women with the following screening results to an infectious diseases specialist or
hepatologist and order the additional investigations (below):
HBsAg positive
HBsAg negative AND anti-HBs negative AND anti-HBc positive.
Additional investigations6,7,8:
Anti-HBc if not performed already
HBeAg
o the e antigen identifies a high infective status
Anti-HBe
o positive status indicates the woman is at lower risk of spreading HBV infection
than HBeAg positive women
Liver function test (repeat at 28 weeks)
Complete blood picture
HBV viral load (HBV DNA viral load)
o provides an accurate reflection of infectivity (high risk carriers have high viral
loads). This should be done before 32 weeks of gestation
PT, INR
Hep A, C and D antibody7
Women with high antenatal viral loads (HBV DNA viral load ? 200,000IU/mL)
Active and passive immunisation (hepatitis B vaccine and HBIG) of babies within 24 hours of birth
is effective in preventing transmission of hepatitis B in more than 95 % of babies. The 5% of
babies who fail to be protected by this regimen and develop hepatitis B are usually those who do
not receive the full regimen of vaccination, or who are born to mothers with very high HBV viral
load.
Oral antiviral agents given from 28-32 weeks gestation have been shown to reduce the viral load
and reduce the risk of mother-to-child transmission at birth.10,11 In consultation with the woman,
the infectious diseases specialist or hepatologist will consider treatment from approximately 28 to
32 weeks with tenofovir 300mg daily.5,11
If treatment is solely for prevention of perinatal transmission then antiviral therapy is often
stopped between 4 and 12 weeks postpartum. However, rebound rise in HBV viral load and / or
ALT may occur; while usually mild women should be monitored closely.1,6
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Women with antenatal HBV DNA viral load < 200,000IU/mL
At present there is no evidence for routine initiation of antiviral therapy to prevent vertical
transmission to the baby.
Antiviral therapy may be considered in cases where it has prevented hepatitis B transmission to a
baby in a previous pregnancy.
Women already taking anti-viral treatment / women with cirrhosis
In pregnant women already taking antiviral therapy with tenofovir or lamivudine, treatment should
be continued. If a pregnant woman is taking entecavir it should be switched to tenofovir (because
of a lack of pregnancy safety data for entecavir). This should take place in consultation with an
infectious diseases or hepatology specialist.12
Long-term treatment with tenofovir is recommended for all pregnant women with cirrhosis and
chronic hepatitis B. Multidisciplinary management of cirrhosis in pregnancy including obstetricians
and hepatologists is advised.13
Risk of vertical transmission during invasive procedures in pregnancy
There is limited research indicating that transmission of HBV to the fetus can occur during
invasive procedures such as amniocentesis or chorionic villus sampling (CVS). It is thought that
the transmission risk is slightly lower with amniocentesis compared to CVS. However,
transplacental amniocentesis increases the risk of blood contamination of amniotic fluid and
should be avoided where possible.5 For women with high viral loads the transmission risk is
increased in both amniocentesis and CVS. Non-invasive perinatal testing may be useful for
women with an identified increased risk of aneuploidy.5
Infection control measures
Attending clinicians should practice standard precautions with blood and body secretions when
giving injections, taking blood or performing vaginal examinations.
Additionally, protective eyewear, gown / apron and gloves should be worn at all times during birth.
Arrange single room with own toilet facilities for women following birth (risk of blood cross-
contamination).
Intrapartum management
Mode of birth (caesarean section versus vaginal birth) has not been shown to affect the risk of
mother-to-infant HBV transmission.
Routine caesarean section is not recommended and should be reserved for usual obstetric
indications.5,10
Procedures to avoid that may infect the baby include:
Fetal scalp electrodes
Fetal scalp blood sampling
Vigorous aspiration or oral suctioning of the baby
Note: If there is an obstetric indication to expedite birth in second stage, an instrumental
birth may be the safest mode; however, there is a small risk of traumatising the fetal skin
and infecting the baby
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Care of the newborn baby
Standard precautions should be utilised when handling the baby.
Consider washing (with soap and water) any visible blood and body fluids from hair or
skin before contact with extended family
The baby should remain in the birthing room until transfer to the ward unless transfer to the
nursery is indicated.
Babies are encouraged to direct room in with their mother or may be cared for in the ward nursery
if clinically indicated.
Aboriginal women should be consulted on the care of the newborn baby in the first
instance. Consult with the preferred aboriginal health professional if requested.
Breastfeeding
Although HBV DNA and HBsAg have been detected in breast milk, breastfeeding does not
appear to increase the risk of HBV transmission to the infant.6
Breastfeeding should be encouraged.
Note: Breastfeeding is not contraindicated in women taking oral antiviral drugs for hepatitis B.11
Newborn Immunoglobulin and Vaccination
Infants of HBsAg positive women should be given both HBIG and the first dose of the hepatitis B
vaccine within 12 hours of birth, followed by a full course of hepatitis B vaccine as part of the
childhood immunisation schedule.2,6
The skin at the injection site should be cleaned with soap and water (if blood is visible)
OR with an alcohol swab before administering hepatitis B vaccine, immunoglobulin and
Konakion (vitamin K) via separate syringes in separate sites
Ensure details of the immunoglobulin / vaccine are entered in the Birth details and
Immunisation record pages of the Government of South Australia My Health and
Development Record (the Blue Book ).
Hepatitis B immunoglobulin:
See Hepatitis B immunoglobulin neonatal medication guideline available at
www.sahealth.sa.gov.au/neonatal).
Obtain HBIG from the Hospital Transfusion service (Request with a Transfusion Request
Form). If there is no 24 hour Transfusion service, contact the Australian Red Cross
Service Inventory and Distribution Department at (08) 83593164 and fax a Transfusion
request form for HBIG 100 units to fax (08) 83325741
Give HBIG 100 units in an intramuscular injection (thigh) within 12 hours of birth (must be
within 48 hours as efficacy decreases markedly if delayed beyond this time).6
Hepatitis B vaccine:
See Hepatitis B vaccine neonatal medication guideline available at
www.sahealth.sa.gov.au/neonatal
Give thiomersal-free monovalent HB vaccine (0.5 mL) 5 micrograms HB-Vax-II OR 10
micrograms Engerix-B paediatric in an intramuscular injection (opposite thigh to HBIG)
If concurrent administration with HBIG is not possible, vaccine must be administered
within 7 days of birth and before discharge
Early administration of HB vaccine (within 12 hours) results in seroconversion rates of
more than 90 % in neonates, despite concurrent administration of HBIG6
*Refer to hospital standard for administration guidelines
Three subsequent doses of hepatitis B containing vaccine should be given at 6-8 weeks,
4 months and 6 months so that the infant receives a total of 4 doses of hepatitis B
containing vaccines, as part of the routine childhood immunisation schedule.
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Low birth weight (LBW) and/or preterm newborn2,6
As LBW infants (< 2,000g) and / or preterm infants (< 32 weeks gestation) do not respond as well
to hepatitis B containing vaccines as full-term infants, the 4 dose schedule of hepatitis B vaccine
at birth, 6-8 weeks, 4 months and 6 months of age is recommended, followed by either:
Measuring anti-HBc and anti-HBs level at 7 months of age; if the antibody titre is < 10
IU/mL giving one further dose at 12 months of age (due to a better immunogenic
response at this age compared with a younger age); OR
Giving one further dose of a hepatitis B containing vaccine at 12 months of age (without
measuring antibody titre).
Universal recommendation for vaccination
The National Health and Medical Research Council2 recommends that all children should be
offered a four dose course of Hepatitis B vaccine, beginning with the first dose a short time after
birth (preferably within 48 hours but always within 7 days), then combination vaccines at 6-8
weeks, 4 and 6 months of age
Details of the vaccine should be entered in the Immunisation record section of the
Government of South Australia My Health and Development Record
Follow up
Infants
Infants of HBsAg positive women should be followed up with medical review approximately 2
months after completion of the primary immunisation course (8-12 months).
Infants of HBsAg positive women should be tested for HBsAg and anti-HBs at 9-12 months of age
(at least 3 months after final dose of hepatitis B vaccine). Follow up of the infant s HBV status
should be advised in the hospital discharge summary. Do not test the infant before 9 months of
age, to avoid detecting anti-HBs from the HBIG given at birth.
If HBsAg is positive, referral to paediatric gastroenterologist or infectious diseases paediatrician is
recommended.
Woman
In cases where HBV is diagnosed during pregnancy, inform the woman s GP. Provide copies of
any relevant blood tests and advise the GP if the woman has been referred to a hepatology or
infectious diseases clinic.7
Recommend that the GP arranges HBV testing for the woman s partner and for any other
household contacts and to offer vaccination if the partner is non- immune.
HBsAg positive women should be followed up by their GP and/or infectious diseases
specialist or hepatologist every 12 months to assess their liver function, viral markers and
to monitor for hepatocellular carcinoma.
Ask the GP to follow up the status of known hepatitis B women in their subsequent
pregnancies.
Ensure the woman is referred to a Viral Hepatitis Nurse for education and support.
Ongoing follow up of the woman s HBV infection should be advised in the hospital
discharge summary following birth.
All follow up of Aboriginal women should be referred to the nominated Aboriginal
Health Professional.
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Exposure to HBV during pregnancy6
For information regarding Hepatitis B exposure post exposure prophylaxis (PEP), follow link to
www.sahealth.sa.gov.au/hepatitisbPEP
If previously known to be hepatitis B immune (previously documented anti-HBs titre ? 10 IU/mL)
no intervention is required.
In the absence of previously documented anti-HBs titre ? 10 IU/mL, antibody levels should be
determined as quickly as possible. If maternal anti-HBs titre < 10 IU/mL with significant exposure,
and there is no evidence of hepatitis B infection (HBsAg negative) give mother:
**Hepatitis B immunoglobulin (HBIG) (400 IU, IM) as soon as possible but within 72 hours
of exposure AND
HB vaccine as soon as possible but within 7 days (percutaneous, ocular or mucous
membrane exposures) or 14 days (sexual exposures) of exposure, and repeat at 1 and 6
months post initial dose
Repeat testing of mother for HBsAg at 1 month and 3 months
**Obtain HBIG from the Hospital Transfusion service (Request with a Transfusion
Request Form). If there is no 24 hour Transfusion service, contact the Australian Red
Cross Service Inventory and Distribution Department at (08) 83593164 and fax a
Transfusion request form for HBIG 100 units to fax (08) 83325741.
Provide pre and post-test counselling and refer to a Viral Hepatitis Nurse if further support
and follow up is required.
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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References
1. Department of Health. Clinical Practice Guidelines: Pregnancy Care. Canberra: Australian
Government Department of Health; 2018 available at:
https://www.health.gov.au/resources/pregnancy-care-guidelines
2. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation
Handbook, Australian Government Department of Health, Canberra, 2018, available at
https://immunisationhandbook.health.gov.au/
3. SA Health. Hepatitis B including symptoms, treatment and prevention [online]. [Cited 2020,
April 29]. Available at:
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/condition
s/infectious+diseases/hepatitis/hepatitis+b+-+including+symptoms+treatment+and+prevention
4. Jonas MM. Hepatitis B and pregnancy: an underestimated issue. Liver International. 2009: 29
(s1): 1330139
5. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
(RANZCOG). Management of hepatitis B in pregnancy. [Internet]. 2019 [updated Nov 2019;
cited 2020 Apr 21]. Available at: https://ranzcog.edu.au/statements-guidelines
6. Palasanthiran P, Starr M, Jones C, Giles M, editors. Management of perinatal infections.
Sydney: Australasian Society for Infectious Diseases (ASID) 2014. Available at:
http://www.asid.net.au/resources/clinical-guidelines
7. Australasian Society for HIV Medicine, Viral Hepatitis and Sexual Health Medicine (ASHM).
Hepatitis B and Primary Care Providers. 2012. Available at:
https://www.ashm.org.au/products/product/1976963395
8. Australasian Society for HIV Medicine, Viral Hepatitis and Sexual Health Medicine (ASHM)
Testing Portal. National HBV Testing Policy, v1.2 [Internet]. 2016 [updated March 2016; cited
2020 Apr 21]. Available from: http://www.testingportal.ashm.org.au/hbv
9. SA Health. Notifiable conditions. South Australian Public Health Act 2011. Government of
South Australia. SA Health. Available at:
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+r
esources/health+notifications/notifiable+disease+reporting
10. Society for Maternal-Fetal Medicine (SMFM), Dionne-Odom J, Tita AT, Silverman NS. #38
Hepatitis B in pregnancy screening, treatment, and prevention of vertical transmission.
American Journal of Obstetrics and Gynaecology. Jan 2016;214(1):6-14
11. Therapeutic Guidelines Ltd (eTG March 2020 edition). Hepatitis B [Internet] 2016 March
[updated 2017 March; cited 2020 Apr 21]. Available from: https://tgldcdp.tg.org.au/etgcomplete
or https://tgldcdp.tg.org.au/etgAccess
12. EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection.
Journal of Hepatology 2017 vol. 67 j 370 398
13. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018
Hepatitis B Guidance. Hepatology 2018 vol 67 1560-1599
Useful web sites
ASHM 2018. All you wanted to know about Hepatitis B. A guide for primary care
providers, available at https://www.hepatitisb.org.au/
o Diagnostic testing and interpreting
o Clinical assessment
o Treatment and management
o Pregnancy, children, co-infection and immunosuppression
RANZCOG Management of hepatitis B in pregnancy , available at:
http://www.ranzcog.edu.au/college-statements-guidelines.html
SA Department of Health: You ve got what hepatitis B Fact Sheet
https://www.sahealth.sa.gov.au/wps/wcm/connect/09b7a61c-68e5-4369-9e76-
870b92446d17/Hepatitis+B+FINAL+20171228.pdf?MOD=AJPERES&amp;CACHEID=R
OOTWORKSPACE-09b7a61c-68e5-4369-9e76-870b92446d17-n5jtl.l
http://www.hepbhelp.org.au/index.asp?PageID=7 Fact Sheets for Consumers
Hepatitis Australia https://www.hepatitisaustralia.com/Pages/Category/hepatitis-b
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Acknowledgements
The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of
clinicians and other stakeholders who participated throughout the guideline development process
particularly:
Write Group
Dr Damian Harding
Luda Mulchanoff
Lucy Ralton
Dr Brett Ritchie
Rebecca Smith
Dr Emily Tucker
Dr Nan Vasilunas
Lead writers for Original Version and Previous Reviews
Dr Brett Ritchie
Allison Rogers
Dr Celia Cooper
SAPPG Management Group Members
Sonia Angus
Lyn Bastian
Dr Elizabeth Beare
Elizabeth Bennett
Dr Feisal Chenia
John Coomblas
Dr Danielle Crosby
Dr Vanessa Ellison
Jackie Kitschke
Dr Kritesh Kumar
Catherine Leggett
Dr Anupam Parange
Rebecca Smith
A/Prof Chris Wilkinson
South Australian Perinatal Practice Guideline
Hepatitis B in Pregnancy
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Document Ownership & History
Developed by: SA Maternal, Neonatal & Gynaecology Community of Practice
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Endorsed by: Commissioning and Performance, SA Health
Next review due: 28/09/2025
ISBN number: 978-1-76083-274-2
PDS reference: CG172
Policy history: Is this a new policy (V1)? N
Does this policy amend or update and existing policy? Y
If so, which version? V 5.0
Does this policy replace another policy with a different title? N
If so, which policy (title)?
Approval
Date Version Who approved New/Revised Version Reason for Change
28/09/20 V6
Lynne Cowan, Deputy CE, Commissioning
and Performance Division, SA Department
for Health and Wellbeing
Reviewed in line with
scheduled 3-5 year plan
19/04/16 V5 SA Health Safety and Quality Strategic Governance Committee Current.
19/12/14 V4 SA Health Safety and Quality Strategic Governance Committee Reviewed
23/08/10 V3 SA Maternal and Neonatal Clinical Network Reviewed.
21/04/08 V2 SA Maternal and Neonatal Clinical Network Reviewed.
08/04/04 V1 SA Maternal and Neonatal Clinical Network Original approved version.
Purpose and Scope of Perinatal Practice Guideline (PPG)
Flowchart 1: Routine screening in pregnancy and reducing risk of maternal to child transmission of hepatitis B virus
Flowchart 2: Screening for women from at risk groups in pregnancy and reducing risk of maternal to child transmission of hepatitis B virus
Flowchart 3: Follow-up of infants whose mothers are HBV positive
Summary of Practice Recommendations
Abbreviations
Hepatitis B Virus (HBV)
Transmission of HBV
At risk groups
Antenatal screening
Routine screening for all pregnant women (see flowchart 1)
Screening women from at risk groups (see flowchart 2)
Interpretation of results
Women who are HBsAg and anti-HBs negative (non-infected and non-immune)
Notification and counselling of women who are HBsAg positive
Notification to the Communicable Disease Control Branch (CDCB)
Post-test counselling
Available support services:
Women who are HBsAg positive OR HBsAg negative, anti-HBs negative and anti-HBc positive
When to refer
Additional investigations6,7,8:
Women with high antenatal viral loads (HBV DNA viral load ? 200,000IU/mL)
Women with antenatal HBV DNA viral load < 200,000IU/mL
Women already taking anti-viral treatment / women with cirrhosis
Risk of vertical transmission during invasive procedures in pregnancy
Infection control measures
Intrapartum management
Care of the newborn baby
Breastfeeding
Newborn Immunoglobulin and Vaccination
Hepatitis B immunoglobulin:
Hepatitis B vaccine:
Low birth weight (LBW) and/or preterm newborn2,6
Universal recommendation for vaccination
Follow up
Infants
Woman
Exposure to HBV during pregnancy6
References
Useful web sites
Acknowledgements
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