• American College of Obstetricians and Gynecologists (ACOG). Viral hepatitis in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2007 Oct. 15 p. (ACOG practice bulletin; no. 86). [69 references]

This is the current release of the guideline.

Viral hepatitis during pregnancy, including:

• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis E

Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment

Gastroenterology
Infectious Diseases
Obstetrics and Gynecology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To describe the specific subtypes of hepatitis, their implications during pregnancy, the risk of perinatal transmission, and issues related to both treatment and prevention of infection

Pregnant women

1. Recognition of clinical manifestations of hepatitis
2. General diagnostic tests
   • Serum transaminase levels
   • Serum bilirubin levels
3. Specific diagnostic/screening tests
   • Hepatitis A virus (HAV) immunoglobulin M (IgM) antibodies
   • Hepatitis B virus (HBV) surface antigen (HbsAg), HBV surface IgG antibody (anti-HBS)
   • Hepatitis C antibody (anti-HCV)
   • Hepatitis D virus (HDV) antigen in hepatic tissue, IgM antibody to HDV
   • Hepatitis E virus-specific antibodies
4. Referral of chronic hepatitis carriers to liver disease experts for treatment and management
5. Reporting to health departments
6. Routine prenatal screening of all pregnancy women for hepatitis B by HBsAg testing
7. Immunoprophylaxis of newborns born to hepatitis B carriers with hepatitis B immune globulin and hepatitis B vaccine
8. Vaccination of infants and at-risk individuals with hepatitis B vaccine, particularly heath care workers.
9. Screening of at-risk pregnant women for HCV infection (routine screening considered but not recommended)
10. Considerations for amniocentesis, route of delivery and breastfeeding in women infected with hepatitis

• Incidence of viral hepatitis infections: hepatitis A, B, C, D, and E
• Incidence of vertical perinatal transmission of viral hepatitis
• Incidence of accidental exposure of healthcare workers

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and February 2007. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

Published cost analyses were of screening and vaccinating for viral hepatitis were reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

• Routine prenatal screening of all pregnant women by hepatitis B surface antigen (HBsAg) testing is recommended.
• Newborns born to hepatitis B carriers should receive combined immunoprophylaxis consisting of hepatitis B immune globulin (HBIG) and hepatitis B vaccine within 12 hours of birth.
• Hepatitis B infection is a preventable disease, and all at-risk individuals, particularly health care workers, should be vaccinated. All infants should receive the hepatitis B vaccine series as part of the recommended childhood immunization schedule.
• Breastfeeding is not contraindicated in women with hepatitis A virus (HAV) infection with appropriate hygienic precautions, in those chronically infected with hepatitis B if the infant receives HBIG passive prophylaxis and vaccine active prophylaxis, or in women with hepatitis C virus (HCV) infection.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

• Routine prenatal HCV screening is not recommended; however, women with significant risk factors for infection should be offered antibody screening.
• Route of delivery has not been shown to influence the risk of vertical HCV transmission, and cesarean delivery should be reserved for obstetric indications in women with HCV infection.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• The risk of transmission of hepatitis B associated with amniocentesis is low.
• Susceptible pregnant women who are at risk for hepatitis B infections should be specifically targeted for vaccination.

Definitions:

Grades of Evidence

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendation

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Accurate diagnosis and appropriate treatment and management of viral hepatitis in pregnant women

Not stated

The use of ribavirin is contraindicated in pregnancy.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better
Living with Illness
Staying Healthy

Effectiveness

• American College of Obstetricians and Gynecologists (ACOG). Viral hepatitis in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2007 Oct. 15 p. (ACOG practice bulletin; no. 86). [69 references]

Not applicable: The guideline was not adapted from another source.

2007 Oct

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins - Obstetrics

Not stated

Not stated

This is the current release of the guideline.

Proposed performance measures are included in the original guideline document.

This NGC summary was completed by ECRI Institute on July 30, 2008. The information was verified by the guideline developer on August 20, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.