Hepatitis B virus (HBV) is a highly infectious DNA virus

and it is estimated that 350 400 million people are

chronically infected worldwide.
1
Women of child bearing
age with chronic HBV infection remain an important
source of vertical transmission. According to recent data
from United States centers of disease control and
prevention, prenatal screening for Hepatitis BsAg
(HBsAg) is universal; 97% of women undergo screening
during pregnancy.
2
Accurate figures from developing
countries are missing but estimates are quite low. All
infants born to HBsAg positive mothers should get active
and passive Hepatitis B immunization.
1
During pregnancy, decision regarding initiation,
continuation or stopping of treatment depends upon
multiple factors. In a series of mothers with high viral
load, the risk of vertical transmission was as high as
28%.
3
Women with high viral load and HBeAg positivity
have higher chance of vertical transmission. Assess-
ment of mother's liver status is the key to decide about
management. Women with mild liver disease and low
viremia can wait till the pregnancy is over. Whereas, in
those patients with mild liver disease but high viral loads
(HBV DNA > 10
8
copies/ml), antiviral treatment should
start at 32 weeks and continue at least 4 weeks
postpartum as it is observed that if mothers viral load
can be decreased, the risk of perinatal transmission is
also reduced. If previous child was HBV positive, then
the risk of perinatal transmission may be higher, so the
threshold for treatment may be lower (HBV DNA > 10
6
copies/ml). Women with advanced liver disease should
continue with antiviral treatment (category B drugs)
(Table I).
4
Interferon is not recommended in pregnancy. All oral
antivirals are either inhibitor of nucleoside or nucleotide
polymerases. Tenofovir is an ideal treatment in
pregnancy because of its safety profile. Lamivudine and
Telbivudine are two alternate agents, but no longer
considered as first line agents because of its antiviral
resistance.
Most women of child bearing age are likely to have mild
disease and treatment can be delayed. Those women
who are already on antiviral before delivery, the decision
to continue it during pregnancy depends upon the risk of
decompensation during or after pregnancy. Majority of
safety data on HBV antiviral come from antiretroviral
pregnancy registry (APR).
5
Tenofovir was given to 606
pregnant women in their first trimester and 336 women
in their second trimester, the rate of birth defects
associated with Tenofovir ranged from 2.3% and 1.5%
respectively, which is similar to background rate.
5
Management of HBV in pregnancy is complicated and
challenging. Before initiating treatment, risks and
benefits must be weighed carefully. Major determinants
of perinatal transmission are previous transmission of
HBV to fetus, viral count and mothers liver condition.
Larger multicentre, randomized long-term follow-up
studies are required on this topic. These patients should
ideally be managed in tertiary care centre, under close
follow up with hepatologist.
REFERENCES
1. World Health Organization. Hepatitis B: fact sheet 2004
[Internet].2004. Available from: http://www.who.int/mediacentre/
factsheets/fs204/en/
2. Schrag SJ, Arnold KE, Mohle-Boetani JC, Lynfield R, Zell ER,
Stefonek K, et al. Prenatal screening for infectious disease and
opportunities for prevention. Obstet Gynecol 2003; 102:753-60.
3. Van Zonneveld M, Van Nunen AB, Niesters HG, De Man RA,
Schalm SW, Janssen HL. Lamivudine treatment during
pregnancy to prevent perinatal transmission of Hepatitis B
virus infection. J Viral Hepat 2003; 10:294-7.
4. Lok AS, MacMahon BJ. Chronic Hepatitis B: update 2009.
Hepatology 2009; 50:1-36.
5. Interim report. The antiretroviral pregnancy registry [Internet].
2013. Available from: http://www.apregistry.com/forms/interim_
report.pdf
Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (1): 73-74 73
LETTERS TO THE EDITOR
Management of Hepatitis B in
Pregnancy: A Challenge
Table I: Pregnancy classification of antiviral therapy.
Antiviral drug Pregnancy category
Adefovir C
Entecavir C
Interferon alpha-2b C
Lamivudine C
Pegylated interferon alpha-2a C
Telbivudine B
Tenofovir B
Pregnancy Category B: Animal reproduction studies have failed to demonstrate a risk to the
fetus and there are no adequate and well controlled studies in pregnant women or animal
studies have shown an adverse effect, but adequate and well-controlled studies in pregnant
women have failed to demonstrate a risk to the fetus in any trimester.
Pregnancy Category C: Animal reproduction studies have shown an adverse effect on the
fetus and there are no adequate and well controlled studies in humans, but potential benefits
may warrant use of the drug in pregnant women despite potential risks.
Lubna Kamani
Department of Gastroenterology and Endoscopy Suit,
Liaquat National Hospital and Medical College, Karachi.
Correspondence: Dr. Lubna Kamani, 2/11, Creek Lane No. 6,
P-Street, Khayaban-e-Muhafiz, Phase 7, DHA, Karachi.
E-mail: lkamani@yahoo.com
Received: August 24, 2012; Accepted: August 30, 2013.
Sir,
Dengue fever (DF), also known as break-bone fever, is
a mosquito vector-borne disease that has gained much
importance for mankind over the years in the context of
morbidity and mortality.
1
It is caused by four different
serotypes of an enveloped, single-stranded, positive
RNA virus (Dengue virus) from the family Flaviviridae.
1-3
A total of 200 serum samples from 130 males and 70
females, who were clinically and serologically confirmed
cases of Dengue fever, were observed to be positive for
Dengue virus-specific IgM and IgG antibodies and
negative for hepatitis A, B, C and E infection. According
to severity of signs and symptoms, the patients were
divided into two groups including Dengue fever (DF) and
Dengue haemorrhagic fever (DHF) having 153 (76.50%)
and 47 (23.50%) patients respectively. The patients
of DHF group were found to have significantly higher
mean serum values of liver enzymes compared to the
DF group.
For evaluating total bilirubin, AST, ALT and ALP, the DF
group was analyzed for 108, 153, 153 and 122 cases
respectively whereas 16, 32, 29 and 17 cases were
assessed in DHF group, respectively. Hepatic dys-
function, in the form of altered total bilirubin, AST, ALT
and ALP was present in 24.07%, 97.1%, 88.82% and
24.59% of the tested patients respectively suffering from
Dengue fever. However, hepatic dysfunction in the form
of abnormal total bilirubin, AST, ALT and ALP of dengue
haemorrhagic fever (DHF) was present in 50%, 100%,
79.31% and 29.41% of tested patients respectively.
The mean total bilirubin, AST, ALT, ALP values were 0.76
0.06 mg/dl, 274.22 17.2 U/L, 168.6 18.02 U/L and
117.44 2.7 U/L respectively in the Dengue fever group.
Whereas, patients with Dengue haemorrhagic fever, the
mean total bilirubin, AST, ALT, ALP values were 0.85
0.11 mg/dl, 427.9 113.5 U/L, 244.5 32.05 U/L and
167.44 19.9 U/L respectively. Results have shown that
mean value of AST was significantly higher than the
mean ALT value (p = 0.043). A significant difference was
observed in the mean values of AST and ALT between
DF and DHF groups. The most notable feature of this
study was AST values that were found considerably
higher in patients with DHF. No significant difference
was observed in LFTs of male and female patients.
It was concluded that hepatic dysfunction is common in
Dengue infection. Patients with DHF are more prone to
have liver enzyme derangement and preferentially
high AST may serve as an early indicator of Dengue
infection.
REFERENCES
1. Shah I. Dengue and liver disease. Scandinavian J Infect Dis
2008; 40:993-4.
2. Goel A, Patel DN, Lakhani KK, Agarwal SB, Agarwal A, Singla
S, et al. Dengue fever: a dangerous foe. J Ind Acad Clin
Medicine 2004; 5:247-58.
3. Khan E, Kisat M, Khan N, Nasir A, Ayub S, Hasan R.
Demographic and clinical features of dengue fever in Pakistan
from 2003-2007: A retrospective cross-sectional study. PLoS
One 2010; 5:e12505.
Letters to the Editor
74 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (1): 73-74
Hepatic Dysfunction in Patients
Infected with Dengue Virus
Sajid Umar
1
, Bilal Ahmad
2
, Muhammad Younas Rana
3
,
Jabar Zaman Khan Khattak
2
and Muhammad Imran Shabbir
2
1
Department of Pathology, Arid Agriculture University,
Rawalpindi.
2
Department of Bioinformatics and Biotechnology, International
Islamic University, Islamabad.
3 Department of Pathology, University of Vaterinary and Animal
Sciences, Lahore.
Correspondence: Dr. Muhammad Imran Shabbir, House No. 135,
Street 159, Sector G-11/1, Islamabad.
E-mail: imran.shabbir@iiu.edu.pk
Received: March 14, 2013; Accepted: August 31, 2013.