••• Chapter 15^ Gastrointestinal Disorders in Pregnancy^163
❍ What is the differential diagnosis of hepatomegaly in pregnancy?
(1) Infiltrative disease: Acute fatty liver of pregnancy
(2) Inflammatory condition: Hepatitis
(3) Passive congestion: Right-sided heart failure or Budd-Chiari syndrome
(4) Malignancy (rare)
❍ What is the differential diagnosis of jaundice in pregnancy?
(1) Viral hepatitis: Serum transaminases increased mild to moderate range, positive serology, and prominent
inflammatory infiltrate on liver biopsy with cellular disarray.
(2) Acute fatty liver of pregnancy: Serum transaminases minimally increased and prominent microvesicular fat
deposition on liver biopsy.
(3) Toxic injury: History of exposure to tetracycline, isoniazid, erythromycin, or methyldopa.
(4) Cholestasis of pregnancy: Pruritus and bile salt elevation.
(5) Severe preeclampsia: Hypertension, proteinuria, thrombocytopenia, elevated creatinine, uric acid, and
transaminases.
(6) Mononucleosis: Flu-like symptoms, elevated transaminases, and positive heterophile antibody.
(7) CMV hepatitis: Elevated transaminases, positive viral culture or PCR, CMV antibodies.
(8) Autoimmune hepatitis: Elevated transaminases, antibodies, and liver-kidney microsomal antibodies.
❍ What is the rate of maternal-fetal transmission of hepatitis B?
Several factors modify the perinatal transmission rate of hepatitis B. In the absence of immunoprophylaxis, 10%
to 20% of women who are seropositive for hepatitis B surface antigen (HbsAg) alone will transmit the virus to
their fetus; this rate increases to 90% in women who are seropositive for both HBsAg and hepatitis B e antigen
(HbeAg). The age of gestation when the illness occurs also affects transmission rates for acute hepatitis B: it is 10%
during the first trimester and increased to 80% to 90% during the third trimester. Intrapartum transmission of the
infant via exposure to contaminated blood and genital secretions accounts for 85% to 95% of cases of perinatal
transmission; and the rest comes about from hematogenous dissemination, breastfeeding, and close physical
contact between the mother and her neonate.
❍ True or False: Immunoprophylaxis of hepatitis B is necessary for the infants of HbeAg-negative and
HBsAg-positive mothers.
True. While on average the risk of transmission is lower in this group, it is still significant. Therefore, infants
of HBsAg-positive mothers, regardless of HbeAg status, should receive both hepatitis B immune globulin and
hepatitis B vaccine within 12 hours after birth, followed by two injections of hepatitis B vaccine during the first
6 months of life.
❍ True or False: Cesarean delivery should be performed in all pregnant women with chronic hepatitis B.
False. Appropriate immunoprophylaxis of the infant after delivery is sufficient.
❍ True or False: Breastfeeding is contraindicated in women with hepatitis.^4
False. Breastfeeding is allowed in women with hepatitis A infection given appropriate hygienic precautions, in
women chronically infected with hepatitis B and the infant has received both passive and active prophylaxis, or in
women with hepatitis C infection.