Chronic hepatitis B infection in pregnancy illustrated by a case of successful treatment with entecavir.

Chronic hepatitis B virus (HBV) infection affects more than 350 million people worldwide [1]. The pregnancy courses of women with chronic HBV infection are generally favorable. However, severe complications of chronic HBV infection can occur during pregnancy. Optimal antiviral treatment of HBV infection during pregnancy is unclear. Keeffe et al. [2] have recommended individualization of therapy for pregnant HBV patients. chronic hepatitis B (CHB) with acute exacerbation has a high fatality rate up to 20–30% [3]. There are few reports on the management of CHB with acute exacerbation during pregnancy [4–7]. We present a successful pregnancy outcome of a woman treated with entecavir for CHB with acute exacerbation during pregnancy. A 36-year-old para-2 woman with CHB attended antenatal care visits our hospital from 6 weeks of gestation. She was diagnosed with CHB for the first time as a result of antenatal HBV screening on her first pregnancy. Since diagnosis, she has been followed by a gastroenterologist at our hospital and has been asymptomatic with the HBV DNA levels of approximately 7 log10 copies/mL and a normal alanine aminotransferase (ALT) level prior to the pregnancy described herein. Her previous pregnancies were uneventful and all resulted in full-term spontaneous deliveries. At 13-week gestation, she complained of fatigue and jaundice. Laboratory findings revealed a total bilirubin level of 3.6 mg/dL, a serum ALT level of 1,309 IU/L, a serum aspartate aminotransferase level of 2,386 IU/L and a lactate dehydrogenase level of 1,252 U/l. She was positive for hepatitis B surface antigen (HbsAg), hepatitis B e antigen (HbeAg) and HBV DNA in her serum. The HBV DNA level was greater than 7.6 log10 copies/mL. Hepatitis B e antibody (HbeAb) was not detected in her serum. Treatment with oral entecavir (0.5 mg/day) was initiated immediately for CHB with acute exacerbation. After initiation of treatment, she showed rapid clinical improvement; her ALT level decreased to 46 IU/L, and her HBV DNA level decreased to 4.6 log10 copies/mL at 2 weeks after initiation of treatment. Entecavir therapy was withdrawn after 32 days of therapy. She underwent hepatitis B e seroconversion during the course of treatment. After cessation of treatment, the patient showed no signs of a hepatitis flare-up. The HBV DNA level reached a plateau of approximately 3 log10 copies/mL with ALT normalization at 6 weeks after initiation of treatment. The spontaneous delivery of a male baby weighing 2,950 g occurred at 39 weeks gestation. The baby had Apgar scores of 8 and 9 at 1 and 5 min. The patient did not experience any adverse effects as the result of the treatment throughout the whole course of the pregnancy. The neonatal physical check-up revealed no congenital anomalies. The patient and the baby did not experience any complications during the postpartum period. Decisions about initiating treatment for HBV infection during pregnancy must include consideration of the risks and benefits for the mother and the fetus. Data on the safety of antiviral treatment of HBV during pregnancy remain limited. The US Food and Drug Administration lists telbivudine and tenofovir as pregnancy category B drugs and lamivudine, entecavir and adefovir as pregnancy category C drugs. Lamivudine is considered safe for use during J. Kakogawa (&) A. Sakurabashi M. Sadatsuki H. Gomibuchi S. Minoura Department of Obstetrics and Gynecology, National Center for Global Health and Medicine, 1-21-1, Shinjuku-ku, Tokyo, Toyama 162-8655, Japan e-mail: jkakogaw@hosp.ncgm.go.jp