Introduction
Viral hepatitis is the common cause of jaundice in pregnancy2 and is still one of the leading causes of maternal death in our country. Western studies report that the course of pregnancy is unaltered by viral hepatitis while Indian studies show a dire maternal and perinatal outcome. This could be due to malnutrition3 superimposed on increased demands of pregnancy and poor sanitation. In a series of 290 cases of jaundice complicating pregnancy, Lahiri from Kolkata that 90% were due to viral hepatitis compared to only 42% reported by Griffin et al in USA.4
Hepatotropic viruses A to E ,Epstein Barr virus, Echo virus, Yellow fever virus5,6 are now well recognized and all are important public health issues. Three additional viruses G, TT, SEN-V have been discovered recently but not yet proved to be hepatotropic.6
Material and Methods
This is a retrospective study of 42 cases of viral hepatitis in pregnancy over a span of 3 years from Jan’02 to Dec’04. We analysed demographic parameters, timing of referrals and associated complications. We evaluated maternal outcome in terms of requirements of intensive care, blood transfusion and components, treatment modalities and ventilatory support etc. The outcome of pregnancy with regards to gestational age at delivery, mode of delivery, incidence and indications of operative intervention as well as associated complications were studied. Perinatal outcome was studied in terms of mortality, NICU admissions , premature unit care, and sepsis etc.
Observation
We studied 42 cases of viral hepatitis in pregnancy giving an incidence of 0.28%. At our centre majority of the women i.e 57.2% were unregistered while 42.8% were registered. At the time of admission 54.76% had hepatic encephalopathy with coma, 4.7% had PPH , Septicaemia and DIC respectively. 24% women presented with jaundice only, out of which 7% had h/o jaundice during present pregnancy but recovered and referred for further management (Fig. 1).
In our study 27 women were with gestational age less than 36 weeks of which only 5 women were referred at < 28 wks. of gestation, 13 were term pregnancy and 2 postpartum cases.
| HEV |
19 |
45% |
| HBV |
9 |
21.4% |
| HAV |
8 |
19% |
| Unknown |
4 |
9.52% |
| HCV |
2 |
4.7% |
|
Viral marker study revealed that 45% women were affected with HEV, 21.4% with HBV, 19 % with HAV. All the patients were managed by supportive measures like Hospitalisation, Universal health precautions, correction of hypoglycaemia and dehydration, high carbohydrate and low fat diet, cholestyramine resin, lactulose, neomycin and supplement of other antibiotics, antiallergic, symptomatic and supportive treatment of complications, use of tocolytics, foetal monitoring methods, control of bleeding in 3rd stage of labour and care of newborn at birth. 76 % of pts. required MICU care, 69 % required ventilatory support.
All patients in our study had spontaneous onset of labour. 31 women delivered vaginally of which 4 required forceps application. Only 6 women underwent L.S.C.S. for obstetric indications. In 5 undelivered women we had 4 deaths and 1 patient was discharged when hepatic functions normalized. Two post partum patients who were referred as PPH managed conservatively and discharged after 1 month . Our study showed 59.5% maternal mortality while 40.5% women recovered. All pts. were given Carboprost, Menadione and monitored for PP.
We had 22 live births and 15 IUFD. Out of 22 live births 15 babies were preterm and 7 full term of these 15 required NICU admission. Out of 15 IUFD 9 babies were preterm and 6 full term, 4 babies died within 24 hrs. of delivery with PNMR of 51.5 which was very high due to prematurity and sepsis.
 |
 |
| Fig. 1: Referal Status. |
Fig. 3: Mode of delivery |
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| Fig. 2: Viral maker study |
Fig. 4: Perinatal outcome |
Discussion
It was observed that majority of the cases were unregistered and had complications associated with viral hepatitis i.e. hepatic encephalopathy, DIC, septicaemia, PPH etc . At the time of admission general condition was poor which contributed to very high maternal as well as perinatal mortality. A more severe course of viral hepatitis in pregnancy has been noted in patients with hepatitis E and markedly increased fatality rates. The various complications which led to such a high maternal mortality were fulminant hepatic failure,7 DIC, septicaemia and acute renal failure. Two major factors responsible for perinatal mortality were prematurity and sepsis. Many of these complications and deaths are preventable. Essential ANC care at domiciliary and peripheral levels, early detection can prevent most of the complications. General health measures such as provision of safe drinking water, environmental sanitation, health education, well balanced diet and prophylactic immunization against the disease would definitely improve maternal and foetal outcome.
References
- Das K, Agarwal A, Andrew R, et al. European Journal of Epidemiology 2000; 16 (10) : 937-40. (4)
- Figueroa DR, Sanchez FL, Benavides CME : Comportamiento y repercusion perinatal de la hepatitis viral en el embarazo. Rev Gastroenterol Mex 1994; 59 (3) : 246-53.
- Beniwal M, Kumar A, Kar P, et al. Indian Journal of Medical Microbiology 2003; 21 (3) : 184-85.
- Pastorec H, Joseph G. The ABC’s of Viral Hepatitis in pregnancy. Clinical Obs. and Gyn 1993; 36 (4) : 834-54.
- Bhasker Rao K, Geeta R. Pregnancy at Risk : Current concept. Hepatitis in Pregnancy 24 : 125-29.
- Deodhare SG. II Viral Hepatitis :Recent Progress, Update 2000 Pathology.
- Hess LW, Morrison JC, Hess DB. General Medical disorders during pregnancy 23 : 479-81. .
WHAT’S NEW IN DIVERTICULITIS?
Recent advances in diagnosis and treatment of diverticular disease have enabled successful medical management of patients who would previously have had surgery, say Janes and colleagues. In a clinical review on management of diverticular disease, the authors revisit pathophysiology, terminology, and diagnostic imaging of this increasingly common disorder and discuss the evidence on the use of dietary fibre and drugs in uncomplicated disease. They document how emergency surgery has evolved from a three stage to a one stage procedure and examine whether elective surgery prevents future complications.
BMJ, 2006, 332 : 271. |
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