Background: Maternal mortality is an important health indicator. Hepatitis E is a common viral infection affecting pregnant women. The maternal morbidity and mortality relating to this infection is not extensively reported and deserves to be studied.Methods: A retrospective study was conducted in a tertiary care referral centre and the obstetric and neonatal outcomes among patients with hepatitis E infection were studied for duration of 1 year.Results: Among 24 patients, there were 7 mortalities. Majorities were primigravidae and presented during third trimester. A sizeable number required blood transfusions and ICU stay. 7 were stillbirths and majorities were low birth weight babies.Conclusions: Hepatitis E causes significant maternal and neonatal morbidity

Hiralal Pardeshi, Sachin

Mayadeo, Niranjan

International Journal of Reproduction Contraception Obstetrics and Gynecology

English

International Journal of Reproduction, Contraception, Obstetrics and Gynecology

                                                                                                                                November 2016 · Volume 5 · Issue 11    Page 3663 International Journal of Reproduction, Contraception, Obstetrics and Gynecology Pardeshi SH et al. Int J Reprod Contracept Obstet Gynecol. 2016 Nov;5(11):3663-3666 www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789 Original Research Article Obstetric and neonatal outcomes among pregnancies                          with hepatitis E infection  Sachin Hiralal Pardeshi*, Niranjan Mayadeo              INTRODUCTION Hepatitis E was previously known as “non-A, non-B enterically transmitted” hepatits virus. The virus is transmitted enterically and is predominant in the Asian subcontinent and Africa. In many of these geographic areas, HEV appears to be the most common cause of acute onset of jaundice. The hepatitis E virus is a positive sense RNA and the existences of 5 different genotypes have been described. During the latter part of incubation period, the virus is excreted in the stools and hence spreads primarily by enteric mode of spread. Young populations that are immune to Hepatitis A appear to be more susceptible to hepatitis E infection. Acute infection elicits immune response and both IgM and IgG against the viral antigens can be detected quite early in the course of infection.1 The Integrated disease surveillance programme in India reported a 2 year data which showed around 8 lakh cases of hepatitis outbreaks. Of these, approximately 10.4% tested positive for hepatitis E. 48% of the outbreak clusters were due to hepatitis E. The burden of hepatitis E is exemplified by this report.2 In a recently published study from urban India, the morbidity patterns of maternal hepatits E infection appear to be much more significant than the other viral hepatitis infections.3 The description of the obstetric and neonatal outcomes among such pregnancies formed the basis of this study.  Aims and objectives of the study were to describe the obstetric and neonatal outcomes among pregnancies complicated by hepatitis E infection.  Department of Obstetrics and Gynecology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India  Received: 27 September 2016 Revised: 29 September 2016 Accepted: 03 October 2016  *Correspondence: Dr. Sachin Hiralal Pardeshi, E-mail: sachinhpardeshi@gmail.com Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: Maternal mortality is an important health indicator. Hepatitis E is a common viral infection affecting pregnant women. The maternal morbidity and mortality relating to this infection is not extensively reported and deserves to be studied. Methods: A retrospective study was conducted in a tertiary care referral centre and the obstetric and neonatal outcomes among patients with hepatitis E infection were studied for duration of 1 year. Results: Among 24 patients, there were 7 mortalities. Majorities were primigravidae and presented during third trimester. A sizeable number required blood transfusions and ICU stay. 7 were stillbirths and majorities were low birth weight babies. Conclusions: Hepatitis E causes significant maternal and neonatal morbidity.  Keywords: DIC, Hepatitis E, Jaundice, Maternal mortality, Viral hepatitis DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20163828 Pardeshi SH et al. Int J Reprod Contracept Obstet Gynecol. 2016 Nov;5(11):3663-3666 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                   Volume 5 · Issue 11    Page 3664 METHODS This was a retrospective observational study conducted in a tertiary care referral institution in urban India. Over duration of 1 year, all obstetric patients (antenatal and postnatal) with hepatitis E infection were included in the study. The case records of the patients were studied, and various parameters relating to the medical, obstetric and neonatal outcomes were noted. The parameters studied included age, parity index, gestational age, mode of delivery, indication (if any instrumental of operative delivery), and requirement of ICU admission, haematological, hepatic and coagulation parameters of the mother, neonatal details and any other co-existing morbidity. Simple statistical calculations such as percentages were computed and the results compared with reported prevalence rates in the existing literature.  RESULTS  A total of 24 pregnant patients with hepatitis E were identified.  Age The mean age in the study group was 25.6 years.  Parity index  As show in Table 1, majority were primigravidae.  Table 1: Distribution of parity index. Parity index Number of patients Primigravida 13 (54.16%) Gravida 2 3 (12.5%) Gravida 3 or above 8 (33.3%) Gestational age  As shown in Table 2, majority presented in the third trimester of pregnancy, and none presented in the first trimester. Table 2: Distribution of gestation age. Gestational age at diagnosis Number First trimester None Second trimester 5 (20.8%) Third trimester 19 (79.16%) >36 weeks 7 (29.16%) <36 weeks  12 (50%) Mode of presentation All the patients presented with acute onset of jaundice. 15 patients (62.5%) presented in a morbid state, necessitating admission to the intensive care unit.  Medical management It was noted that all the patients were provided standard management and care which involved monitoring of haematological parameters, anti-encephalopathy measures, antibiotics and symptomatic management based on specific clinical findings and abnormalities in investigation parameters. All patients included in the study had IgM Anti-hepatitis E positive status. Hepatic function abnormalities such as raised liver enzymes and raised bilirubin value were seen in all patients. The average bilirubin value at admission was 9.09mg/dl. As shown in Table 3, encephalopathy was seen in 29% of the patients, coagulopathy was seen in 45% and renal failure occurred in 20%. Blood transfusion was required in 25% of patients, and 45% required transfusion of blood products such as fresh frozen plasma, platelets and cryoprecipitate.  Table 3: Associated medical complications. Medical complications Number Encephalopathy 7 (29.1%) Coagulopathy  11 (45.8%) Renal failure 5 (20.8%) Need for blood transfusion 6 (25%) Need for blood product transfusion 11 (45.8%) Obstetric outcomes As shown in the Table 4, although a conservative management was followed and 70% had spontaneous labour onset and progress. 16% required induction of labour for progressive derangement of liver functions. Despite poor maternal status, one patient required LSCS due to bleeding placenta previa. One patient each had been diagnosed earlier with gestational diabetes mellitus, preeclampsia and morbid obesity.  Table 4: Mode of delivery details. Mode of delivery Number Spontaneous 17 (70.8%) Induced 4 (16.6%) Died undelivered 2 (8.3%) LSCS 1 (4.1%) Neonatal outcomes As shown in Tables 5 and 6, 2 patients had been brought in postpartum status and 2 patients died undelivered. 1 patient aborted at around 18 weeks of gestation. Among those delivered, 5 were fresh still births and 2 were macerated still births. Only 6 babies were transferred to the mother. The rest needed NICU care. The main reason for NICU transfer was low birth weight. The majority (70%) of the babies were in the weight group of 1 to 2.5kilograms. Pardeshi SH et al. Int J Reprod Contracept Obstet Gynecol. 2016 Nov;5(11):3663-3666 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                   Volume 5 · Issue 11    Page 3665 Table 5: Fetal outcome details. Fetal outcomes Numbers  Abortus 1  FSB 5  MSB 2  Not transferred to NICU 6  Transferred to NICU 6  Died undelivered 2  Delivered outside (neonate not brought) 2  Table 6: Birth weight distribution. Weight at delivery   Less than 1kg 3 (15%) 1 to 2.5kg  14 (70%) More than 2.5kg  3 (15%) Total  20 Among those who recovered, the average stay of patients in the hospital ranged 7-13 days, with an average of 9 days.  Maternal deaths There were a total of 7 maternal deaths in the study group. The duration between admission and death ranged from 1 day to 5 days, with an average of 3 days.  The common factors leading to the death were DIC, hepatic encephalopathy and renal failure.  DISCUSSION The mean age of our patients was 25.6 year. This is quite similar to the study conducted by Shinde et al where the mean age of the pregnant patients was 24.1 years.4 Majority (79%) of our patients were diagnosed of the hepatitis during the third trimester. This is quite similar to the findings of Begum et al, who found that hepatitis E is more common and more fatal in the third trimester. The average gestational age in our group of patients was 31.2 weeks.5 This is similar to the findings described by Sultana et al, who described an average gestational age of 32 weeks.6 This high number of preterm deliveries is also in congruence with the study reported by Singla et al wherein the proportion of preterm deliveries was 76%.3  The majority (54.1%) of the patients were primigravidae. This is comparable to the results reported by Sultana et al, wherein 40% of the patients were primigravidae.  A conservative approach was followed for the management of the pregnancies. Only 16% underwent induction of labour. This is in agreement with the approach followed by Singla et al, wherein also the rate of induction was small, at 25%.3 Majority (63%) of the babies were in the range of birthweight 1 to 2.5kg; and average birth weight of neonate was 1.6kg. Perinatal mortality was 33%, which was accounted for by 5 fresh still births and 2 macerated still births. This perinatal mortality rate is comparable to the 26% reported by Sultana et al. These values are consistent with unfavourable fetal prognosis, which has also been suggested by a review by El Sayed et al.7 The important observation from the study is that all babies that delivered live survived. This finding has been supported in a review by Jin H et al, which concluded that upon pooled data analysis, intrauterine fetal mortality was statistically higher than neonatal mortality.8  In our study, out of 24 patients, there were 7 maternal deaths. In the study by Singla et al, among all the viral hepatitis, hepatitis E was the only causative agent. The contribution of hepatitis E to maternal mortality continues to be high, as evidenced by other studies also.9 CONCLUSION In conclusion, the morbidity caused by hepatitis E infection among the pregnant population continues to be high. Due to fulminant course among infected individuals (as described in this study), prevention of the occurrence of infection Measures to prevent feco-oral transmission of the virus need to be emphasized by health authorities. ACKNOWLEDGEMENTS  The corresponding author would like to thank Dr. M Prasad for help in improvement of manuscript.  Funding: No funding sources Conflict of interest: None declared Ethical approval: Not required REFERENCES 1. Dienstag JL. Acute Viral Hepatitis In: Longo LD, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine. New York. 18th edn. McGraw Hill; 2014. 2. Kumar T, Shrivastava A, Kumar A, Laserson KF, Narain JP, Venkatesh S. Viral Hepatitis Surveillance--India, 2011-2013. MMWR Morb Mortal Wkly Rep. 2015;64(28):758-62.  3. Singla A, Mehta S, Rajaram S, Shree S. Materno-Fetal Outcomes with Viral Hepatitis in Pregnancy. J Obst Gyn India. 2016;66(3):166-9.  4. Shinde N, Patil T, Deshpande A, Gulhane R, Patil M, Bansod Y. Clinical profile, maternal and fetal outcomes of acute hepatitis E in pregnancy. Ann Med Health Sci Res. 2014;4(2):S133-9.  Pardeshi SH et al. Int J Reprod Contracept Obstet Gynecol. 2016 Nov;5(11):3663-3666 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                   Volume 5 · Issue 11    Page 3666 5. Begum N, Devi SG, Husain SA, Kumar A, Kar P. Seroprevalence of subclinical HEV infection in pregnant women from north India: a hospital based study. Indian J Med Res. 2009;130(6):709-13.  6. Sultana R, Humayun S. Fetomaternal outcome in acute hepatitis e. J Coll Physicians Surg Pak. 2014;24(2):127-30.  7. El Sayed Zaki M, El Razek MMA, El Razek HMA. Maternal-Fetal hepatitis E Transmission: Is It Underestimated? J Clin Transl Hepatol. 2014;2(2):117-23.  8. Jin H, Zhao Y, Zhang X, Wang B, Liu P. Case-fatality risk of pregnant women with acute viral hepatitis type E: a systematic review and meta-analysis. Epidemiol Infect. 2016;144(10):2098-106.  9. Khaskheli MN, Baloch S, Sheeba A, Baloch S. Acute hepatitis E Viral Infection in Pregnancy and Maternal Morbidity. J Coll Physicians Surg Pak. 2015;25(10):734-7.        Cite this article as: Pardeshi SH, Mayadeo N. Obstetric and neonatal outcomes among pregnancies with hepatitis E infection. Int J Reprod Contracept Obstet Gynecol 2016;5:3663-6. 

Obstetric and neonatal outcomes among pregnancies with hepatitis E infection

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