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Hepatitis B - Management of women identified through antenatal screening

GG&C Obstetric Guidelines March 2015

Antenatal screening for four communicable diseases – hepatitis B, HIV, syphilis and immunity to rubella - is offered to all pregnant women. The uptake is over 99% across Greater Glasgow and Clyde for all four diseases. The primary aim of screening for hepatitis B is to ensure a plan for treatment and management for affected individuals and their babies. This allows treatment to be given, which can reduce the risk of mother to child transmission, improves the long-term outcome and development of affected children, and ensures that women, their partners and families are offered appropriate referral, testing and treatment.

Approximately 75 mothers are identified by West of Scotland Specialist Virology Centre (WoSSVC) every year in NHS GGC as being hepatitis B surface antigen positive during antenatal screening.

1. The initial screening blood test will record HBsAg, HBeAg, anti-HBe. If these are positive, the laboratory will proceed to HBV DNA viral load, genotype and anti-Hepatitis D virus results. HIV test will also have been done if the mother has consented.

2. Following identification of an HBsAg positive test from the booking blood sample, the WoSSVC writes to the clinician in charge of the patient and the nominated obstetrician at the referring unit in GGC as below:

Princess Royal Maternity                Dr Victoria Brace

Southern General Hospital             Dr Marianne Ledingham

Royal Alexandra Hospital               Dr Andrew Quinn

3. This letter will inform the obstetrician of the diagnosis of hepatitis B in the mother and will indicate, depending on available viral markers, if the baby requires immunoglobulin AND vaccine OR vaccine alone at birth (as per current Green Book recommendations, see below). This letter will also contain a section to be completed by the obstetrician once the 26 week gestation hepatitis B DNA levels are know, along with instructions on how this will affect the recommendations for neonatal treatment.

The WoSSVC also writes to the GP at this point to invite the GP to continue the vaccination programme which will be started in the maternity unit. Public health coordinate the response and follow up programme for the baby.

4. The letter sent to the Obstetrician is placed in the mother’s notes for the attention of the neonatal paediatrician. The letter advises the paediatricians to inform the NHS GGC Screening Dept at Templeton by email of the birth of the baby - [email protected]

5. The nominated obstetrician will:

a) Immediately refer the patient to the local hepatitis service for clinical review and advice

b) Send a letter to the patient informing them of the hepatitis B result

c) Offer to refer the patient to the Counselling and Support Team (CAST) at the Brownlee Centre where screening of family members and contract tracing will be carried out

d) Give the patient an appointment to attend for review at 26 weeks

e) Ensure the hepatitis B status and management plan is clearly documented in the Neonatal section of the Yellow Alert Sheet which starts every inpatient maternity record.

6. At the 26 week review the nominated obstetrician will have a sample taken for the HBV DNA viral load, liver function tests, prothrombin time and anti hepatitis C.

7. If the HBV DNA viral load at booking is >106 IU/mL (log 6, or 1,000,000   IU/ml) then urgent referral to the hepatitis service should be made and antiviral therapy during the third trimester (from week 28 to delivery) will be considered, to reduce viral load and risk of transmission to the infant.

8. If the HBV DNA viral load is >106IU/mL (log 6, or 1,000,000 IU/ml) at any point during pregnancy then urgent referral to the hepatitis service should be made AND hepatitis B immunoglobulin (HBIg) should be given to the infant at birth.

9. The HBV DNA viral load should be documented clearly by the responsible obstetrician in the relevant section of the letter from the WoSSVC. The neonatal section of the Yellow Alert Sheet should also be amended with this level and the implications for neonatal management.

10. If HBV DNA viral load is <106 IU/L (log 6, or 1,000,000 IU/ml), then the woman would be monitored as normal during pregnancy. Again the HBV DNA viral load should be documented clearly by the responsible obstetrician in the relevant section of the letter from the WoSSVC. The neonatal section of the Yellow Alert Sheet should also be amended with this level and the implications for neonatal management.

11. When the woman is in labour, the obstetrician/midwife informs the   paediatric team that the baby will require vaccination +/- immunoglobulin at birth as per letter from WoSSVC and the Green Book criteria.

12. Neonatal paediatrician gives first dose of vaccine (and immunoglobulin if required) and informs the NHS GGC Screening Dept by email (mailto:[email protected])

13. HBV vaccine and HBIg must be administered within 24 hours of birth, ideally as soon as possible (i.e. within 4 hours). HBV vaccine – Engerix B 10 mcg (0.5ml) or HBvaxPRO 5 mcg (0.5ml) given IM into anterolateral thigh (not into buttock). HBIg - 200IU (2 ml) given IM into upper outer quadrant of the buttock or anterolateral thigh of the opposite leg from site of HBV vaccination. Routine postnatal care, including breast feeding, is appropriate.

14. Before discharge from the maternity unit a check should be made that mothers have already attended the hepatitis service and if not a further appointment at 2 months is made.

15. The NHS GGC Screening Dept arrange call/recall for subsequent vaccination of the infant at 1, 2, 12 months and pre-school booster schedule. Invitation letters and reminder letters are sent to the mother, health visitor and GP of baby.

16. Following the 12 month dose of hepatitis B vaccine, the infant must be checked for response by assay for HBsAg and anti-HBs. The GP is asked by public health to refer the baby to the Paediatric Infectious Disease service at Yorkhill for this assay. To improve uptake of testing, the Screening Dept should also email the reminder letter for the 12 month booster to Dr Rosie Hague at Yorkhill to ensure that all babies are offered testing.

17. The Public Health Protection Unit (PHPU) monitors uptake of all babies receiving hepatitis B vaccination from data supplied by Screening Dept. PHPU liaises with the health visitor to promote uptake of vaccine in babies who have not completed the course. PHPU produces regular uptake figures to feedback to all involved. PHPU carries out a yearly audit of all HBV notifications in pregnancy.

Gartnavel General Hospital:

Hepatology - Prof Peter Mills, Dr Matthew Priest

Infectious Diseases - Dr Erica Peters, Dr David Bell

Glasgow Royal Infirmary:

Dr Ewan Forrest, Dr Adrian Stanley, Dr Stephen Barclay

Southern General Hospital:

Dr Jude Morris

Victoria Infirmary:

Dr Shouren Datta

Royal Alexandra Hospital:

Dr James McPeake, Dr Rizwana Hamid

Green Book 2010: Vaccination of term babies according to the hepatitis B status of the mother (modified) Hepatitis B status of mother


Baby should receive



B vaccine


HBsAg positive and HBeAg positive



HBsAg positive, HBeAg negative and anti-HBe negative



HBsAg positive where e-markers have not been determined



Acute hepatitis B during pregnancy



HbsAg positive and a baby birthweight of 1500g or less, regardless of e-antigen status of the mother



A woman who is HBsAg seropositive and known to have an HBV DNA level equal or above 1x106 IU/mL(log 6, or 1,000,000 IU/ml) in any antenatal sample†



HBsAg positive, anti-HBe positive



HBsAG negative, Anti HBcore positive but risk of environmental transmission



HBsAG negative, Anti HBcore negative but risk of environmental transmission



HBsAG negative, Anti HBcore negative but no risk of environmental transmission



† Where viral load testing has been performed to inform the management of the mother.


Algorithm for assessment of hepatitis B in pregnancy

NB Stop Tenofovir on day of delivery if breast feeding is anticipated.

All children of HBsAg +ve mothers should receive Hepatitis B vaccine.

To be read in conjunction with ‘Protocol for significant laboratory results – hepatitis B’ which is one of the 4 communicable diseases in pregnancy screening protocols currently in operation within NHS GGC, and the NHS GG&C “immunisation of neonates” guideline.



Prof Peter Mills and Hepatitis B in Pregnancy and Newborn Guideline Group

Others consulted for latest review

Dr D Bell, Dr C Aitken, Virology, Dr A Mathers, Dr R Hague, Dr G Penrice, Public Health + others

Title Hepatitis B positive - management of women identified through antenatal screening

Implementation/Review Dates

Implemented 4/1/2012, Latest Revision March 2015, Next Review March 2017