HepC - Benha University Hospital Egypt Delta(Mansura&...

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Unformatted text preview: Benha University Hospital, Egypt Delta (Mansura) & Benha Fertility Centers Email: [email protected] 1.. In Egypt: a major health problem 1 20-40% of the all-viral hepatitis. High prevalence of carrier state. High 0.01–0.1% in the United Kingdom and 0.01–0.1% Scandinavia to 17–26% in Egypt (Wasley & Alter,2000) (Wasley up to 70% progress to chronic hepatitis C with serious complications The infection rate peaks among adults aged 30–49 2.. Incidence 2 is rising most rapidly among patients aged 20­ 45 which will eventually lead to increased incidence of hepatitis C during pregnancy (Sharara et al., 1996) 3. High risk groups 3. High risk groups Obstetricians need to be aware of the risk factors leading to hepatitis C infection 1­ Recipients of blood and blood products 2­ Intravenous drug abusers 3­ Health care workers 4­ Dialysis patients 5­ Organ transplantation recipients 5­ Organ transplantation recipients 5­ Organ transplantation recipients 6­ Homosexual 7­ Infants of carrier mothers 8­ Dental surgery 9­ Tattooed Unsterilized medical equipments is an important factor in Egypt. It is thought that the schistosomiasis eradication programs during 1970s which used unsterilized equipments (Arthur et al, 1997) 69% of the pregnant women were newly diagnosed and 73% had no risk factors for hepatitis C (Conte et al,2002). HCV RNA has also been detected in Saliva Urine breast milk, semen, and menstrual fluid. Therefore, both sexual and vertical transmissions have been suggested as alternative modes for transmission of HCV (Eriksen, 1999) Parenteral Non parenteral Parenteral Transfusion Vertical associated Sexual parenteral Horizontal Needle sticks and (intrafamilial) sharp injuries Body secretions Community Unknown acquired modes 1.. Needle sticks and sharp injuries 1 The incidence 1.8% (range: 0%--7%) [Alter 1997; CDC 1998b]. •One study indicating that transmission occurred only from hollow-bore needles compared with other sharps •Transmission rarely occurs from mucous membrane exposures to blood Management: Currently no vaccine exists to prevent HCV infection, and neither immunoglobulin nor antiviral therapy is recommended [CDC, 1998]. •Follow-up at baseline and 6 months for seroconversion. •Antivirals given when HCV RNA first becomes detectable might prevent the development of chronic infection. 2. Vertical (mother­to­infant) 2. Vertical (mother­to­infant) transmission •Incidence: 0-33%, an overall risk of 5.2% (Marcellin et al., 1993) (Marcellin an is lower than for HBV infection {different patient population, different rates of RNA positivity, different assays to determine neonatal infection} Timing & Mechanism: At conception, in utero, perinatally, or during lactation. Timing & Mechanisms remain largely unknown. • It occurs In the perinatal period rather than in utero (Simmonds,2001). Only when serum HCV RNA is detectable i.e. limited to infants whose mothers are viremic The risk of V. transmission is The risk of V. transmission is enhanced by: :High level of HCV RNA titers. 1 High level of copies/ ml: the risk increased 106< 10 copies/ ml: to 36% 4 copies/ml: No transmission 10 > 2. Mothers with concomitant HIV. 3. Mothers with multiple risk No association between V. transmission and 1. Gestational age, 2. Type of delivery, 3. Chorioamnionitis (Ohto et al,1994; Alter,1995). 4. 5. Subsequent pregnancies. Breast feeding. Controversial points Controversial 1. The viral genotype: Mothers infected with a highly pathogenic HCV. with 2. Use of internal fetal monitoring: Use of fetal scalp electrode (Mazza et al,1998). 3. Duration of ruptured membranes. Membrane rupture >6 hours prior to delivery (Resti et al., 1998) Prevention In absence of maternal treatment to reduce viral load, or effective vaccination for neonates, obstetric (preventive measures (Simmonds,2001 . Avoidance of invasive procedures e.g Chorionic villous biopsy that damage the integrity of the placental membrane. Fetal blood sampling Scalp electrode 3. Assisted conception: •HCV can be found in the semen (only low levels of HCV RNA) Transmission of viral hepatitis in assisted reproduction is possible, but the magnitude of the risk is unknown (ASRM,2004(. Recommendation of ASRM 1.Testing for HCV of high-risk infertile couples seeking fertility therapy. {To reduce the potential risk for transmission to an uninfected partner, baby, staff members, and disease-free gametes and embryos in the same laboratory} (ASRM,2004). . Testing for HCV of couple. 2 prior to cryopreservation of (.semen or embryos (ASRM,2004 Semen and embryos from.3 HCV patients should be stored in HCV designated storage (.tanks (ASRM,2004 4. Reducing the potential risk of virus transmission among cryopreserved sperm and embryos by: a. storage of sample in the nitrogen vapor state instead of the liquid state. b. use of sperm washing techniques to reduce viral load prior to freezing semen samples. c. use of a double-sealing technique for cryocontainers (ASRM,2004). 4. Sexual transmission: controversial Incidence: •Very low. •much lower than that of hepatitis B or HIV. •does not correlate with intensity and duration of sexual exposure. •HCV should not viewed as STD from the perspective of population health strategies (Giles et al, 2003) Precautions: No need to avoid close contact with family members or to avoid sharing meals or eating utensils. 1. Sexual partners of infected patients should be tested for HCV antibodies. 2. Safe sexual practices Condom for those not trying to conceive (ASRM,2004). minimize the extent of blood contact Covering open wounds 1.. Effect of pregnancy on HCV 1 Effect Most women are asymptomatic Most No deleterious effect of pregnancy on the course of HCV infection. Pregnancy does not adversely affect the course of hepatitis C. During the course of pregnancy increased During production of different hormones and cytokines might influence HCV activity and influence the underlying liver disease (Chard et al., 1986) 1. Improvement in biochemical marker of liver damage {Haemodilution, secondary to a relative increase in circulating blood volume in rd the 3 trimester} 10% will have elevated transaminases (Floreani et al., 1996) ALT levels (Floreani decrease during the 3rd trimester & return to levels found before pregnancy shortly after delivery { changes in immune response during pregnancy play a role in the hostHCV interaction}. 2. A linear increase in HCV viraemia throughout pregnancy {impaired immune reactivity}. HCV-RNA levels increase late in pregnancy and return to baseline levels within 1 yr after delivery. {immune-mediated mechanisms in controlling viral replication and contributing to liver injury in chronic hepatitis} 3. The rate of cholestasis is significantly higher, and occurs earlier. Early occurrence of cholestasis of pregnancy may be an indication for serologic testing for HCV. 2.. Effect of HCV on pregnancy: 2 1. Hepatitis C infection does not affect pregnancy complications and outcomes. 2. Hepatitis in pregnancy is not associated 2. not with increased abortion rate, lower birth weights, stillbirth or congenital malformation. 3. Prematurity seems to be increased if hepatitis Prematurity is acquired in the last trimester (Levy and Koren, 1991). Not confirmed (Bohman et al., 1992) 1991). 1. Antenatal screening Benefits of screening: •Detect at an early stage asymptomatic adults, who would benefit from education and treatment: Modify their alcohol intake, sexual behavior and views on tissue and organ donation. •Mothers and children with chronic hepatitis C should be immunized against hepatitis A and B {super infection may have a more severe course} •Identify children at risk of acquiring HCV How: Anti-HCV, and if positive HCV RNA (Roberts, Yeung, 2002). Types: 1. Universal=Routine not justified in areas with low HCV prevalence e.g. UK. {lack of measures to prevent transmission and to treat the infection efficiently}. 2. Selective: certain high risk categories Disadvantages: miss more than half of HCV positive pregnant women. 2. Treatment 2. Treatment Combination therapy, IFN­ plus ribavirin, has resulted in a better response rate compared with monotherapy and is now considered first­ line therapy (Leikin et al,1996) a. IInterferon: a. nterferon: Patients with chronic hepatitis whose therapy chronic can be delayed should not be treated with interferon Women exposed to interferon inadvertently during pregnancy may be encouraged to continue pregnancy. Patients with acute hepatitis C during pregnancy, the acute use of interferon therapy should be considered with close monitoring (Ozaslan et al, 2002). There have been 27 infants born to 26 mothers, who were exposed to IF alpha in utero. Six women (23%) were administered IF alpha inadvertently during pregnancy (Hiratsuka et al, 2000). 15%: premature. 22%: IUGR 22%: No IF alpha-related malformed infants. No lack of teratogenicity: IFN does not cross the placenta (Category C) IFN use in pregnancy is not advised (ASRM,2004). b. Ribavirin: Category X should not be used by: pregnant women, women attempting pregnancy, or their male partners (Ohto et al, 1994) 3. Elective Cesarean section is not recommended { Role in reducing vertical transmission is uncertain}. 4. Breast feeding 4. Breast feeding HCV RNA can be found in breast milk; infection through breastfeeding has not been demonstrated. 1. Found in tiny amount: Unable to infect the newborn (Polywaka et al,1999) Easily inactivated by gastric juices. 2. The integrity of the oral and gastrointestinal mucosa. 3. If nipples are not traumatized Therefore, breastfeeding is not contraindicated (CDC or the American Academy of Pediatrics). 5.. Screening in children 5 Screening Most infants delivered to HCV­infected mothers (106 copies/mL) progress to chronic hepatitis. The American Academy of Pediatrics and the CDC recommended that all children born to women who are infected with HCV be screened for this virus. Antibodies to HCV cross the placenta and may Antibodies persist in the infant for up to 15 months. Transmission occurs in the perinatal period & PCR Transmission assay at birth are unhelpful (Simmonds, 2001) (Simmonds, Optimal screening for HCV in the offspring can be done by testing for HCV RNA at 6-12 HCV months of age. Some consider PCR testing at 3 months provides the earliest & the most conclusive evidence for both infection & lack of infection (Gibb et al, 2000) (Gibb Alternatively, HCV antibody screening using a Alternatively, HCV recombinant immunoblot assay can be performed at 18-24 months (Palomba et al., 1996). (Palomba Anti-HCV testing after the first year of life is used by most experts. 300 PREGNANT WOMEN ELISA Positive Negative 40 (13.33%) 260 (86.67%) PCR Positive 30 (75%) Negative 10 (25%) Infants (6 months after delivery) PCR Positive Negative 2 (6.67%) 28 (93.33%) Table (1) : Characteristics of the study population (n = 300) Range Age Mean SD Median 41 – 17 26.2 5 25 Parity 8–0 1.4 1.5 1 Previous surgery 5–0 0.8 1 .Positive No )%( 1 Blood transfusion )9.33( 28 History of jaundice )3.33( 10 Health care worker )1.00 ( 3 Drugs )0.00( 0 Insulin dependent diabetes mellitus )2.33( 7 Bilharziasis )0.33( 1 Hepatomegaly )0.00( 0 Table (2) : PCR and ELISA in relation to risk factors for HCV infection PCR )+(ve (n = 30) Range Age ELISA )+(ve (n = 40) Range 19-37 Mean ± SD ± 5.1 26.5 ± 4.9 27.1 Range 1-4 0-7 ± 1 1.8 ± 1.5 1.8 0-5 0-5 *± 1.4 2.1 *± 1.3 2 )%(Positive *)56.67( 17 *)60.00( 24 )%(Negative )43.33( 13 )40.00( 16 )%(Positive *)16.67( 5 *)12.50( 5 )%(Negative )83.33( 25 )87.50( 35 )%(Positive )0.00( 0 )0.00( 0 )%(Negative )100.00( 30 )100.00( 40 )%(Positive *)10.00( 3 *)10.00( 4 )%(Negative )90.00( 27 )90.00( 36 )%(Positive )0.00( 0 )0.00( 0 )%(Negative Parity 19-37 )100.00( 30 )100.00( 40 )%(Positive *)40.00( 12 *)32.50( 13 )%(Negative )60.00( 18 )67.50( 27 Mean ± SD Previous surgery Range Mean ± SD Blood transfusion History of jaundice Health care worker Insulin dependent diabetes mellitus Bilharziasis History of husband risk * Significant difference to (-)ve group. Table (3) : PCR of infants (6 months after delivery) PCR )+( ve ELISA )+( ve No. of cases 30 40 Positive 2 2 6.67 5.00 28 38 93.33 95.00 (S )0.002 (S )0.010 Positive )%( Negative Negative )%( P S : Significant difference. Conclusions: Conclusions: 1­ The prevalence of anti­ HCV antibodies among pregnant women was 13.3%, whereas confirmed cases with PCR represented 10% 2­ Hepatitis C virus infection was 2­ Hepatitis C virus infection was found more among those women with history of Surgical operation, Blood transfusion, Jaundice, Insulin dependant diabetes mellitus With husbands having risk factors for HCV infection 3­ There was no correlation 3­ There was no correlation between the age and parity and the incidence of hepatitis C infection 4­ The vertical transmission rate (detected at 6 months of age) was found to be 6.7% RECOMMENDATIONS RECOMMENDATIONS 1­ Screening of pregnant women at high risk for HCV antibodies is justifiable in Egypt 2­ Neonates of PCR positive pregnant women should be investigated by PCR test at Benha University Hospital Delta (Mansura) & Benha Fertility Centers Email: [email protected] ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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