Visió obstètrica toxoplasmosis Dra. Anna Suy · RPM, PP, RCIU, meconi, apgar
Transcript of Visió obstètrica toxoplasmosis Dra. Anna Suy · RPM, PP, RCIU, meconi, apgar
Toxoplasma gondii
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Visioacute obstegravetrica toxoplasmosis
Toxoplasma gondii
Importagravencia 10-50 poblacioacute infectada 15-45a 75-90 seronegatives embaragraves (12 espanyoles vs 41 immigrantes i 0 asiagravetiques) TXP congegravenita 03x 1000 Dinamarca coriorretinitis 1 Europa vs 20 Brasil
McAuley JB Congenital Toxoplasmosis J Pediatric Infect Dis Soc 2014 3(Suppl 1)S30-S35 Lindsay DS Dubey JP Toxoplasma Gondii the changing paradigm of congenital toxoplasmosis Parasitology 20111381829-31
La diferencia en la infectivitat depegraven de 1- reactivacioacute 2- diferents genotips T Gondii En diferents parts del mon Aixograve pot explicar les diferegravencies en els diferents paiumlsos en la incidegravencia i gravetat de la TXP congegravenita i els diferents protocols drsquoactuacioacute
2010
2010
2005
Toxoplasma gondii
Criteris cribratge prenatal
The condition is an important public health problem The natural history is well understood A safe valid and reliable screening test is available which is acceptable to those being tested
Treatment or an intervention of proven effectiveness is available
The risk of harm both physical and psychological is less than tne chance of benefit
Toxoplasma gondii
Transmissioacute carn crua o fruits o vegetals contaminats aigua no filtrada
Taxa infeccioacute 1-8 x 1000 embarassos susceptibles
TV (gt transmissioacute gtsetmanes)
Risc TV Risc sequumleles
7-15 setm 6-26 13 setm 61
26 setm 32-44
36 setm 71-93 36 setm 9
The condition is an important public health problem
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Toxoplasma gondii
Importagravencia 10-50 poblacioacute infectada 15-45a 75-90 seronegatives embaragraves (12 espanyoles vs 41 immigrantes i 0 asiagravetiques) TXP congegravenita 03x 1000 Dinamarca coriorretinitis 1 Europa vs 20 Brasil
McAuley JB Congenital Toxoplasmosis J Pediatric Infect Dis Soc 2014 3(Suppl 1)S30-S35 Lindsay DS Dubey JP Toxoplasma Gondii the changing paradigm of congenital toxoplasmosis Parasitology 20111381829-31
La diferencia en la infectivitat depegraven de 1- reactivacioacute 2- diferents genotips T Gondii En diferents parts del mon Aixograve pot explicar les diferegravencies en els diferents paiumlsos en la incidegravencia i gravetat de la TXP congegravenita i els diferents protocols drsquoactuacioacute
2010
2010
2005
Toxoplasma gondii
Criteris cribratge prenatal
The condition is an important public health problem The natural history is well understood A safe valid and reliable screening test is available which is acceptable to those being tested
Treatment or an intervention of proven effectiveness is available
The risk of harm both physical and psychological is less than tne chance of benefit
Toxoplasma gondii
Transmissioacute carn crua o fruits o vegetals contaminats aigua no filtrada
Taxa infeccioacute 1-8 x 1000 embarassos susceptibles
TV (gt transmissioacute gtsetmanes)
Risc TV Risc sequumleles
7-15 setm 6-26 13 setm 61
26 setm 32-44
36 setm 71-93 36 setm 9
The condition is an important public health problem
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
2010
2010
2005
Toxoplasma gondii
Criteris cribratge prenatal
The condition is an important public health problem The natural history is well understood A safe valid and reliable screening test is available which is acceptable to those being tested
Treatment or an intervention of proven effectiveness is available
The risk of harm both physical and psychological is less than tne chance of benefit
Toxoplasma gondii
Transmissioacute carn crua o fruits o vegetals contaminats aigua no filtrada
Taxa infeccioacute 1-8 x 1000 embarassos susceptibles
TV (gt transmissioacute gtsetmanes)
Risc TV Risc sequumleles
7-15 setm 6-26 13 setm 61
26 setm 32-44
36 setm 71-93 36 setm 9
The condition is an important public health problem
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
2010
2005
Toxoplasma gondii
Criteris cribratge prenatal
The condition is an important public health problem The natural history is well understood A safe valid and reliable screening test is available which is acceptable to those being tested
Treatment or an intervention of proven effectiveness is available
The risk of harm both physical and psychological is less than tne chance of benefit
Toxoplasma gondii
Transmissioacute carn crua o fruits o vegetals contaminats aigua no filtrada
Taxa infeccioacute 1-8 x 1000 embarassos susceptibles
TV (gt transmissioacute gtsetmanes)
Risc TV Risc sequumleles
7-15 setm 6-26 13 setm 61
26 setm 32-44
36 setm 71-93 36 setm 9
The condition is an important public health problem
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
2005
Toxoplasma gondii
Criteris cribratge prenatal
The condition is an important public health problem The natural history is well understood A safe valid and reliable screening test is available which is acceptable to those being tested
Treatment or an intervention of proven effectiveness is available
The risk of harm both physical and psychological is less than tne chance of benefit
Toxoplasma gondii
Transmissioacute carn crua o fruits o vegetals contaminats aigua no filtrada
Taxa infeccioacute 1-8 x 1000 embarassos susceptibles
TV (gt transmissioacute gtsetmanes)
Risc TV Risc sequumleles
7-15 setm 6-26 13 setm 61
26 setm 32-44
36 setm 71-93 36 setm 9
The condition is an important public health problem
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Toxoplasma gondii
Criteris cribratge prenatal
The condition is an important public health problem The natural history is well understood A safe valid and reliable screening test is available which is acceptable to those being tested
Treatment or an intervention of proven effectiveness is available
The risk of harm both physical and psychological is less than tne chance of benefit
Toxoplasma gondii
Transmissioacute carn crua o fruits o vegetals contaminats aigua no filtrada
Taxa infeccioacute 1-8 x 1000 embarassos susceptibles
TV (gt transmissioacute gtsetmanes)
Risc TV Risc sequumleles
7-15 setm 6-26 13 setm 61
26 setm 32-44
36 setm 71-93 36 setm 9
The condition is an important public health problem
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Toxoplasma gondii
Transmissioacute carn crua o fruits o vegetals contaminats aigua no filtrada
Taxa infeccioacute 1-8 x 1000 embarassos susceptibles
TV (gt transmissioacute gtsetmanes)
Risc TV Risc sequumleles
7-15 setm 6-26 13 setm 61
26 setm 32-44
36 setm 71-93 36 setm 9
The condition is an important public health problem
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Toxoplasma gondii
SOSPITA PRIMOINFECCIOacute bull repetir Ig G en 2-3 setm x 4 veg el tiacutetol AC= sospita primoinfeccioacute bull test avidesa bull AMNIO gt18 setm i gt4 setm primoinfeccioacute si infeccioacute recent confirmada si no possible excloure infeccioacute recent si troballes ECO sospitoses
Diagnogravestic
Serologia Ig M + 10-13 mesos o anys primer trimestre IgG i IgM + (1-3 prob infeccioacute embaragraves) Test avidesa IgG pot ser baix durant anys Real time PCR S=922 E=100 S no depegraven del moment de la seroconversioacute
A safe valid and reliable screening test is available which is acceptable to those being tested
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Toxoplasma gondii
Tractament redueix alteracions neurologravegiques greus
si redueix risc de TV no redueix risc coriorretinitis pot produir aplagravesia medulmiddotlar
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
PCR (-) Espiramicina 1g8h PCR (+) Pirimetamina 50 mgdia + sulfadiazina 3gd + ac foliacutenic 25mgd alternsetm Espiramicina 1g8h
Espiramicina macrogravelid que no travessa placenta perograve que es concentra en la placenta serveix per prevenir la infeccioacute (eficagravecia de aprox 60)
Trials screening prenatal i tractament vs risc i benefici del tractament
Treatment or an intervention of proven effectiveness is available
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Valentini P Buonsenso D Barone G et al Spiramycincotrimoxazole versus pyrimethaminesulfonamide and spiramycin alone for the treatment of toxoplasmosis in pregnancy Journal of Perinatology 20141-5
Tractament
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
1438 mares tractades identificades prenatalment Tractament iniciat lt 3 setm vs gt 8 setm seroconversioacute redueix TV (OR 0middot48 95 CI 0middot28mdash0middot80 p=0middot05) 550 infectats vius diagnogravestic prenatal o neonatal screening Tractament no disminueix manifestacions cliacuteniques (OR 1middot11 95 CI 0middot61mdash2middot02) gtSG seroconversioacute gt TV (OR 1middot15 95 CI 1middot12mdash1middot17) gtSG seroconversioacute lt lesions intracranials (OR 0middot91 0middot87mdash0middot95) not with eye lesions (OR 0middot97 0middot93mdash1middot00)
Interpretation Only a large randomised controlled clinical trial would provide clinicians and patients with valid
evidence of the potential benefit of prenatal treatment
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Tractament SYROCOT
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Toxoplasma gondii
SYROCOT (Systematic Review on Congenital Toxoplasmosis) study group Thieacutebaut R Leproust S Checircne G Gilbert R Effectiveness of prenatal treatment for congenital toxoplasmosis a meta-analysis of individual patients data Lancet 2007 Jan 13369(9556)115-22
Recommendation Routine antenatal serological screening for toxoplasmosis should not be offered because the risks of screening may outweigh the potential benefits
Prevencioacute Viatges a paiumlsos en desenvolupament (Sud-Amegraverica) Tocar terra i rentar-se mans Consumir carn crua (ge66ordmC) o Congelar gt24h (lt-12ordmC) Rentar-se mans al cuinar Gats canvi terra per altre persona No consum aigua no filtrada Rentar fruita i verdura Treballs jardineria
Siacute
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
NO SCREENING UNIVERSAL NOMEacuteS SI SOSPITA DE PRIMOINFECCIOacute
SEROLOGIA EN CENTRE REFEREgraveNCIA previ a qualsevol actuacioacute
Repetir serologies 2-3 sem si sospita infeccioacute aguda + ESPIRAMICINA
AMNIOCENTESIS a) diagnogravestic de primoinfeccioacute materna b) diagnogravestic serologravegic mare no concloent c) alteracions ECO
J Obstet Gynaecol Can 201335(1)78ndash79
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
SCREENING TXP ECO similar TORCH inclou ascitis HE megagravelia i RCIU
SOSPITA TXP expert en TXP
Infeccioacute materna iniciar ESPIRAMICINA
AMNIOCENTSIS gt18 setm + gt4 setm despreacutes primoinfeccioacute
J Obstet Gynaecol Can 201335(1)78ndash79
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
PCR LA + PIRIMETAMINA SULFADIAZINA + AC FOLINIC
NO TRACTAMENT SI infeccioacute pregravevia per TXP en immunocompetent
Screening HIV + i immunodeprimits
Primoinfeccioacute embaragraves passats 6 mesos
Informacioacute profilaxis TXP totes les gestants
J Obstet Gynaecol Can 201335(1)78ndash79
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Toxoplasma gondii
Estudi cost-efectivitat Model screening franceacutes es aplicable a EEUU (seroprevalenccedila 44 en 2004) (1mes a totes seronegatives) Basa bull cost del test bull valor estadiacutestic de la vida bull seroprevalenccedila en dones en edat reproductiva bull pegraverdues drsquoembaragraves per les amnios bull incidegravencia de primoinfeccioacute per TXP durant embaragraves Segons aixograve es cost efectiu si Test de 12 dogravelars taxes de infeccioacute congegravenita de gt110000 nascuts vius
Stillwaggon E Carrier CS Sautter M McLeod R Maternal Serologic Screening to Prevent Congenital Toxoplasmosis A Decision-Analytic Economic Model PLoS Negl Trop Dis 2011 5(9) e1333
Franccedila 15 anys protocol Alt iacutendex IVE (inici programa) TC 1987 19 - 321000 nascuts vius 2007 19 - 3210000 nascuts vius
EEUU Seroprevalenccedila 15-44 anys 11 TC 110000 nascuts vius
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Seguiment i tractament de la infeccioacute pel virus de la Hepatitis B en lrsquoembaragraves
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Importagravencia bull 350-360 million people
bull Prevalenccedila HbsAg UK 05-1
Italia 04 italianes i 23 immigrants
Xina 35-50 VHB c sograven de TV
Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195
Cirrosis hepagravetica
Risc cronificacioacute TV mares HBeAg + 80-90 0-6 anys risc 30 Adolescegravencia 12
x100 hepatocarcinoma
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
VHB ndash embaragraves
bull Diabetes Mellitus
bull Hemorragravegia avant-part
bull Prematuritat
bull Baix pes al neacuteixer
bull EHE
Lao TT et al Maternal hepatitis B surface antigen and incidence of pre-eclampsia J Viral Hepat 2013 20343-349 Lao TT Chan BC Leung WC et al Maternal hepatitis B infection and gestational diabetes mellitus J Hepatol 200747(1)46ndash50 Tse KY Ho LF LaoT The impact of maternal HBsAg carrier status on pregnancy outcomes a case-control study J Hepatol 200543 (5)771ndash775 Reddick KL Jhaveri R Gandhi M et al Pregnancy outcomes associated with viral hepatitis J Viral Hepat 201118(7) e394ndashe398 Safir A Levy A Sikuler E et al Sheiner E Maternal hepatitis B virus or hepatitis C virus carrier status as an independent risk factor for adverse perinatal outcome Liver Int 201030(5)765ndash770 Wong S Chan LY Yu V Ho L Hepatitis B carrier and perinatal outcome in singleton pregnancy Am J Perinatol 199916(9)485ndash488
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
VHB ndash embaragraves
bull Prematuritat
bull Asfixia
Luo L Wu J Qu Y et al Association between maternal HBsAg carrier status and neonatal adverse outcomes meta-analysis J Matern Fetal Neonatal Med 2014 181-10
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
VHB - embaragraves
bull ALT increment final embaragraves i postpart
bull DNA VHB increment postpart
bull HBeAg + seroconversiograve 12-17
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
VHB ndash Profilaxi TV
profilaxi postexposicioacute
Vacuna + Immunoglobulina
5 fallo (30 en mares alta cagraverrega viral)
Nelson NP Jamieson DJ Murphy TV Prevention of Perinatal Hepatitis B Virus Transmission Journal of the Pediatric Infectious Diseases Society 2014 3(Suppl 1)S7ndashS12 Wong F Pai R Van Schalkwyk J Yoshida EM Hepatitis B in pregnancy a concise review of neonatal vertical transmission and antiviral prophilaxis Annals of Hepatology 201413(2)187-195 Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
100 TV intrauacuteter 5 TV perinatal
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
bull VHB placenta gt19 setm de gestacioacute
bull APP VHB detectable fetus
bull Cell-to-cell transfer alta taxa infeccioacute cel endotelials de la placenta (OR1846 95 IC 286-15278)
Transmissioacute intrauacuteter
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
1 any postpart
bull Eutogravecic 73
bull Fograverceps77
bull Cesagraverea68 p=089
RPM PP RCIU meconi apgarlt7 + immunoprofilaxis
no associat a TV
Hu Y chen J Wen J et al Effect of elective cesarean section on the risk of mother-to-child transmission of hepatitis B virus BMC Pregnancy and Childbirth 2013 13119 Effect of delivery mode on maternal-infant transmission of Hepatitis B virus by immunoprophylaxis Chin Med J 20021151510-12
Transmissioacute partperinatal
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Lactagravencia materna
Immunoprofilaxi + lactagravencia materna
bull No increment del risc de transmissioacute
bull No increment clivelles
Chen Z Chen J Wen J et al Breast feeding is not a risk factor for mother to child transmission of Hepatitis B virus Plos One 2013 8 E55303
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Factors de Risc TV
bull HBe Ag HBeAg + 65-78 HBeAg - 9-23 bull VHB DNA viral load gt DNA VHB gt TV Cutt off 105-108 cogravepiesmL TV 9 gt 1x108 cogravepiesmL TV= 0 lt 1x108 cogravepiesmL
CV millor predictor independent HBeAg+
Wiseman E Fraser M Holden S et al Perinatal transmission of hepatitis B virus an Australian experience Med J Aust 2009190489-92
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Factors de NO Risc TV
bull Genotip
bull Amenaccedila avortament i multiparitat
bull CV VHB + sang cordoacute srsquoassocia a part preterme perograve no a TV
bull Amniocentesis Biogravepsia corion no dades
Elefsiniotis I Tsoumakas K Papadakis M et al Importance of maternal and cord blood viremia in pregnant women with chronic hepatitis B virus infection Eur J Intern Med 2011 22182-6 Lopez M Coll O Chronic viral infections and invasive procedures risk of vertical transmission and current recomendations Fetal Diagn Ther 2010281-8
APP OR544 95 IC=115-2567
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull IGHB nou nat TV OR 05 CI 95= 041-06 Pool donants VHB- immunes im immunitzacioacute immediata i perecedera
bull IGHB mare infectada VHB IGHB nou nat + IGHB mare 3er trimestre 100-200 UI im 28-32-36 w Disminucioacute CV i pas immunitat transplacentagraveria reduccioacute TV si indicat cagraverrega viral OR015 CI 007-03 HBsAg OR022 CI027-02
Shi Z Li X Ma L et al Hepatitis B Immunoglobulin injection in pregnancy to interrup hepatitis B virus mother-to-child transmission ndasha meta-analysis Int J Infect Dis 201014e622-e634
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Immunoprofilaxis IGHB +- Vacuna VHB
bull Vacuna VHB Proteiumlnes virals purificades HBsAg (DNA recombinant) ndash no infecciosa
3 dosis (primera neacuteixer)
HBsAc
Vacuna RR028 CI 02-04
Vacuna sola proteccioacute gt 83
Chen D Hepatitis B vaccination The Key towards elimination and eradication of hepatitis B J Hepatol 2009 50805-16
Lee C Gong I Brok J et al Effect of Hepatitis B immunization in newborn infants of mothers positive for hepatitis B Surface antigen systematic review and meta-analysis BMJ 2006332328-36
bull IGHB + Vacuna VHB vs placebo
RR 008 CI 003-017
bull IGHB + Vacuna VHB vs Vacuna VHB
RR 054 CI 041-053
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Fallo Immunoprofilaxis
Del Canho R Grosheide P Mazel J et al Ten-year neonatal hepatitis B vaccination program The Netherlands 1982-1992 protective efficacy and long term immunogenicity Vaccine 199715 1624-30
bull HBs Ag + o DNA VHB detectable 9-12 meses
nen ha rebut IGHB + vacuna
Transmissioacute intrauterina causa principal HBeAg + DNA VHB gt1x108 copiasmL
1-14
Meta anagravelisis Holanda (10 anys immunoprofilaxis) eficagravecia 100 DNA viral load lt1x107 copiasmL eficagravecia 68 DNA viral load gt1x107 copiasmL
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Antivirals
bull Descens DNA VHB pas transplacentari fallo immunoprofilaxis
bull Tractament segur i no teratogegravenic Antivirals no autoritzats durant embaragraves
bull Inici final 2o trimestre o 3er trimestre finalitzada organogegravenesis major taxa TV VHB bull Indicacions DNA VHB gt1x10 6-7 cogravepiesmL (EASL)
European Association for the Study of the Liver EASL Clinical Practice Guidelines Management of chronic hepatitis B virus infection J Hepatol 2012 57167ndash185
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Patton H and Tran TT Management of hepatitia B during pregnancy Nat Rev Gastroenterol Hepatol 2014
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
bull ITIAN inhibeix replicacioacute DNA VHB (97 disminucioacute en 2 setm)
bull 100 mgdia inici 28 setm fins 1 mes postpart
bull lt TV intrauacuteter 12-238 vs placebo
bull 9-12m 14-2 menys TV
HBsAg OR031 CI 015-063 plt001
DNA VHB OR02 CI 01-039 plt001
bull Segur pre i durant embaragraves (gt4000 gestants HIV
bull Alta taxa resistegravencies
24 despreacutes de 1 any de tractament
70 despreacutes de 4 anys
Shi Z Yang Y Ma L et al Lamivudina in late pregnancy to interrup in utero transmission of hepatitis B virus a systematic review and meta-analysis Obstet Gynecol 2010 116147-59
LAMIVUDINA
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
TELBIVUDINA
bull ITIAN inhibeix replicacioacute DNA VHB
bull 600 mgdia inici a las 28 setm fins 1 mes postpart
bull 9-12m menys TV
HBsAg RR011 CI 004-031
DNA VHB RR009 CI 004-022
bull FDA B
bull Taxa de resistegravencies
5 despreacutes de 1 any de tractament
11 despreacutes de 2 anys
Deng M Zhou X Gao S et al The effects of Telbivudina in late pregnancy to prevent intrauterine transmission of hepatitis B virus a systematic review and meta-analysis Virol J 2012 9185
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
TENOFOVIR
bull ITIAN inhibeix replicacioacute DNA VHB
bull 300 mgdia inici a les 28 setm fins 1 mes postpart bull Disminucioacute TV intrauacuteter
Reduccioacute DNA VHB 525 +-179 vs 887 +-045 log 10 cogravepiesmL plt001
bull FDA B
bull No resistegravencies (eleccioacute en no gestants)
Falten estudis de seguritat i eficagravecia (gt2000 gestants HIV)
lower leght and head circunference Z-score at 1 year ()
New York retrospectiu 9 pacients (HBeAg + DNA VHB + )
no TV
no efectes adversos ni malformacions
Pan C MI L Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B infection by highly viremic pregnant women a case series Dig Dis Sci 2012572423-9
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
ARV consideracions especials
bull ARV preembaragraves stop 1-2 trimestre
50 gt ALT x5 normal
no descompensacioacute hepagravetica
bull ARV lactagravencia materna NO TDF
TDF Llet materna TNF 003 dosis nounat TNF no absorbeix GI adult
concentracioacute simulada en plasma es extremadament baixa
bull ARV Cirrosis
Augment mortalitat complicacions
mare 18 vs 0 plt00001 EHE DPPNI HPP
fetus 52 vs 21 plt0001 PP RCIU
Tractament tot embaragraves
Kim H Choi J Park C et al Outcomes after discontinuing antiviral agents during pregnacy in chronic infection with hepatitis B virus J Clin Virol 201356299-305 Shi Z Wang H Screiber A et al Breastfeeding of newborns by mothers carrying hepatitis B virus a meta-analysis and systematic review Arch Pediatr Med 2011165-837-46
Benaboud S Pruvost A Coffie PA et al Concentrations of tenofovir and emtricitabine in breast milk of HIV-1-infected women in Abidjan Cote dIvoire in the ANRS 12109 TEmAA Study Step 2 Antimicrob Agents Chemother 201155(3)1315
Pan CQ Mi LJ Bunchorntavakul C et al Tenofovir disoproxil fumarate for prevention of vertical transmission of hepatitis B virus infection by highly viremic pregnant women a case series Dig Dis Sci 2012 57(9) 2423ndash2429 Ehrhardt S Xie C Guo N et al Breastfeedint while taking lamiivudine or Tenofovir Disoproxil fumarate a revioew of the evidence CID 2014 131-4 European Association for the study of the Liver EASL clinical proactice gyuidelines management of chronic hepatitis B virus infection J Hepatol 201257 (1)167-185 Shaheen AA Myers RP The outcomes of pregnancy in patients with cirrhosis a populations-based study Liver Int 201030(2)275-283
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Tractament preembaragraves
DNA VHB indetectable preembaragraves
Hepatitis B virus DNA and RNA analyses in oocytes and embryos and virus particles containing HBsAgs HBV in oocytes and embryos suggests the possibility of vertical transmission of HBV via the germ line
Pan C Lee HM Antiviral Therapy for Chronic Hepatitis B in Pregnancy Semin Liver Dis 201333138ndash146 Nie R Jin L Zhang H et al Presence of hepatitis B virus in oocytes and embryosa risk of hepatitis B virus transmission during in vitro fertilization Fertil Steril 201195(5)1667-1671
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
Bzowej NH Optimal Management of the hepatitis B patient who desires pregnancy or is pregnant Curr Hepatitis Rep 20121182-89
Scre
en
ing
To
tes
les
emb
aras
sad
es (
grau
A)
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Hepatitis B
2007-2014 (ARV 2010) N=137 TV=0
635 primera visitagt24 setm 219 diagnogravestic embaragraves
18
1
3419
9
9
10
Blanca
Gitana
Asiagravetica
Negra
Aacuterab
Llatinoamerican
a
Europa Est
EgraveTNIA
0 50 100
NO
HIV
VHC
VHD
LUES
Coinfeccions
83
1
79 Desconeguda
Transfussioacute
Sexual
Vertical
Transmissioacute
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
bullNo 88 bullPP 15 bullRPM 1 bullCorioamnionitis 1
59
9
23
9
Eutocic
Instrumentat
Cesarea
NI
Lactagravencia Materna 5985
Hepatitis B
bullAmnios 19 sem 1 x10 8
18 sem + ph calota CV indetectable 1 amniodrenaje bullShunt pleural
bullPE 5 bullRCIU 3 bullMalformacioacuten fetal 3 bullDG 13 bullTORCH 1
Proves invasives Complicacions embaragraves
Tipus de part
Lactagravencia
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
visita infecc any gen
CV pretract
GOTGPT preTT
ARV Inic ARV
CV post GOTGPT post
part lactagravencia VHB nadoacute
profilaxis
1 22 VHB 2011 C 73x10 7 9248 TDF 26 11x10 5 4824 eutogravecic LA neg IgHB + vacuna x 3
2 34 VHB 2013 C 10 8 147 TDF 364
3 16 VHB 2011 C 10 8 3228 TDF 28 lt20 4234 Ces elec
LM neg IgHB + vacuna x 3
4 18 VHB 2012 C 11x10 7 5647 TDF 28 55x10 3 2918 Eutogravecic LA neg IgHB + vacuna x 3
5 19 VHB 2014 C 10 8 1611 TDF 32 99x 10 5 2012 Ces elec
LA neg IgHB + vacuna x 3
6 34 VHB+VIH 2008 FTC TDF + LPV
35 Ces VIH
LA neg IgHB + vacuna x 3
7 10 VIH+VHB +VHC
2010 ATZ + RTV + RAL
Previ gestacioacute
lt20 127175 Eutoacutecic LA neg IgHB + vacuna x 3
8 21 VIH+VHB 2010 LPVr+ NVP+ TDF
Previo gestacioacute
1180 2620 Ces parto
LA neg IgHB + vacuna x 3
9 12 VIH+VHB 2014 FTC TDF +RTVDRV
Previ gestacioacute
lt20 4250 Eutoacutecic LA neg IgHB + vacuna x 3
10 8 VIH+VHB 2012 FTC TDF + RTV DRV
Previ gestacioacute
lt20 158
Embarassades VHB amb ARV HVH 2007-2014
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
137
mares
122 nens Vacuna + IgHB
105 nens 2 vacuna
86 nens 3 vacuna
60 nens Sans als 9 mesos
19nens No informacioacute
17nens No informacioacute
15 nens No informacioacute
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Dra Anna Suy
Coordinadora Urgegravencies Ginecologravegiques i Obstegravetriques
Vall drsquoHebron
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Streptococcus agalactiae
Pautes actuals de prevencioacute de la transmissioacute mare-fill
Ohlsson A Shah VS Intrapartum antibiotics for known maternal Group B streptococcal colonization Cochrane Database of Systematic Reviews 2014
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Screening universal 35-37 setmanes gestacioacute
Profilaxis GBS intrapart NO profilaxis GBS intrapart
GBS cultiu + Cultiu SBG negatiu
Fill previ segravepsia GBS GBS + en anterior gestacioacute
GBS bacteriuacuteria en gestacioacute actual
Bacteriuacuteria GBS en anterior gestacioacute
Cultiu GBS desconegut al part + 1 dels seguumlents bull lt37 setmanes bull RPM gt18 h bull Tge380ordmC bull PCR SBG + intrapart
Cesagraveria electiva amb membranes integres
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Streptococcus agalactiae
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Part prematur
No
Prendre cultiu vagino-rectal EGB
Iniciar PAI si es preveu inci de part imminent
Srsquo inicia realment el part
Iniciar o continuar
PAI fins part Parar PAI
Si
Iniciar PAI quan srsquoinici el part
Resultat cultiu EGB
Positiu Negatiu No disponible al inici del part i es lt37 setmanes
No PAI
Repetir el cultiu vagino-rectal 35-37 setmanes
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
NO
Cultiu EGB vagino-rectal +
iniciar antibiogravetics per lategravencia io PAI EGB
Srsquoinicia realment el part
Continuar antibiogravetics
fins part
Seguir antibioacutetics segons
protocol de lategravencia o
seguir antibioacutetics 48 hores si srsquoestaacuten
aplicant per PAI
SI
Obtenir resultat del cultiu EGB
Positiu Negatiu
No disponible lrsquoinici del part
Administrar PAI al
inici real del part
No PAI quan inici real del part
Repetir el cultiu vagino-rectal 35-37 setm
RPM
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
almiddotlegravergica a penicilmiddotlina
Penicilina G iv 5 milions UI
(dosis inicial) Seguida de 25 a 3
milions cada 4 h fins part
o
Ampicilina 2g iv (dosis incial)
seguida de 1g cada 4h fins part
EGB sensible a clindamicina i
eritromicina
Vancomicina iv 1g cada
12 h fins part
Clindamicina 900 mg iv 8 h
Fins part
Siacute
No Siacute
No o
desconocido
Tractament antibiogravetic recomanat
Pacient ha patit despreacutes de prendre
penicilina o cefalosporines
bull anafilaxia
bull angioedema
bull distress respiratori
bull urticaria
Siacute No
Cefazolina 2g iv seguit de 1 g8h
fins part
Centers for Disease Control and Prevention Prevention of Perinatal Group B Streptococcal Disease MMWR 201059(10)1-10)
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
Turrentine M Intrapartum antibiotic prophylaxis for group B Streptococcus has the time come to wait more than 4 hours Am J Obstet Gynecol 2014715-17 Konikkara KP et al Detection of Group B Streptococcus in pregnant women Journal of Clinical and Diagnostic Reserch 20148(2)47-49 Chen VL Avci FY Kasper DL A maternal vaccine against Group B Streptococcus Past present and future Vaccine 201331(04)D13-D19
Streptococcus agalactiae
Temps de profilaxis ge 4 hores 2 hores GBS vaginal colony counts decrease by 5-fold 4 hores GBS vaginal colony counts decrease by 50-fold menor risc infeccioacute neonatal si induccioacute immediata despreacutes RPM OR 029 95 008-105 NS
Utilitat PCR
Vacuna EGB Ac tipus III CPS Ag confereixen proteccioacute per early and late SGB sepsis
EGB consideracions especials
asuyvhebronnet
asuyvhebronnet