Viral hepatitis during pregnancy in Israel

Int. J. Gynaecol. Obstet., 1982, 20: 73-18 International Federation of Gynaecology & Obstetrics

VIRAL HEPATITIS DURING PREGNANCY IN ISRAEL

ELIEZER SHALEVa and HARRY M. BASSANb aDepartment of Obstetrics and Gynecology, Central Emek Hospital, Afula, and bDepartment of Medicine B, Rothschild UniversityHos$tal, Faculty of Medicine, Technion, Haifa, Israel (Received April 23rd, 1981) (Accepted June 29th, 1981)

Abstract

Introduction

Shalev E, Bassan HM (Dept of Obstetrics and Gynecology, Central Emek Hospital, Afula and Dept of Medicine B, Rothschild University Hospital, Faculty of Medicine, Technion, Haifa, Israel). Viral hepatitis during pregnancy in Israel. Int J Gynaecol Obstet 20: 73- 78, I982 Epidemiological, clinical and laboratory data were obtained relating to 89 pregnant women who suffered from viral hepatitis during the period 1967-19 77 in Israel. The obstetrical data, course of labor and details about the newborn, were all compared with the accepted obstetrical standards in Israel and abroad. A follow-up study was made of the 89 women and 69 of the offspring from these pregnancies, covering a period of from 2 to 10 years. The data of the present study demonstrate that during the last decade, a period of generally rising socio-economic status in Israel, viral hepatitis in pregnant women, ran a more favorable course than that previously reported. The incidence of hepatitis is equal in all trimesters of pregnancy, and a favorable outcome may usually be anticipated for the mother and the newborn.

Opinions concerning the course of viral hepatitis in pregnancy are controversial. A high incidence of fetal and maternal mortality has been reported, mainly from underdeveloped countries, such as India [l-3], the Middle East [4,5], the Gulf of Persia [6] and North Africa [ 7,8 I. By contrast, studies made in Europe and the U.S. have shown that the course of viral hepatitis (VH) is not altered by pregnancy and the fatality rate is the same as in the general population [ 9- 151. Zondek and Bromberg in 1947 [ 161 and Peretz et al. in 1959 [ 171 investigated the course and outcome of VH in pregnancy in Israel. Both groups of investigators concluded that in Israel VH in pregnancy has a severe course, with a high incidence of fetal and maternal mortality. The aim of the present study has been to evaluate the course of VH during pregnancy in Israel, during the past decade, which has evidenced improved socioeconomic conditions in this country.

Key words: Viral hepatitis; Epidemiological, clinical and laboratory data; Hemoglobin values; Bilirubin level; Deep hepatic coma; Fulminant hepatitis; Massive multilobular necrosis 002-7292/82/0000-0000/$02.75 0 1982 International Federation of Gynaecology & Obstetrics

Materials and methods Epidemiological, clinical and la’boratory data were obtained during the period 19671977, relating to 89 pregnant women who suffered from VH, for which had been admitted to 13 general or maternity hospitals in Israel. The diagnosis of VH was established accordInt J Gynaecol Obstet 20

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Shalev and Bassan

ing to standard clinical and laboratory findings [ 18-201. Demographic and socioeconomic status were compared to demographic data related to the general population in Israel as based on information obtained from the Israel Central Bureau of Statistics for the same period [ 21,221. Data regarding the course of the current pregnancy and labor, details of the newborn in the neonatal and post neonatal period, were all collected and compared with the accepted obstetrical standards in Israel and abroad [23-281. A follow-up study was made of the 89 women and 69 of the offspring from these pregnancies covering a period of from 2 to 10 years. This follow-up was conducted either by correspondence or by personal interviews. The results were statistically evaluated according to the t and Wilks test.

Table II. Viral hepatitis in pregnancy country of origin, 89 patients. No. Sepharadiafiental Asia North-Africa Ashkenazi Europe South-Africa Israel Ashkenazi Arabs Sepharadi

Table I. Viral hepatitis in pregnancy age distribution, 89 patients.

Age

No.

%

15-19 20-24 25-29 30-34 35-39

7 32 30 13 I

7.86 35.95 33.70 14.60 7.86

20

22.4 7 13

12

13.4 11 1

12.3 1.1

57

64.2 28 16 13

31.5 17.9 14.6

Urban Development centers Arabic village Jewish village Kibutz

No.

%

%a

48 16 15 6 4

54.7 17.8 16.8 6.7 4.4

68 15 6 8 3

aGeneral population division (22).

Table IV. signs.

Viral hepatitis in pregnancy symptoms and

Fever Preicteric stage Icteric stage Loss of appetite Nausea Weakness Abdominal pain Vomiting Pruritus Arthralgia Hepatomegaly Splenomegaly HBsAg

No.~

%

22128 12171 42144 43146 44147 48154 42149 17176 8157 54187 17117 10134

78.6 16.9 95.6 93.5 93.6 88.9 85.7 22.3 14.0 62.1 22.1 29.4

aNo. patients/No. of patients examined. Int J Gynaecol Obstet 20

7.9 14.7

Table III. Viral hepatitis in pregnancy type of community, 89 patients.

Results The proportional distribution of VII by trimester of pregnancy was nearly equal. Thirty women developed the disease during the first trimester, 33 during the second and 26 during the third trimester of pregnancy. There was no apparent seasonal factor, and the disease appeared throughout the year. Sixty-nine percent of the women in this series were affected at an age of maximal reproductive potential - 20 to 29 years (Table I). There was a close correlation between the patients in this series and the general population in Israel with respect to country of origin and ethnic distribution [ 211 (Table II). Comparing the communities to which the

%

Viralhepatitisduring pregnancy in Israel Table V.

Viral hepatitis in pregnancy laboratory findings.

Hemoglobin g/100 ml Bilirubin mg/lOO ml Got, Ku Alkaline phosphatase IU Albumin g/100 ml Globulin g/100 ml

11.9 1.5 1488 120 3.5 2.9

f 1.4 f 5.3 f 573 f 49 * 0.6 f 0.5

Table VI. Viral hepatitis in pregnancy bilirubin value in I, II, Ill trimester. Serum bilirubin mg/lOO ml

I No.

II No.

Ill No.

Total

Under 10 10-20 Over 20

22 4 4

27 5 1

21 5 -

70 14 5

Table VII. Viral hepatitis in pregnancy outcome of pregnancy, 74 patients. Trimester

Labor at term Normal fetus Congenital malformation Premature labor Living singleton Twins Perinatal death Abortions Spontaneous Induced

I No.

II No.

Ill No.

Total

17 -

23 -

15 1

55 1

1

1 1

8

10 1 1

-

4-2--

1

4 2

patients belonged showed a high incidence of VH in the Arab villages (Table III). Details of the clinical symptoms, the signs and the results of the laboratory investigations are summarized in Tables IV, V and VI. The hemoglobin values in this series were significantly lower (P < 0.01) than the hemoglobin of patients in general, who suffered from VH in Israel [29,30], but similar to the average hemoglobin level of the population of pregnant women [ 251. The average bilirubin level was 7.47 mg% with no variation in which ever of the three trimesters of pregnancy the disease occurred. HBsAg was positive in ten

75

out of the 34 pregnant women tested (29.4%), the same percentage as in another group of patients hospitalized with VH in Israel [ 291. The course of VI-I in pregnancy proved to be benign and free of complications in 79 patients (88.7%). Chronic active hepatitis developed in two patients - respectively 6 months and 3 years following recovery from the acute episode of VH in pregnancy. Three patients, all from a low socioeconomic background, dveloped deep hepatic coma. Of these, one recovered, following premature labor. Two others died: a 37-yearold woman following an 8-week abortion; and a 25yearold woman in the 6th month of pregnancy who needed repeated blood transfusion after a hemolytic crisis. Post-mortem examination in both cases confirmed the diagnosis of fulminant hepatitis, with massive multilobular necrosis. Information concerning the outcome of the pregnancy following the occurrence of VH was available in 74 of the 89 pregnant women: 68 went into labor of which 64 gave birth spontaneously and without complications. Caesarean section was performed in one case for a purely obstetric reason. Three cases were complicated by early post-partum hemorrhage, each due to a retained placenta and without any coagulation defect. Of the 68 who had normal labor there was no incidence of maternal mortality. Six women aborted, four spontaneously, and in two others the abortion was induced. Of the 68 deliveries, I2 (17.6%) were premature as estimated by the week of gestation (Table VII). In cases hospitalized during the third trimester on account of VH, 66% gave birth prematurely during the acute episode and while still in hospital. One incidence of early neonatal death was recorded after a premature home delivery. The cause of death was delined as respiratory distress. Three of 69 newborn infants were small for gestational age. The only occurrence of a congenital defect was a single case of Down’s syndrome. Physical and mental development ZntJ Gynaecol Obstet 20

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Shalev and Bassan

was found to be normal during a 2-l 0 years’ follow-up period. Discussion

Viral hepatitis during pregnancy has been described in many studies as being a severe disease affecting particularly women of low socioeconomic class, most often during the last trimester of pregnancy and with a high incidence of fetal and maternal mortality [ l-8, 3 l-341 . Two of the studies sharing this point of view were published in Israel during the previous decades [ 16,171. In the light of the improved socio-economic conditions which have occurred in Israel during the last decade, it seemed necessary to reevaluate the interrelation between VH and pregnancy in this country. The findings in the present study group confirm the assumption that VH during pregnancy in Israel resembles the pattern of VH in pregnant women from western countries [g-15]. Israel is considered to be a hyperendemic area for VI-I, with a relatively high annual incidence, between 180 and 297 cases/lOO,OOO population. The disease occurs predominantly in early childhood and the majority of the patients are treated at home. Ethnographical data reveal that the pregnant women in this study group were similar to the patients hospitalized for VII in Israel, as shown in another study of VH in this country [29]. Among the women in the present group we found a relatively high incidence of VI-I in pregnant women from the low socioeconomic class, and the demographic division reveals clear prevalence of VH in the Arab villages. There was no correlation between the incidence of VH in pregnancy and the parity of the affected patients. No increased frequency of VII in pregnancy was found with higher parity rates. Borhanmanesh [6] has reported a fati course of VI-I in primigravidae. Mickal [ 31 I has reported a preponderance of VH in pregInt J Gynaecol Obstet 20

nancy occurring in multigravidae. Our studies have confirmed the findings of Elegast [ 101, Thorling [ 111 and others [ 12,35,36] that the frequency of VH was equal in all trimesters of pregnancy with no increased tendency to complications in any of the trimesters. Zondek [ 171, Borhanmanesh [ 61, Christie [ 81 and others [ 3 l-341 claim that VI-I is more frequent in the last trimester, occurring also with a more severe course. The majority of the patients in our study group were of the non B type viral hepatitis. HBsAg was found to be positive in 29.4% of the pregnant women tested. This incidence is higher even than that reported from Libya [81, where the death-rate from VH during pregnancy is high. The course of labor was regular in most cases, and was not influenced by the disease. Profuse hemorrhage was not observed. We found a clear tendency to premature labor. This is in accordance with, and common to a large number of studies [2,4,5,33,34,381. Rao [ 391 and Parker 1401 have reported 45% and 54%, respectively, of premature deliveries after VH during pregnancy. The question is whether the influence on premature labor is peculiar to VII, or whether it is the influence of infectious disease in general. Congenital defects were observed only in one case which had Down’s syndrome after viral hepatitis during the third trimester of the pregnancy. The clinical symptoms and signs, as well as the laboratory findings were similar to those found in general patients with VH in Israel [29-301. The low average hemoglobin value found in this group of pregnant women cannot be attributed to VH, but rather to the pregnancy. The percentage of spontaneous abortions was lower than expected [261. Spontaneous abortion in this study group seemed to be unrelated to VH. Perinatal mortality is reported to be high in studies from areas where protein malnutrition is frequent, like that of Ezes of Algeria [7], D’cruz of India [3] and others [2,61. Common to all these reports is the high per-

Viralhepatitisduring pregnancy in Israel

centage of premature labor which constitutes the main cause of neonatal mortality. We assume that as VH is an infectious disease, it causes prematurity which brings about an rate, increase in the neonatal mortality expecially in countries where newborn infants are inadequately treated. In this survey, in spite of the high rate of prematurity, there was not found a high incidence of neonatal mortality. We believe that neonatal mortality can be minimized by intensive care of the newborn. The data of the present study clearly demonstrate that during the last decade, during which a higher socioeconomic status prevailed in Israel, VH in pregnant women runs a more favorable course than was previouly reported [ 16,171. The incidence of hepatitis is equal in all trimesters of pregnancy, and a favorable outcome may usually be anticipated for the mother and the newborn. References

5 6

7

8 9 10

11

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hepatitis

Address for reprints: Dr. HM. Bassan Head, Dept of Medicine B Rothschild University Hospital The Faculty of Medicine Technion Haifa, Israel

in pregnancy.

Med J