Hello. I was diagnosed with chronic hepatitis b during pregnancy. My family has a history of hepatitis b and close family members whom i lived with also have CHB, so I’m probably a carrier since birth or very young. Back in September, during my first trimester, i had a viral load of 21 million. Now not even 3 months later, my viral load is 38 million. I was advised to start Tenofovir in my 28th week, but I’ve read research indicating that starting Tenofovir in the second trimester (or late second trimester) is safe and could achieve better viral load suppression
I’m really concerned about liver damage and the stress that this is causing me. Would it be ill-advised for me to speak to my doctor about starting the medication now? Also, is it concerning that my viral load has increased so much in such short period of time? All my liver enzymes are normal and a liver ultrasound i had back in October indicated everything was normal with my liver and surrounding organs.
Hi @optimisticmama,
I hear you. Your numbers are concerning and I agree with you worrying about liver damage.
Find here the guidelines addressing HBV, pregnancy and treatments etc. shared recently. I hope you can bring this to your doctor and discuss this matter further. Keep us posted. Bansah1
Congratulations on your upcoming motherhood. The medical advice you are getting is consistent with the recommended practice as outlined in the reference materials that @Bansah1 has posted.
The increase from 21 million to 38 million isn’t really considered clinically significant. What’s more is that it is expected: during pregnancy your body undergoes a lot of changes, including having a reduced immune system - this ensures that the mother’s immune system doesn’t start attacking the baby. We do know of post-partum flares, which are caused by the immune system waking up again after the birth and attacking the HBV-infected liver cells.
That said, if you feel that you would benefit from antiviral therapy now (e.g., that it would ease your anxiety), it would be worth discussing it with your provider.
This is such useful information to have. I’m in the process of switching my liver specialist because my current one has provided absolutely no information about my condition, which led me to reading medical journals and research online on my own. Your explanation not only soothe my anxiety regarding my current problem, but you also provided useful info for what I should be expecting for postpartum. I really appreciate it.
I had a second opinion from a different specialist, so I will first note my test results along with the differences in treatment from the two. The first specialist I worked with is actually a hepatologist and the second specialist is a general gastroenterologist.
My test results are the following:
HEP B CORE AB - POS
HEP B E AB - NEG
HEP B DNA - 38,700,000Iu/ml
HEP B S AB - POS
HEP B S AG - POS
Hepatologist treatment plan:
-Start Entecavir in the third trimester, switched to Tenofovir after OB intervention.
-Continue taking Tenofovir after pregnancy for the rest of my life.
-Monitor with HEP B DNA, ALT, AST, ALKALINE PHOSPHATASE, TOTAL BILIRUBIN, CBC. And also CREATININE because ongoing use of antivirals could lead to kidney damage every three months.
-Possible interferon later.
General Gastroenterologist treatment plan:
-Start Tenofovir in the third trimester.
-Stop taking Tenofovir after delivery.
-Fibroscan after delivery.
-Monitor HEP B DNA, ALT, AST, ALKALINE PHOSPHATASE, TOTAL BILIRUBIN every four weeks during pregnancy until three four-week period after birth, then monitor every three months.
I went with the recommendations of the general gastroenterologist, though I’m not entirely sure why the hepatologist recommended that I would have to take Tenofovir for the rest of my life, even though all recent literatures recommend stopping either immediately or within three months after fiving birth. I understand that I may have to take the medication for the rest of my life, and the risks associated with stopping medication. The general GI informed me that drug resistance could be tested, and if resistance to Tenofovir happens, then she’d switch me to Entecavir.
I also spoke with my high risk OBGYN, and she told me it’d be reasonable to start Tenofovir in the second trimester to reduce chances of MTCT based on the updated guidelines.
I am assuming you / your doctors are not forgetting birth dose vaccination for your child with the first inoculation within 24h after delivery. This is CRITICAL for your child.
I would recommend TDF instead of ETV. Antiviral responses are a bit faster and this is what is important in your case.
The issue with stopping TDF after delivery is an older notion that breastfeeding should not happen if you are on antiviral therapy. Breastfeeding your baby is important for the baby’s heath and immune function during the first six months of life and you may wish to do this for your baby. The most recent clinical data show that the infants exposure to TDF in breast milk is lower than the exposure in utero during the third trimesters (see here and here). Mothers are now encouraged to breastfeed and not stop TDF after delivery.
In your case (and with many other HBV infected mothers), with such a currently high HBV viral load (38 million IU/mL of HBV DNA is quite high), should you stop TDF after only taking it for three months, there should be a strong concern about aggressive viral rebound over the next three months with liver complications.
I wish you the best of luck, your baby will be healthy!
Hello! Thank you for your response. Do you happen to have newer literature that recommends continuing use of Tenofovir after pregnancy rather than stopping, and the implications of stopping, especially if the mother has high viral load during pregnancy?
I am not choosing to stop medication becausee of the outdated notion that it may affect breastmilk, since evidence suggests that this is unlikely to be the case. I’m stopping to see if my immune system could fight the infection on its own.
I was also under the impression that high viral load during pregnancy is not uncommon:
I would really like to know what the updated science is on this.
I have sent you some recent direct literature with data and commentary on this subject in my last post (see blue hyperlinks).
The most recent AASLD guidelines (2018) indicate that the use of TDF during breastfeeding is supported. See the 2nd paragraph from the bottom on page 8 here.
Of course this should be discussed with your doctor. If you choose to stop TDF you at least need to be followed regularly for at least three months. At some point you will have to restart TDF to prevent the onset of liver disease from your infection.
I’m sorry, but the paragraph you’re referencing only says breastfeeding is safe when using Tenofovir. I’m not concerned about Tenofovir affecting breastfeeding. Per the following study from AASLD, “Cessation of prophylactic TDF right after delivery showed similar rates of VR or retreatment compared to stopping TDF ≥4 weeks postpartum.”
I’m also not seeing anywhere that AASLD recommends continuing use of Tenofovir after pregnancy. I’m only seeing that it’s recommended to stop either immediately at birth or within 3 months. In the latter case, the rates of retreatment is practically the same.
Virologic rebound (virtually 100%) is common in scenarios where TDF is withdrawn after delivery. The web link you posted shows this: either withdraw of TDF either right after delivery or delayed 4 weeks after delivery actually have no difference in their impact on this rebound. This is also described in the recent study you already posted here .
Retreatment is required is a significant proportion of women due to aggressive rebound of HBV with liver complications upto 13% witihin 6 months and the incidence of retreatment is related to baseline HBV DNA during pregnancy before TDF therapy is started. However, in those women who experience viral rebound NOT requiring re-treatment, allowing persistent HBV DNA replication increases the chances of liver cancer in the long term.
Most of these studies are limited to 6 months of follow-up so we don’t know how permanent discontinuation of TDF therapy impacts HBV rebound, liver disease and HCC risk in the long term but this is well known for the patient population in general.
@availlant
My baby is now only 1 month and a half old,
and I started tdf at 28 weeks of pregnancy and got the hbig vaccine after 1 hour of giving birth.
I have continued TDF until now, after researching, I thought and concluded that there was no problem with 1 pill every day and the side effects were low,
However, the benefit is very large, reducing the risk of liver disease due to HBV
I am 28 years old, without any symptoms.
Have I done this?
and how effective is TDF in avoiding serious complications, and how big are the short and long term side effects of TDF?
Hello. Thank you for this information. If VR is virtually a guarantee after stopping medication post pregnancy in the longterm, why is cessation at delivery something to be considered in so many studies? Is it just for research sake?
With this information about VR, it makes no sense to stop taking Tenofovir, so why are doctors and patients choosing to stop medication just to see a relapse happen and potentially cause liver damage in the process?
I’m not exactly sure about the specific rationale used for guidelines to consider stopping antivirals post-partum. However, many medical guidelines are based on limiting use of medications only to when there are specific measurable benefits with respect to health outcomes.
My understanding is that the goal of treatment during pregnancy is to prevent transmission to the new-born: once that goal is achieved, there may be limited benefit of ongoing treatment with respect to measurable differences in liver disease progression and cancer (because these generally occur later in life and many studies do not extend to the time when these occur). From the Australian guidelines (Managing hepatitis B virus in pregnancy and children - B Positive):
Postpartum flares have also been observed in HBeAg-negative mothers. Flares are usually asymptomatic and most settle spontaneously (30). If a flare is noted, it can be observed for up to 6 months to assess whether it will resolve spontaneously, or require treatment. It does not appear that antiviral therapy in pregnancy will increase the rate or severity of postpartum flares (18,31,32), nor that extending antiviral therapy beyond birth prevents the postpartum flare, although data are limited (30).
There is increasing evidence that antivirals can decrease the risk of cancer over longer periods, and can help with other aspects (e.g., limiting anxiety of disease progression or onward transmission, stigma, reducing the number of HBV infected cells in the liver, etc.), but there are limited randomised control studies.
Hope this gives some context to why the recommendations are the way they are and gives you more information to make your decision.
With earlier generation NUCs for HBV (and other NUCs for other viral infections), toxicology in infants was either unknown or its use contraindicated. This is where the paradigm of treating the mother until birth and then ceasing afterwards comes from.
Also it is only in recent years that the lack of efficacy of NUC therapy to lower HCC risk when withheld until later on in the disease was more widely known in the medical community.
You are correct, if there is no harm to the baby, it does not make sense to remove TDF therapy during breastfeeding (or ever for that matter) in the mother. The exception to this is if you become HBsAg negative - if this happens than NUC therapy can be safely withdrawn while maintaining the lowest possible risk of HCC.
I should point out (for the community at large) that this issue of TDF therapy being present during the last trimester of pregnancy and or continuing therapy with TDF while breast feeding is currently NOT recommended for TAF. We do not yet have enough data to be confident in safety for the newborn infant with this drug yet.
Thank you both. The information you’ve given me is extremely helpful. It seems to me that the optimal path for me to take as a risk-averse and anxious patient is to continue TDF treatment post-birth, especially with a family history of HCC, and then consider switching to Vemlidy for the lower dosage to reduce the risk of bone and kidney problems after breastfeeding, while monitoring HbsAg in the process.
This is a good plan. If you do not have access to Vemlidy or it is not covered by your insurance, you can consider remaining on TDF and altering the dose to once every other day only if you develop long term issues (this does not happen in the majority of patients taking TDF). This is a recognized method for reversing kidney dysfunction while maintaining antiviral efficacy with TDF.
