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Understanding Acute Hepatitis E infection in pregnancy

Hepatitis E is a virus that infects the Liver; most times, the patient's condition improves or he/she recovers completely after acute Hepatitis infection within a few weeks or months. Sometimes this infection can be dangerous and might lead to Fulminant Acute Liver Failure - a life-threatening condition in which the Liver fails. Patients with Acute Liver Failure need to undergo urgent Liver transplantation. 

Each year, more than 20 million estimated cases of Hepatitis E virus infection occur globally. Hepatitis E virus was first recognized in 1978 during an epidemic in Kashmir Valley. The majority of the sporadic and epidemic cases of Acute Viral Hepatitis in India are caused by the Hepatitis E virus.

TRANSMISSION OF HEP-E: Hepatitis E is a water-borne pathogen and this infection is transmitted by the fecal-oral route, which means that the patient can catch this infection if they drink or eat something that has been in contact with the stool of someone who has been infected with this virus. That is why this infection is more common in countries with poor handwashing habits and lack of clean drinking water supply. Direct person to person transmission of this infection is uncommon. Hepatitis E is a RNA virus with four genotypes, of which, type 1 genotype is common in Asia. There are evidences which show that Hepatitis E virus is an important contributor to maternal morbidity and mortality in South Asia, especially if the infection occurs in the third trimester of pregnancy with genotype 1.

SYMPTOMS: Usually symptoms of acute Hepatitis E virus infection starts 2 to 6 weeks after infection. Sometimes patients may not have any symptoms and disease resolves on its own without any treatment. Or they can experience fever, nausea, vomiting, yellowness of eyes, loss of appetite, feeling tired, abdominal pain or discomfort. 

PREGNANCY & VULNERABILITY TOWARDS ALF: Pregnant women are more vulnerable to this infection, risk of mortality also spikes in this phase. Hepatitis E infection during third trimester of the pregnancy, especially with genotype 1, can cause more severe infection and might lead to Liver Failure and maternal death in up to 15 to 25% patients. During pregnancy, there are some immunologic and hormonal changes which promote the maintenance of the foetus in the maternal environment. Because of these immunologic changes, pregnant women are more susceptible to viral infections like Hepatitis E. Hepatitis E infection during pregnancy can cause Acute Liver Failure (ALF) which is manifested by Jaundice followed by mental status changes and coagulopathy. There are studies which have shown that pregnant patients with acute Hepatitis E infection can progress to Acute Liver Failure in 15–60% patients. There are around 50% chances of transmission of this infection from mother to the child. This can cause still births or neonatal mortality. So Acute Hepatitis E infection during pregnancy is a critical risk for both mother and her child as well!

MANAGEMENT Of PATIENTS WITH ALF: Acute Liver Failure patients should be managed in a centre where Liver Transplant facility is available. If patient meets Liver Transplant criteria, they should be listed immediately for cadaveric donor liver transplantation list. Acute Liver Failure patients are given priority when cadaveric organ is available in the city, over the Chronic Liver Disease patients. At the same time, blood group matching donors should be identified in the family and evaluated if they are willing to donate a part of their Liver without any pressure or financial benefit. Liver Transplantation is the only treatment option when patients with Acute Liver Failure do not respond to medical management. 

PREVENTION: Maintaining personal hygiene, improving sanitary conditions, using clean drinking water, proper sewage disposal, appropriate hand hygiene and awareness about the infection and method of its spread are the mainstay for the prevention of Hepatitis E virus infection. 

TREATMENT: If a patient with Acute Hepatitis E virus infection goes into Liver Failure, Liver Transplant is the only curative option. Such patients should be managed in a centre which has a comprehensive Liver Intensive Care Unit and Liver Transplant facility.