Hepatitis B in Pregnancy
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults, Updated for the 2023 Edition
O98.4
DESCRIPTION
Hepatitis B virus (HBV) is transmitted sexually or by percutaneous exposure to infectious body fluids, i.e., blood, saliva, vaginal fluid, and semen. Diagnosis is confirmed serologically by a positive hepatitis B surface antigen (HBsAg).
Screening in pregnancy for HBsAg should ideally be performed in the first trimester. HBeAg positive pregnant women are more infectious than HBsAg positive women, as they have higher rates of HBV replication.
GENERAL MEASURES
Screen sexual contact(s); if they are sero-negative, give hepatitis B vaccination.
All infected patients should be counselled with regard to lifestyle modifications to reduce hepatotoxicity, including alcohol, substance abuse, and co-prescription of herbal and traditional medicines.
MEDICINE TREATMENT
Indications for medical therapy in HIV-uninfected pregnant women are the same as for non-pregnant adults.
- For management of chronic hepatitis B, without chronic HIV infection, see Hepatitis B, chronic (non-HIV coinfection).
- For management of chronic hepatitis B with chronic HIV infection, see HIV and AIDS. (ART for women with chronic Hepatitis B should always include ARVs active against hepatitis B).
Note:
• Ensure normal renal function before starting treatment with TDF (serum creatinine <85 micromol/L or creatinine clearance >60 mL/minute).
• Monitor ALT and HBV DNA viral load at 6 months after commencing treatment.
• An adequate virological response is an HBV DNA VL<2000 IU/mL.
Prevention of perinatal transmission
- Caesarean delivery is reserved for obstetric indications only.
- Delivery should take place in a facility that can offer Hepatitis B vaccination to the baby at birth.
- Administration of ARVs active against HBV from 28 weeks of pregnancy will further reduce risk of vertical transmission.
Pregnant women who are HBsAg/ HBeAg positive and HIV negative
- All HIV negative pregnant women are eligible for HIV Pre-exposure prophylaxis (PrEP) (see Pre-exposure prophylaxis (PrEP)). TDF, which is included in the oral PrEP regimen, has anti-HBV activity, and will reduce the risk of vertical transmission of HBV.
- Women who are HIV negative and HBsAg positive who decline PrEP must be counselled that TDF will reduce risk of vertical transmission of Hepatitis B to the baby, particularly if HBeAg is positive or HBV viral load is high.
- TDF 300 mg daily should be administered from 28 weeks of pregnancy until birth to women with a high hepatitis viral load (≥200 000 IU/mL), or positive HBeAg, or where HBeAg/viral load result is unavailable at 28 weeks.
- For care of babies born to: (1) mothers with acute hepatitis B infection at the time of delivery, (2) mothers who are HBsAg-positive, or (3) mothers who are HBeAg-positive, see Perinatal transmission of hepatitis B.
- Obtain infectious disease specialist or internal medicine physician opinion before stopping TDF as there is a risk for postpartum hepatitis flare.
- Consider continued treatment for HBV after delivery where indicated (see Hepatitis B, chronic (non-HIV coinfection)).
For Pregnant women who are HBsAg/ HBeAg positive and HIV negative
- TDF, oral, 300 mg daily (from 28 weeks of pregnancy until birth).
LoE:IVbxxvi
REFERRAL
- Cirrhosis.
- Liver failure.
- Renal dysfunction (TDF is contraindicated in renal impairment. Tenofovir alafenamide (TAF) should be prescribed in place of TDF).
- Refer all infected babies to a specialist paediatrician for further management.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2025-9 Review_Version 2.0_26 March 2026
Chapter 6 Obstetrics_6.8 Hepatitis B in Pregnancy