01Role and principlesWho benefits and the main preventive aims.
Perinatal HBV prevention is a coordinated screening, hepatology, maternity, neonatal immunisation and primary-care programme. HBsAg is offered early in every pregnancy, irrespective of prior results or treatment. A confirmed positive result triggers assessment of HBV DNA, HBeAg or anti-HBe, ALT, liver reserve, coinfections and fibrosis where appropriate. The pregnant person needs care for her own liver as well as transmission prevention. High maternal viraemia increases breakthrough risk despite infant immunisation; NICE recommends tenofovir disoproxil in the final trimester when its viral-load criterion is met. The postpartum plan must say whether treatment continues for maternal indication or is stopped with flare monitoring.
The infant pathway is time-critical. Monovalent hepatitis B vaccine is given as soon as possible, ideally within 24 hours, to every baby born to an HBsAg-positive mother. HBIG is added for higher-infectivity pregnancies and low-birth-weight situations defined by current UKHSA guidance. The child then completes the selective hepatitis B schedule integrated with the national routine programme. Because schedules changed recently, clinicians should use the current Green Book and aide memoire rather than a remembered list. Definitive infection testing occurs between one year and 18 months in the current England pathway; failsafe systems must track every dose and result across maternity, child-health information systems and primary care.
HCV care differs. Universal antenatal HCV screening is not part of the NHS IDPS offer, so test people with relevant blood exposure, abnormal liver tests, HIV or other indications, using RNA to confirm current infection. Direct-acting antiviral use during pregnancy remains specialist and is not routine solely to prevent transmission; ribavirin is teratogenic. Caesarean birth is not routinely performed only for HCV, but avoid unnecessary fetal scalp electrodes or prolonged invasive exposure to maternal blood when alternatives exist. Breast or chest feeding is generally possible with HCV, pausing from a bleeding or cracked nipple and seeking specialist advice. Infant testing follows the locally commissioned paediatric pathway because maternal antibody can persist. Acute HAV is managed supportively with public-health involvement; acute HEV, especially after endemic-region exposure, carries a severe maternal risk and warrants urgent care.
Key points
- The NHS offers and recommends HBsAg screening in every pregnancy, even when hepatitis B is already known or a previous pregnancy screen was negative.
- A confirmed HBsAg-positive result needs prompt screening-team and specialist referral, quantitative HBV DNA, infectivity markers, liver assessment and a written birth plan.
- Maternal tenofovir disoproxil is offered in late pregnancy when HBV viral load meets the NICE threshold, with specialist planning for postpartum continuation or cessation.
- Every infant born to an HBsAg-positive mother needs monovalent hepatitis B vaccine promptly after birth and completion of the current selective schedule.
- Add HBIG within the recommended birth window for higher-infectivity pregnancies and specified low-birth-weight infants; vaccine must not be delayed if HBIG is unavailable.
- HCV is not part of the universal NHS infectious-diseases pregnancy screen; test when risk or clinical indication exists and confirm exposure with HCV RNA.
- No delivery intervention or neonatal immunoglobulin reliably prevents HCV transmission, so minimise avoidable blood exposure and ensure paediatric virological follow-up.
- HAV vaccination can be used when indicated after risk assessment, while acute HEV in pregnancy merits urgent specialist review because severe liver failure is possible.
02Assessment and patient selectionRisk features, eligibility and important cautions.
A confirmed screen-positive result may represent known chronic infection, newly recognised chronic disease or acute infection; all require prompt specialist and screening-team coordination rather than a delayed routine referral.
High HBV DNA, HBeAg and specific serological combinations identify pregnancies needing enhanced surveillance, planned HBIG and consideration of maternal antiviral treatment.
No reliable accredited result at delivery demands urgent maternal testing and newborn vaccination planning; undocumented verbal reassurance from a previous pregnancy is insufficient.
Current or previous injecting, unscreened blood exposure, high-prevalence healthcare or an HCV-positive partner should prompt non-stigmatising antibody and reflex RNA testing.
Nausea, pruritus, hypertension, thrombocytopenia, abdominal pain or hypoglycaemia may indicate pregnancy-specific or biliary disease as well as viral hepatitis, so investigate broadly.
A pregnant traveller or resident returning from an endemic area with hepatitis and jaundice needs urgent HEV testing and liver-centre awareness because rapid failure can occur.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Antenatal HBsAg screening and confirmationFirst step - Why
- Detect maternal current HBV infection early enough to protect both pregnant person and baby.
- Interpretation and limitations
- Offer in every pregnancy and confirm reactive results through the accredited laboratory algorithm. Do not infer acute versus chronic infection from HBsAg alone; retrieve previous tests and additional markers.
- 02
Quantitative HBV DNA and infectivity markers - Why
- Guide maternal antiviral discussion, enhanced surveillance and neonatal HBIG planning.
- Interpretation and limitations
- Measure DNA early enough for a late-pregnancy plan and apply current NICE and UKHSA criteria. HBeAg adds risk information but does not replace the quantitative viral load.
- 03
Maternal liver and coinfection assessment - Why
- Identify active hepatitis, fibrosis, decompensation and HIV, HCV or HDV that changes care.
- Interpretation and limitations
- Interpret ALT, bilirubin, albumin, INR, platelets, renal function and imaging with pregnancy physiology. Maternal treatment for cirrhosis or active hepatitis may continue beyond pregnancy independently of transmission prevention.
- 04
Anti-HCV with reflex HCV RNA - Why
- Diagnose current maternal hepatitis C when risk, symptoms or liver tests justify testing.
- Interpretation and limitations
- Reactive antibody needs RNA; detectable RNA identifies a baby requiring paediatric follow-up. Negative RNA means no current viraemia at that point, but repeat testing may be needed after ongoing exposure.
- 05
Acute viral and pregnancy-liver screen - Why
- Differentiate HAV, HEV, acute HBV and other hepatic or obstetric causes of jaundice.
- Interpretation and limitations
- Request HAV IgM and HEV serology or RNA according to exposure and immune status while testing for other viral, autoimmune, drug, biliary, HELLP and acute fatty liver causes.
- 06
Infant HBV status test - Why
- Determine whether perinatal transmission occurred despite prophylaxis.
- Interpretation and limitations
- Use the current national dried-blood-spot or local validated HBsAg and anti-HBc pathway between one year and 18 months; birth surveillance samples do not replace definitive later testing.
04InterventionsLifestyle, treatment and escalation options.
01ScreenBuild the antenatal HBV planFirst stepPregnancy is booked, HBV is already known, or HBsAg screening is confirmed positive.+
- 1Offer HBsAg screening in every pregnancy and refer a confirmed positive result immediately to the screening team, then to specialist hepatology within the national pathway timescale.
- 2Measure HBV DNA and infectivity markers, assess maternal liver disease and coinfections, and decide whether late-pregnancy tenofovir is indicated under current NICE guidance.
- 3Create a confidential written birth plan specifying vaccine, whether named HBIG is required, neonatal samples, responsible teams and failsafes for transfers, home birth or unplanned labour.
02ProtectComplete neonatal HBV prophylaxisA baby is born to an HBsAg-positive mother or maternal status remains genuinely unknown at delivery.+
- 1Give monovalent hepatitis B vaccine as soon as possible and ideally within 24 hours; do not delay vaccine while arranging HBIG or awaiting a late maternal result.
- 2Administer HBIG within the current window when higher-infectivity or low-birth-weight criteria are met, following the UKHSA product, documentation and emergency-supply pathway.
- 3DefinitiveNotify child-health and primary-care teams, complete the current selective vaccine schedule and secure definitive infection testing between one year and 18 months through an active failsafe.
03CoordinateManage HCV and acute hepatitisMaternal HCV RNA is detectable, or acute HAV, HEV or HBV is suspected during pregnancy.+
- 1For HCV, involve hepatology, obstetrics and paediatrics, review medicines and exposure prevention, avoid ribavirin, and plan postpartum DAA therapy unless an expert team recommends otherwise.
- 2Use obstetric indications to choose mode of birth, while avoiding unnecessary invasive fetal monitoring and securing a named infant testing pathway after maternal HCV viraemia.
- 3EscalationFor acute jaundice, monitor maternal and fetal status, investigate pregnancy-specific causes in parallel and escalate HEV or acute liver failure early to specialist liver and obstetric critical care.
05Medicines and treatment safetyRegimens, contraindications and review points.
Tenofovir disoproxil in HBV pregnancy
Use the licensed adult 245 mg once-daily tablet with food when the specialist team selects it; initiation timing and postpartum duration follow NICE, maternal viral load, renal safety and the individual's own HBV indication.Check renal function, phosphate and bone risk, test for HIV and avoid unreviewed nephrotoxins. Do not stop after birth without a documented HBV flare-monitoring plan; maternal antiviral treatment never replaces prompt neonatal vaccine and indicated HBIG.
06Targets, monitoring and follow-upResponse, safety and longer-term review.
- Track maternal ALT, liver reserve, HBV DNA and renal safety through pregnancy and after any postpartum antiviral change, with rapid review for jaundice or flare.
- Audit each infant HBV vaccine and HBIG dose against the current schedule, recording exact date and time and actively recovering missed appointments.
- Ensure definitive infant HBV testing between one year and 18 months is completed and acted upon; a vaccine record alone does not prove non-transmission.
- For maternal HCV RNA positivity, document neonatal referral and testing responsibility before discharge, and re-engage the mother for curative postpartum treatment.
- Reassess ongoing blood exposure, safeguarding, substance-use treatment and social barriers respectfully because continuity improves both maternal and infant outcomes.
- In acute hepatitis, trend glucose, INR, bilirubin, renal function, platelets and cognition with obstetric observations and fetal surveillance appropriate to gestation and severity.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Screen every pregnancy
A previous negative result can become outdated and a known positive result can be lost between systems; repeating the offer creates a national failsafe and an updated care pathway.
Two prevention layers
Maternal viral suppression reduces exposure risk, while infant vaccine and selected HBIG provide active and passive protection; neither layer should displace the other.
Birth vaccine cannot wait
HBIG adds temporary antibody for higher-risk babies, but logistical delay in obtaining it must never postpone the time-critical active hepatitis B vaccine.
Schedules evolve
Recent national childhood immunisation changes alter later doses and testing logistics, making the current Green Book and aide memoire safer than memorised historical schedules.
HCV needs a named handover
Maternal antibody complicates infant testing and postpartum care is easily fragmented, so discharge documentation must identify who will test the baby and treat the mother.
08Common pitfallsFrequent interpretation and management errors.
- 01
Omitting antenatal HBsAg screening because the woman was negative in a previous pregnancy or is already known positive.
- 02
Using HBeAg alone rather than HBV DNA and current criteria to plan maternal and neonatal interventions.
- 03
Waiting for HBIG or a complete late laboratory panel before giving the newborn hepatitis B vaccine.
- 04
Assuming maternal tenofovir removes the need for the baby's full selective vaccine course and later status testing.
- 05
Ordering only anti-HCV and failing to confirm current maternal viraemia with RNA.
- 06
Attributing jaundice to viral hepatitis without evaluating acute fatty liver, HELLP, biliary obstruction and medicine toxicity.