Pregnancy with viral hepatitis

Introduction to pregnancy with viral hepatitis Pregnancy with viral hepatitis is a common infectious disease in obstetrics. It has a great impact on mothers and infants and has received increasing attention. In particular, research on viral hepatitis at home and abroad has progressed in recent years, thus affecting the mother and baby. For example, vertical transmission of mother and child, maternal and child death, and breastfeeding are more concerned. The incidence of viral hepatitis in pregnancy is about 0.025% to 0.08%, and the incidence rate is higher in the third trimester. basic knowledge Sickness ratio: 5% Susceptible population: pregnant women Mode of infection: 1. Respiratory spread 2. Iatrogenic transmission 3. Vertical transmission Complications: disseminated intravascular coagulation

Pregnancy with viral hepatitis

Causes:

Pregnancy and hepatitis are mutually unfavorable factors, that is, hepatitis can affect the normal development of pregnancy, and can have adverse consequences for mother and child, such as pregnancy-induced hypertension, postpartum hemorrhage, fetal distress, limited fetal growth and development, premature delivery, stillbirth, stillbirth, etc. The rate is obviously increased [2]; and pregnancy can affect hepatitis, metabolism during pregnancy is strong, fetal respiratory excretion and other functions need to be completed by the mother; liver is the main place for sex hormone metabolism and inactivation, females secreted by the fetal cavity during pregnancy, progesterone The amount of calories required by pregnant women during pregnancy is 20% higher than that of non-pregnant period. The demand for iron, calcium, various vitamins and protein is greatly increased. If the pregnant woman is malnourished, the liver function is reduced and the condition is aggravated; The sign can cause small blood vessels to sputum, reduce liver and kidney blood flow, and kidney function damage, metabolite excretion is blocked, which can further aggravate liver damage, easily cause massive hepatocyte necrosis, and induce severe hepatitis.

Pathogenesis:

1. The effect of viral hepatitis on pregnancy:

(1) The effect on the mother: the combination of viral hepatitis in early pregnancy can aggravate the pregnancy reaction, which occurs in the third trimester of pregnancy, and the incidence of hypertensive disorder in pregnancy is increased, which may be related to the decreased ability of aldosterone inactivation during liver disease. Due to impaired liver function, the synthesis of clotting factors is diminished, and the rate of postpartum hemorrhage is increased. If it is severe hepatitis, it often has diffuse intravascular coagulation (DIC), which has a tendency to systemic bleeding and is directly life-threatening.

(2) Impact on the fetus: Hepatitis in early pregnancy, the rate of fetal malformation is about 2 times higher. In recent years, continuous research has pointed out that viral hepatitis is closely related to the onset of Down syndrome. Pregnant women with hepatitis have miscarriage, premature delivery, stillbirth, stillbirth and Neonatal deaths are higher than non-hepatitis pregnant women, perinatal mortality is significantly increased, and toxic hepatitis is present during pregnancy. Newborns can be infected by vertical transmission from mother to baby, especially hepatitis B virus.

(3) Mother-to-child transmission:

1 Hepatitis A: Whether HAV can pass mother-to-child transmission, there is still no evidence. It is generally believed that HAV is transmitted through fecal-oral and will not be transmitted to the fetus through the placenta or other means. In the 1988 Shanghai hepatitis A pandemic, no pregnant women with hepatitis A were found. The newborns born are infected, indicating that the probability of mother-to-child transmission is very small. In recent years, foreign data reported that acute hepatitis A in the third trimester can cause maternal fetal transmission, which may be due to fetal exposure to contaminated maternal blood during childbirth or The result of feces.

2 Hepatitis B: Mother-to-child transmission is different in different regions. Mother-to-child transmission is very common in Southeast Asia. It is reported that 35% to 40% of new-onset people are caused by perinatal transmission, but perinatal in North America and Western Europe. Period transmission is not common, and the mother-to-child transmission route of hepatitis B can be divided into the following three aspects:

A. Intrauterine transmission: In the past, HBV rarely passed through the placenta, causing intrauterine infection through the placenta by 5% to 10%. In recent years, more data have confirmed that the intrauterine infection rate is 9.1% to 36.7%. Tong et al. HBV-DNA was detected in the tissues of the fetal liver, spleen, pancreas, kidney, placenta, etc., confirming the existence of intrauterine infection. The mechanism of HBV passing through the placental barrier is still unclear. It is believed that the placental barrier is damaged or transparent. Sexual changes cause maternal blood leakage.

Wong et al. have proposed diagnostic criteria for intrauterine transmission: a. cord blood or venous blood in infants with anti-HBcIgM on day 3 after birth, because IgM cannot pass through the placenta, suggesting that the baby has HBV infection recently; b. vein on the third day after birth The blood HBsAg level is higher than the cord blood level, which often indicates that the baby has viral replication; c. The baby is injected with hepatitis B high-valent immunoglobulin (HBIG) at birth, because HBsAg can be neutralized by passively immunized HBs antibodies, such as the third The presence of HBsAg in the venous blood of the day, regardless of the level of high blood pressure means intrauterine infection, but whether anti-HBeIgM can determine HBV intrauterine infection, has not been determined, IgM is the earliest synthetic immunoglobulin in the development of the body, the content of maternal blood 10 %, if the fetus has intrauterine infection, the serum IgM amount is significantly increased, so theoretically, the IgM level in cord blood can be used as an indicator for the diagnosis of fetal infection. It should be noted that although IgM cannot pass through the placenta in normal pregnancy, However, when maternal blood leaks into the fetal blood circulation, the concentration of IgM can also increase, and the concentration of IgA also increases at the same time. Both of them rapidly decrease after birth. Some scholars have suggested that anti-HBcIgM can be used as a neonatal infection and virus complex. Stimulates the immune system, but the anti-HBcIgM is not found in the birth of some intrauterine infections. It may be related to the immature fetal immune system and no response or low response to HBcAg. Therefore, some people think that anti-HBcIgM is used alone. As a judgment of HBV intrauterine infection is not very reliable, since the 1980s, HBV-DNA detection has become a sensitive marker of HBV infection, providing a reliable basis for the prevention and treatment of HBV intrauterine infection.

Factors affecting intrauterine transmission: a. Pregnant women with acute hepatitis in late pregnancy are easily transmitted to the fetus. Tong reported that no HBsAg-positive infants born to women with acute HBV infection before 12 weeks of gestation, 28 weeks after gestation or acute HB in puerperium 75% infant HBsAg positive, b. combined with e antigen positive, because e antigen is small, and is not bound by HBs antibody, easy to pass through the placenta, maternal and intrauterine transmission risk, c. HBsAg in amniotic fluid, amniotic cavity reported The positive rate of HBsAg in amniotic fluid was 26%, which was higher in pregnant women with positive e antigen. In those with positive amniotic fluid, HBsAg was positive at the first month of age.

B. Time of transmission: According to current data, infection is the main route of mother-to-child transmission of HBV, which accounts for 40% to 60%. The neonatal cord blood HBsAg is negative, and it is positive within 3 months, which is consistent with the incubation period of hepatitis. Because the positive rate of HBsAg in vaginal secretions is higher than that in amniotic fluid, neonatal blood, HBsAg-containing maternal blood, amniotic fluid, vaginal secretions, or contraction of the uterus in the process of delivery cause rupture of the placental villus, maternal blood. Leakage into the fetal blood circulation, as long as 10-8ml of maternal blood into the fetus can spread hepatitis B.

Factors affecting the transmission of time: a. pregnant women e antigen positive, according to the study of e antigen-positive carriers of vaginal secretions 96% of the existence of HBsAg, the neonatal gastric juice is 90% positive; b. more than 9h cord blood positive The rate is high, because the length of labor is proportional to the blood exchange between mother and child; c. The higher the titer of HBsAg, the greater the possibility of mother-child transmission. When the HBsAg titer is 1:128, the positive rate of newborn is 45.5%, and the titer is When 1:256, 70% of infants were positive. Because of high titer, there was a sufficient amount of HBsAg transmission in trace blood exchange. The presence of HBeAg was related to the HBsAg titer. HBeAg-positive HBsAg had higher titer, so the transmission rate was also high.

C. Postpartum transmission: The mother is infected with the virus mainly through maternal and child contact, mainly related to contact with mother saliva and breastfeeding. Lee studies the HBsAg positive maternal milk virus carrying rate of 70%, and believes that breastfeeding is one of the mother-to-child transmission routes. However, the epidemiological investigations in the future have not confirmed that most scholars believe that the positive rate of HBV-DNA in colostrum of patients with hepatitis B and HBeAg plus anti-HBC is 100%, which is not suitable for breastfeeding, but currently for HBsAg positive mothers. There is no consensus on whether breast-feeding is a double-positive person.

About 1/3 of HBsAg-positive carriers in China are derived from mother-to-child transmission, and 2/3 are derived from the horizontal transmission of infants. The T cell function of infants is not fully developed, and it is immune to HBsAg, which is easy to become a chronic carrier. Hardened and primary liver cancer.

3 Hepatitis C: According to the HCV research data, most people think that HCV can spread vertically between mother and baby, HC in late pregnancy, 2/3 mother-to-child transmission, and one third of them develop chronic liver disease. Children have no other clinical manifestations except for elevated transaminase. In addition, pregnant women who are intravenous drug addicts and HIV-infected patients are risk factors for perinatal transmission of HCV, but some authors believe that HCV is very low in blood, vertical. Transmission rarely occurs, and more information is needed on mother-to-child transmission of HCV.

HDV mother-to-child vertical transmission is relatively rare, mainly seen in HBeAg-positive pregnant women. The mother-to-child transmission of HEV has not been reported in China. Khuroo conducted a study on 8 neonates with HE who were pregnant during pregnancy and found 5 newborns born. HEV-RNA was detected in the blood samples at the same time, and IgG was positive for HVE, and one of them was born with jaundice and elevated ALT.

2. The effect of pregnancy on viral hepatitis:

The metabolic rate during pregnancy is high, and the nutrient consumption is high. The metabolism and detoxification of the fetus depends on the maternal liver. The large amount of sex hormones produced during the pregnancy change, such as estrogen, need to be metabolized and inactivated in the liver, and fatigue during childbirth. , bleeding, surgery and anesthesia all increase the burden on the liver, so it is easy to get viral hepatitis during pregnancy, or easy to promote the existing liver disease, pregnant women with hepatitis is more serious than non-pregnancy, and the later the pregnancy The more likely it is to have severe hepatitis, but in the past 20 years, the European and American literature emphasizes that pregnancy does not increase the incidence of hepatitis. The severity of hepatitis is not related to pregnancy itself, but the data of developing countries still believe that the prognosis of hepatitis during pregnancy is poor. Especially in advanced pregnancy, such as acute hepatitis, severe hepatitis and death, the chance of death is much higher than that of non-pregnancy hepatitis patients. For example, if the hepatitis is in the third trimester, the mortality rate of pregnant women can reach 10% to 20%.

Pregnancy with viral hepatitis prevention

1. Strengthening education and perinatal care

Patients in the acute phase should be treated in isolation. Special attention should be paid to the prevention of iatrogenic transmission and nosocomial infection. The delivery room should strictly separate the HBsAg-positive beds, delivery rooms, labor beds and instruments. Pregnant women in the epidemic areas should strengthen nutrition and increase resistance. In the occurrence of hepatitis, pregnant women who have recently been exposed to hepatitis A should be given human gamma globulin. Women with hepatitis should be pregnant after half a year of hepatitis recovery, preferably 2 years later. HBsAg and HBeAg positive pregnant women should be strictly disinfected during childbirth. System, shorten the labor process, prevent fetal distress, amniotic fluid inhalation and soft birth canal laceration, strengthen food hygiene publicity and education, pay attention to tableware disinfection, especially for raw mixed vegetables should pay attention to health, hepatitis A is a benign self-limiting disease, hepatitis A virus is contaminated by feces, Oral infection, especially for buttercup foods.

2. Immunization prevention

The live hepatitis A vaccine can be vaccinated against children or adults over 1 year old. If injected with human gamma globulin, it should be injected after 8 weeks.

Hepatitis B immunoglobulin (HBIG) is a high-priced anti-HBV immunoglobulin that can passively immunize mothers or newborns. It is an effective measure to prevent hepatitis B infection. HBsAg carries pregnant women intramuscularly every month for 3 months before delivery. Injection of HBIG can significantly reduce intrauterine infection in neonates. There is no adverse reaction during follow-up. The time of neonatal injection is preferably within 24 hours after birth, generally not more than 48 hours. The number of injections is good, and it can be injected once a month. A total of 2 to 3 times, the dose of 0.5mL / kg each time, or 1 ~ 2ml each time, accidental exposure should be urgent injection, usually 1 ~ 2ml, the last time at the same time began to inject hepatitis B vaccine.

Hepatitis B vaccine has two kinds of blood source vaccines and genetic recombinant vaccines. The latter is superior in immunogenicity to blood-borne vaccines. The safety, immunogenicity, protectiveness and long-lasting antibody production of the two vaccines are similar. HBV carriers, who are exposed to HBV and their newborns, have a protection rate of 80%. The combination of HBIG and HBeAg positive mothers can increase the protection rate by 95%. After the whole process of immunization If the antibody production is not good, the immunization can be boosted once more. The development of HCV DNA vaccine is still based on animal experiments, but the safe and reliable human gamma globulin can be used to counteract the passive immunization of HCV-positive mothers before the age of 1 year. There is no vaccine for hepatitis D, D, and E.

Pregnancy with viral hepatitis complications Complications, disseminated intravascular coagulation

(1) Pregnancy with viral hepatitis can aggravate pregnancy reaction, and the incidence of abortion and fetal malformation is about 2 times higher.

(2) The combination of viral hepatitis in the third trimester of pregnancy can increase the incidence of pregnancy-induced hypertension: may be related to the liver's ability to inactivate aldosterone. Can increase the incidence of postpartum hemorrhage: due to decreased clotting factor synthesis. In the case of severe hepatitis, DIC is often complicated, and there is a tendency to systemic bleeding, which directly threatens maternal and child safety.

(3) Vertical transmission of liver and mother of liver virus.

Pregnancy with viral hepatitis symptoms common symptoms jaundice nausea fatigue liver contraction ascites pre-pregnancy reaction abortion stillbirth

Pregnancy with hepatitis A

The symptoms are the same as those of non-pregnant women. The incidence is more urgent. In addition to gastrointestinal symptoms and jaundice, anti-HAV-IgM positive in serological tests can be confirmed.

Pregnancy with hepatitis B

(1) There are digestive symptoms (nausea, vomiting) and fatigue, jaundice, etc., acute onset, elevated serum ALT.

(2) Serological test indicators:

1 Hepatitis B surface antigen (HBsAg): the most commonly used indicator of hepatitis B infection, HBsAg can be positive before the incubation period, serum ALT is elevated; when HBsAg is high titer, then e antigen (HBeAg) is also positive, clinical It is not enough to use a single HBsAg as an indicator of infection, and should be judged in combination with clinical manifestations and other indicators.

2 Hepatitis B surface antibody (anti-HBs): It is a protective antibody. When an acute hepatitis B virus is infected, after a period of time, anti-HBs appear to indicate that the body has obtained immunity.

3 Hepatitis B e antigen (HBeAg): is a degradation product of HBcAg. The appearance of HBeAg is slightly later than HBsAg in acute infection, and the subtype e1 and e2 of e antigen reflect the activity of hepatitis B virus replication.

4 Hepatitis B e antibody (anti-HBe): Generally, HBeAg disappears in the blood, and then anti-HBe appears, suggesting that the virus replication is reduced, the infectivity is reduced, and the condition is gradually stabilized.

5 core antibody (anti-HBc): In acute infection, HBsAg can be detected 2 to 4 weeks after the onset of clinical symptoms, so anti-HBC-IgM is more common in the early stage of infection or active period of chronic infection.

6 Hepatitis B virus DNA (HBV-DNA): HBV-DNA positive is the direct evidence of hepatitis B virus replication and infectious indicators. HBV-DNA is in equilibrium with HBeAg and DNA-polymerase. In HBeAg-positive blood, 86%-100 % can detect HBV-DNA.

According to clinical symptoms, signs, liver function tests and serological indicators, the diagnosis of pregnancy with hepatitis B can be quickly determined.

Serological diagnosis of hepatitis B virus intra-fetal infection should pay attention to the following three criteria:

(1) Neonatal umbilical serum HBsAg positive can be a reference indicator.

(2) Intrauterine infection can be confirmed by neonatal umbilical serum HBcAb-IgM positive.

(3) If the umbilical serum is tested conditionally, the hepatitis B virus DNA is positive, and the diagnosis can be confirmed, but this indicator cannot be promoted and applied in China.

Pregnancy with severe hepatitis

Diagnostic criteria

The onset is sharp, the symptoms of poisoning are obvious, and jaundice is serious.

(1) Serum bilirubin 171 mol/L (10 mg/dl) in 1 week, or daily 17.1 mol/L (1 mg/dl).

(2) Prothrombin time is significantly prolonged, which is 0.5 to 1 times longer or longer than normal.

(3) There are different degrees of hepatic coma, and severe liver odor can occur.

(4) There may be ascites or even liver dullness.

Pregnancy with hepatitis A effect

Impact of hepatitis A on perinatal children: According to the data of Shanghai First Maternal and Infant Health Hospital, the pregnancy outcomes of pregnant women in the second trimester and third trimester of pregnancy, the perinatal mortality rate is 42.3 and 125, respectively, that is, perinatal in the third trimester The mortality rate was significantly higher. Compared with the perinatal mortality rate of 14.1 in normal mothers in Shanghai in the same year, there was a significant difference between the two. Although there was no maternal death in hepatitis A, the perinatal mortality rate was not high. Neglected problems.

Pregnancy with hepatitis B effect

The impact of hepatitis B on pregnancy: abortion of hepatitis B maternal, premature delivery, stillbirth, stillbirth, neonatal asphyxia rate and neonatal mortality increased significantly, which is related to acute jaundice hepatitis in late pregnancy, especially severe or even fulminant hepatitis, outbreak The mortality rate of hepatitis is higher than that of non-pregnant women. It is especially prone to fulminant hepatitis during pregnancy, especially in late pregnancy.

The effect of pregnancy on viral hepatitis: Some people think that pregnancy is prone to non-specific hypersensitivity, and the pregnancy is in a state of preparation for non-specific hypersensitivity, so the probability of severe or fulminant hepatitis during pregnancy is significantly increased, animal experiments prove The acute hepatic necrosis in prenatal and postpartum rabbits is more serious in pregnant rabbits. Therefore, in recent years, HBeAg-positive patients are likely to have artificial abortion at the same time as HBsAg titers in the first trimester. In the third trimester, due to the relative lack of liver blood flow, and concurrent hepatitis, Liver blood flow is relatively reduced, which can make hepatitis worse or even become severe hepatitis.

Examination of pregnancy with viral hepatitis

Laboratory inspection

(1) peripheral blood: acute white blood cells are often slightly lower or normal, lymphocytes are relatively increased, occasionally there may be abnormal lymphocytes, but generally not more than 10%, chronic hepatitis white blood cells are often reduced, acute severe hepatitis is the total number of white blood cells and neutral particles The percentage of cells can be significantly increased, and platelets can be reduced in some patients with chronic hepatitis.

(2) Liver function test:

1 serum enzyme assay: a wide variety of serum enzymes, mainly to check the enzymes that reflect liver parenchymal damage, according to domestic experience alanine transferase (ALT), carboxy-aspartate transferase (AST) is more sensitive, more widely used Although its specificity is not strong, if it can exclude other factors that cause elevation, especially when the value is very high (more than 10 times greater than the normal value), and the duration is longer, the diagnostic value for hepatitis is great, AST has Two kinds, one is ASTs located in the cytoplasm, the other is ASTm, which is present in the mitochondria of liver cells, and the increase of ASTm is mainly in severe hepatitis. Since the half-life of ASTm is shorter than ASTs, the recovery is earlier, in acute hepatitis. When ASTm continues to rise, it may become chronic. In chronic hepatitis, ASTm continues to increase. It should be considered as chronic active hepatitis. Some people think that the ALT/AST ratio has a certain significance for differential diagnosis. The ratio of viral hepatitis is 0.56. Obstructive jaundice is 1.03, normal human is 1.15, glutathione-S-transferase (GST) is the earliest elevated in severe hepatitis, which is helpful for early diagnosis. Fructose 1,6 bisphosphatase is glycogen synthase First, all types are slow Significantly increased serum levels of hepatitis.

2 other: prothrombin time and its activity can be used to determine severe hepatitis, such as injection of vitamin K is still abnormal, often indicating severe damage to liver tissue, poor prognosis, in addition, such as cholesterol, cholesterol esters are significantly reduced, also Often suggest a poor prognosis, blood ammonia determination is helpful for the diagnosis of hepatic encephalopathy.

Serology and pathogen detection

(1) Hepatitis A:

1 Etiology: In the late incubation period and early acute, HAV virus and antigen can be detected, HAV particles can be detected by immunoelectron microscopy, or HAVRNA can be detected by PCR-RNA hybridization and polymerase chain reaction (PCR). (RIA) and enzyme immunoassay (EIA) detect HAAg.

2 Serological examination: anti-HAV antibody, commonly used RIA and EIA methods, can be used to determine anti-HAV IgG and IgG antibodies, anti-HAV-IgM acute phase patients can be positive in the first week of onset, 1 to 2 months antibody titer and The positive rate decreases and disappears after 3 to 6 months. Therefore, it is very important for early diagnosis and high specificity. HAV-IgG appears in the late acute phase and early recovery, lasting for several years or more, mainly used to understand past infections and The level of immunity in the population makes more sense for epidemiological investigations.

(2) Hepatitis B:

1HBV antigen-antibody assay: After HBV infection in humans, a series of HBV-related serological markers can appear in the blood, which can be used as indicators for clinical diagnosis and epidemiological investigation. Commonly used markers are HBsAg, HBeAg and HBeAg and their antibodies. The system, the measurement method is the most sensitive with RIA and EIA.

A. Detection of HBsAg and anti-HBs: HBsAg-positive is a specific marker of HBV infection, and its titer decreases with the recovery of the disease. Chronic hepatitis, asymptomatic carriers can detect HBsAg for a long time, but the titer and condition of HBsAg are not Parallel relationship, HBsAg is the surface of the virus, non-infectious, anti-HBs positive in serum, suggesting that there is HBV infection, it is a protective antibody, positive in serum indicates that the body is immune, it is not easy to get hepatitis B again In addition, after hepatitis B vaccination, detection of anti-HBs is one of the important indicators for evaluating the efficacy of vaccines.

B. Detection of HBeAg and anti-HBe: Since HBeAg is a component of core antigen, its positive and titer often reflect the replication of HBV and determine the strength of infectivity. HBeAg is transiently positive in acute hepatitis B, such as continuous positive prompt Chronic, in chronic HBV infection, HBeAg positive often indicates active replication of HBV in hepatocytes; when HBeAg is negative, anti-HBe conversion often indicates that HBV replication stops, anti-HBe appears in the recovery period of acute hepatitis B, sustainable For a long time, the appearance of anti-HBe means that there are few or no Dane particles in the serum, and the infection is low.

C. Detection of HBcAg and anti-HBc: HBcAg in the nucleus of hepatocytes can be detected by electron microscopy and immunoenzymatic staining. It is generally considered that there is no free HBcAg in serum, so HBcAg cannot be directly determined from serum, but can be found from blood. Dane granules, using descaling agent to remove the protein shell of Dane granules, exposing HBcAg, detecting HBcAg by known anti-HBc enzyme labeling method, HBcAg positivity means HBV replication in vivo, reflecting the amount of Dane particles in serum and DNA The polymerase is closely related. Anti-HBc includes anti-HBc total antibody, anti-HBcIgM and anti-HBclgG. Anti-HBc occurs in the acute phase of acute hepatitis B. It can last for several years or longer after recovery, and the titer is gradually decreased. Chronic HBV infection Anti-HBc is persistently positive. Single anti-HBc positivity indicates that HBV may have been infected in the past. It must be combined with other markers to determine the anti-HBcIgM and HBcIgG. The anti-IgM of acute hepatitis B patients is highly titer positive, especially for HBsAg. Patients who turned negative ("window period"), anti-HBclgM positive can be diagnosed as acute hepatitis B, anti-HBcIgG appeared later than HBclgM, mainly in the recovery period and chronic infection.

D. Pre-S1, pre-S2 and PHSA receptors (the ability to bind to poly-human serum albumin) are the coat proteins of HBV, and the positive rate and titer are positively correlated with HBsAg titer, HBeAg, HBV-DNA, As a new marker of HBV infection, serum pre-S1 antibody positive is an early diagnostic indicator of acute hepatitis B. Because anti-pre-S1 occurs in hepatitis B latency, pre-S2 antibody appears before viral replication is terminated, so serum anti-pre-S2 is Indicators of hepatitis recovery period.

2 virus logo:

A. Detection of HBV-DNA: DNA hybridization and PCR technology were used. HBV-DNA positive indicates HBV replication in vivo, which has reference significance for the diagnosis of this disease and the evaluation of antiviral drugs.

B. Detection of DNA polymerase: As a core component of HBCAg, DNA polymerase (DNAP) is positive for one of the direct signs of HBV, and indicates that the virus is replicating in vivo.

(3) Hepatitis C: At present, the HCV in vitro culture system has not been established, and the immunological characteristics of HCV antigen are not known. Due to the low level of virus mutation and serum markers, the detection of HCV is difficult, and the serum antigen is lower than the current method. The level can be detected and only antibodies can be detected.

1 Anti-HCV test: HCV antibody can be diagnosed as HCV infection in serum. Now anti-HCV reagents are derived from various gene fragments, which have different sensitivity and specificity, and may also have false positive or false negative, such as antibody positive. It is a current infection or a previous infection. It is not certain that the infection has healed or the virus is still infectious. Therefore, the interpretation of each test report needs to be closely related to the clinical, and should be familiar with the characteristics, significance, value and various reagents. Limitation, when it is determined that it is difficult, it must be determined by PCR detection of HCV-RNA.

2HCV-RNA detection: detection of serum antibodies is not a direct evidence of viremia. In recent years, reverse transcription RNA PCR has been used to detect the specificity of HCV-RNA in blood, with high sensitivity, positive appearance, wide application, detectable tissue and RNA in body fluids, but the operation procedure is more complicated, the technical requirements are strict, the detection cost is high, and it is limited to the conditional laboratory for research.

(4) Hepatitis D: HDV is a defective virus, which can only be replicated and expressed according to HBV infection. However, hepatitis D has no special clinical features. It should be considered in the following cases: HBsAg carriers have acute hepatitis attacks, acute hepatitis has biphasic Increased transaminase, slow-acting hepatitis B but no HBV replication, original hepatitis B with severe hepatitis or liver failure, the main diagnosis based on serum viral RNA, HDAg, anti-HDV antibody and liver tissue HDAg and viral RNA determination, but with serum The method of measuring antigens and antibodies is the most common.

1HDAg: When suffering from acute hepatitis, serum HDAg appears in the late incubation period and early acute phase, and disappears soon after. In chronic infection, the detection rate of RIA or EIA is extremely low, but it can still be detected by immunoblotting. Or when the anti-HDV appears to turn negative, but the liver continues to have HDAg.

2 anti-HDV: HDV-IgM and anti-HDV-IgG were measured separately. In acute HDV infection, anti-HDV-IgM was positive after several days of clinical symptoms, generally lasting 2 to 4 weeks, anti-HDV-IgG was positive, both antibodies The titer is generally not high. When chronic HDV infection, anti-HDV-IgM is persistently positive, accompanied by high titer of anti-HDV-IgG. Determination of HDV-IgM not only contributes to early diagnosis, but also decreases and increases its titer. Often indicates a disease relief or progression.

3HDV-RNA: The presence of viral nucleic acids in serum and liver can be determined by molecular hybridization techniques, nucleic acid blotting assays or PCR methods.

(5) Hepatitis E:

1 Fecal virus test: 27-34 nm virus-like particles can be detected by immunoelectron microscopy (IEM) from the faeces of patients with latent and acute phase, after acute and convalescent serum treatment.

2 Specific antibody assay: The patient's acute phase serum contains high titers of IgM antibodies, and low levels of IgG antibodies can be detected in the serum of convalescent patients.

B-mode ultrasound diagnosis has reference value for judging cirrhosis, biliary tract abnormalities, and intrahepatic space-occupying lesions. Liver biopsy is important for determining diffuse liver disease and distinguishing the clinical type of chronic hepatitis.

Diagnosis and identification of pregnancy complicated with viral hepatitis

Differential diagnosis

Intrahepatic cholestasis of pregnancy

The characteristics of the disease: 1 with general itching, jaundice as the main performance, gastrointestinal symptoms are not obvious; 2 after 20 weeks of gestation, mostly occurred in the third trimester of pregnancy, symptoms disappeared within 1 week after delivery; 3 increased bile acid, transaminase There may be a slight increase, rarely exceeding 300 U; bilirubin is normal or elevated, but rarely exceeds 30 mol/L; 4 serological examination of the virus antigen and antibody are negative; 5 liver biopsy is mainly cholestasis.

2. Acute fatty liver during pregnancy

Often occurs in the third trimester of pregnancy, acute onset, serious illness, high mortality, often have upper abdominal pain, nausea and vomiting and other gastrointestinal symptoms; further development of acute liver dysfunction, manifested as clotting factor deficiency, bleeding tendency, low Blood sugar, deep jaundice, hepatic encephalopathy, etc., liver function test transaminase increased, direct bilirubin and indirect bilirubin are elevated, but urinary bilirubin is negative, renal function abnormality may occur, manifested as hepatorenal syndrome, Ultrasound examination showed diffuse echo intensity in the liver area, which was snow-like, and liver biopsy showed severe steatosis without obvious hepatocyte necrosis.

3. HELLP syndrome

On the basis of severe pregnancy-induced hypertension, a syndrome characterized by elevated liver enzymes, hemolytic anemia and thrombocytopenia occurs. This disease often has symptoms of pregnancy-induced hypertension, such as hypertension, proteinuria, edema, etc. Pain in the upper abdomen, jaundice is lighter, and the condition is quickly relieved after the end of pregnancy.

4. Pregnancy reaction

Early pregnancy response is mainly due to loss of appetite, nausea and vomiting, lethargy, etc. In severe cases, there may be mild abnormal liver function, ketoacidosis, but jaundice rarely occurs. Viral hepatitis in early pregnancy is often misdiagnosed as pregnancy before the appearance of jaundice. Response, for the early pregnancy response to severe nausea and vomiting, must be vigilant, combined with medical history and clinical manifestations, early liver function tests and serological examination of hepatitis virus.

5. Drug-induced liver damage

Drugs that are commonly used in the pregnancy to damage the liver include chlorpromazine, promethazine, methimazole (tabazole), isoniazid, rifampicin, sulfonamides, tetracycline, etc., often with mild elevation of transaminase. Without splenomegaly, liver function recovery after stopping the drug.

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