* Vaccination: Vaccination: Hepat.i.tis A vaccination is recommended for all children starting at age 1 year, travelers to certain countries, and others at risk. Hepat.i.tis A vaccination is recommended for all children starting at age 1 year, travelers to certain countries, and others at risk.

Hepat.i.tis B Hepat.i.tis B is a liver disease caused by the hepat.i.tis B virus (HBV).

It ranges in severity from a mild illness, lasting a few weeks (acute), to a serious long-term (chronic) illness that can lead to liver disease or liver cancer.

* Transmission: Transmission: Contact with infectious blood, s.e.m.e.n, and other body fluids from having s.e.x with an infected person, sharing contaminated needles to inject drugs, or from an infected mother to her newborn. Contact with infectious blood, s.e.m.e.n, and other body fluids from having s.e.x with an infected person, sharing contaminated needles to inject drugs, or from an infected mother to her newborn.

* Vaccination: Vaccination: Hepat.i.tis B vaccination is recommended for all infants, older children and adolescents who were not vaccinated previously, and adults at risk for HBV infection. Hepat.i.tis B vaccination is recommended for all infants, older children and adolescents who were not vaccinated previously, and adults at risk for HBV infection.

Hepat.i.tis C Hepat.i.tis C is a liver disease caused by the hepat.i.tis C virus (HCV).

HCV infection sometimes results in an acute illness, but most often 414 Hepat.i.tis B and Pregnancy becomes a chronic condition that can lead to cirrhosis of the liver and liver cancer.

* Transmission: Transmission: Contact with the blood of an infected person, primarily through sharing contaminated needles to inject drugs. Contact with the blood of an infected person, primarily through sharing contaminated needles to inject drugs.

* Vaccination: Vaccination: There is no vaccine for hepat.i.tis C. There is no vaccine for hepat.i.tis C.

Hepat.i.tis D Hepat.i.tis D is a serious liver disease caused by the hepat.i.tis D virus (HDV) and relies on HBV to replicate. It is uncommon in the United States.

* Transmission: Transmission: Contact with infectious blood, similar to how HBV is spread. Contact with infectious blood, similar to how HBV is spread.

* Vaccination: Vaccination: There is no vaccine for hepat.i.tis D. There is no vaccine for hepat.i.tis D.

Hepat.i.tis E Hepat.i.tis E is a serious liver disease caused by the hepat.i.tis E virus (HEV) that usually results in an acute infection. It does not lead to a chronic infection. While rare in the United States, hepat.i.tis E is common in many parts of the world.

* Transmission: Transmission: Ingestion of fecal matter, even in microscopic amounts; outbreaks are usually a.s.sociated with contaminated water supply in countries with poor sanitation. Ingestion of fecal matter, even in microscopic amounts; outbreaks are usually a.s.sociated with contaminated water supply in countries with poor sanitation.

* Vaccination: Vaccination: There is currently no FDA [U.S. Food and Drug Administration]-approved vaccine for hepat.i.tis E. There is currently no FDA [U.S. Food and Drug Administration]-approved vaccine for hepat.i.tis E.

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Pregnancy and Birth Sourcebook, Third Edition Section 52.2 Frequently Asked Questions about Pregnancy and Hepat.i.tis B "Pregnancy and HBV: FAQ," 2008 Hepat.i.tis B Foundation (www.hepb.org). Reprinted with permission.

Should I be tested for hepat.i.tis B if I am pregnant?

Yes. All pregnant women should be tested for hepat.i.tis B. Testing is especially important for women who fall into high-risk groups such as health care workers, women from ethnic communities where hepat.i.tis B is common, spouses or partners living with an infected person, etc. If you are pregnant, be sure your doctor tests you for hepat.i.tis B before your baby is born.

Why are these tests so important for pregnant women?

If you test positive for hepat.i.tis B and are pregnant, the virus can be pa.s.sed on to your newborn baby during delivery. If your doctor is aware that you have hepat.i.tis B, he or she can make arrangements to have the proper medications in the delivery room to prevent your baby from being infected. If the proper procedures are not followed, your baby has a 95% chance of developing chronic hepat.i.tis B.

Will a hepat.i.tis B infection affect my pregnancy?

A hepat.i.tis B infection should not cause any problems for you or your unborn baby during your pregnancy. It is important for your doctor to be aware of your hepat.i.tis B infection so that he or she can monitor your health and so your baby can be protected from an infection after it is born.

If I am pregnant and have hepat.i.tis B, how can I protect my baby?

If you test positive for hepat.i.tis B, then your newborn must be given two shots immediately in the delivery room: 416.

Hepat.i.tis B and Pregnancy * First dose of the hepat.i.tis B vaccine * One dose of the hepat.i.tis B immune globulin (HBIG) If these two medications are given correctly within the first 12 hours of life, a newborn has more than a 90% chance of being protected against a lifelong hepat.i.tis B infection. You must make sure your baby receives the second and third dose of the hepat.i.tis B vaccine at one and six months of age to ensure complete protection.

There is no second chance to protect your newborn baby.

Can I breastfeed my baby if I have hepat.i.tis B?

The Centers for Disease Control (CDC) recommend that all women with hepat.i.tis B should be encouraged to breastfeed their newborns.

The benefits of breastfeeding outweigh the potential risk of infection, which is minimal. In addition, since it is recommended that all infants be vaccinated against hepat.i.tis B at birth, any potential risk is further reduced.

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Chapter 53.

Human Immunodeficiency Virus (HIV) during Pregnancy, Labor and Delivery, and Birth I am pregnant, and I may have human immunodeficiency virus (HIV). Will I be tested for HIV when I visit a doctor?

In most cases, health care providers cannot test you for HIV without your permission. However, the U.S. Public Health Service recommends that all pregnant women be tested. If you are thinking about being tested, it is important to understand the different ways perinatal HIV testing is done. There are two main approaches to HIV testing in pregnant women: opt-in and opt-out testing.

In opt-in testing, a woman cannot be given an HIV test unless she specifically requests to be tested. Often, she must put this request in writing.

In opt-out testing, health care providers must inform pregnant women that an HIV test will be included in the standard group of tests pregnant women receive. A woman will receive that HIV test unless she specifically refuses. The CDC (Centers for Disease Control and Prevention) currently recommends that health care providers adopt an opt-out approach to perinatal HIV testing.

What are the benefits of being tested?

By knowing your HIV status, you and your doctor can decide on the best treatment for you and your baby and can take steps to prevent Excerpted from "HIV During Pregnancy, Labor and Delivery, and After Birth,"

by AIDSinfo (http://www.aidsinfo.nih.gov), a part of the U.S. Department of Health and Human Services, February 2008.

419.

Pregnancy and Birth Sourcebook, Third Edition mother-to-child transmission of HIV. It is also important to know your HIV status so that you can take the appropriate steps to avoid infecting others.

Will my baby be tested for HIV?

Health care providers recommend that all babies born to HIV positive mothers be tested for HIV. However, states differ in the ways they approach HIV testing for babies.

I am HIV positive and pregnant. Should I take anti-HIV medications?

Yes. If you are HIV positive and pregnant, it is recommended that you take anti-HIV medications to prevent your baby from becoming infected with HIV, and in some cases, for your own health. Anti-HIV medications are recommended for all pregnant women regardless of CD4 count and viral load. HIV treatment is an important part of preventing your baby from becoming infected with HIV and maintaining your health.

When should I consider starting anti-HIV treatment?

When you start treatment will depend mostly on whether you need treatment only to prevent your baby from becoming infected with HIV or if you also need treatment for your own health. In general, it is recommended that pregnant women who are starting therapy for their own health be treated as soon as possible, including in the first trimester. For women who are beginning therapy only to prevent mother-to-child transmission, delaying anti-HIV medication until after the first trimester can be considered. You should discuss when to begin treatment with your doctor.

How do I find out which HIV treatment regimen is best for me?

Decisions about which HIV treatment regimen you will start should be based on many of the same factors that women who are not pregnant must consider. These factors include: * risk that the HIV infection may become worse; * risks and benefits of delaying treatment; * potential drug toxicities and interactions with other drugs you are taking; 420.

HIV during Pregnancy, Labor and Delivery, and Birth * the need to adhere to a treatment regimen closely; * the results of drug resistance testing.

In addition to these factors, pregnant women must consider the following issues: * benefit of lowering viral load and reducing the risk of mother-to-child transmission of HIV; * unknown long-term effects on your baby if you take anti-HIV medications during your pregnancy; * information available about the use of anti-HIV medications during pregnancy.

You should discuss your treatment options with your doctor so that together you can decide which treatment regimen is best for you and your baby.

What treatment regimen should I follow during my preg- nancy if I have never taken anti-HIV medications?

Your best treatment options depend on when you were diagnosed with HIV, when you found out you were pregnant, at what point you sought medical treatment during your pregnancy, and whether you need treatment for your own health. Women who are in the first trimester of pregnancy and who do not have symptoms of HIV disease may consider delaying treatment until after 10 to 12 weeks into their pregnancies. After the first trimester, pregnant women with HIV should receive at least AZT (Retrovir or zidovudine); your doctor may recommend additional medications depending on your CD4 count, viral load, and drug resistance testing.

I am currently taking anti-HIV medications, and I just learned that I am pregnant. Should I stop taking my medi- cations?

Do not stop taking any of your medications without consulting your doctor first. Stopping HIV treatment could lead to problems for you and your baby. If you are taking anti-HIV medications and your pregnancy is identified during the first trimester, talk with your doctor about the risks and benefits of continuing your current regimen. Your doctor may recommend that you change the medications you take. If your pregnancy is identified after the first trimester, it is recommended 421 Pregnancy and Birth Sourcebook, Third Edition that you continue with your current treatment. No matter what HIV treatment regimen you were on before your pregnancy, it is generally recommended that AZT become part of your regimen.

Will I need treatment during labor and delivery?

Most mother-to-child transmission of HIV occurs around the time of labor and delivery. Therefore, HIV treatment during this time is very important for protecting your baby from HIV infection. Several treatments can be used together to reduce the risk of transmission to your baby.

Highly active antiretroviral therapy (HAART) is recommended even for HIV-infected pregnant women who do not need treatment for their own health. If possible, HAART should include AZT (Retrovir or zidovudine).

During labor and delivery, you should receive intravenous (IV) AZT.

Your baby should take AZT (in liquid form) every 6 hours for 6 weeks after birth.

If you have been taking any other anti-HIV medications during your pregnancy, your doctor will probably recommend that you continue to take them on schedule during labor.

Better understanding of HIV transmission has contributed to dramatically reduced rates of mother-to-child transmission of HIV. Discuss the benefits of HIV treatment during pregnancy with your doctor; these benefits should be weighed against the risks to you and to your baby.

I am HIV positive and pregnant. Are there any anti-HIV medications that may be dangerous to me or my baby dur- ing my pregnancy?

Yes. Although information on anti-HIV medications in pregnant women is limited, enough is known to make recommendations about medications for you and your baby. However, the long-term effects of babies' exposure to anti-HIV medications in utero are unknown. Talk to your doctor about which medications may be harmful during your pregnancy and what medication and dose changes are possible.

In general, protease inhibitors (PIs) are a.s.sociated with increased levels of blood sugar (hyperglycemia), development of diabetes mellitus or worsening of diabetes mellitus symptoms, and diabetic ketoacidosis. Pregnancy is also a risk factor for hyperglycemia, but it is not 422 HIV during Pregnancy, Labor and Delivery, and Birth known whether PI use increases the risk for pregnancy-a.s.sociated hyperglycemia or gestational diabetes.

Two non-nucleoside reverse transcriptase inhibitors (NNRTIs), Rescriptor (delavirdine) and Sustiva (efavirenz), are not recommended for the treatment of HIV-infected pregnant women. Use of these medications during pregnancy may lead to birth defects. Another NNRTI, Viramune (nevirapine), may be part of your HIV treatment regimen.

Long-term use of Viramune may cause negative side effects, such as exhaustion or weakness; nausea or lack of appet.i.te; yellowing of eyes or skin; or signs of liver toxicity, such as severe skin rash, chills, fever, sore throat, or other flu-like symptoms, liver tenderness or enlargement or elevated liver enzyme levels. These negative side effects are not normally seen with short-term use (one or two doses) of Viramune during pregnancy. However, because pregnancy and early symptoms of liver toxicity can be similar, your doctor should monitor you closely while you are taking Viramune. Also, Viramune should be used with caution in women who have never received HIV treatment and who have CD4 counts greater than 250 cells/mm3. Liver toxicity has occurred more frequently in these patients.

Nucleoside reverse transcriptase inhibitors (NRTIs) may cause mitochondrial toxicity, which may lead to a buildup of lactic acid in the blood. This buildup is known as hyperlactatemia or lactic acidosis. This toxicity may be of particular concern for pregnant women and babies exposed to NRTIs in utero.

There is very little known about the use of the entry inhibitors Fuzeon (enfuvirtide) and Selzentry (maraviroc) and the integrase inhibitor, Isentress (raltegravir), during pregnancy.

I am HIV positive and pregnant. What delivery options are available to me when I give birth?

Depending on your health and treatment status, you may plan to have either a cesarean (also called c-section) or a v.a.g.i.n.al delivery. The decision of whether to have a cesarean or a v.a.g.i.n.al delivery is something that you should discuss with your doctor during your pregnancy.

How do I decide which delivery option is best for my baby and me?

It is important that you discuss your delivery options with your doctor as early as possible in your pregnancy so that he or she can help you decide which delivery method is most appropriate for you.

Cesarean delivery is recommended for an HIV positive mother when: 423 Pregnancy and Birth Sourcebook, Third Edition * her viral load is unknown or is greater than 1,000 copies/mL at 36 weeks of pregnancy; * she has not taken any anti-HIV medications or has only taken AZT (Retrovir or zidovudine) during her pregnancy; * she has not received prenatal care until 36 weeks into her pregnancy or later.

To be most effective in preventing transmission, the cesarean should be scheduled at 38 weeks or should be done before the rupture of membranes (also called water breaking).

v.a.g.i.n.al delivery is recommended for an HIV positive mother when: * she has been receiving prenatal care throughout her pregnancy; * she has a viral load less than 1,000 copies/mL at 36 weeks.

v.a.g.i.n.al delivery may also be recommended if a mother has ruptured membranes and labor is progressing rapidly.

What are the risks involved with these delivery options?

All deliveries have risks. The risk of mother-to-child transmission of HIV may be higher for v.a.g.i.n.al delivery than for a scheduled cesarean. For the mother, cesarean delivery has an increased risk of infection, anesthesia-related problems, and other risks a.s.sociated with any type of surgery. For the infant, cesarean delivery has an increased risk of infant respiratory distress.

Is there anything else I should know about labor and de- livery?

Intravenous (IV) AZT should be started 3 hours before a scheduled cesarean delivery and should be continued until delivery. IV AZT should be given throughout labor and delivery for a v.a.g.i.n.al delivery.

It is also important to minimize the baby's exposure to the mother's blood. This can be done by avoiding any invasive monitoring and forceps- or vacuum-a.s.sisted delivery. All babies born to HIV positive mothers should receive anti-HIV medication to prevent mother-to-child transmission of HIV. The usual treatment for infants is 6 weeks of AZT; sometimes, additional medications are also given.

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Chapter 54.

Group B Streptococcus (GBS).

If you are pregnant-or know anyone who is-you need to know about group B strep. Group B streptococcal bacteria (also called GBS, group B strep, or baby strep) is very common to all types of women and can be pa.s.sed on to your baby during childbirth. Your baby can get very sick and even die if you are not tested and treated.

Group B strep (sometimes called GBS) is a type of bacteria that is often found in the v.a.g.i.n.a and r.e.c.t.u.m of healthy women. In the United States, about 1 in 4 women carry this type of bacteria. Women of any race or ethnicity can carry these bacteria.

Being a carrier for these bacteria does not mean you have an infection. It only means that you have group B strep bacteria in your body, usually living in the r.e.c.t.u.m or v.a.g.i.n.a. You would not feel the bacteria or have symptoms like a yeast infection. These bacteria are usually not harmful to you-only to your baby during labor.

Preventing Group B Strep Ask your doctor for a GBS test when you are 35 to 37 weeks pregnant (in your 9th month). The test is an easy swab of the v.a.g.i.n.a and r.e.c.t.u.m that should not hurt.

Each time you are pregnant, you need to be tested for GBS. It doesn't matter if you did or did not have this type of bacteria before- each pregnancy is different.

From "Are You Pregnant? Protect your baby from group B strep!" by the Centers for Disease Control and Prevention (CDC, www.cdc.gov), April 2008.

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Pregnancy and Birth Sourcebook, Third Edition Finding the GBS bacteria does not mean that you are not clean, and it does not mean that you have a s.e.xually transmitted disease.

The bacteria are not spread from food, s.e.x, water, or anything that you might have come into contact with. They can come and go naturally in the body.

The medicine to stop GBS from spreading to your baby is an antibiotic given during labor. The antibiotic (usually penicillin) is given to you through an IV (intravenous-in the vein) during childbirth. If you are allergic to penicillin, there are still other choices to help treat you during labor.