Volume 03 · Issue 01 · 2021

Mother-to-child transmission (MTCT) of hepatitis B virus (HBV) is the main cause of chronic hepatitis B. The prevention of MTCT plays a critical role in control chronic hepatitis B. The main purpose of the present clinical guidelines is to aid healthcare providers in managing pregnant women with positive HBsAg and in preventing MTCT of HBV. We recommend: (1) all pregnant women require prenatal screen for hepatitis B serological markers; (2) newborn infants of mothers with negative hepatitis B surface (HBsAg) require administration of hepatitis B vaccine on a 0, 1, and 6 month-schedule; (3) newborn infants of mothers with positive HBsAg need hepatitis B immunoglobulin (HBIG) and birth dose vaccine within 12 hours (the sooner the better) after birth, followed by injection of the second and third dose of hepatitis B vaccine at the age of one and six months respectively; (4) in preterm neonates or neonates with poor health conditions born to HBsAg-positive mothers, the immunoprophylaxis measures should be appropriately taken; (5) to further reduce MTCT of HBV, pregnant women with HBV DNA levels >2×10⁵ IU/mL or positive hepatitis B e antigen may receive oral antivirals, starting from 28 to 32 weeks of gestation and discontinuing the drug on the delivery day; (6) cesarean section is not recommended to reduce MTCT of HBV; (7) breastfeeding is recommended in infants of HBsAg-positive mothers, regardless of maternally positive hepatitis B e antigen, maternal nipple injury or bleeding, oral mucosal injury in neonates or infants; (8) breastfeeding is recommended in infants born to HBsAg-positive mothers who require continuation of antiviral therapy after delivery, and the infants should be followed up to observe whether adverse effects develop; and (9) the infants born to HBsAg-positive mothers should be tested for hepatitis B serological markers at the age of 7-12 months, and those who are negative for HBsAg and anti-HBs should receive three doses of hepatitis B vaccine on the 0, 1, and 6 month-schedule as soon as possible.

Twin anemia polycythemia sequence (TAPS) is a chronic form of unbalanced feto-fetal transfusion through minuscule placental anastomoses in monochorionic twin pregnancies, leading to anemia in the donor twin and polycythemia in the recipient twin. TAPS can occur spontaneously in up to 5% of monochorionic twins or can arise in 2%-16% of cases after incomplete laser surgery for twin-twin transfusion syndrome. TAPS can develop across the entire second and third trimester. Antenatal diagnosis for TAPS is reached via Doppler measurement of the fetal middle cerebral artery peak systolic velocity, showing an increased velocity in the donor, combined with a decreased velocity in the recipient. Treatment options for TAPS include expectant management, preterm delivery, intrauterine blood transfusion with or without a partial exchange transfusion, fetoscopic laser surgery and selective feticide. The best treatment option is unclear and is currently being investigated in an international multicenter randomized trial (the TAPS trial). Spontaneous fetal demise occurs in 5%-11% of TAPS twins, more often in donors (8%-18%) than in recipients (2%-5%). Severe long-term neurodevelopmental impairment is seen in 9% of TAPS twins, with donors having an increased risk for cognitive impairment and hearing problems (15%).

One in three monochorionic twins may develop complications during pregnancy. Monochorionic twins, especially monochorionic diamniotic (MCDA), present specific problems caused by the presence of interfetal placental anastomoses. The first critical step in the management of MCDA twins is identification in the first trimester. Secondly, close follow-up every 2 weeks is mandatory to allow early diagnosis and timely treatment of twin-twin transfusion syndrome. Other potentially severe complications include selective fetal growth restriction, twin anemia polycythemia syndrome or single fetal death. Thirdly, a correct differential diagnosis is critical to establish the best therapy. This may represent a clinical challenge since MCDA twin complications often overlap. A simple diagnostic algorithm may be of great help to establish the right diagnosis and management option. In this review we summarize the main steps for the clinical follow-up, differential diagnosis, and targeted management of MCDA twins complications.

Human coronavirus (HCoV) causes potentially fatal respiratory disease. Pregnancy is a physiological state that predisposes women to viral infection. In this review, we aim to present advances in the pathogenesis, clinical features, diagnosis, and treatment in HCoV in pregnancy. We retrieved information from the Pubmed database up to June 2020, using various search terms and relevant words, including coronaviruses, severe acute respiratory syndrome coronavirus, Middle East respiratory syndrome coronavirus, 2019 coronavirus disease, and pregnancy. Both basic and clinical studies were selected. We found no evidence that pregnant women are more susceptible to HCoV infection or that those with HCoV infection are more prone to developing severe pneumonia. There is also no confirmed evidence of vertical mother-to-child transmission of HcoV infection during maternal HCoV infection. Those diagnosed with infection should be promptly admitted to a negative-pressure isolation ward, preferably in a designated hospital with adequate facilities and multi-disciplinary expertise to manage critically ill obstetric patients. Antiviral treatment has been routinely used to treat pregnant women with HCoV infection. The timing and mode of delivery should be individualized, depending mainly on the clinical status of the patient, gestational age, and fetal condition. Early cord clamping and temporary separation of the newborn for at least 2 weeks is recommended. All medical staff caring for patients with HCoV infection should use personal protective equipment. This review highlights the advances in pathogenesis, maternal-fetal outcome, maternal-fetal transmission, diagnosis and treatment in HCoV including severe acute respiratory syndrome coronavirus, Middle East respiratory syndrome coronavirus, and coronavirus disease 2019 in pregnancy.

The management of preterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation is intractable, due to pulmonary immaturity, many complications, poor pregnancy outcomes. In particular, the pre-viable PPROM (<23 weeks of gestation) is much more difficult to be treated. The clinical recommendation is to terminate the pregnancy as soon as possible. The pregnancy outcomes of PPROM in the early second-trimester of two twin pregnant women in our hospital were reported to explore the treatment protocols. The pregnancies of the two women developed PROM at 12 and 16 weeks of gestation, respectively. After expectant treatment, they were deliveried successfully at 34⁺⁶ and 34⁺⁴ weeks of gestation, respectively. The assessment of growth and development of infants was normal during the following six months after birth. Therefore, if PPROM occurs in the early second-trimester of pregnancy, the management of PPROM should be individualized, it’s a long process which should include comprehensive communication between patients and families regarding alternative treatment options (including expectant management) and risks and benefits of the procedure. In the absence of spontaneous labor or occurrence of complications that would prompt delivery (intra-amniotic infection, abruptio placenta, cord prolapse), and fetal status is normal, the patients should proceed with expectant treatment, induction of labor is commonly performed in pregnancies with PPROM ≥34 weeks of gestation.

Hepatitis C infection is not uncommon in pregnant women. Vertical transmission of the virus from mother to fetus is estimated at 4%-8%, however this transmission rate is significantly higher when the mother is co-infected with HIV. Intrauterine blood transfusions can be a necessary part of management for certain perinatal conditions like hemolytic disease of the fetus. Currently there is no published material available on the vertical transmission risk of HCV infection to the fetus as a result of this procedure, irrespective of HIV coinfection. We present a case of a pregnant woman co-infected with HCV and HIV that required an intrauterine blood transfusion during pregnancy. Vertical transmission of either infection to the child did not occur. This provides important evidence that vertical transmission of HCV and/or HIV does not necessarily occur with intrauterine blood transfusions.

Hypertrophic cardiomyopathy (HCM), the most common single-gene cardiovascular disease, is associated with increased risk for arrhythmias, heart failure, and sudden cardiac death. The hemodynamic changes known to occur during pregnancy can exacerbate heart failure and arrhythmias in women with HCM. We present a 30-year-old woman with HCM to illustrate the benefits of multidisciplinary team management of severe left ventricular outflow tract obstruction (peak gradient >100 mmHg) for optimal maternal and fetal outcomes.