Authors (including presenting author) :
Ma ACK (1), Yim TY (3), Leung KW (4), Chan TT (1), Lui RN (1), Chan KH (3), Yip WM (4), Tsang CC (3), Wong GLH (2), Wong VWS (2)
Affiliation :
(1) Department of Medicine and Therapeutics, Prince of Wales Hospital (2) Department of Medicine and Therapeutics, The Chinese University of Hong Kong (3) Department of Medicine, North District Hospital (4) Department of Medicine, Alice Ho Miu Ling Nethersole Hospital
Introduction :
Since 2020, a new integrated clinic service model co-run by hepatologists and hepatology nurses has been introduced to prescribe perinatal tenofovir to mothers who are hepatitis B surface antigen (HBsAg) positive with high viral load (HBV DNA > 200,000 IU/mL) for the prevention of HBV mother-to-child-transmission (MTCT). With different phases for the implementation of the integrated clinic model, PWH served as a pilot with the clinic starting since February 2020, NDH started since October 2020, followed by AHNH in October 2021.
Objectives :
To review real world experience of introduction of antivirals to Hepatitis B pregnant ladies and its obstacles
Methodology :
Hepatology nurses educate and monitor the pregnant mothers with high viral load. At gestation week 20, nurses meet the clients to educate and counsel them about use of tenofovir to reduce MTCT of HBV infection, and book the next clinic follow-up at around gestation week 28-32 to see doctors for initiation of therapy. At gestation week 32, nurses follow-up the mothers for side effects and reassure them on importance of drug compliance. Tenofovir is usually stopped by week 4 to week 12 post-partum if liver enzymes remain normal in the absence of liver cirrhosis or advanced fibrosis. Nurses then arrange blood tests to ensure close monitoring every 4 weeks until 6 months and at 9 months after cessation of treatment. Abnormal liver enzymes are assessed by hepatologists and the cases are subject to early review if needed.
Result & Outcome :
In NTEC, a total of 57 pregnant ladies were referred by obstetricians, 44 (77.1%) were hepatitis B e-antigen positive. The mean age at enrolment was 34 years old. Mean HBV DNA was approximately 1.4x 108 IU/mL. The median gestational age to start tenofovir was 28 weeks. Three patients refused tenofovir treatment after counselling. Most tolerated tenofovir well, except for one mother who stopped treatment prematurely at 34 weeks of gestation due to increase in foetal movement, poor appetite and palpitations, also one of the cases reported severe vomiting while on treatment. So far ten subjects were advised to continue tenofovir and four had to restart the medication (24% of the patients had to exit the pathway earlier). Six of them already had abnormal ALT before the introduction of tenofovir, twelve of the pregnant ladies experienced rising ALT in between treatment, and four of them had flare of ALT after the cessation of tenofovir. Serial blood taking requested and monitored by nurses allowed for early detection of abnormalities, and the cases were referred back to hepatologists for early attention. Conclusion: NTEC has one of the greatest pool of pregnant ladies with high viral load, and Hepatology teams from NTEC hospitals have delivered a systematic network to care for them, six cases were referred back to NDH hepatology team after consultation by PWH hepatology nurses, and ten cases were referred back to AHNH for the continuation of care. Our cluster served as a pilot to start the service with NDH and AHNH joining in later phases as we aim to deliver expert care to clients as early as possible. There was a smooth transition with cases handed over once nursing specialists were available at NDH and AHNH in October 2020 and October 2021.
