Review Question - QID 107174

Hepatitis E virus (HEV) infection is typically self-limited in men and non-pregnant women; however, the disease is more severe in pregnant patients, often leading to fulminant hepatic failure. The mortality rate of HEV infected women in their 3rd trimester is 20%.

HEV is a positive, single-stranded RNA virus that is transmitted primarily via a fecal-oral route. Outbreaks are most common in developing countries, where access to clean water, sanitation, and hygiene is limited (particularly Asia, Africa, India, South America). In non-pregnant patients who suffer relatively mild disease, the presentation is similar to that of hepatitis A virus, with nausea, vomiting, and mild jaundice. Mild HEV in the general nonpregnant population is self-limited. Diagnosis is suspected clinically and confirmed with the presence of anti-HEV antibodies.

Hunt et al. review liver disease in pregnancy. The most common cause of jaundice in the pregnant patient is acute viral hepatitis. With the exception of hepatitis E and disseminated herpes virus infections, the course of acute viral hepatitis is unaffected by a pregnancy. However, maternal and fetal mortality rates are significantly increased in pregnant patients infected with hepatitis E or disseminated herpes simplex.

Navaneethan et al. discuss the pathogenesis related to hepatitis E infection in pregnancy. The high mortality rate in pregnant patients with a hepatitis E infection is hypothesized to be due to the hormonal changes associated with pregnancy and resulting immunological changes. Such changes cause the host to be more susceptible to development of fulminant liver failure, increased viral replication, and virus-mediated direct immunologic damage.

Illustration A is a map from the CDC showing areas where HEV is endemic. Illustration B summarizes the pathogenesis of HEV infection in pregnancy.

Answers 1-4: Hepatitis E is associated with an increased mortality rate in 3rd trimester pregnant women.