Any pregnant women being treated for HBV

[Cabin3]

Any pregnant women being treated for HBV?  What is your experience?

[StephenCastlecrag]

You have to consider two aspects in your case. First of all, the risk of vertical transmission to your baby, given your high viral load. You will also have to consider whether you will have a high ALT for the rest of your pregnancy, impacting on both the health of your baby and yourself.
Secondly, you have to consider your own health. It seems to me that you have been in the immune clearance phase for several years now. How is the state of your liver? Because of your pregnancy, I assume it would be difficult to check with Fibroscan or ultrasound imaging. Perhaps, your doctor can get an idea from your liver function panel. In the immune clearance phase, hbvdna will generally trend lower( with minor fluctuations), your ALT will also goes up and down. During each flare of ALT, some damage is done to the liver resulting in some scarring(fibrosis). Some patients will have a relatively short clearance phase, achieving e-seroconversion naturally with minimal fibrosis. For others, the clearance phase goes on for a longtime, with lots of fibrosis but no e-seroconversion. Doctors then usually start treatment in order to stop further scarring and maintain the liver in a reasonable state. Eventually, the patients will undergo e-seroconversion under treatment. At this time, treatment may be stopped after a period of consolidation.
So starting treatment will be because of reducing the risk of vertical transmission and may also because of the state of your liver fibrosis. Stopping treatment will also ultimately depend on the state of your liver and whether your HBV will be active or under control.
TDF has no known drug resistance issue and is generally safe. There maybe issues with kidney function and bone density. These are well known and can be managed.
As you can see, there are many issues to consider, risks and benefits to balance. We are not doctors and cannot advise you what to do. Doctors have the knowledge and experience and they have a duty of care to you and your baby. There is no need to make decision on your own. Doctors should be happy to answer your questions.

[StephenCastlecrag]

In the first link I provided, the AASLD guideline should give you the information you seek. if not, Google "natural history HBV" and "Viread label information".

[Cabin3]

Thank you.  I just looked it up.  I know you aren't in the same situation as I am, women and pregnant.  But can I ask about you?  What are you on, how long, any side effects, and where are your results today?

[StephenCastlecrag]

In my opinion, you are in the Immune Clearance phase. In the Immune control phase, you should be HBeAg negative, very low viral load, less than 1,000 iu/ml, and normal ALT.
I am only providing information, hopefully accurate, that I read from the HBV literature. Your liver specialist should be very familiar with the information. I don't have clinical experience. If you wish to delay your treatment after birth, you should discuss with your specialist and ask questions that you want to know the answers. Best.

[Cabin3]

Hi Stephen, can you define "immune clearance phase".  I'm not very familiar with the different phases.  Plus I see my dr on 9/23/16.  He had already prescribed viread and highly encouraged me to take it.  Also mentioned that it's case by case situation that he takes you off antivirals about 3 or so months after delivery.  It's also hard to ask him a lot of questions bc it feels like I'm bothering him with questions.  Which antivirals are you on and for how long and also any side effects for you?  I asked him if I need to do fibroscan or ultra sound and he said "not at this moment, maybe after delivery".  Is there a stage where it is too late to take antivirals?  And if so, I'm assuming you would start having symptoms?

[Liverpatient]

Hi Cabin, i think you should not worry about asking too many questions to your doctor; it is better than too few questions, and above all this is your health. I'm surprised by your doctor's decision not to give you ultrasound and fibroscan tests; in my opinion these are important in the decision to start treatment. The fact that you have had high VL and lft for years, but not yet taken these tests is strange.

[Cabin3]

Stephen and Liverpatient: is there a resistant to TdF treatment at all or that you know of.  It looks like my ALT numbers do go up in 3rd trimester and right after birth, according to my last pregnancy record.  Then comes down to almost normal ALT but viral load is slowing coming down and now in 2,000,000 vs 4,000,000.  If I go on TDF, will it interfere with my body's natural process to bring it down or is this thought irrelavent?  I'd like to go on TDF and come off when levels come down even if HB antigen positive.  Is this possible and will I develope a resistant to TDF?  In addition, have you heard of anyone that has/had lactic acidosis from TDF?

[Cabin3]

Back in 2013 my VL was greater than 170 million and ALT and AST was slightly elevated.  I got retested again in 4/14 and VL 17 Mil and Alt 450 and AST 390 this is a month after I gave birth.  Then 2/15, VL is 10 mil, ALT 83, AST 49.  Not sure how to translate this.  Am I in the tolerance phase?  And now pregnant again, It seems that my ALT and AST is higher during pregnancy but my VL is coming down.  Should I go on Viread only until right after birth, is there a greater chance of having a stronger relapse bc of stopping viread?

[StephenCastlecrag]

I am not a doctor and certainly do not have personal experience with being pregnant. Congratulations on your pregnancy and best wishes.
All the guidelines now recommend pregnant HBV women with HBeAg positive and very high viral load (AASLD guideline > 200,000 iu/ml) to commence antiviral treatment with Tenofovir at the third trimester. The aim is to reduce viral load in order to further reduce the risk of vertical transmission. All the safety issues are discussed in the following literature:
https://www.aasld.org/sites/default/files/guideline_documents/hep28156.pdf
http://www.medscape.com/viewarticle/836367_2
In your case, not knowing your full history, your viral load of 4 million (iu/ml) is considered high. It seems your ALT is elevated and your viral load is coming down from a very high value, indicating you may be in the Immune Tolerant/Clearance phase, but the state of your liver in terms of fibrosis is unknown. All these should be discussed with your obstetrician and liver specialist. It would be a matter of balance between the health of your baby(including risk of vertical transmission), your own health, and medical evidence regarding Tenofovir(Viread).

[Cabin3]

Thank you for your response.  I've done some research on Viread and it seems reasonable safe for pregnancy and my dr. Says that little traces are detected in the breast milk.  
My concern is the kidneys since that is one of the side effect.  Can anyone even healthy person have complications with their kidneys?  I'm due in two months and would like to see if I can avoid antivirals or is it useless to wait?  And if I do go on viread, can I stop after delivery or when my levels are back to normal range?  Is there a slingshot effect?  Forgot to mention that I'm chronic HBV from birth.

[StephenCastlecrag]

If you read the guidelines carefully for women in pregnancy, there is mention of patients stopping the antiviral after birth if they are HBeAg positive and in the Immune Tolerant phase, hence the high viral load necessitating antiviral in the third trimester to further reduce the risk of vertical transmission. As I mentioned before, since your viral load had come down and your ALT is elevated, so it seems that you may be in the Immune Clearance phase (generally immune system is suppressed during pregnancy). So the matters to consider are: how long have you been in the clearance phase and what is the state of your liver? Whether this present flare in ALT will lead you to e-seroconversion? If the state of your liver indicates significant fibrosis and this present flare maynot lead you to e-seroconvert, then antiviral may be needed for your own health as well. Another matter to consider is that, irrespective of pregnancy or not, some guidelines do suggest stopping antiviral after e-seroconversion and several years of consolidation. The success rate is not 100% but can be tried, especially using HBsAg levels as guide. Finally, Viread is well tolerated for patients with no kidney issue, there may be a small drop in kidney function initially, but then it will stabilize for most patients.
There are many issues to consider and they are best discussed with your doctors.

[Cabin3]

Stephen, let me clarify that it came down from 10,000,000 to 4,000,000 VL.  Isn't this considered still really high even though it is decreasing, would it be considered control phase?