[APASLSTC 2011]妊娠及哺乳期间的抗HBV治疗热点答疑Kumar Visvanathan

MP4

国际肝病作者：发布时间：2011-10-11
http://apaslstc2011.ihepa.com/62-518-4450.html
文章导读：妊娠期间机体免疫抑制会增强，以保证胎儿不会被排斥。同时，在妊娠期间，针对乙肝的免疫反应也被抑制，分娩后病毒复制则突然加速。这就是产后乙肝复发的原因。对于妊娠期妇女的治疗，Visvanathan教授认为应该选用有良好安全性参数的药物尽量在孕期持续进行治疗，而不应该推迟治疗。这对于母亲来说比较重要。

　　Hepatology Digest: We know that during pregnancy， the immune system undergoes great change and we also know that hepatitis B is a disease closely correlated to the immune response. Do you think there is an interaction between pregnancy and hepatitis B?
　　《国际肝病》：我们知道在妊娠期，免疫系统会有很大的变化，而乙肝是一种与免疫密切相关的疾病，您是否认为妊娠与乙肝之间有相互影响呢？
　　Dr Visvanathan: The answer is yes. As you suggested， we know that there is a lot of immunosuppression in pregnancy and this is mainly to ensure the fetus is not rejected during the term of pregnancy. In the same way， the immune response to hepatitis B is suppressed during pregnancy and after pregnancy it is suddenly accelerated. That is why we get flares in hepatitis B post-partum.
　　Visvanathan博士：答案是肯定的。就像你所说的，我们知道妊娠期间机体免疫抑制会增强，以保证胎儿不会被排斥。同时，在妊娠期间，针对乙肝的免疫反应也被抑制，分娩后病毒复制则突然加速。这就是产后乙肝复发的原因。
　　Hepatology Digest: Because the management of hepatitis B infection in pregnant women is very complex， it is thought by some that it is reasonable to postpone treatment until after delivery to avoid exposure to the drugs. What is your opinion on this?
　　《国际肝病》：由于妊娠期妇女乙肝治疗非常复杂，一些人认为应该将治疗推迟到产后以避免胎儿受到药物的影响。您的意见呢？
　　Dr Visvanathan: There are two separate questions: one is to treat the women who need treatment during pregnancy because they are decompensating in terms of their liver disease; and secondly， how to prevent the transmission of the virus from the mother to the fetus? In terms of the treatment of women during pregnancy， we believe that providing the drugs used have a good safety parameter， we should try to continue treatment through the pregnancy and not defer. It is important for the mother.
　　Visvanathan博士：这是两个相互独立的问题：一方面对需要治疗的妊娠期妇女要进行治疗，因为她们的肝脏疾患处于失代偿期；另一方面，如何阻止病毒从母亲传染给胎儿？对于妊娠期妇女的治疗，我们认为应该选用有良好安全性参数的药物尽量在孕期持续进行治疗，而不应该推迟治疗。这对母亲来说是重要的。
　　Hepatology Digest: What do you think is the optimal strategy for women with chronic hepatitis B during pregnancy?
　　《国际肝病》：您认为对于慢性乙肝妊娠期妇女，什么样的治疗策略最适合？
　　Dr Visvanathan: If the mother is already on treatment and becomes pregnant， ordinarily we wouldn’t stop therapy if it was based on tenofovir or lamivudine therapy. We would be worried if it was entecavir or another of the class C drugs.
　　Visvanathan博士：如果母亲正在治疗中而妊娠，常规来说，如果是基于替诺福韦或拉米夫定的治疗，我们不会停止治疗。如果是应用恩替卡韦或其它C级药物，我们会担心（有影响）。
　　Hepatology Digest: Currently the presence of HBV DNA， HBeAg and HBsAg in breast milk has been confirmed. Is there a risk of transmission of the virus when the mother breastfeeds their baby?
　　《国际肝病》：目前已经确定母乳中可存在HBV DNA、HBeAg和HBsAg。当母亲哺乳时有没有把病毒传染给婴儿的危险？
　　Dr Visvanathan: We believe in universal vaccination， so providing the baby is vaccinated when it is born， the risk of transmission is in fact non-existent. Remember also， the drugs tenofovir and lamivudine both appear in breast milk but in very low levels and probably have little effect.
　　Visvanathan博士：我们信赖常规免疫。所以当婴儿出生时接种疫苗后，实际上是不存在传染风险的。但我们也要记住，替诺福韦和拉米夫定也都会出现在母乳中，不过其含量非常低，可能不会有太大影响。
　　Hepatology Digest: So even if the mother takes the drugs， the baby is safe?
　　《国际肝病》：那么即使母亲服药，婴儿也是安全的？
　　Dr Visvanathan: I think so.
　　Visvanathan博士：我是这样认为。
　　Hepatology Digest: When intra-uterine transmission happens， the vaccination and hepatitis B immunoglobulin might not be functional. What is the incidence of this and how might we prevent it?
　　《国际肝病》：如果在子宫内发生了传染，可能疫苗和乙肝免疫球蛋白就会不起作用了。这种情况发生的几率有多大，我们如何防止这种情况？
　　Dr Visvanathan: Most of the infection is prevented by the immunoglobulin and vaccination – 90% of the infection is stopped that way. The problem is the remaining 7%-10% that is not stopped. This situation is directly related to how much virus is in the mother. If there are very high levels of virus present， we believe the best treatment would be with one of the antiviral drugs in the last trimester of pregnancy to reduce transmission. This would be one of the class B drugs (telbivudine or tenofovir) hopefully or lamivudine.
　　Visvanathan博士：大部分感染都可以通过免疫球蛋白和疫苗来防止，90%的感染可以通过这种方式预防。问题是，还有剩下的7%~10%感染几率无法被预防。这直接与母亲体内病毒量相关。如果病毒水平很高，我们认为最好在妊娠期的最后三个月进行抗病毒治疗以降低传染几率。应该选用B级药物（替比夫定或替诺福韦）或拉米夫定。