SEVERE FETAL HEPATITIS E VIRUS INFECTION IS THE POSSIBLE CAUSE OF INCREASED SEVERITY OF HEPATITIS E VIRUS INFECTION IN THE MOTHER

Abstract

Purpose: The cause of increased severity of hepatitis E virus (HEV) infection in pregnancy is not known. We sought to find out if fetal HEV infection and fetal disease could influence the course of HEV infection in the mother. Methods: We studied clinical and biochemical characteristics of 36 consecutive pregnant women with acute HEV infection. Babies borne to these women were assessed for vertically-transmitted HEV infection and the severity of liver disease in the newborn. The severity of disease in the newborn was correlated with the maternal disease. Results: Of the 36 pregnant women with HEV infection, 20 (55.6%) had nonfulminant disease and 16 (44.4%) had fulminant hepatic failure (FHF). Nine (56.3%) of the 16 mothers with FHF had disseminated intravascular coagulation. 6 (37.5%) women with FHF survived and 10 (62.5%) died. Twenty-five (69.4%) infants had HEV infection at birth. Fourteen (56%) of such infants died with a clinical syndrome resembling FHF. Babies borne to mothers with FHF were more often HEV infected and viremic ((15/16; 93.8%% for both) than those with nonfulminant disease (10/20; 50% and 5/20; 25%) (p = 0.004 and <0.001 respectively). Twelve (75%) of the 16 babies borne to mothers with FHF had clinical syndrome of FHF as a result of massive hepatic necrosis. In contrast only 2 (10%) of the 20 mothers with nonfulminant disease delivered babies who developed FHF (p = 0.008) All the 6 mothers who survived had delivered babies within 4 days (2.3 ±1.0 days) of onset of encephalopathy. In contrast, all the 10 mothers who died had delivered babies 4 days (9.6 ± 3.0 days) after onset of encephalopathy (p = 0.02). Conclusions: We hypothesize that severe fetal liver disease caused by vertically-transmitted HEV infection causes severe maternal liver disease, akin to what happens in mirror syndrome. Fetus with severe liver disease may produce toxins which cross to the maternal blood and precipitate FHF and DIC in the HEV infected mother. (This work was done at the Department of Gastroenterology Sher-I-Kashmir Institute of Medicine Srinagar, Kashmir, India.)