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Infections During Pregnancy

Hepatitis B Virus Infection in Pregnancy

Hepatitis B virus (HBV) is a vaccine-preventable bloodborne and sexually transmitted DNA virus. In pregnancy, the main clinical priorities are identifying maternal infection, determining immunity and vaccination needs, assessing viral load when infection is present, reducing perinatal transmission, and ensuring newborn immunoprophylaxis and follow-up testing.

Updated:June 9,  2026. This page is for clinical education and should not replace individualized medical care, specialist consultation, or local public health reporting requirements.

Cause, virology, and incubation

Hepatitis B virion, also known as the Dane particle

Hepatitis B is caused by the hepatitis B virus (HBV). HBV is a partially double-stranded DNA virus in the Hepadnaviridae family that primarily affects the liver. The illustration shows an HBV virion, also known as a Dane particle. The virus consists of an outer lipid envelope and a protein core that encapsulates a small, partially double-stranded genome and HBV DNA polymerase.

HBV can cause acute infection, chronic infection, or reactivation in the setting of immunosuppression. In pregnancy, the major fetal/newborn concern is perinatal transmission, especially when maternal HBV DNA levels are high.

HBV genome products

The HBV DNA genome encodes:

Incubation
The incubation period is typically about 90 days after exposure, with a usual range of approximately 60–150 days.
Symptoms of acute infection
Acute HBV infection may be asymptomatic or may present with fatigue, anorexia, nausea, vomiting, abdominal pain, dark urine, pale stools, jaundice, and elevated liver enzymes.
Key serologic markers
HBsAg indicates current infection. Anti-HBs indicates immunity. Total anti-HBc indicates previous or current natural infection. IgM anti-HBc supports recent or acute infection.
Pregnancy relevance
Maternal HBV DNA level guides antiviral decisions in pregnancy. Timely newborn hepatitis B vaccine plus HBIG prevents most perinatal infections.

Epidemiology and transmission

HBV remains a major global cause of chronic liver disease. More than 290 million people worldwide and almost 2 million people in the United States are infected with HBV. Chronic HBV prevalence in pregnancy in the United States is estimated at approximately 0.7% to 0.9%, with more than 25,000 infants born annually at risk for chronic infection from perinatal exposure.

Route Clinical relevance
Perinatal exposure A major route of infection worldwide. Transmission may occur during pregnancy or, more commonly, around delivery through exposure to infected blood and secretions.
Sexual exposure Important adult transmission route in the United States. Sexual partners should be tested and vaccinated if susceptible.
Blood or percutaneous exposure Includes injection drug use, needlestick injury, contaminated equipment, contaminated tattoo or piercing equipment, transfusion in settings without appropriate screening, or needlestick injury.
Household contact Household contacts should be evaluated and vaccinated if susceptible. Avoid sharing razors, toothbrushes, or other items that may be contaminated with blood.
Perinatal prevention: Infants born to HBsAg-positive people require hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. The birth dose also serves as a safety net when maternal HBsAg status is unknown, unavailable, or incorrectly documented at delivery.

Natural history and sequelae

The likelihood of chronic HBV infection depends strongly on age at acquisition. Perinatal infection has the highest risk of chronicity. Without appropriate immunoprophylaxis, chronic infection can develop in up to 90% of perinatally infected neonates, compared with a much lower chronicity risk after adult-acquired infection.

Clinical stage or outcome Key points
Acute HBV infection May be asymptomatic or symptomatic. Symptoms can include malaise, anorexia, nausea, abdominal pain, dark urine, pale stools, and jaundice. Severe acute hepatitis and acute liver failure are uncommon but clinically important.
Chronic HBV infection May remain asymptomatic for years but can progress to fibrosis, cirrhosis, hepatic decompensation, and hepatocellular carcinoma.
Perinatal infection Highest risk of chronic infection. Prevention depends on maternal screening, appropriate maternal antiviral therapy when viral load is high, and timely neonatal vaccine plus HBIG.
Pregnancy outcome Chronic HBV infection alone is not a consistent indication for additional fetal surveillance. Obstetric management is otherwise guided by usual maternal and fetal indications.
Long-term risk: Chronic HBV infection is a major cause of cirrhosis and hepatocellular carcinoma. Patients with confirmed infection should be linked to longitudinal hepatitis care beyond pregnancy.

Current recommendations — concise summary

Screen in every pregnancy.
Perform HBsAg screening during each pregnancy, preferably in the first trimester.
Use triple-panel testing when appropriate.
If not previously documented, obtain HBsAg, anti-HBs, and total anti-HBc to define infection, immunity, prior infection, or susceptibility.
Evaluate positive HBsAg.
Obtain HBV DNA, HBeAg, ALT/liver panel, and assess for coinfections and liver disease.
Treat high viral load.
If HBV DNA is >200,000 IU/mL, use tenofovir in the third trimester, usually beginning at 28–32 weeks, as an adjunct to newborn immunoprophylaxis.
No cesarean solely for HBV.
Mode of delivery should be based on obstetric indications, not HBV status alone.
Protect the newborn immediately.
Infants of HBsAg-positive or unknown-status patients should receive HepB vaccine and HBIG within 12 hours of birth.
Key prevention point: Maternal antiviral therapy does not replace newborn immunoprophylaxis. Hepatitis B vaccine plus HBIG at birth remains standard for infants born to HBsAg-positive patients.

Clinical algorithm

Original flowchart created for this page. It summarizes a practical prenatal-to-newborn workflow and avoids reproduction of copyrighted figures.

Screening and serology interpretation

Current guidance emphasizes universal pregnancy screening and adult triple-panel testing. HBsAg identifies current infection; anti-HBs identifies immunity; total anti-HBc identifies prior or current natural infection.

HBsAg Anti-HBs Total anti-HBc Interpretation Pregnancy action
Negative Negative Negative Susceptible; no evidence of infection or immunity. Recommend hepatitis B vaccination in pregnancy.
Positive Negative Positive Current hepatitis B infection. Obtain HBV DNA, HBeAg, liver panel; refer/link to hepatitis or infectious disease care.
Negative Positive Positive Immune due to prior natural infection. No vaccine needed; counsel about reactivation risk if future immunosuppression.
Negative Positive Negative Immune due to vaccination. No vaccine needed if completed series documented.
Negative Negative Positive Uncertain: resolved infection with waned anti-HBs, false-positive anti-HBc, occult infection, or mutant HBsAg. Consider specialist input and individualized follow-up testing.
Delivery admission: If HBsAg status is unknown or undocumented when delivery is anticipated, obtain HBsAg testing urgently and manage the infant as exposed unless maternal status is confirmed negative in time for neonatal decision-making.

Maternal evaluation after HBsAg-positive result

Pregnancy and fetal surveillance

Chronic HBV infection alone is not an indication for additional antenatal fetal surveillance. Routine obstetric care is appropriate unless other maternal, fetal, or obstetric indications are present.

Invasive prenatal diagnosis

If CVS or amniocentesis is desired, counsel using shared decision-making. Available data are limited, and counseling should consider maternal viral load, whether results will change clinical management, and patient values. Specialist input may be helpful when viral load is high.

Antiviral therapy in pregnancy

Clinical situation Recommended approach
HBV DNA >200,000 IU/mL Recommend tenofovir in the third trimester, typically initiated at 28–32 weeks, to reduce perinatal transmission risk.
Already on tenofovir before pregnancy Continue therapy if clinically indicated; coordinate with hepatitis specialist.
Already on entecavir or another nonpreferred agent Discuss switching to tenofovir because entecavir is generally avoided in pregnancy.
Treatment only for transmission prevention Postpartum discontinuation may be appropriate, with ALT and HBV DNA monitoring for flares.
Maternal liver disease indication Continue or initiate treatment based on maternal disease severity and specialist recommendations.
Medication note: Tenofovir disoproxil fumarate has the most extensive pregnancy safety experience. Tenofovir alafenamide is included in more recent guidance but has less pregnancy safety experience than TDF.
Postpartum medication and flare monitoring

If tenofovir was started only to reduce perinatal transmission risk, discontinuation after delivery may be appropriate. If therapy is stopped, monitor ALT and HBV DNA for postpartum flares. Patients who meet usual chronic HBV treatment criteria should continue therapy under hepatitis-specialist guidance.

Delivery and breastfeeding

Newborn management and post-vaccination testing

Maternal HBsAg status Immediate newborn action Follow-up
HBsAg positive Hepatitis B vaccine + HBIG within 12 hours of birth. Complete vaccine series. Check HBsAg and anti-HBs at 9–12 months or 1–2 months after series completion if delayed.
Unknown or undocumented Give hepatitis B vaccine within 12 hours. Give HBIG per CDC/AAP birthweight and timing guidance if maternal status remains positive or unknown. Confirm maternal testing and complete infant follow-up per exposure status.
HBsAg negative Birth dose hepatitis B vaccine is recommended for all infants. Complete vaccine series per routine immunization schedule.
Do not delay newborn prophylaxis. For exposed infants, hepatitis B vaccine and HBIG are most effective when given as soon as possible and within 12 hours of birth.

Patient handouts and multilingual CDC resources

CDC provides perinatal hepatitis B clinical resources and patient education materials, including materials in multiple languages. Link patients and staff to the CDC Perinatal Hepatitis B Provider Overview:

CDC: Clinical Overview of Perinatal Hepatitis B

Suggested page wording: “Patient education materials in multiple languages are available through CDC’s Perinatal Hepatitis B resources.”

EMR-ready counseling text

HBsAg-positive pregnancy counseling

Hepatitis B virus infection in pregnancy was reviewed. HBV is a vaccine-preventable infection that can be transmitted perinatally. Maternal evaluation includes HBV DNA viral load, HBeAg, liver function testing, assessment for coinfections, and linkage to hepatology/infectious disease or an HBV-experienced clinician. If HBV DNA is greater than 200,000 IU/mL, tenofovir therapy in the third trimester is recommended as an adjunct to neonatal immunoprophylaxis to reduce transmission risk.

Cesarean delivery is not recommended solely for HBV infection. Routine intrapartum care does not need to be altered solely for chronic HBV when neonatal immunoprophylaxis is planned. Breastfeeding is acceptable after the infant receives immunoprophylaxis at birth; avoid breastfeeding from a breast with cracked or bleeding nipples until healed. The pediatric/newborn team should be notified before delivery. The infant should receive hepatitis B vaccine and HBIG within 12 hours of birth, complete the vaccine series, and have post-vaccination serologic testing with HBsAg and anti-HBs at 9–12 months or 1–2 months after vaccine series completion if delayed.

HBV-susceptible pregnancy counseling

Hepatitis B serology indicates susceptibility without evidence of immunity. Hepatitis B vaccination in pregnancy was recommended. Vaccination is safe in pregnancy and helps protect the patient and infant from HBV infection.

References

  1. Badell ML, Prabhu M, Dionne J, Tita ATN, Silverman NS; Society for Maternal-Fetal Medicine. SMFM Consult Series #69: Hepatitis B in pregnancy: updated guidelines. Am J Obstet Gynecol. 2024;230:B2-B14. Full text.
  2. American College of Obstetricians and Gynecologists. Viral Hepatitis in Pregnancy. Clinical Practice Guideline No. 6. Obstet Gynecol. 2023;142:745-759. ACOG guidance.
  3. Conners EE, Panagiotakopoulos L, Hofmeister MG, et al. Screening and Testing for Hepatitis B Virus Infection: CDC Recommendations — United States, 2023. MMWR Recomm Rep. 2023;72(1):1-25. CDC MMWR.
  4. Centers for Disease Control and Prevention. Clinical Overview of Perinatal Hepatitis B. CDC perinatal provider overview.
  5. Centers for Disease Control and Prevention. Clinical Testing and Diagnosis for Hepatitis B. CDC testing guidance.
  6. Centers for Disease Control and Prevention. Hepatitis B Perinatal Vaccine Information. CDC vaccine administration guidance.
  7. Centers for Disease Control and Prevention. Guidelines for Perinatal Post-Vaccination Serologic Testing. CDC PVST guidance.
  8. Ghany MG, Pan CQ, Lok AS, Feld JJ, Lim JK, Wang SH, et al. AASLD-IDSA Practice Guideline on treatment of chronic hepatitis B. Hepatology. 2026;83:974-997.
  9. Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018;67:1560-1599. PubMed.
  10. U.S. Preventive Services Task Force. Screening for Hepatitis B Virus Infection in Pregnant Women: Reaffirmation Recommendation Statement. JAMA. 2019;322:349-354. PubMed.
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