Viral hepatitis affects both the pregnant and the non-pregnant individuals. A common cause of jaundice during pregnancy is acute viral Hepatitis.1 affecting fetuses as abortion, stillbirths, NICU admission and neonatal death.1,2Pregnancy itself is a risk factor for viral replication due to low immunity. There will be fivefold increase in serum aspartate amino-transferase or clinical jaundice or both. Hepatitis can be caused by diseases that are clearly related to pregnancy and diseases that are not clearly related to pregnancy. Disorders clearly associated with pregnancy include acute fatty liver during pregnancy, vomiting during pregnancy, intrahepatic cholestasis during pregnancy, severe preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count) .3 Worldwide, one in five Hepatitis viruses (Hepatitis A, B, C, D, or E) infections cause 1.34 million deaths each year from complications of liver cirrhosis and hepatocellular carcinoma.2 Acute Hepatitis is caused by all five viruses, but Hepatitis E virus (HEV) infection poses the greatest risk to pregnant women, because of the high number of maternal and subsequent fetal deaths, the obvious geographical distribution, and the outbreak of water safety. HEV is contributing to increase mortality in pregnant woman (20-30%) compared to general population. Co-infection is important for disease severity, choosing the management option and poor outcome.8 There are two enterically transmitted viruses: Hepatitis A (HAV) and Hepatitis E (HEV).4,7 Hepatitis B, C and D are parenterally transmitted . Cases in developed countries usually occur in individuals returning from visits to high endemic areas such as South-East Asia, the Indian subcontinent and Mexico. Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Hepatitis D virus (HDV) are associated with chronic infections, affecting 325 million people worldwide and accounting for 96% of deaths from viral Hepatitis.1,5,6 When treating viral Hepatitis during pregnancy, the health of the mother and the developing baby should be considered, because the immunosuppressive state of the pregnant woman and the hormonal changes during pregnancy and after delivery will alter the natural course of infection. In order to achieve implementation goals, prevention strategies must take into account local health and socio-economic aspects.

Source of data: The cases of the study were taken from the patients who were admitted in the department of general medicine and obstetrics and gynecology in Shardaben hospital. Duration of study: August 2019 to September 2021. Inclusion criteria: • Pregnant female with signs and symptoms of acute viral Hepatitis. Exclusion criteria: • Women with Hepatitis with non-viral origin. • Drug induced Hepatitis. • Autoimmune Hepatitis. • Women with viral Hepatitis not delivered in study periods August 2019 to September 2021. • Women with daily alcohol intake >30gm/day. Outcome measured • Maternal complications. • Mortality. • Foetal outcome. Patients satisfying inclusion and exclusion criteria were enrolled for this study and after taking written informed consent, thorough medical history of symptoms like nausea , vomiting ,fever , abdominal pain with laboratory investigations like complete blood count , liver function tests mainly serum bilirubin , Serum alanine transaminase , serum aspartate transaminase ,serum alkaline phosphatase, prothrombin time , serum protein, urine routine micro , renal function test , random blood sugar viral markers including anti HAV IgM antibodies, HBsAg , HBV DNA , Anti HBc antibodies, HCV, anti HEV IgM antibodies, and radiological investigations like Ultrasound abdomen were performed on the patients.

This was a prospective study of 30 cases of acute viral Hepatitis in pregnancy admitted in department of general medicine and obstetrics and gynecology at Shardaben hospital. Table 1.Area wise distribution of the patients studied Area Number Percentage Urban 11 36.67% Rural 19 63.33% Total 30 100% Table 1 shows that majority of the patients (63.33%) were from rural area and 36.67% of the patients were from urban area. Table 2. Age wise distribution of the patients studied Age( in years ) Numbers Percentage <20 1 3.33% 20-24 14 46.66% 25-30 12 40% >30 3 10% TOTAL 30 100% Above table shows that majority of the patients (86.66%) belonged to age group of 20 to 30 years. Table 3. Parity of patients studied Parity Number Percentage(%) Shukla et al[35](n=100) Primigravida 16 53.33% 41% Multigravida 14 46.66% 59% Total 30 100% 100% Majority (53.33%) of the patients were primigravida and rest (46.66%) were multigravida. Table 4. Comparative study of clinical presentation at the time of admission PRESENT STUDY Symptomatology N =30 % JAUNDICE 28 93.33% NAUSEA 20 66.67% FEVER 16 53.33% VOMITING 13 43.33% DECREASED APPETITE 12 40.00% ABDOMINAL PAIN 9 30.00% ALTERED SENSORIUM 4 13.33% EASY FATIGUABILITY 1 3.33% Above table shows that majority (93.33%) of the patients presented with jaundice followed by nausea (66.67%) associated with low grade fever (53.33%) and vomiting 43.33%. More than one symptoms were found in most of the patients. Table 5.Hepatitis virus Classification Hepatitis Virus Classification Number Percentage HAV 9 30.00% HBV 6 20.00% HCV 2 6.67% HEV 13 43.33% Total 30 100% Table shows majority of patients presented with Hepatitis E (43.33%). Rest of the patients were of Hepatitis A(30%) , Hepatitis B (20%) and Hepatitis C (6.67%).In our study , majority (43.33%) of the patients presented with acute Hepatitis E as compared to other variants. Table 6.Thrombocytopenia in different variants of Hepatitis Study THROMBOCYTOPENIA Total Present Percentage Absent Percentage Present Study 24 80.00% 6 20.00% 30 Nelson et al(n=100) 80.00% 20.00% In our study, 20% of the patients were having thrombocytopenia. Table 7.Prothrombin time abnormality in present study PT INR Total Normal Percentage Abnormal Percentage 24 80.00% 6 20.00% 30 In our study, 6(20%) patients had altered prothrombin time. Table 8. Serum bilirubin of patients with viral Hepatitis HEPATITIS BILIRUBIN(mg/dL) TOTAL 0 TO 5 5 TO 9 10 TO 14 15 TO 19 >20 HAV 3 4 1 1 0 9 HBV 2 4 0 0 0 2 HCV 1 1 0 0 0 2 HEV 5 2 3 2 1 13 TOTAL 11 11 4 3 1 30 Majority of the patients (73.33%) had bilirubin levels <10. 13.33% of the patients had bilirubin levels between 10 to 14. 10% had levels between 15 to 19. Only 1 patient had level of bilirubin >20. Amongst patients with bilirubin levels >10 , highest number of the patients were of Hepatitis E. . Table 9 .Serum Bilirubin and its relation to maternal outcome Maternal mortality (%) Serum bilirubin level(mg/dL) <10 10 to 14 15 to 19 >20 Present study 0 25 66.66 100 Above table shows that higher serum bilirubin level is associated with worse maternal outcome. The comparison between above studies shows that maternal death rate is directly proportional to the on admission bilirubin levels. Table 10. Ultrasonography of Viral Hepatitis patients USG FINDING HAV HBV HCV HEV Total HEPATOMEGALY 5(55.56%) 0 1(50%) 5(38.46%) 11(36.37%) SPLENOMEGALY 3(33.33%) 0 1(50%) 3(23.08%) 7(23.33%) ASCITES 0 0 0 4(30.77%) 4(13.33%) GB WALL THICKENING 9(100%) 3(50%) 0 9(69.23%) 21(70%) Above table shows that most common USG finding was turned out to be GB wall thickness (70%). Among HEV Hepatitis it was present in 69.23%cases while it was present in all cases of HAV Hepatitis. Table 11. Maternal outcomes and Hepatitis virus classification Hepatitis Virus Classification MATERNAL OUTCOME Total p value Discharged Percentage Expired Percentage HAV 9 100% 0 0.00% 9 0.111 HBV 6 100% 0 0.00% 6 HCV 2 100% 0 0.00% 13 HEV 9 69.23% 4 30.77% 2 Total 26 86.67% 4 13.33% 30 Above table shows maternal outcome in patients with acute viral Hepatitis. Out of 30 patients 26 patients (86.67%) discharged and 4 patients (13.33%) expired in hospital. All of the 4 expired patients belong to Hepatitis E group , which suggests mortality was 30.77%.Case fatality rate of viral Hepatitis is 13.33% in All viral Hepatitis and among Hepatitis E , it was 30.77%. Table 12 . Number of Complications And Hepatitis virus classification Hepatitis Complications Total Present Percentage Absent Percentage HAV 7 77.78% 2 22.22% 9 HBV 0 0.00% 6 100% 6 HCV 0 0.00% 2 100% 2 HEV 5 38.46% 8 61.54% 13 Total 12 40% 18 60% 30 The table shows occurence of number of complications in different types of Hepatitis virus. It shows that majority (77.78%) of the complications occurred in patients with Hepatitis A. Table 13 .Maternal complication and Hepatitis virus classification Hepatitis virus classification Maternal complication Total DIC Acute fulminant hepatitis Hepatic encephalopathy Post partumhaemrrhage Puerperium pyrexia Pre termlabour Thrmbocytopenia Nil HAV 0 0 0 1 1 5 0 2 9 HBV 0 0 0 0 0 0 0 6 6 HCV 0 0 0 0 0 0 1 2 2 HEV 2 1 1 0 0 0 0 8 13 Total 2 1 1 1 1 5 1 18 30 The table shows various maternal complications in different types of Hepatitis. Most common complication was found to be preterm labor (41.66%) and the most common variant associated with it was Heaptitis A. Table 14.Foetal outcome in present study Study NICU Admission Total YES % NO % Present Study 8 30.77% 18 69.23% 26 In our study, 30.77% of the babies required NICU admission. Table 15.Comparative study of IUD incidence Study IUD Total YES Percentage NO Percentage Present Study 4 13.33% 26 86.67% 30 In this study, IUD was detected in 13.23% cases.

In our study majority patients (63.33%) were from rural area and (36.67%) of the patients were from urban area. The results of which are in concordance with Tripti et al11, which showed (65%) patients were from rural area and rest (35%) from urban area. The majority of the patients (86.66%) in our study belonged to age group of 20 to 30 years. which is comparable with studies by Nath et al (75%) 9, Sarkar et al (70%).10 and Tripti et al(89.02%).11 Majority (53.33%) of the patients were primigravida and rest(46.66%) were multigravida , which is discordant to findings of Shukla et al12 which had 41% of primigravida and 59% of multigravida. In our study that majority (93.33%) of the patients presented with jaundice followed by nausea (66.67%) More than one symptoms were found in most of the patients , while in the study done by Sudhamshu KC13 had decreased appetite as the most common symptom(96.67%) followed by jaundice(87.33%).In our study , majority (43.33%) of the patients presented with acute Hepatitis E as compared to other variants. The results are comparable to Thakur HS et al (55.55%).1 In Parveen T et al15 also majority of the patients(80.4%) were of Hepatitis E. Above table shows that higher serum bilirubin level is associated with worse maternal outcome. The maternal death rate is directly proportional to the on admission bilirubin levels. Our results were comparable with Tripti et al.11 Most common USG finding was turned out to be GB wall thickness (70%). Among HEV Hepatitis it was present in 69.23%cases while it was present in all cases of HAV Hepatitis. These results were comparable with the study done by Sudhamshu KC et al13In our study, Case Fatality Rate is found to be 30.77% which was concordant with Shukla et al (33.3%).12 The table shows various maternal complications in different types of Hepatitis. Most common complication was found to be preterm labour (41.66%) and the most common variant associated with it was Heaptitis A. Chilaka V15 et al showed 60% of the patients with Hepatitis A had preterm labour as a complication which is in concordance with our study (55.55%).In our study, 30.77% of the babies required NICU admission, while in Thakur HS et al1 study 56.6% babies needed NICU admission. In this study, IUD was detected in 13.23% cases while in OladokunAet al16 it was found to be 8.3% cases. The result of which is comparable to our study.

In the present study 63.33% of patient came from Rural Area. 53.33% of patients were primigravida and 46.67% of patients were multigravida. Majority of patients presented with multiple symptoms, among them 93.33% presented with jaundice which was the most common symptom, followed by nausea(66.67%).Most common type was Hepatitis E [13(43.33%)] followed by 9(30%) with HepatitisA. Majority (73.33%) of patients had serum bilirubin level <10mg. amongst patients having bilirubin levels (26.67%) >10, majority of the patients had HEV. (86.67%) patient got discharged and (13.33%) patients expired during hospital stay.(30.77%) babies required NICU admission. Case fatality rate was 30.77% in Hepatitis E patients. Maternal mortality rate was 4(13.33%) in this study.

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