WOMEN with hepatitis B virus (HBV) infection who experienced HBeAg clearance after childbirth were significantly more likely to have experienced a flare in alanine aminotransferase (ALT) levels around delivery, according to long-term follow-up of 293 women enrolled in clinical trials of antiviral therapy to prevent mother-to-child transmission (MTCT).
HBV infection remains a major global health problem, affecting an estimated 254 million people worldwide, with MTCT the predominant route of transmission.
The findings suggest that intensive ALT monitoring during the peripartum period may help identify women more likely to achieve earlier HBeAg clearance and could support more individualised postpartum management. No adverse hepatic outcomes were observed during follow-up.
ALT Patterns Offer Clues to Postpartum HBeAg Clearance
Current guidance recommends antiviral treatment for pregnant women with high hepatitis B viral loads to reduce MTCT, but evidence on long-term maternal outcomes has been limited.
The analysis included 293 HBeAg-positive women with HBV DNA levels exceeding 200,000 IU/mL who had previously participated in trials of tenofovir disoproxil fumarate or tenofovir alafenamide. Among them, 204 received antiviral treatment during pregnancy, while 89 did not.
ALT levels were monitored intensively from late pregnancy until 6 months postpartum before women transitioned to standard guideline-based care, with postpartum antiviral treatment determined by national reimbursement criteria and shared decision-making.
Peripartum ALT Flares Predicted Earlier HBeAg Clearance
During a median postpartum follow-up of 27.1 months, 50 women achieved HBeAg clearance, corresponding to an incidence of 5.03 per 100 person-years.
Women with a flare-type ALT trajectory (n=43) around childbirth had a significantly higher likelihood of earlier HBeAg clearance than those with stable ALT levels (p<0.001). After adjustment for age, HBV genotype, viral load at baseline and delivery, postpartum antiviral therapy and subsequent pregnancies, the flare trajectory remained an independent predictor, with a more than 10-fold higher rate of HBeAg clearance (HR 10.37).
Cumulative HBeAg clearance rates were higher in the flare group than the stable group at 12 months (2.3% vs 0.4%), 24 months (25.3% vs 3.9%) and 60 months (85.9% vs 11.9%).
Findings May Help Guide Postpartum HBV Care
The investigators concluded that longitudinal ALT monitoring during the peripartum period provides an important opportunity to tailor postpartum treatment strategies. They also reported favourable treatment experiences among women with HBV infection, a population in which antiviral treatment uptake remains suboptimal. Beyond reducing MTCT, the findings support wider implementation of antiviral therapy as part of efforts to improve maternal HBV care and contribute to hepatitis elimination initiatives.
Reference
Wen W-H et al. Peripartum ALT flares predict earlier postpartum HBeAg clearance in highly viremic HBV-infected women: a long-term follow-up study. JHEP Rep. 2026;DOI:10.1016/j.jhepr.2026.101936.
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