Peripartum ALT Flares Predict Earlier Postpartum HBeAg Clearance in Highly Viremic HBV-Infected Women: A Long-term Follow-up Study.

BACKGROUND & AIMS: Current guidelines recommend antivirals for highly viremic HBV-infected pregnant women to prevent mother-to-child transmission (MTCT), but data on long-term maternal outcomes remain limited.

METHODS

We analyzed 293 HBeAg-positive women with high viral load (>200,000 IU/mL) enrolled in prior trials of tenofovir disoproxil fumarate or tenofovir alafenamide for MTCT prevention. Alanine aminotransferase (ALT) levels were intensively monitored from late pregnancy through 6 months postpartum. Peripartum ALT trajectories (flare vs. stable) were identified using previously validated group-based trajectory modeling. After 6 months postpartum, participants received follow-up and postpartum antiviral therapy based on national reimbursement criteria complemented by shared decision-making per standard care. Cox proportional hazard regression, adjusted for multiple covariates, estimated hazard ratios (HR) and 95% confidence intervals (CI) for postpartum HBeAg clearance.

RESULTS

Among the 204 pregnancy-treated and 89 -untreated women, 50 cleared HBeAg over a median follow-up of 27.1 months (range, 0.03-147.8) postpartum, representing an incidence of 5.03 per 100 person-years. No adverse hepatic outcomes were observed. A flare-type peripartum ALT trajectory was a strong independent predictor of earlier HBeAg clearance (HR, 10.37; 95% CI, 5.44-19.76; P<0.001), independent of age, HBV genotype, baseline or delivery viral load, postpartum antiviral therapy, and subsequent deliveries. Cumulative HBeAg clearance rates were significantly higher in the flare group (N=43) than in the stable group (N=250) at 12, 24, and 60 months (2.3%, 25.3%, and 85.9% vs. 0.4%, 3.9%, and 11.9%, respectively).

CONCLUSIONS

Peripartum ALT flares are strongly associated with accelerated HBeAg clearance. Longitudinal ALT monitoring around childbirth provides a critical window to guide individualized postpartum treatment strategies.

IMPACT AND IMPLICATIONS: This study provides long-term follow-up data in highly viremic women receiving antiviral therapy during pregnancy to prevent mother-to-child transmission, with a focus on postpartum HBeAg clearance. Peripartum ALT flares are associated with significantly earlier HBeAg clearance, suggesting ALT monitoring around delivery to inform postpartum management. Our findings also demonstrate favorable treatment experiences among HBV-infected women, a population in which treatment uptake remains suboptimal. Beyond the prevention of mother-to-child transmission, these results support broader implementation of antiviral therapy to improve care for HBV-infected women and contribute to global hepatitis elimination efforts.

CLINICAL TRIAL NUMBERS: NCT01312012, NCT03695029.