Peripartum ALT flares predict earlier postpartum HBeAg clearance in highly viremic HBV-infected women: A long-term follow-up study.

BACKGROUND &

aimsCurrent guidelines recommend antiviral therapy for pregnant women with chronic HBV infection and high viral load to prevent mother-to-child transmission (MTCT), but data on long-term maternal outcomes remain limited.

methodsWe analyzed 293 HBeAg-positive pregnant women with high viral load (>200,000 IU/ml) enrolled in previous trials of tenofovir disoproxil fumarate or tenofovir alafenamide for MTCT prevention. Alanine aminotransferase (ALT) levels were serially 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, follow-up and initiation of antiviral therapy were guided by national reimbursement criteria and shared decision-making as part of routine clinical care. Cox proportional hazards regression, adjusted for multiple covariates, was used to estimate hazard ratios (HRs) and 95% CIs for postpartum HBeAg clearance.

resultsAmong 204 women who received antiviral therapy during pregnancy and 89 who did not, 50 achieved HBeAg clearance over a median postpartum follow-up of 27.1 months (range 0.03-147.8), corresponding to 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 pregnancies. 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).

conclusionsPeripartum 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.