Through pregnancy, it is routine to monitor LFT tests at each antenatal clinic appointment as a marker for potential obstetric complications

(HELLP, pre-eclampsia, acute fatty liver, etc.), particularly in the final trimester. Finally, in those diagnosed late and not receiving HBV treatment incorporated into cART, LFT flares may be seen shortly after delivery, which in some relates to HBeAg seroconversion and reappearance or a marked increase in HBV DNA levels. Where acute infection is suspected, testing for anti-HBc IgM is recommended. Acute HBV is uncommon during pregnancy and each case needs to be managed with specialist advice. Data suggest that lamivudine as part of cART does not completely protect against the development of acute HBV infection, although it is unknown whether

this is also the case HIF inhibitor with tenofovir with or without lamivudine/emtricitabine. Although there is a theoretical risk of high HBV DNA levels and the linked association with increased risk of transmission combined with the potential for acute hepatitis and threat to maternal and fetal health, the presumption would be that this would be abrogated by the patient already being on cART incorporating tenofovir and either emtricitabine or lamivudine. Where the woman is not on ART, a tenofovir-based ART regimen HM781-36B nmr should be commenced immediately. 6.1.3 Where pegylated interferon or adefovir is being used to treat HBV in a woman who does not yet require HIV treatment and who discovers she is pregnant, treatment should be stopped and switched to a tenofovir-based cART regimen. Grading: 1C If a woman on pegylated interferon becomes pregnant it should be discontinued and changed to a tenofovir-based cART regimen because of the anti-proliferative effect of the drug. Few data are available on the risk of congenital malformation with first-trimester exposure to the newer therapies telbivudine (FDA category B) and entecavir (FDA Category C). The outcome of the pregnancy should be reported to the Interferon Pregnancy and Antiretroviral Pregnancy Registries. 6.1.4 Since there is no evidence of any adverse effect on maternal or neonatal health if women become

pregnant while taking antiretroviral pentoxifylline therapy active against HBV, treatment should be continued. Grading: 1C For tenofovir, emtricitabine and lamivudine, APR [53] and the Development of Antiretroviral Therapy Study (DART) [190] have not identified any increased risk in prevalence or any specific pattern of anomaly, even when administered in the first trimester. Hence, when a patient becomes pregnant on an anti-HBV viral agent as part of their cART (tenofovir, lamivudine or emtricitabine), as for HIV management, cART should be continued as the potential risk to the fetus from drug exposure is outweighed by that of a hepatitis flare or liver disease progression if the drug(s) were to be discontinued in addition to HIV virological rebound and risk of MTCT.