What are current recommendations on the screening and management of hepatitis B infection in pregnancy?

Background
Hepatitis B virus (HBV) is an enveloped, partially double-stranded, circular DNA virus within the Hepadnaviridae family of viruses that primarily infects hepatocytes.1,2 The virus has an average incubation period of 60 days.2 The intact virus is known as the Dane particle, which comprises 3 major antigens. The hepatitis B surface antigen (HBsAg) is located on the viral envelope and is also found circulating freely in the serum. The central portion of the Dane particle contains the hepatitis B core antigen (HBcAg), which is confined to hepatocytes and is not present in the serum. The hepatitis B e antigen (HBeAg) is produced from the same genomic region that encodes HBcAg and serves as a marker of high viral load and active viral replication.

Hepatitis B is transmitted through contact with infected blood or body fluids, including through sexual exposure, injection drug use, and vertical transmission during pregnancy or delivery.3 Sexual transmission and injection drug use are the predominant routes of HBV acquisition among adults in the U.S.4 However, perinatal transmission accounts for up to 50% of HBV infections globally and is associated with the highest risk of progression to chronic infection.3,4 In the U.S., the prevalence of chronic HBV infection during pregnancy is estimated at 0.7% to 0.9%, placing more than 25,000 infants born each year are at risk for chronic infection due to perinatal transmission.4

Acute viral hepatitis during pregnancy may be asymptomatic or present with mild clinical manifestations.1 When present, symptoms are often nonspecific and may include jaundice, nausea, vomiting, anorexia, abdominal discomfort/pain, fatigue, fever, malaise, myalgia, and dark-colored urine. Among adults who acquire HBV infection, approximately 10% to 15% will develop chronic infection.2 Pregnant women with chronic HBV infection may experience disease progression including the development of decompensated cirrhosis.1 In addition, chronic HBV infection during pregnancy has been associated with adverse obstetric outcomes, including placental abruption, preterm delivery, gestational hypertension, and fetal growth restriction.

Screening for HBV in Pregnancy
Several professional and public health organizations have recommendations on screening for HBV infection during pregnancy; these are summarized in Table 1.2-6 Although specific recommendations differ slightly across organizations, universal screening for HBV at the initial prenatal visit, preferably in the first trimester, is generally recommended for every pregnancy.

The Centers for Disease Control and Prevention (CDC) and Society for Maternal-Fetal Medicine (SMFM) recommend initial prenatal screening using a triple panel consisting of HBsAg, hepatitis B surface antibody (anti-HBs), and anti-hepatitis B core total antibodies (anti-HBc).3,4 The 2023 CDC hepatitis screening guidelines newly introduced the recommendation to use a triple-panel testing strategy, whereas prior CDC guidance primarily emphasized HBsAg testing alone.3 The rationale for employing a triple panel for initial screening is that it enables identification of individuals with active HBV infection who can be linked to appropriate care, those with resolved infection who may be at risk for reactivation (e.g., immunocompromised individuals), individuals who are susceptible and require vaccination, and those who have immunity due to prior vaccination. Table 2 includes details on interpreting HBV triple panel test results.2,4,7 Generally, HBsAg indicates an active HBV infection and potential infectivity.3 Anti-HBs reflects immunity gained through vaccination or recovery from infection. Total anti-HBc indicates previous or current exposure to HBV and remains lifelong but does not appear in vaccine-induced immunity.

The American Association for the Study of Liver Diseases (AASLD) recommends that a positive HbsAg result in pregnant women prompt further evaluation with quantitative HBV DNA, HBeAg, and alanine aminotransferase (ALT) testing to assess the severity of maternal liver disease and the risk of perinatal transmission.8 Although noninvasive fibrosis assessments may be less reliable during pregnancy, evaluation for cirrhosis through ultrasonography and/or clinical examination is recommended, since the presence of cirrhosis may affect clinical management.

Table 1. Recommendations for HBV Screening in Pregnancy.2-6
OrganizationRecommendations
ACOG
  • Screen with HBsAg test in all pregnant women at the first prenatal visit during each pregnancy, regardless of vaccination status or prior testing
  • Screen with triple panela (regardless of vaccination status or prior testing) in women without a documented negative triple panel after 18 years of age, women who have not completed HBV vaccine series, or women with ongoing risk factors for HBV infection
CDC
  • Screen with triple panela in all pregnant women during each pregnancy, preferably in the first trimester, regardless of vaccination status or prior testing
  • Screen with HBsAg alone in pregnant women with a history of appropriately timed triple panel screening and without subsequent risk for exposure to HBV (i.e., no new HBV exposure since triple panel screening)
SMFM
  • Screen using triple panela at the initial prenatal visit for pregnant women without prior documented results
  • Screen with HBsAg alone at the initial prenatal visit for pregnancies with a previously documented negative triple panel
  • Individuals with unknown HBsAg status: Screen upon any presentation for prenatal care
  • Individuals with clinical hepatitis or risk factors for acute HBV infection: Screen at the time of admission to a birthing facility for delivery
USPSTFb
  • Screen with HBsAg test in all pregnant women at the first prenatal visit during each pregnancy, regardless of vaccination status or prior testing
  • Individuals with unknown HBsAg status or with new or ongoing risk factors for HBV infection (e.g., injection drug use, presence of a sexually transmitted infection): Screen upon admission to a hospital or other delivery setting
aTriple panel consists of HBsAg, anti-HBs, and anti-HBc.
bThe AAFP supports the USPSTF recommendations.
Abbreviations: AAFP=American Academy of Family Physicians; ACOG=American College of Obstetricians and Gynecologists; anti-HBc=hepatitis B core antibody; anti-HBs=hepatitis B surface antibody; CDC=Centers for Disease Control and Prevention; HBsAg=hepatitis B surface antigen; HBV=hepatitis B virus; SMFM=Society for Maternal-Fetal Medicine; USPSTF=U.S. Preventive Services Task Force.
Table 2. Interpretation of HBV serologic test results.2,4,7
Triple panel laboratory resultsHBV statusManagement
HBsAganti-HBsanti-HBc
NegativeNegativeNegativeSusceptible, never infectedOffer HepB vaccine per ACIP recommendations
PositiveNegativePositiveInfectedRefer to hepatitis/ID care

Evaluate for treatment in pregnancy
NegativePositivePositiveImmune due to natural infection (resolved infection)Refer to hepatitis/ID care if immunocompromised

Counsel about HBV reactivation risk
NegativePositiveNegativeImmune due to previous vaccinationIf no documentation of complete HepB vaccination series, offer HepB vaccine per ACIP recommendations
NegativeNegativePositiveUncertainaRefer to hepatitis/ID care

Consider HepB vaccination after hepatitis/ID evaluation
aFour possibilities: 1) resolved infection (most common); 2) false-positive total anti-HBc; 3) occult infection; 4) mutant HBsAg strain not detectable by laboratory assay.
Abbreviations: ACIP=Advisory Committee on Immunization Practices; anti-HBc=hepatitis B core antibody; anti-HBs=hepatitis B surface antibody; HBsAg=hepatitis B surface antigen; HepB=hepatitis B; ID=infectious diseases.

Management of HBV in Pregnancy
The AASLD and SMFM provide recommendations for the treatment of HBV infection in pregnancy.4,8 When treatment is indicated, the recommended antiviral regimen is tenofovir alafenamide (TAF) 25 mg daily or tenofovir disoproxil fumarate (TDF) 300 mg daily. While the SMFM does not state a preference between these 2 drugs, the AASLD gives preference for TDF because of its more extensive safety record in pregnancy. Among the supporting evidence cited by the AASLD is a 2024 meta-analysis of 31 studies that compared TAF and TDF for preventing vertical transmission in mothers with chronic HBV infection.9 Compared to placebo or no treatment, both drugs were equally effective in reducing the mother-to-child transmission rate, and the surface under the cumulative ranking curve suggested that TDF is the most effective agent (probability ranking, 0.77 versus 0.72 with TAF).

The AASLD recommends that HBsAg-positive patients receiving other antivirals including entecavir should transition to TDF or TAF during pregnancy and the postpartum period.8 For patients newly diagnosed as HBsAg-positive who are not on antiviral therapy, either TDF or TAF should be initiated if HBV DNA levels are >200,000 IU/mL at any point during pregnancy, regardless of HBeAg status, preferably at approximately 28 weeks’ gestation or any time prior to delivery. The SMFM similarly recommends initiation of TAF or TDF in the third trimester (28 to 32 weeks’ gestation) in pregnant individuals with HBV DNA >200,000 IU/mL as an adjunct to neonatal immunoprophylaxis.4 Refer to the AASLD and SMFM guidelines for specific information on neonatal immunoprophylaxis.4,8

Antiviral therapy initiated solely for the prevention of perinatal transmission may be discontinued at delivery in the absence of other indications for ongoing treatment.8 However, treatment cessation is associated with an increased risk of HBV flares during the first 6 months postpartum.4 In patients who discontinue therapy, close monitoring of HBV DNA and ALT is recommended every 1 to 3 months for up to 6 months to detect withdrawal flares.8 Patients should also be counseled regarding symptoms of HBV flares, which may include fevers, nausea, vomiting, fatigue, loss of appetite, yellowing of skin, abdominal pain, or dark urine. Antiviral therapy should be resumed if a significant flare occurs, defined as ALT ≥5 times the upper limit of normal.

Additional Clinical Considerations
Pregnant women with HBV should be informed on the critical role of neonatal immunoprophylaxis, as well as partner and household contact management.4,8,10 All close contacts should be tested for HBV and vaccinated according to Advisory Committee on Immunization Practices (ACIP) recommendations if susceptible. Patients should also be counseled on risk-reduction measures, including consistent condom use until immunity is confirmed, avoidance of sharing personal items that may be contaminated with blood, and adherence to the recommended monitoring throughout pregnancy and postpartum. Close coordination among obstetric, hepatology, and pediatric care teams is important to ensure aligned maternal management and optimal neonatal outcomes.

Conclusion
Hepatitis B infection in pregnancy requires systematic screening and targeted management to reduce maternal complications and prevent perinatal transmission.2-6 Current guidelines consistently support universal prenatal screening for HBV, with virologic and biochemical evaluation of HBsAg-positive individuals to guide risk stratification and treatment decisions. In pregnant patients with high viral load, initiation of a tenofovir-based antiviral regimen in the third trimester, combined with timely neonatal immunoprophylaxis, is recommended to minimize vertical transmission.4,8 Postpartum management should include close monitoring for hepatitis flares if antiviral therapy is discontinued, along with comprehensive patient counseling. Coordinated multidisciplinary care is essential to optimize maternal health and neonatal outcomes.

References

  1. Asafo-Agyei KO, Samant H. Pregnancy and viral hepatitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; January 22, 2025.
  2. Viral hepatitis in pregnancy: ACOG Clinical Practice Guideline No. 6. Obstet Gynecol. 2023;142(3):745-759. doi:10.1097/AOG.0000000000005300
  3. Conners EE, Panagiotakopoulos L, Hofmeister MG, et al. Screening and testing for hepatitis B virus infection: CDC recommendations – United States, 2023. MMWR Recomm Rep. 2023;72(1):1-25. doi:10.15585/mmwr.rr7201a1
  4. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Badell ML, Prabhu M, et al. Society for Maternal-Fetal Medicine Consult Series #69: Hepatitis B in pregnancy: updated guidelines. Am J Obstet Gynecol. 2024;230(4):B2-B11. doi:10.1016/j.ajog.2023.12.023
  5. US Preventive Services Task Force, Owens DK, Davidson KW, et al. Screening for hepatitis B virus infection in pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2019;322(4):349-354. doi:10.1001/jama.2019.9365
  6. American Academy of Family Physicians. Clinical preventive service recommendation: hepatitis. Accessed January 6, 2026. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/hepatitis.html
  7. Interpretation of hepatitis B serologic test results. U.S. Centers for Disease Control and Prevention. Accessed January 6, 2026. https://stacks.cdc.gov/view/cdc/31556
  8. Ghany MG, Pan CQ, Lok AS, et al. AASLD/IDSA practice guideline on treatment of chronic hepatitis B. Hepatology. Published online November 4, 2025. doi:10.1097/HEP.0000000000001549
  9. Pan CQ, Zhu L, Yu AS, Zhao Y, Zhu B, Dai E. Tenofovir alafenamide versus tenofovir disoproxil fumarate for preventing vertical transmission in chronic hepatitis B Mothers: A systematic review and meta-analysis. Clin Infect Dis. 2024;79(4):953-964. doi:10.1093/cid/ciae288
  10. Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. doi:10.15585/mmwr.rr7004a1

Prepared by:
Honey Joseph, PharmD, BCPS
Clinical Assistant Professor, Drug Information Specialist
University of Illinois at Chicago Retzky College of Pharmacy

February 2026

The information presented is current as of January 9, 2026. This information is intended as an educational piece and should not be used as the sole source for clinical decision-making.