Hepatitis E (HEV) among aborted and pregnant women in Maternity any Children's Hospital, Riyadh 1995

Hepatitis E virus (HEV) infection is a known risk factor in pregnancy leading to high mortality due to fulminant hepatic failure in (10-20%) of cases, particularly in the third trimester [1,2). HEV is transmitted from infected mothers to their infants (vertical transmission) and causes significant prenatal morbidity and mortality [3].

The prevalence of anti-HEV in Saudi Arabia is estimated at 8-9% [4]. Since there are no statistics about HEV in pregnant Saudi women, we conducted a case-control study of pregnant women, including those having abortions who were admitted to Maternity and Children's Hospital (MCH). The objectives of this study were to determine the association between having HEV and abortion and to identify the risk factors for acquiring HEV.

We collected information from medical charts upon admission, family medical files in primary health care centers (PHCCs), and through direct interviews with patients. Case-patients included women up to 22 weeks of gestation , who were having abortions and were admitted to MCH from 30/5/1995 to 13/7/1995. Control-patients were pregnant women in antenatal clinics who were more than 24 gestation4eeks to be certain they exceeded the abortion period during the study. Blood samples were collected from all cases and controls. We used a standardized form to collect data on demographic characteristic, medical and family history, clinical symptoms on-admission, previous abortions, obstetric history, contraception uses, gravidity and parity, and environment (water source, hygiene level, sanitation system, number of family members per room and bed, and travel history).Odds Ratios (OR) were calculated and P-value <0.05 was considered statistically significant.

The study included 204 women, 102 case-patients and 102 control-patients; 141(70%) were Saudi and 63 (30%) were non-Saudi. The median age was 31 years (range 15-46 years). The median week of gestation for cases was 12 (range 6-22 weeks); the median week of gestation for controls was 33 (range 27-39 weeks). The median number of abortions was 1 (range 0-12); 63 % of the abortions occurred in the first trimester and 19% occurred in the second trimester. The median gravidity was 5 (range 1-17) and the median parity was 4 (range 0-12). There were 10 (4.9%) stillbirth and 19 (9.3%) prenatal deaths.

Anti-HEV was positive in 22 of cases and in 9 of controls (OR=2.8, 95%CI=1.15-7.16, P-value = 0.01). These positive HEV cases were free from rubella, toxoplasmosis, or any other cause of abortion. After stratification in univariate analysis, there was a statistically significant association between having one abortion or more and having anti-HEV (OR=8, 95% CI=1.5-58, P-value=0.002).

The use of IUCD as a contraceptive, use of traditional medicine, habitual abortion, and history of blood transfusions were statistically significant (Table 1).

Regarding the risk factors, drinking water from jerry cans and living in houses which reported having insects and flies, or sewage leaks in the area were associated with having anti-HEV, while households which employed servants were protected against having HEV (Table 2).

This study is the first to describe the prevalence of antibodies against HEV and its effects on pregnant women in Saudi Arabia. Our findings indicate that HEV IgG was significant and associated with abortion. The association between having HEV and history of one or more abortions was not confounded by habitual abortion or other risk factors .But, here we cannot confirm if these cases were infected in the past or acquired recently. It is not clear how long after infection these antibodies persist, therefore it is not known whether the antibody positively represents infection in the recent or distant past [5]. HEV IgM is not commercially available and is still under trial, however the persistence of antibodies to HEV has still to be determined [4].

Having a servant in the houses was protective; this is perhaps because the level of hygiene in a house with a servant is higher than in a house without one. Having anti-HEV is related to the level of hygiene at home and for drinking water.

Studies should be conducted to determine the association between having HEV and stillbirth, since hepatitis E is a higher risk if it occurs in the third trimester . Our study deals only with abortion, so women more than 24 gestation weeks were excluded from this study. Further analytical studies should be carried out in KSA to clarify the public health importance of HEV. Anti-HEV testing should be on a routine diagnostic basis and should be part of screening tests for any pregnant women. Emphasis should be placed on educating the public about proper hygiene levels for homes and surrounding areas and the use of insecticides for keeping insects and flies away. People need to be informed that drinking water must not be bought from unmonitored stations and emphasize the importance of proper handling and storage of water.