Hepatitis E in pregnancy — DTM&H MCQ

Correct answer: A — Hepatitis E

Hepatitis E (option A) is the correct answer. Hepatitis E virus (genotypes 1 and 2, endemic in South Asia) spreads by the faecal-oral route via contaminated water, and flooding of the water supply is the classic epidemiological trigger for large waterborne outbreaks. Pregnancy is a specific risk factor for severe HEV disease: infection in the third trimester carries a markedly increased risk of fulminant hepatic failure, and this combination of jaundice, malaise and markedly raised transaminases in a pregnant woman after a flood in a South Asian setting is textbook for HEV. During HEV infection, the risk of progression towards fulminant hepatitis is higher among pregnant women as compared to men and non-pregnant women. This pattern (source, geography, gestation, severity) is the key discriminator that separates HEV from the other hepatotropic causes listed. Why the other options are wrong: B. Hepatitis C: transmitted parenterally (blood, needles, vertically), not via faecal-oral contaminated water, so a flood-associated outbreak does not fit; it also does not have the same pregnancy-specific fulminant risk. D. Leptospirosis: follows exposure to water contaminated with infected animal urine and causes jaundice with renal impairment and conjunctival suffusion, but transaminases are only mildly to moderately raised rather than markedly elevated as in viral hepatitis. C. Amoebic liver abscess: presents with fever and right upper quadrant pain with a mass lesion on imaging, not diffuse hepatocellular jaundice with markedly raised transaminases, and it is not linked to acute flooding outbreaks. E. Yellow fever: is transmitted by Aedes mosquitoes, not water contamination, and is not endemic in Nepal. Key point: markedly raised transaminases plus jaundice in a pregnant woman after a flood-contaminated water supply in a South Asian endemic area points to hepatitis E, which carries a specific risk of fulminant hepatic failure in pregnancy.

Reference: Hakim MS et al. The global burden of hepatitis E outbreaks: a systematic review. Liver International 2017; 37(1):19-31 (Wiley); see also UKHSA guidance on hepatitis E (gov.uk).