In the United States each year, 24,000 infants are born to women who are infected with the hepatitis B virus (HBV) and an estimated 1000 newborns acquire the infection through vertical transmission from their mother. The approach to a pregnant patient with HBV infection includes assessing the need for therapy in the mother and evaluating possible interventions that may reduce mother-to-child transmission of HBV infection. Rates of mother-to-child transmission of HBV can be greatly reduced if the current guidelines for screening and immunization are universally followed. The use of oral antiviral therapy in highly viremic mothers to reduce mother-to-child transmission is controversial but should be considered on a case-by-case basis, realizing that the available antiviral medications to treat HBV are not approved by the Food and Drug Administration for use during pregnancy. We review the literature and present our suggested management approach to the pregnant patient with chronic HBV.