SMFM Consult Series #43, Hepatitis C in pregnancy: screening, treatment, and management

Women at increased risk for hepatitis C virus (HCV) should be screened with anti-hepatitis C virus antibodies. 

Pregnant women with HCV: 

• Abstain from alcohol
• DAA regimens only be used in the research setting or be deferred postpartum
• Amniocentesis is recommended over chorionic villus sampling 
• Against cesarean delivery solely for the indication of hepatitis C
• Internal fetal monitoring, prolonged rupture of membranes, and episiotomy should be avoided

 Diagnosis/definition:

•  Acute: The first 6 months after exposure to HCV. Asymptomatic in 75% of cases; when symptoms occur, they include abdominal pain, nausea, anorexia, jaundice, or malaise. 15% of infected individuals spontaneously clear HCV within 6 months of infection.
• Chronic: Those who do not clear the virus and harbor it for the rest of their lives. It accounts for most HCV-associated morbidity and mortality. Asymptomatic, although it can cause progressive liver damage with serious consequences. 15-30% of patients with chronic HCV infection develop cirrhosis within 20 years. 27% of those with cirrhosis develop hepatocellular carcinoma (HCC) within 10 years. HCC is a primary cause of mortality from HCV infection.

Epidemiology/Incidence:

• Up to 8% of pregnant women are infected with hepatitis C virus (HCV).
• In the United States, the estimated prevalence of antenatal HCV infection is 1-2.5%.

Management: 

Screening/Work-up:

• Screen women who are at increased risk for HCV by testing for anti-HCV antibodies at their first prenatal visit. 
•  If initial results are negative, HCV screening should be repeated later in pregnancy in women with persistent or new risk factors for HCV infection (eg, new or ongoing use of injected or intranasal illicit drugs).
• Against universal screening during pregnancy at this time.
• Diagnosis of HCV infection depends on detection of anti-HCV antibodies and HCV RNA
•  Antibody test: A positive antibody test: active HCV infection (acute or chronic), or past infection that has resolved, or false positive. If positive: a quantitative nucleic acid test for HCV RNA.
• HCV RNA PCR: 
• • HCV viremia:  HCV RNA in the blood, active infection (1-3 weeks after exposure.)
• • Negative HCV RNA within the past 6 months & patient newly found to be viremic acute HCV infection is confirmed.
• • No previous testing for hepatitis C tests & positive for both anti-HCV antibodies and HCV RNA: cannot distinguish acute from chronic HCV infection.
•  Exposure to HCV within 6month and antibody negative
•  DO PCR (seroconversion may not have happened yet).
•  Screen HCV-positive pregnant women for other sexually transmitted diseases, including HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV).

Treatment:

• Patients with HCV, including pregnant women, be counseled to abstain from alcohol.
• None of the antiviral therapies (Second generation DAA) recommended for HCV infection are currently approved for use in pregnant women.
• Ribavirin is contraindicated in pregnancy (embryocidal and/or teratogenic effects in all animal species studied).
• DAA regimens only be used in the setting of a clinical trial or that antiviral treatment be deferred to the postpartum period as DAA regimens are not currently approved for use in pregnancy.
• Methods to reduce vertical transmission:
• Invasive prenatal diagnostic testing is requested, women be counseled that data on the risk of vertical transmission are reassuring but limited; amniocentesis is recommended over chorionic villus sampling given the lack of data on the latter.
• Cesarean Delivery is not recommended for the solely indication of HCV.
• Internal fetal monitoring, prolonged rupture of membranes, and episiotomy should be avoided in managing labor in HCV-positive women.
• Breastfeeding should not be discouraged.