Hepatitis C Virus in Pregnancy
1. What every clinician should know
Clinical features and incidence
The prevalence of the hepatitis C virus (HCV) in the U.S. is estimated at 1.6%. The prevalence of HCV in reproductive-aged women has not been definitively studied, but ranges from 0.6-2.4%. Reproductive-aged women are not routinely screened for HCV in the U.S., as no effective treatment is currently available during pregnancy. The mother-To-child Transmission rate of HCV is estimated at 5-8%, with increased efficiency in those patients with HIV coinfection approaching 15-18%.
The following conditions can underlie HCV in pregnancy:
Multiple sexual partners
Risk factors for mother-To-child transmission mirror those of HIV: viremia, duration of rupture of membranes, use of internal monitoring and exposure to maternal blood. To date, there is no definitive study that suggests obstetric intervention, such as cesarean delivery, will prevent mother-to-child transmission of HCV.
Breastfeeding is not contraindicated in HCV positive patients.
If a patient is found to be HCV+ on antibody testing but has no demonstrable viral load, the risk of mother-To-child transmission is essentially 0%.
2. Diagnosis and differential diagnosis
The screening test for HCV is antibody testing: order HCV antibody via ELISA. Sensititivity and specificity is 99%. Confirmatory testing is via RIBA or more commonly RT-PCR for assessment of viral load. (See Figure 1: Interpretation of HCV assays.)
CDC recommendations for HCV screening: Ever use of intravenous drugs, history of receiving clotting factor concentrates produced prior to 1987, persons with blood transfusion/organ transplant prior to 1992 (when effective screening of donors became available), persons on hemodialysis, persons with persistently elevated liver transaminases, healthcare workers with known exposure, and children born to HCV infected mothers (a population not routinely screened).
The American Congress of Obstetricians and Gynecologists (ACOG) states the following populations are of uncertain need for HCV screening: recipients of tissue transplants, users of other illicit/noninjected drugs, history of tattoos or body-piercing, history of STDs or multiple sexual partners, long-term sex partner of an HCV-infected individual.
Routine screening for HCV has not been shown to be cost-effective, however risk-factor based screening may underestimate the affected population, as 40% of women seropositive for HCV may have no known identifiable risk factor.
In patients with history of opiate abuse, incarceration, prostitution or objective signs of hepatitis (jaundice, nausea, fatigue, malaise, RUQ pain, itching), testing would be recommended.
In the setting of acute HCV, treatment is supportive. Consultation with hepatology is warranted to determine propriety of initiating treatment.
Current therapies for Chronic HCV are considered Category X in pregnancy and therefore not recommended. There are, however, case studies of successful pregnancy outcomes in patients exposed to Ribavirin/Interferon during pregnancy.
In patients with HCV in pregnancy, vaccinations for HBV and HAV are recommended.
Recommendations to avoid alcohol and acetaminophen should be made.
Reducing shared household items and encouraging safe sexual practices to reduce transmission risks also are recommended.
While pregnant, it is important to assess degree of liver impairment, as an acute blood loss is inevitable and liver function essential to blood clotting. Recommend testing coagulation factors (Platelets, PT/PTT/INR, fibrinogen) so appropriate anticipation of blood product replacement can be enhanced.
HCV genotype should be performed, as postpartum treatment success may depend upon genotype.
Generally, pregnancy does not alter the course of hepatitis C. If cirrhosis is present, there is a higher chance of developing acute fatty liver due to the extra demands of pregnancy.
5. Prognosis and outcome
60% of patients with HCV develop chronic infection, of whom 20% will develop cirrhosis. HCV is a leading cause of death from liver disease and the leading cause of liver transplant.
Spontaneous resolution of the disease is more common in young women and infants than older adults contracting acute HCV.
Non type-1 genotypes and those with lower viral loads are more likely to respond to treatment.
Pregnancy is not known to alter the disease course in mothers.
Pregnancies of mothers with HCV can be complicated by low birthweight, small for gestational age infants, NICU admissions, need for mechanical ventilation, gestational diabetes and cholestasis of pregnancy, though data in this regard is limited.
The mother-to-child transmission rate is 5-8%, in absence of HIV coinfection.
6. What is the evidence for specific management and treatment recommendations
Benova, L, Mohamoud, YA, Calvert, C, Abu-Raddad, LJ. “Vertical transmission of hepatitis C virus: systematic review and meta-analysis”. Clin Infect Dis. vol. pii. 2014. pp. ciu 447
Gentile, I, Zappulo, E, Buonomo, AR, Borgia, G. “Prevention of mother-to-child transmission of hepatitis B virus and hepatitis C virus”. Expert Rev Anti Infect Ther. vol. 12. 2014. pp. 775-82.
Floreani, A. “Hepatitis C and pregnancy”. World J Gastroenterol. vol. 19. 2013. pp. 6714-20.
Mover, VA. “U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: recommendation statement”. Ann Intern Med . vol. 159. 2013. pp. 349-57.
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