SUMMARY:

SMFM has released guidance on the screening, treatment and management of women infected with hepatitis C virus (HCV) in pregnancy. HCV is a global problem with at least 1% to 2.5% of women infected in the US alone. 8% of pregnant women are infected and there is a risk of transmission to the fetus.

KEY POINTS:

• Acute Hepatitis C  occurs within the first 6 months after exposure to HCV
• Most women will remain asymptomatic, with only 25% exhibiting symptoms | Symptoms typically appear within 2 to 12 weeks (range of 2 to 26 weeks) 
• 15% of patients will spontaneously clear the virus within 6 months
• Signs and symptoms of acute HCV infection
  • Fever | Fatigue | Dark urine | Clay-colored stool | Abdominal pain | Loss of appetite | Nausea and vomiting | Joint pain | Jaundice
  • Most individuals with newly acquired HCV infection will be asymptomatic 
• Signs and of chronic HCV infection
  • Most people are asymptomatic or have non-specific symptoms (e.g., chronic fatigue and depression)
  • Many eventually develop chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer
  • Chronic HCV infection is typically not recognized until asymptomatic people are identified as HCV-positive when screened for blood donation or liver function tests return an abnormal result (e.g., elevated ALT), often during routine evaluation 

HCV and Pregnancy 

• Pregnancy may be associated with a decrease in HCV liver damage, however data is conflicting 
• HCV is associated with poor pregnancy outcomes 
  • Small for gestational age 
  • Fetal growth restriction  
  • Low birthweight 
  • Increased NICU admissions  
  • Preterm birth 
  • Intrahepatic cholestasis of pregnancy (odds with HCV are increased 20-fold over non-HCV population)
• Congenital anomalies and GDM have also been reported 
• Above findings are associations only and more research is required to determine causation

HCV and Vertical Transmission 

• The risk of transmission is approximately 5%  
• Risk only for women with detectable HCV RNA during pregnancy 
• A pooled meta-analysis of 17 studies demonstrated the following risks in women with chronic HCV 
  • HIV neg: 5.8% 
  • HIV pos: 10.8% but may be lower in women using modern antiretroviral therapies 

Screening for HCV in Pregnancy 

SMFM recommends risk-based HCV screening in pregnancy

• Screen high risk women at the first prenatal visit 
  • Past or current injection drug use (even once) 
  • Blood transfusion or transplants before July 1992 
  • Unregulated tattoo 
  • Long-term hemodialysis 
  • Intranasal drug use and other percutaneous exposures 
  • Long-term hemodialysis 
  • Recipients of clotting factor concentrates produced before 1987 
  • Recipients of blood products from donor who later tested positive for HCV 
  • History of incarceration 
  • Women seeking evaluation or care for sexually transmitted infection including HIV 
  • Unexplained chronic liver disease (including persistently elevated ALT) 

SMFM recommendations (Grade 1B) 

• Test for anti-HCV antibodies at their first prenatal visit 
• Negative anti-HCV antibodies 
  • Repeat later in pregnancy in women with persistent or new risk factors 
  • If HCV exposure < 6 months, perform HCV RNA as patient may not have seroconverted  
  • Positive anti-HCV antibodies: Follow up with HCV RNA 
• Universal HCV screening is not recommended 

Obstetrical Management 

• Invasive prenatal diagnosis 
  • Data on risk of invasive testing appears ‘reassuring but limited’ 
  • Amniocentesis recommended over CVS (Grade 2C) 
• HCV is not an indication for cesarean section in isolation (Grade 1B) 
• Avoid internal fetal heart monitoring, prolonged rupture of membranes and episiotomy (Grade 1B) 

Treatment  

• Screen for other for other STDs (Grade 1B) 
  • Overlapping risk factors between HCV and HBV  
• Counsel patients to avoid alcohol (Best Practice)  
• No antiviral therapies for HCV infection are approved in pregnancy 
  • Direct-acting antiviral (DAA) agents should only be used in pregnancy in the setting of a clinical trial or defer to postpartum (Grade 1C) 
• Ribavirin is contraindicated in pregnancy due to potential teratogenicity 

Postpartum  

• Breast feeding should NOT be discouraged (Grade 1A) 
• Presence of anti-HCV antibodies in newborn is not diagnostic 
• The CDC recommends that  
  • Children should be tested for anti-HCV > age 18 months because anti-HCV from the mother might last until this age 
  • If diagnosis is desired before the child turns 18 months, testing for HCV RNA could be performed at or after the infant’s first well-child visit at age 1–2 months 
    • HCV RNA testing should then be repeated at a subsequent visit, independent of the initial HCV RNA test result 

Other Guidance on Prenatal Screening for HCV

• ACOG also currently advise risk-based screening
• USPSTF recommends universal screening, including pregnant women,  between ages 18 and 79|The USPSTF guidelines include the following data and rationale for potentially offering screening to pregnant women <18 years of age
  • HCV prevalence has doubled in women aged 15 to 44 years (2006 to 2014)
  • 0.73% of pregnant women tested had an HCV infection (2011 to 2014), with a 68% increase in the proportion of infants born to HCV-infected mothers
  • Approximately 1700 infected infants are born annually to 29,000 HCV-infected mothers
  • “Because of the increasing prevalence of HCV in women aged 15 to 44 years and in infants born to HCV-infected mothers, clinicians may want to consider screening pregnant persons younger than 18 years.” 
• CDC recommends universal screening for HCV
• AASLD and IDSA (2018) recommend universal screening in pregnancy, ideally at the initiation of prenatal care (see ‘Learn More – Primary Sources’ below)

Learn More – Primary Sources:  

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

AASLD / IDSA: HCV in Pregnancy

CDC: Hepatitis C FAQs for Health Professionals

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

Reported Prevalence of Maternal Hepatitis C Virus Infection in the United States

USPSTF: Screening for Hepatitis C Virus Infection in Adolescents and Adults US Preventive Services Task Force Recommendation Statement

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