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
• 15% of patients will spontaneously clear the virus within 6 months

Definition of Acute vs Chronic

Acute Hepatitis C

• Clinical Criteria for Diagnosis (CDC 2016 Case Definition)
  • Illness with discrete onset of any sign or symptom consistent with acute viral hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, and abdominal pain)
    AND
    (a) jaundice, OR
    (b) a peak elevated serum alanine aminotransferase (ALT) level >200 IU/L during the period of acute illness
• Laboratory Criteria for Diagnosis (CDC 2016 Case Definition)
  • A positive test for antibodies to hepatitis C virus (anti-HCV)
  • Hepatitis C virus detection test
    • Nucleic acid test (NAT) for HCV RNA positive (including qualitative, quantitative or genotype testing)
    • A positive test indicating presence of hepatitis C viral antigen(s) (HCV antigen)

Chronic Hepatitis C 

• Describes those patients who will not clear the virus  
• Associated Morbidity and Mortality 
  • 15-30% cirrhosis within 20 years 
  • 27% of cirrhosis go on to liver cancer (hepatocellular carcinoma) within 10 years 

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

•  CDC and ACOG also currently advise risk-based screening
• 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

Hepatitis C, Acute 2016 Case Definition

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