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CMECNE

SMFM Releases Guidelines on Screening and Management of Hepatitis C in Pregnancy 

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the latest recommendations for HCV screening in pregnancy
2. State the management of women with HCV in pregnancy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

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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Related ObG Topics:

Practical obstetrics info for your women's healthcare practice
STD Screening in Pregnancy: CDC Recommendations
What is the Effect of Hepatitis C on Fertility and Pregnancy Outcomes?

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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

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Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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