HCV in Pregnancy Overview | HCV Screening in Pregnancy | HCV: Antepartum, Intrapartum and Postpartum Management | HCV Treatment in Pregnancy and Postpartum | HCV Professional Resources
Review the latest recommendations with
Alex Miller, MD and Katherine S. Kohari, MD, FACOG
Dr. Miller is a Maternal-Fetal Medicine fellow at the Yale School of Medicine
Dr. Kohari, a Maternal-Fetal Medicine specialist, is an Assistant Professor and the Medical Director for MFM Outpatient Services in the Department of Obstetrics and Gynecology at the Yale School of Medicine in New Haven, CT
Learning Objectives:
Upon completion of this activity, participants should be better able to:
- Understand potential risks associated with HCV and pregnancy
- Counsel patients regarding the potential for vertical transmission
- Care for pregnant patients with HCV during labor and birth
- Counsel patients regarding lactation practices
- Understand longitudinal health maintenance and recommendations
Contents:
- Management of Patients with HCV During Pregnancy
- Initial Testing and Follow-up
- Vertical Transmission and Intrapartum Management
- Lactation Considerations of Patients with HCV
- Newborn Considerations
- Postpartum Management of Patients with HCV
- Key Points
- Learn More – Primary Resources
Management of Patients with HCV During Pregnancy
HCV is now considered a curable disease, although treatments have not been evaluated for use in pregnancy
- Until therapy during pregnancy is an option, management during pregnancy is focused on lifestyle modification, establishment of care with a specialist for long term treatment, and optimization of pregnancy
- HCV treatment should be pursued prior to planned pregnancy
- Patients with HCV in pregnancy should be counseled on the associated increased risk of adverse maternal outcomes
- Associated outcomes may be due to confounders in this population therefore more research is required to elucidate if risks are due to HCV or confounding factors
- Increased maternal risks include
- Risk of blood transfusion
- Abnormalities in liver function testing
- Diagnosis of intrahepatic cholestasis of pregnancy
- ICU admission especially in the setting of cirrhosis
- Fetal risks include
- Fetal growth restriction
- Small for gestational age
- Pregnancy does not appear to worsen disease course or progression
- Pregnancy is an optimal time to effect change on lifestyle, such as initiating opiate replacement therapy and smoking cessation
- Alcohol cessation is an important aspect of improving clinical outcomes
Initial Testing and Follow-up
Initial testing
- Evaluation of HCV RNA often with viral genotyping
- ALT, AST, bilirubin, CBC with platelet count, albumin, prothrombin time, INR
- STI testing
- Hepatitis A
Serial testing
- Evaluation of liver function
- Repeat viral load in third trimester to assess for spontaneous clearance
If clinical suspicion of cirrhosis
- Serum fibrosis marker panels (i.e. FIB-4 index, AST to platelet ratio index (APRI))
- Transient elastography via ultrasound (i.e. Fibroscan)
- Liver imaging (US or CT)
Patients desiring invasive or diagnostic genetic testing for the pregnancy
- Limited data to guide recommendations
- Amniocentesis does not increase risk for vertical transmission, however this data is small and not stratified by amount of circulating viral RNA
- No data on chorionic villus sampling
Fetal management
- There are no set guidelines for management for the fetus
- Serial assessment of fetal growth in the third trimester due to increased associated risk for fetal growth restrictions and small for gestational age newborns
Vertical Transmission/Intrapartum Management
Transfer of the HCV can occur at any point during pregnancy as well as during labor and delivery.
- The overall rate of vertical transmission is estimated to be between 2 to 8%
- It is estimated that a majority of cases of vertical transmission occur in the last month of pregnancy or during labor and delivery
- Importantly, vertical transmission accounts for most cases of childhood HCV infection
- It has been documented that co-infection with HIV increases the risk of vertical transmission, as well as maternal HCV disease progression
- Undetectable viral loads significantly decreases the risk for vertical transmission to almost negligible
- Rates of transmission are irrespective of mode of delivery; therefore, cesarean delivery should be reserved for obstetric indications
Note: It is unclear whether the HCV viral load affects the risk of vertical transmission. | Various studies have shown an association for increased risk of transmission with higher viral loads, while others have not | However, if the viral load is undetectable then the risk for vertical transmission is negligible
- Risk factors reported to increase risk for vertical transmission
- Maternal co-infection with HIV
- Detectable viral load of HCV
- Use of internal monitoring both uterine and fetal scalp electrode
- Episiotomy
- Rupture of membranes >6hrs
Note: Much of this data is derived from retrospective observational data with very small sample sizes |There have been no direct studies on interventions such as internal monitoring and some associations have conflicting results
Lactation
- HCV RNA has been detected in colostrum and breastmilk of infected women; however there is no evidence of newborn transmission via breastmilk
- Additionally, the presence of HCV RNA in breastmilk is independent of maternal viral load
- Therefore, women with HCV who are HIV negative should be encouraged to breastfeed
- If cracked or bloody nipples occur
- Breastmilk should be discarded until healing is complete due to the unknown risk for transmission
Newborn Considerations
- Neonates born to mothers with HCV, even after adjustment for gestational age, have been reported to have
- Increased rate of NICU admission
- Need for assisted ventilation and SGA
- Other associations reported include feeding difficulties and neonatal seizures
- It is unclear the exact pathophysiology for these associations and whether it is truly related to the presence of the virus or with confounders in the population
- Newborns are born with maternal HCV antibodies, most of which are cleared by 18 months of life.
- HCV infection is diagnosed by the presence of viral RNA in the newborn
- Similar to adults, most children clear HCV infection over time
- Infants born to mothers with HCV should undergo serial laboratory assessment of anti-HCV antibody testing at 18 months or HCV RNA twice between 2 and 6 months of age
Postpartum Management
- If not previously done, women in the postpartum period should establish care with a hepatologist or infectious disease specialist to aide in the initiation of treatment of HCV with a direct-acting anti-viral medication (DAA)
- Pre-therapy workup can begin in the postpartum period.
- DAA therapy is not recommended during lactation and therefore patients should be counseled to refrain from initiation until lactation is completed
Contraception
- Almost all forms of contraception are safe for use in women with HCV
- Combined oral contraceptives should be avoided in women with acute HCV infection or in women with liver cirrhosis
- Continuation of lifestyle modifications (opioid replacement therapy, smoking cessation, etc.) should be emphasized postpartum
KEY POINTS:
- Pregnant women with HCV are reported to have increased rates of adverse maternal outcomes, including cesarean delivery, transfusion, and ICU admission
- Serial growth scans are recommended during pregnancy to detect fetal growth restriction
- Pregnancy does not worsen HCV
- The risk of vertical transmission has been estimated to be between 2 to 8%
- There is no difference in rate of vertical transmission based on mode of delivery
- Presence of HCV in a laboring patient should generally not alter obstetric management
- Breastfeeding should be encouraged in women with HCV
- Neonates born to mothers with HCV have been reported to have increased rate of NICU admission, need for assisted ventilation and small for gestational age
Learn More – Primary Resources:
SMFM: Consult Series #56: Hepatitis C in pregnancy—updated guidelines
United States CDC Medical Eligibility Criteria for Contraception
Commercial Support
This educational activity is supported by an independent educational grant from Gilead Sciences
Faculty Disclosures
Dr. Miller has no relevant financial relationships to disclose
Dr. Kohari has no relevant financial relationships to disclose