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HCV in Pregnancy Overview

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 case, participants should be able to:

  • Understand incidence and risk factors for hepatitis C virus (HCV) in pregnancy
  • Define recommendations for screening for HCV in pregnancy
  • Identify treatment goals during pregnancy

Contents

The Case

A 26 yo G1P0 presents to your office for an initial prenatal visit

  • She is approximately 11 weeks by her last menstrual period
  • In eliciting her history, she recounts a period in her late teens when she used opiates and heroin
  • You include a HCV antibody test in her initial prenatal labs, which results as positive
  • You now need to discuss the results, follow-up testing, and implications to this pregnancy

SYNOPSIS:

Incidence and Risks of of HCV in Pregnancy 

Although estimates during pregnancy vary, rates of HCV at time of childbirth have dramatically increased over the past ten years

  • The exact prevalence for HCV in pregnant women is difficult to determine as it was only added to birth certificate data in 2003
  • The incidence of HCV among pregnant women in the US is on the rise partly due to the opioid epidemic and the use of intravenous illicit drugs
  • The most recent MMWR on HCV and pregnancy reports the presence of HCV at the time of birth to be 3.4 per 1000 births during the time period of 2009-2014
  • A recent population-based retrospective cohort of the time period 2009-2017 reported an incidence of 4.7 per 1000 live births
  • Importantly, the presence of HCV at the time of childbirth increased 161% during this period.

HCV is the most common cause of chronic liver disease in the US

  • While 15 to 45% of patients who contract HCV will go on to completely clear the virus, the remainder will have chronic infection
  • Chronic infection increases the risk for cirrhosis and subsequent hepatocellular carcinoma

HCV during pregnancy has increased maternal and fetal risks

  • For pregnant women, HCV infection confers additional risk for fetal growth restriction, as well as concern for vertical transmission. 
  • There is a 5% risk for vertical transmission which can occur during antepartum or intrapartum
  • There is an increased risk for co-infection with STIs in pregnant women with HCV infection and appropriate screening should be performed
  • Avoidance of invasive procedures such as amniocentesis and the use of fetal scalp electrodes are thought to reduce this risk, although they have never been directly studied.

Screening Guidelines

Multiple organizations recommend universal HCV screenings | Given the increasing incidence of HCV infection in women of childbearing age, there has been movement towards the recommendation of universal screening for HCV in each pregnancy

  • Currently, the CDC, USPTF, AASLD, and IDSA recommend universal screening except in locations where the baseline prevalence is <0.1%
  • SMFM and ACOG are aligned with the above organizations and recommend routine screening during each pregnancy

Note: During pregnancy patients should be tested for hepatitis B, HIV, gonorrhea, chlamydia, and syphilis

HCV Testing During Pregnancy

  • HCV is performed by screening with antibody testing
    • If this results as positive for the presence of HCV antibody, next step is to check the amount of HCV RNA in the patient’s blood
    • If HCV RNA is present, then patient has a current HCV infection
  • For patients with HCV infection, assessment of liver function with LFTs and a coagulation profile should be assessed
    • Additional testing may be performed with the purpose of preparing the patient for initiation of treatment once delivered
  • There does not appear to be a role for serial assessment of viral load or liver function

Intrapartum Management

  • While there is a risk of vertical transmission, there are no current interventions or treatments to reduce this risk | The mode of delivery does not appear to prevent transmission, regardless of viral load
  • Generally operative vaginal delivery and fetal scalp electrode use should be discouraged
  • Increased rates of vertical transmission have been reported with the use of episiotomy and in instances of prolonged rupture of membranes

Postpartum Management

  • Lactation should be encouraged for women with HCV infection
  • If cracked or bleeding nipples occur, milk should be discarded until healing is completed
  • Women should complete lactation prior to initiating treatment for HCV infection

HCV Treatment

Guidelines now recommend treatment for all patients with chronic HCV infection, except pregnant women and those with a short life expectancy not expected to be altered with treatment

  • The first line treatment for HCV is now with a direct acting antiviral or DAA
  • These medications are better tolerated and more effective than older regimens which were primarily pegylated interferon and ribavirin
  • The role of the OBGYN should be to advocate for the patient to establish care with an infectious disease or hepatology specialist with plan for treatment initiation postpartum once lactation is complete

KEY POINTS:

  • Pregnancies in women with HCV often proceed without major complication but obstetricians should view this diagnosis as an opportunity to enhance access to medical care
  • There is no current treatment for HCV in pregnancy, but with the advent of DAA’s, chronic HCV can be considered curable
  • Patients should establish care with a hepatologist for long term follow up and initiation of treatment

Learn More – Primary Sources

Does My Pregnant Patient Have Hepatitis C? Screening and Next Steps – Curbside Consult

Reported Prevalence of Maternal Hepatitis C Virus Infection in the United States. Obstetrics and Gynecology (Rossi et al. Obstet Gynecol, 2020)

Hepatitis C Virus Infection Among Women Giving Birth — Tennessee and United States, 2009–2014 (Patrick et al. CDC Guidelines, 2017)

ACOG Practice Advisory: Routine Hepatitis C Virus Screening in Pregnant Individuals

SMFM: Consult Series #56: Hepatitis C in pregnancy—updated guidelines

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