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Hepatitis C in Pregnancy

Lakecia Pitts, MD, Matthew Zeitler, MD, and Michael Baca-Atlas, MD
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In the US, 1-2.5% of pregnant women have Hepatitis C, so we may very well come across this in our practice. Listen in as Matt and Michael discuss Hepatitis C in pregnancy with HIV fellowship-trained Family Medicine physician, Dr. Lakecia Pitts.

Pearls:

  • Screen for HCV with an antibody test at least once in pregnancy and more frequently based on ongoing risk because HCV is associated with adverse neonatal and pregnancy outcomes.

  • Breastfeeding is safe in pregnancy if there is no cracking or bleeding.

  • For infants born to mothers with HCV, test them at 18 months with an antibody test.

 

  • Epidemiology:

    • Hepatitis C (HCV) is the most common blood-borne pathogen in the US

      • Sexual transmission is much lower and less common than HIV or Hep B

    • 1-3% of pregnant women have HCV and about 5-7% of them have a risk of transmitting to their infants

    • 50% of maternal-child transmission occurs before the last month of pregnancy

  • Effects on mother and infant:

    • Infant - small for gestational age, low birth weight or growth restricted, subsequently admitted to the NICU after they're born, and need for assisted ventilation or breathing support

    • Mother - intrahepatic cholestasis of pregnancy (20x more likely), preterm delivery, preeclampsia, gestational diabetes

  • Screening:

    • USPSTF and CDC recommend routine screening of all pregnant women with a HCV antibody test

    • Re-screen in late third trimester for women with ongoing risk factors such as IV drug use, history of incarceration, unexplained liver disease or women who had tattoos at unlicensed facilities

    • If the antibody comes back positive, check:

      • RNA level OR if you have a strong suspicion for infection with the past 6 months, check an RNA level because they may not have converted yet

      • LFTs

      • CBC for platelets

      • Hep A and B immunity

  • Antepartum tips during pregnancy:

    • Not currently recommended because none of the direct acting antivirals are approved for use during pregnancy and the older medications (interferon) are teratogenic

    • Counsel on avoidance of alcohol, limiting acetaminophen use to < 2g if advanced liver disease

    • No need to routinely check liver labs unless there is a change in the clinical picture

    • Amniocentesis is preferred method of genetic testing because there is less data about chorionic villus sampling

    • Pearl: Vaginal delivery is possible as mode of delivery has not been shown to be a risk factor for vertical transmission

  • Intrapartum management:

    • Procedures that increase the risk of vertical transmission include: fetal scalp electrodes, instrumented vaginal deliveries, episiotomies

    • Prolonged rupture of membranes >18 hours also increases vertical transmission

  • Breastfeeding and HCV:

    • Breastfeeding is safe if nipples aren’t cracked or bleeding

    • If cracked or bleeding, then encourage pumping and dumping

  • Postpartum:

    • Infant:

      • Test at 18 months with HCV antibody test. Maternal antibodies can circulate leading to false positives if testing earlier.

      • Confirm HCV RNA on a second sample if antibody positive

      • If they have HCV, treatment doesn’t start until age 3. Important to counsel of ways to avoid blood exposure (ie: sharing razors, toothbrushes)

    • Mother:

      • Ok to defer treatment until after breastfeeding is completed

      • Up to 25% of women will clear HCV in the postpartum period

 

References:

  1. Chappell CA, et al. Ledipasvir plus sofosbuvir in pregnant women with hepatitis C virus infection: a phase 1 pharmacokinetic study. Lancet Microbe. 2020;1(5):e200-e208. PMID: 32939459

  2. Hochman JA, Balistreri WF. Chronic viral hepatitis: always be current!. Pediatr Rev. 2003;24(12):399-410. PMID: 14645627

  3. Mast EE, et al. Risk factors for perinatal transmission of hepatitis C virus (HCV) and the natural history of HCV infection acquired in infancy. J Infect Dis. 2005;192(11):1880-1889. PMID: 16267758

  4. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Hughes BL, Page CM, Kuller JA. Hepatitis C in pregnancy: screening, treatment, and management. Am J Obstet Gynecol. 2017;217(5):B2-B12. PMID: 28782502

  5. AASLD-IDSA HCV Guidance Panel. Hepatitis C Guidance 2018 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection. Clin Infect Dis. 2018;67(10):1477-1492. PMID: 30215672

  6. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Hughes BL, Page CM, Kuller JA. Hepatitis C in pregnancy: screening, treatment, and management. Am J Obstet Gynecol. 2017;217(5):B2-B12. PMID: 28782502

  7. Liu M, Wu R, Liu X, et al. Validation of the GALAD Model and Establishment of GAAP Model for Diagnosis of Hepatocellular Carcinoma in Chinese Patients. J Hepatocell Carcinoma. 2020;7:219-232. Published 2020 Oct 23. PMID: 33123501

  8. US Preventive Services Task Force, Owens DK, Davidson KW, et al. Screening for Hepatitis C Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020;323(10):970-975. PMID: 32119076

  9. Centers for Disease Control and Prevention (CDC). Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep. 2013;62(18):362-365. PMID: 23657112

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Hippo Primary Care Written Summary December 2021 233 KB - PDF

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