Society for Maternal-Fetal Medicine Consult Series #56: Hepatitis C in pregnancy—updated guidelines

Abstract

In the United States, it is estimated that 1% to 4% of pregnant women are infected with hepatitis C virus, which carries approximately a 5% risk of transmission from mother to infant. Hepatitis C virus can be transmitted to the infant in utero or during the peripartum period, and infection during pregnancy is associated with an increased risk of adverse fetal outcomes, including fetal growth restriction and low birthweight. The purpose of this document is to discuss the current evidence, provide updated recommendations regarding screening, review treatment, and address management of hepatitis C virus during pregnancy. The following are the Society for Maternal-Fetal Medicine's recommendations: (1) We suggest that third trimester assessment of fetal growth may be performed, but antenatal testing is not indicated in the setting of hepatitis C virus diagnosis alone (GRADE 2C); (2) we suggest screening for viral hepatitis in patients with a diagnosis of intrahepatic cholestasis of pregnancy at an early gestational age or with high levels of bile acids (GRADE 2C); (3) we recommend that obstetrical providers screen all pregnant patients for hepatitis C virus by testing for antiehepatitis C virus antibodies in every pregnancy (GRADE 1B); (4) we suggest that obstetrical care providers screen hepatitis C virusepositive pregnant patients for other sexually transmitted infections (if not done previously), including human immunodeficiency virus, syphilis, gonorrhea, chlamydia, and hepatitis B virus (GRADE 2C); (5) we recommend vaccination against hepatitis A and B viruses (if not immune) for patients with hepatitis C virus (GRADE 1B); (6) we recommend that direct-acting antiviral regimens only be initiated in the setting of a clinical trial during pregnancy and that people who become pregnant while taking a direct-acting antiviral should be counseled in a shared decision-making framework about the risks and benefits of continuation (GRADE 1C); ( 7) we suggest that if prenatal diagnostic testing is requested, patients are counseled that data regarding the risk of vertical transmission are reassuring but limited (GRADE 2C); (8) we recommend against cesarean delivery solely for the indication of hepatitis C virus (GRADE 1B); ( 9) we suggest that obstetrical care providers avoid internal fetal monitors and early artificial rupture of membranes when managing labor in patients with hepatitis C virus unless necessary in the course of management (ie, when unable to trace the fetal heart rate with external monitors and the alternative is proceeding with cesarean delivery) (GRADE 2B); (10) we recommend that hepatitis C virus status not alter standard breastfeeding counseling and recommendations unless nipples are cracked or bleeding (GRADE 1A).

Universal versus targeted screening for HCV infection in pregnancy in a diverse, multi‐ethnic population: Universal screening is more comprehensive

“…[1][2][3][4][5] Furthermore, testing during pregnancy enables where possible, avoidance of invasive obstetric interventions to minimize the risk of mother-to-child transmission (MTCT). [6][7][8] Based on a recent modelling study, it is estimated that there are almost 15 million women of child-bearing age (15-49 years) infected with HCV infection, 9 predominantly in low-and middleincome countries. While unsafe healthcare practices are leading drivers of HCV transmission in low-and middle-income countries, widespread use of unregulated tattooing, piercing or small cosmetic procedures represent another risk for HCV transmission in young females.…”

Sofosbuvir‐based therapy for late pregnant women and infants with severe chronic hepatitis C: A case series study

“…Currently, the safety and efficacy data of DAAs in HCV‐infected pregnant women are extremely limited, and none are licensed for use in pregnancy 1,2 . Children aged 3–11 years can be treated with DAAs; thus, children less than 3 years of age are not eligible for treatment 1,2,6 . Our current study included three unique patients who urgently required treatment, and sofosbuvir‐based DAAs were administered.…”

“…Although the “responsible inclusion of pregnant individuals in eradicating HCV” and “pregnant women with HCV prefer to be treated during pregnancy” are reasonable goals, 7,8 safety and efficacy data are lacking. Therefore, no DAAs are licensed for use in pregnancy to date 1–3,6,7,9 10 …”

“…1,2 Children aged 3-11 years can be treated with DAAs; thus, children less than 3 years of age are not eligible for treatment. 1,2,6 Our current study included three unique patients who urgently required treatment, and sofosbuvir-based DAAs were administered. Fortunately, all three patients were successfully cured with favorable tolerance and without severe adverse events or The adverse events that occurred during treatment also existed before treatment; notably, these symptoms disappeared gradually with treatment.…”

“…Therefore, no DAAs are licensed for use in pregnancy to date. [1][2][3]6,7,9 In addition, although children less than 3 years old are not eligible for DAA treatment, however, one acute HCV-infected infant cured by sofosbuvir/ledipasvir has been reported previously. 10 Most recently, Jhaveri et al 7 performed a systematic review on HCV DAA treatment in pregnancy.…”