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Until 2018, the recommendations for testing women for HCV during pregnancy had been focused on risk-based screening. That is, if women come to prenatal care and report that they have risk for HCV—eg, injection-drug use, having been born to a mother with HCV themselves, being a dialysis patient, being infected with HIV—the recommendation would be to screen them for HCV during pregnancy. However, there had always been the issue of whether women would reliably report those risks. We do know that risk is often underreported in pregnancy.
Due to this recognition of underreporting of risk behaviors, as well as the documented increase in HCV among women of childbearing age over the last 10 years, the American Association for the Study of Liver Diseases (AASLD), which issues HCV guidelines jointly with the Infectious Diseases Society of America (IDSA), made the recommendation in May 2018 to start universal screening for HCV during pregnancy. By these recommendations, all women who present to prenatal care should be screened for HCV.
More recently, other major guideline panels have echoed the AASLD/IDSA recommendation, again in recognition of the increase in HCV infections, particularly among women of reproductive age. This slide reflects a new recommendation released by the US Preventive Services Task Force (USPSTF) in 2020 that all adults 18-79 years of age be screened for HCV. That recommendation, of course, includes women who are pregnant and those of childbearing age. The USPSTF specifically cited evidence showing an increase in HCV among pregnant women, women of childbearing age, and infants of mothers with HCV infection, demonstrating the importance of screening all women during pregnancy.
Subsequent to that recommendation, the CDC revised their guidance to also recommend HCV screening for all pregnant women—not just women with known risk—during each pregnancy, except in settings where the prevalence of HCV infection is very low. A helpful resource for tracking HCV statistics in one’s state can be found here: https://hepvu.org/local-data/#/.
On the other hand, the American College of Obstetricians and Gynecologists (ACOG) still has not endorsed universal HCV screening for all pregnant women; their guidelines still recommend risk-based screening. However, in response to the updated USPSTF and CDC recommendations, ACOG reported that they are reviewing their practice bulletin on the subject and may update their guidance soon.
It may be difficult to implement widespread universal screening across practice settings without ACOG’s endorsement of this strategy, because obstetricians—the frontline providers of care during pregnancy—are the providers who are ultimately doing the prenatal screening.
A potential concern regarding universal screening for HCV during pregnancy is whether it is cost-effective to screen all pregnant women vs only those with documented risk factors. Several studies have evaluated this question.[13-15] This slide represents the results of one of those studies; it analyzed cost-effectiveness of implementing universal HCV screening compared with risk-based screening during pregnancy across different healthcare settings with different HCV prevalence rates.
The study authors found that HCV screening is indeed cost-effective, even in relatively low prevalence settings and across all liver fibrosis stages. They found that universal screening during pregnancy would allow for identification of significantly more women (~ 33,000 more) and infants (~ 300 more) with HCV compared with risk-based screening.
How do we counsel and monitor women when they are diagnosed with HCV during pregnancy? There are several concrete AASLD recommendations. To determine the severity of the HCV disease, HCV RNA and routine liver function tests must be ordered.
Regardless of the severity of liver disease, all pregnant women with HCV should receive appropriate prenatal and intrapartum care. At this time, no known intervention significantly reduces mother-to-child transmission (MTCT) of HCV, so not many obstetric management considerations need to be implemented.
In pregnant women with HCV and pruritus or jaundice, there should be a high index of suspicion for intrahepatic cholestasis of pregnancy (ICP). The association between HCV and ICP has been well established.[17,18] Therefore, it is important to counsel women to be on the lookout for the symptoms of this complication of pregnancy.
Finally, women with HCV and cirrhosis should be counseled about an increased risk of adverse maternal and perinatal outcomes.
I recommend that all pregnant women with HCV—not just those with cirrhosis—be followed by a high-risk pregnancy obstetrician, recognizing that those recommendations may vary based on practice settings.