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Hepatitis C in Women: Updated Guidance on Screening and Management

Tatyana Kushner, MD, MSCE
Released: December 1, 2020

HCV Treatment of Women of Childbearing Age and During Pregnancy

AASLD: Treatment of Women of Childbearing Age

What are the expert guidelines on treatment of HCV in women of childbearing age? Again, there are concrete AASLD recommendations.[16] For women of reproductive age with known HCV, antiviral therapy should be completed before considering pregnancy to provide a cure and avoid the previously described risks of adverse pregnancy outcomes associated with HCV, as well as to decrease the potential for vertical transmission of HCV to the infant. Therefore, if a woman of childbearing age comes to the clinic and is considering pregnancy, one should counsel about the benefits of treating her HCV infection before she becomes pregnant.

If a woman becomes pregnant while receiving HCV treatment, providers should discuss the risks and benefits of continuing treatment. Limited data are available on the safety of HCV treatment with newer direct-acting antiviral agents (DAAs) during pregnancy. In particular, there is heightened concern regarding the potential for teratogenicity during early pregnancy (the period of fetal organogenesis).

It is also important to remember that ribavirin is absolutely contraindicated in pregnancy due to its known teratogenic effects. Fortunately, ribavirin is rarely used in current treatment regimens, particularly for women of childbearing age, who typically do not have advanced HCV that might require a regimen including it. 

AASLD Statement: HCV Treatment During Pregnancy

What do the experts say about HCV treatment during pregnancy? The AASLD has stated that, despite the lack of a recommendation, treatment can be considered during pregnancy on an individual basis after a patient-physician discussion about the potential risks and benefits.[16] For women receiving therapy who become pregnant, the decision to continue therapy requires careful consideration of risk for virologic relapse, risk of vertical transmission, access and financial concerns, patient and clinician preferences, and limited safety data on DAAs in pregnancy.[24]

This is a paradigm shift for the AASLD, because the guideline panel previously had said that treatment during pregnancy was not recommended. That may have reflected a lack of data on the safety of the newer drugs. But now that more data are available on DAA use in the general population of people with HCV, the recommendation has shifted to say that treatment may be considered on a case-by-case basis during pregnancy. 

Why Consider Antiviral Therapy During Pregnancy?

Why would we consider antiviral therapy for HCV during pregnancy? There is the potential to reduce the risk of MTCT. This risk reduction has been shown in other infectious diseases, and treatment to prevent vertical transmission has been implemented in other viral illnesses, including HBV. In pregnant women with HBV and HBV RNA > 200,000 IU/mL, the AASLD recommends treatment during the third trimester of pregnancy to lower their risk of HBV transmission to the baby.[25] It is hypothesized that this risk reduction may also apply to HCV, although we do not have the data to support this supposition.

In addition, pregnancy is often a time when women are engaged in care, and it may be the only time that a woman has health insurance. Therefore, there is an opportunity to treat HCV concurrent with pregnancy and cure the mother before she may be potentially lost to follow-up or lose health insurance coverage. Having the mother engaged in treatment provides the opportunity to cure HCV in women at high risk of transmitting HCV to others, including injecting partners. There are many potential benefits. 

Risk of MTCT of HCV by Maternal HIV Serostatus

What is the risk of MTCT of HCV? The study shown on this slide provides the most cited analysis of the risk of transmission.[26] It pooled data from > 100 studies into a systematic review and meta-analysis. Taking all these data together, investigators determined that the overall the risk of MTCT of HCV was approximately 5.8% if the mother has HCV monoinfection. However, if the woman has HIV/HCV coinfection, that risk is significantly increased to 10.8%. The data from this study are the numbers that I most commonly quote in clinical practice.

Therefore, when a women with HCV presents to you for prenatal care, this is an important part of the counseling that we must provide: There is a risk of HCV transmission to their baby, and they should be aware of this risk. 

Can MTCT Be Prevented During and After Pregnancy?

Can MTCT of HCV be prevented during and after pregnancy? This slide summarizes an analysis of several studies that looked at different aspects of pregnancy management and how they might affect MTCT.[27]

Although several studies have looked at cesarean section vs vaginal delivery, the quality of the evidence is low; therefore, we should counsel women that there is no association between mode of delivery and risk of HCV transmission. Women should not be counseled to choose a certain mode of delivery to reduce their risk of HCV transmission.

There is some evidence suggesting that invasive fetal monitoring may increase transmission risk, based on a single good quality study showing an increased risk; however, a separate study showed no association. Therefore, it is appropriate to counsel women that if they have to undergo invasive fetal monitoring, there may be a slightly increased risk of HCV transmission to the infant. Although, as always, the risks and benefits of the invasive monitoring must be presented. If invasive monitoring is recommended, there is generally an important reason and it is unlikely that HCV status would affect the decision to proceed.

There are also some data demonstrating an association between prolonged rupture of membranes and increased risk of transmission. These data may guide management of the delivery. For example, if there is prolonged rupture of membranes, there may be an increased likelihood of recommending delivery by cesarean section to avoid even further prolongation.

Finally, taking into account data from 14 cohort studies, no association has been found between breastfeeding and risk of HCV transmission from mother to infant. It is important to counsel women that breastfeeding is not discouraged in the setting of HCV infection. The only caveat to that recommendation is that if there are cracked or bleeding nipples, one may desire to bottle feed during that time period. But, in general, there is no evidence of increased risk of HCV transmission with breastfeeding. 

Recommendations of SMFM Regarding Prevention of MTCT of HCV

This slide lists recommendations from the Society of Maternal-Fetal Medicine (SMFM) regarding prevention of MTCT of HCV.[28] For prenatal diagnosis, amniocentesis is recommended over chorionic villus sampling. However, this recommendation actually reflects the lack of data on chorionic villus sampling and risk of HCV transmission. 

Echoing data on the previous slide, there is no recommendation for cesarean delivery solely to prevent MTCT of HCV. Obstetric care providers are recommended to avoid internal fetal monitoring, prolonged rupture of membranes, and episiotomy in managing labor in women with HCV. As noted earlier, a risk-benefit analysis would be done with all of these procedures, but to the degree that these procedures can be avoided, the recommendation is to avoid them. It is important to note that this recommendation is based on moderate-quality evidence.

Finally, the SMFM recommends that providers not discourage breastfeeding based solely on positive HCV status. 

MTCT Most Common Cause of HCV in Children

What are the implications of MTCT in children? First, MTCT is the most common cause of HCV in children. The good news is that many infants do clear HCV on their own at a relatively young age of 2-3 years.[29] However, the development of chronic HCV infection may have an impact on the child beyond a higher rate of liver disease. There are studies showing that children who have HCV may have decreased quality of life with regard to physical and cognitive functioning and that their caregivers may also have a decreased quality of life.[29,30]

If the child is infected at birth, their liver disease may progress, and they may develop cirrhosis at younger ages than people who acquire HCV infection later in life.[29,31] They may also be at increased risk for hepatocellular carcinoma because of having HCV from birth.[29,31]

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