What are the recommendations for treatment of Hepatitis C (HCV) virus infection in pregnant women?

From the Guidelines

The current recommendation for hepatitis C virus (HCV) infection during pregnancy is to consider treatment on a case-by-case basis after a discussion of potential risks and benefits, with the most recent guidelines suggesting that direct-acting antiviral (DAA) treatment may be considered during pregnancy. This is based on the latest evidence from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, as reported in the study by 1.

Key Considerations

• Screening for HCV is recommended for all pregnant women during each pregnancy, ideally at the initial prenatal visit, as supported by the Centers for Disease Control and Prevention and the study by 1.
• If a pregnant woman is diagnosed with HCV, monitoring of liver function tests is advised, and treatment should be considered based on individual circumstances.
• The use of DAAs during pregnancy or soon after delivery is being investigated, with some studies showing promising results, such as the trial of sofosbuvir/ledipasvir in pregnant women, as reported in the study by 1.
• Breastfeeding is considered safe for mothers with HCV, as the virus is not transmitted through breast milk, though caution is advised if nipples are cracked or bleeding.

Treatment Options

• After delivery, standard HCV treatment regimens can be initiated, such as glecaprevir/pibrentasvir (Mavyret) for 8-12 weeks or sofosbuvir/velpatasvir (Epclusa) for 12 weeks, depending on the genotype and presence of cirrhosis, as these medications have cure rates exceeding 95%, as reported in the study by 1.
• The risk of vertical transmission from mother to infant is approximately 5-6%, with higher rates in women who are co-infected with HIV or have high HCV viral loads, and there is currently no intervention proven to reduce this transmission risk during pregnancy or delivery, as reported in the study by 1.

Ongoing Research

• The full results of ongoing trials for treatment of hepatitis C virus during pregnancy are awaited to guide management of hepatitis C virus in this setting, as reported in the study by 1.

From the Research

Recommendations for Treatment of Hepatitis C in Pregnancy

• The Society for Maternal-Fetal Medicine recommends that obstetric care providers screen women who are at increased risk for hepatitis C infection by testing for anti-hepatitis C virus antibodies at their first prenatal visit 2.
• Direct-acting antiviral regimens should only be used in the setting of a clinical trial or antiviral treatment should be deferred to the postpartum period as direct-acting antiviral regimens are not currently approved for use in pregnancy 2.
• Patients with hepatitis C virus, including pregnant women, should be counseled to abstain from alcohol 2.
• Current guidelines recommend universal HCV screening during each pregnancy, with varying guidance regarding the use of direct-acting antivirals (DAAs) during pregnancy 3.

Management of Hepatitis C in Pregnancy

• Hepatitis C virus-positive pregnant women should be screened for other sexually transmitted diseases, including HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus 2.
• If invasive prenatal diagnostic testing is requested, women should be counseled that data on the risk of vertical transmission are reassuring but limited; amniocentesis is recommended over chorionic villus sampling given the lack of data on the latter 2.
• Cesarean delivery should not be performed solely for the indication of hepatitis C virus 2.
• Obstetric care providers should avoid internal fetal monitoring, prolonged rupture of membranes, and episiotomy in managing labor in hepatitis C virus-positive women 2.

Breastfeeding and Hepatitis C

• Providers should not discourage breast-feeding based on a positive hepatitis C virus infection status 2.

Treatment of Hepatitis C

• The combination of ledipasvir and sofosbuvir has been shown to be effective in treating genotype 1 hepatitis C virus infection, with high rates of sustained virologic response 12 weeks after treatment (SVR12) 4, 5.
• Sofosbuvir plus daclatasvir and sofosbuvir plus ledipasvir were both efficacious and well-tolerated in patients with HCV genotype 4 infection 6.