What are the management and treatment recommendations for Hepatitis C Virus (HCV) infection during pregnancy and lactation?

Management and Treatment of HCV Infection During Pregnancy and Lactation

Direct-acting antiviral (DAA) treatment for HCV is not recommended during pregnancy due to insufficient safety data, and management should focus on screening, monitoring, and planning for postpartum treatment.

Screening and Diagnosis

• Universal screening is recommended for all pregnant women for HCV by testing for anti-HCV antibodies at their first prenatal visit 1
• If initial results are negative, repeat screening later in pregnancy for women with persistent or new risk factors (e.g., ongoing drug use) 2
• For confirmed HCV infection, recommended laboratory tests include:
  • Liver function tests (AST, ALT, bilirubin)
  • Albumin
  • Platelet count
  • Prothrombin time
  • Quantitative HCV RNA
  • HCV genotype (if not previously obtained) 1

Additional Testing for HCV-Positive Pregnant Women

• Screen for other sexually transmitted infections:
  • HIV
  • Syphilis
  • Gonorrhea
  • Chlamydia
  • Hepatitis B virus 1, 2
• Vaccination against HAV and HBV (if not immune) is recommended 1

Monitoring During Pregnancy

• Serial laboratory surveillance of liver function or viral load during pregnancy is generally not recommended 1
• Third trimester assessment of fetal growth may be performed, but antenatal testing is not indicated for HCV diagnosis alone 1
• Consider screening for intrahepatic cholestasis of pregnancy, as HCV increases this risk 3

Treatment Considerations

• Currently, no DAA therapies are approved for use during pregnancy 1
• Treatment should be deferred to the postpartum period in most cases 1
• DAA regimens should only be initiated during pregnancy in the setting of a clinical trial 1
• If a woman becomes pregnant while taking DAAs, shared decision-making regarding continuation should occur, with counseling that:
  • Animal data do not suggest teratogenic risk
  • Human data are limited 1
  • A phase 1 trial of ledipasvir/sofosbuvir showed promising results with 100% cure rates and no significant adverse effects 1

Labor and Delivery Management

• Cesarean delivery is not recommended solely for the indication of HCV 1
• Avoid if possible:
  • Internal fetal monitoring
  • Early artificial rupture of membranes
  • Episiotomy 1, 2
• These interventions should only be used when necessary for standard obstetric indications 1

Breastfeeding Recommendations

• HCV status should not alter standard breastfeeding recommendations 1
• Breastfeeding is not contraindicated in women with HCV 1
• Exception: Temporarily suspend breastfeeding if nipples are cracked or bleeding due to risk of blood exposure 1

Postpartum Care

• Women of reproductive age with HCV should be counseled to undergo antiviral treatment before pregnancy or after delivery and breastfeeding 1
• DAA therapy should be initiated postpartum for optimal maternal outcomes and to prevent transmission in future pregnancies 1

Future Considerations

• Emerging data suggest DAAs may be safe during pregnancy:
  • A phase 1 trial of ledipasvir/sofosbuvir showed 100% cure rates with no significant adverse effects 1
  • Limited data from 74 women treated with DAAs during pregnancy showed 98.4% SVR12 with no serious adverse events 3
  • However, more research is needed before routine use can be recommended 4, 5

Common Pitfalls to Avoid

• Don't perform cesarean delivery solely for HCV status
• Don't discourage breastfeeding based on HCV status alone
• Don't routinely perform serial liver function tests or viral load monitoring during pregnancy
• Don't initiate DAA treatment during pregnancy outside of clinical trials
• Don't forget to screen for other STIs and vaccinate against HAV/HBV if not immune