What are the delivery and treatment recommendations for a pregnant patient who is hepatitis C (HCV) positive at the time of delivery?

Management of Hepatitis C Positive Pregnant Patients at Delivery

For pregnant patients who are hepatitis C positive at delivery, vaginal delivery is recommended with avoidance of invasive monitoring procedures, and breastfeeding can be continued unless nipples are cracked or bleeding.

Delivery Recommendations

• Cesarean delivery is NOT recommended solely for the indication of HCV infection as it has not been shown to reduce the risk of vertical transmission 1
• Obstetrical care providers should avoid the following during labor management unless medically necessary:
  • Internal fetal monitors 1, 2
  • Early artificial rupture of membranes 1, 2
  • Episiotomy 3
  • Prolonged rupture of membranes (>6 hours) 4
• These interventions should only be used when clinically indicated (e.g., when unable to trace fetal heart rate with external monitors and the alternative is proceeding with cesarean delivery) 1

Postpartum and Breastfeeding Recommendations

• HCV status should not alter standard breastfeeding counseling and recommendations unless nipples are cracked or bleeding 1, 3
• Although HCV virus can be found in maternal milk, breastfeeding is not contraindicated 4
• The benefits of breastfeeding outweigh the minimal risk of HCV transmission when proper precautions are taken 2

Antiviral Treatment Considerations

• Direct-acting antiviral (DAA) regimens are not currently approved for use during pregnancy 1, 3
• DAA regimens should only be initiated in the setting of a clinical trial during pregnancy 1
• Treatment for HCV infection should be deferred to the postpartum period 3
• Women of reproductive age with HCV infection should be counseled to undergo antiviral treatment before pregnancy or after delivery and breastfeeding 1

Prenatal Care and Monitoring

• Third trimester assessment of fetal growth may be performed, but antenatal testing is not indicated in the setting of HCV diagnosis alone 1
• Serial laboratory surveillance of liver function or viral load assessment during pregnancy is generally not recommended 1
• Screening for other sexually transmitted infections is recommended if not done previously:
  • HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus 1
• Vaccination against hepatitis A and B viruses (if not immune) is recommended for patients with HCV 1

Risk of Vertical Transmission

• The risk of vertical transmission from mother to infant is approximately 5% 1, 3
• Higher viral loads may increase the risk of vertical transmission 4
• Coinfection with HIV also increases the risk of vertical transmission 4

Important Caveats

• If prenatal diagnostic testing is requested, patients should be counseled that data regarding the risk of vertical transmission are reassuring but limited 1
• Amniocentesis appears safer than chorionic villus sampling, which should be avoided 3
• Women should be counseled to abstain from alcohol during pregnancy 3
• Most HCV-infected pregnant women do not have obstetric complications in the absence of cirrhosis and portal hypertension 4

By following these evidence-based recommendations, healthcare providers can optimize outcomes for both mother and infant when managing hepatitis C positive patients at delivery.