What is the recommended management for a pregnant woman with hepatitis C (HCV)?

Management of Hepatitis C in Pregnancy

All pregnant women should be screened for hepatitis C with anti-HCV antibodies, and if positive, direct-acting antiviral (DAA) treatment should NOT be initiated during pregnancy except within a clinical trial—treatment should be deferred until after delivery and breastfeeding cessation. 1

Screening and Initial Workup

Universal Screening

• Screen all pregnant patients for HCV by testing for anti-HCV antibodies at every pregnancy, regardless of risk factors 1
• This universal screening approach is now supported by the CDC and USPSTF and has been shown to be cost-effective 1

Confirmatory Testing and Baseline Assessment

When anti-HCV antibodies are positive, obtain the following laboratory tests 1:

• Quantitative HCV RNA to confirm active infection
• HCV genotype (if not previously obtained)
• Liver function tests (AST, ALT, bilirubin)
• Albumin
• Platelet count
• Prothrombin time
• Screen for co-infections: HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus 1

Vaccination

• Vaccinate against hepatitis A and hepatitis B if not immune 1

Antiviral Treatment During Pregnancy

Current Recommendations

DAA regimens should only be initiated within a clinical trial setting during pregnancy 1. The Society for Maternal-Fetal Medicine gives this a GRADE 1C recommendation, reflecting that while the evidence is limited, the recommendation is strong 1

Rationale for Deferring Treatment

• No DAA therapy has been approved for use during pregnancy due to lack of adequate human safety data 1
• Safety data come entirely from animal reproduction studies, which show no adverse fetal effects 1
• A phase 1 trial of ledipasvir/sofosbuvir showed 100% cure rates and no adverse maternal/infant effects, but larger studies are needed 1

If Patient Becomes Pregnant While on DAAs

Engage in shared decision-making regarding continuation versus cessation, counseling that animal data are reassuring but human data are lacking 1

Optimal Treatment Timing

• Ideally, treat women before conception 1
• Alternative: Treat postpartum after cessation of breastfeeding 1
• The AASLD/IDSA now states that "treatment can be considered during pregnancy on an individual basis after a patient-physician discussion about the potential risks and benefits" 1

Pregnancy Management

Monitoring During Pregnancy

• Serial laboratory surveillance of liver function or viral load is NOT recommended during pregnancy 1
• ALT levels naturally decrease during the second and third trimesters 1

Fetal Surveillance

• Third trimester assessment of fetal growth may be performed 1, 2
• Antenatal testing is NOT indicated based on HCV diagnosis alone 1, 2

Lifestyle Counseling

• Counsel complete abstinence from alcohol, as even modest amounts accelerate liver disease progression 1
• Avoid sharing personal hygiene items (razors, nail clippers, scissors, toothbrushes) 1
• Avoid needle sharing in the setting of intravenous drug use 1
• Acetaminophen is safe but limit to 2g daily maximum (rather than 4g) if cirrhosis is present 1

Delivery Management

Mode of Delivery

Cesarean delivery is NOT recommended solely for HCV indication, as it does not reduce vertical transmission risk (approximately 5%) 1, 2

Intrapartum Precautions

Avoid the following unless medically necessary 1, 2:

• Internal fetal monitors
• Early artificial rupture of membranes
• Prolonged rupture of membranes 3
• Episiotomy 3

These interventions may theoretically increase vertical transmission risk, though data are limited 1

Breastfeeding

Standard Recommendations

HCV status should NOT alter standard breastfeeding counseling and recommendations 1, 2

Important Exception

If nipples are cracked or bleeding, temporarily abstain from breastfeeding until healing occurs 2, 4. The CDC and EASL recommend stopping breastfeeding and expressing milk during this period 4

Vertical Transmission Risk

• Mother-to-child transmission risk is approximately 5% in HCV-monoinfected women 2, 3
• If prenatal diagnostic testing is requested, counsel that data on vertical transmission risk with amniocentesis are reassuring but limited; amniocentesis is preferred over chorionic villus sampling due to lack of data on the latter 1

Key Clinical Pitfalls

Common Mistakes to Avoid

• Do not initiate DAA therapy outside of clinical trials during pregnancy, despite promising early data 1
• Do not perform cesarean delivery for HCV indication alone—this is not evidence-based 1, 2
• Do not discourage breastfeeding unless nipples are actively bleeding or cracked 1, 2, 4
• Do not perform serial viral load monitoring during pregnancy—it does not change management 1

Evolving Landscape

While current guidelines strongly recommend deferring treatment, the landscape is rapidly evolving 1. The most recent 2024 AGA guidelines note that "treatment may be considered during pregnancy on a case-by-case basis" per IDSA/AASLD recommendations, reflecting growing evidence of safety 1. However, the 2021 SMFM guidelines (the most comprehensive obstetric-specific guidance) maintain that DAAs should only be used in clinical trials during pregnancy 1.