From the Guidelines
The treatment of hepatitis C during pregnancy is not routinely recommended, and treatment is typically deferred until after delivery, due to limited safety data on direct-acting antivirals (DAAs) in pregnant women. The standard approach is to monitor viral load during pregnancy and plan for postpartum treatment. For women diagnosed during pregnancy, the focus is on preventing vertical transmission through appropriate prenatal care and avoiding invasive procedures that might increase transmission risk. According to the most recent guidelines from the Society for Maternal-Fetal Medicine 1, DAA regimens should only be initiated in the setting of a clinical trial during pregnancy, and people who become pregnant while taking a DAA should be counseled in a shared decision-making framework about the risks and benefits of continuation.
Some key considerations for managing hepatitis C in pregnancy include:
- Screening all pregnant patients for HCV by testing for anti-HCV antibodies in every pregnancy, as recommended by the Society for Maternal-Fetal Medicine 1
- Avoiding internal fetal monitors and early artificial rupture of membranes when managing labor in patients with HCV, unless necessary in the course of management 1
- Recommending vaccination against HAV and HBV (if not immune) for patients with HCV 1
- Considering referral to a hepatologist or infectious disease specialist during pregnancy for patients with HCV to expedite therapy after pregnancy
After delivery, recommended DAA regimens include glecaprevir/pibrentasvir (Mavyret) for 8-12 weeks or sofosbuvir/velpatasvir (Epclusa) for 12 weeks, depending on the viral genotype and presence of cirrhosis, as suggested by the European Association for the Study of the Liver 1. These medications have cure rates exceeding 95% with minimal side effects. Breastfeeding is generally considered safe for mothers with hepatitis C, as the virus is not transmitted through breast milk, unless there are bleeding or cracked nipples, in which case specialist input should be provided 1. Regular monitoring of liver function and viral load is essential throughout pregnancy, and infants born to infected mothers should be tested for HCV RNA after 18 months of age to confirm whether vertical transmission has occurred.
From the Research
Screening and Diagnosis
- Hepatitis C virus (HCV) infection is estimated to affect 1-2.5% of pregnant women in the United States, with a 5-6% risk of mother-to-infant transmission 2, 3.
- The Society for Maternal-Fetal Medicine recommends screening women at increased risk for HCV infection by testing for anti-HCV antibodies at their first prenatal visit, and repeating the screening later in pregnancy if risk factors persist or new ones arise 2.
- HCV-positive pregnant women should also be screened for other sexually transmitted diseases, including HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus 2.
Treatment and Management
- Currently, there are no approved treatment regimens for HCV in pregnancy, and direct-acting antiviral regimens should only be used in the setting of a clinical trial or deferred to the postpartum period 2, 3, 4.
- Patients with HCV, including pregnant women, should be counseled to abstain from alcohol 2.
- The mode of delivery does not affect the risk of mother-to-child transmission, and cesarean delivery should not be performed solely for the indication of HCV 2, 4.
Pregnancy and Childbirth Considerations
- HCV infection in pregnancy is associated with an increased risk of adverse fetal outcomes, including fetal growth restriction and low birth weight 2, 3, 4.
- Invasive prenatal diagnostic testing should be approached with caution, and amniocentesis is recommended over chorionic villus sampling due to limited data on the latter 2.
- Breastfeeding is not contraindicated in HCV-positive women, but breastfeeding with cracked or bleeding nipples should be avoided 2, 4.
Future Directions
- Universal screening and antepartum therapy for HCV during pregnancy may be beneficial, but further research is needed to establish safety and efficacy 5.
- A Community of Practice has been established to improve linkage to HCV care and treatment for pregnant and postpartum women, with a focus on colocation of services, treatment by nonspecialist providers, and active engagement and patient navigation 6.