What is the treatment approach for Hepatitis C (HCV) infection in pregnant women?

From the Guidelines

Treatment of hepatitis C during pregnancy should be individualized, considering the potential risks and benefits, and may involve deferring treatment until after delivery, except in cases where the benefits of treatment outweigh the risks, as determined by a patient-physician discussion 1.

Key Considerations

• The standard treatment for hepatitis C, direct-acting antivirals (DAAs), is generally not recommended during pregnancy due to limited safety data, but recent studies suggest that treatment can be considered on an individual basis 1.
• The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend treating all patients with chronic HCV infection, except those with short life expectancies that cannot be extended by treatment, but this does not currently apply to pregnant women due to lack of safety data 1.
• A recent trial of HCV treatment during pregnancy using sofosbuvir/ledipasvir showed promising results, with 100% cure rates and no clinically meaningful adverse effects on the mother/infant dyad, suggesting that treatment during pregnancy may be safe and effective in certain cases 1.

Management Approach

• For pregnant women with hepatitis C, monitoring liver function tests quarterly is advised, with management focusing on supportive care.
• After delivery, standard DAA regimens can be initiated, such as glecaprevir/pibrentasvir (Mavyret) for 8-12 weeks or sofosbuvir/velpatasvir (Epclusa) for 12 weeks, depending on the viral genotype and presence of cirrhosis.
• Breastfeeding is considered safe for mothers with hepatitis C unless nipples are cracked or bleeding.
• The risk of vertical transmission is approximately 5-6%, with higher rates in women who are co-infected with HIV or have high viral loads.
• Screening infants born to mothers with hepatitis C is recommended at 18 months of age using antibody testing, as maternal antibodies can persist in the infant's bloodstream for up to 18 months.

Recent Developments

• Universal screening during pregnancy is supported by the CDC and USPFTF, and has been shown to be cost-effective 1.
• The use of DAAs during pregnancy or soon after delivery is being investigated, with recent trials showing promising results 1.

From the Research

Screening and Diagnosis

• Hepatitis C virus (HCV) infection is a significant concern during pregnancy, with an estimated 1-2.5% of pregnant women in the United States infected with the virus 2, 3.
• The Society for Maternal-Fetal Medicine recommends screening women who are at increased risk for HCV infection by testing for anti-hepatitis C virus antibodies at their first prenatal visit 2.
• If initial results are negative, HCV screening should be repeated later in pregnancy in women with persistent or new risk factors for HCV infection 2.

Treatment and Management

• Direct-acting antiviral regimens are not currently approved for use in pregnancy, and treatment is typically deferred to the postpartum period 2, 3.
• However, some studies suggest that universal screening and antepartum therapy for HCV during pregnancy may be beneficial in reducing mother-to-child transmission 4, 5.
• The use of direct-acting antivirals (DAAs) during pregnancy is being studied, with recent research focusing on the safety and efficacy of DAA initiation during pregnancy 6.

Pregnancy and Childbirth Considerations

• HCV infection during pregnancy is associated with an increased risk of adverse fetal outcomes, including fetal growth restriction and low birth weight 2, 3.
• No perinatal intervention has been shown to reduce the risk of vertical transmission, but some may increase this risk 3.
• The Society for Maternal-Fetal Medicine recommends against cesarean delivery solely for the indication of HCV 2.
• Breast-feeding is not discouraged based on a positive HCV infection status 2.

Future Directions

• Universal HCV screening during each pregnancy is recommended, with a focus on improving treatment rates in the postpartum period through innovative linkage to care efforts, telemedicine, and reducing barriers to care for patients 6.
• Further research is needed to evaluate the safety and efficacy of DAA use during pregnancy and to develop effective strategies for reducing mother-to-child transmission of HCV 4, 5, 6.