Monday, 17 May 2010

Hepatitis C in Pregnancy

Hepatitis C is a RNA virus.
It leads to chronic hepatitis in 70%,cirrhosis in 20-30% in about 10-30  years .
1-6% of cirrohotic patients develop hepatocellular carcinoma.

The commonest risk factor for hepatitis C infection in UK is past or present IV drug abuse.


Serological diagnosis
(I)Testing for Anti-HCV antibodies
(II)HCV RNA using PCR

Hepatitis C anti body indicates previous infection but positive PCR beyond six month indicates chronic infection.
 


Effect of disease in pregnancy
(i)Acute or chronic hepatitis C doesn't seem to adversely affect the pregnancy.
(ii) Vertical transmission is less frequent(3-5% of cases)  than Hepatitis B virus.High viral load,Co-infection with HIV and active i.v. drug use are major risk factors for vertical transmission.
(iii) There is an increased risk of obstetric cholestasis.

Effect of pregnancy on liver disease
(i) pregnancy doesn't induce deterioration in liver disease.

Management.


Preconceptional care

(i) Vaccination against Hepatitis A & B should be offered.

(ii) Current IV drug users should be offered treatment programmes & needle exchange programmes.



Antenatal
(i) Routine screening isn't recommended.
    Selective screening is offered to high risk individuals:
       intravenous drug users
       patients who had multiple blood transfusion in the past
       women with HIV or HBV infection


(ii) Mutli disciplinary management with the involvement of hepatologist.

(iii)Perinatal transmission is uncommon, so there is no specific recommendations on  delivery or breast feeding.

(iv) Patients should avoid alcohol in the interest of minimizing liver damage.

(v) Amniocentesis  does not seem to significantly increase the risk of vertical transmission, but women should be counseled that very few studies have properly addressed this possibility.





Delivery
Universal precautions must be followed.
Caesarean section is not recommended.
There isn't enough evidence to make recommendation on artificial rupture of membranes,fetal scalp electrode and fetal blood sampling but these procedures are better avoided whenever possible.(SOGC guideline)
Pediatrician should be notified about the baby.

Postnatal
(i) anti-HCV antibodies in the baby may be due to tranplacental maternal antibodies.Antibody testing should be delayed up to 18 months post delivery.
(ii)HCV RNA testing could be used.Undetectable levels(less than 100 copies/ml) at 3 months makes vertical transmission unlikely.
(iii) Mother should be referred to hepatologist for antiviral therapy (interferon and ribavirin). These drugs are contraindicated in pregnancy.
(iv) transmission by breast milk is uncommon.
(v)contraception must be discussed.  

A past history  of a child infected perinatally with HCV does not increase the risk of transmission in subsequent pregnancies.   

The Reproductive Care of Women Living With Hepatitis C Infection-SOGC guideline















Sources
• Nelson-Piercy C. Handbook of obstetric medicine. Taylor & Francis; 2002.
• Swiet MD. Medical disorders in obstetric practice. Wiley-Blackwell; 2002.

Hadzić N. Hepatitis C in pregnancy. Arch. Dis. Child. Fetal Neonatal Ed. 2001 May;84(3):F201-204.