Clinical Consensus Statement No. 458: Hepatitis C Virus in Pregnancy

Abstract

Objective

Provide guidance for routine antenatal screening of hepatitis C virus in pregnancy to support best practice and optimize antenatal and infectious disease care.

Target Population

Pregnant women/pregnant individuals receiving antenatal care in Canada and consenting to routine infectious disease screening. Options include reviewing prior serology and avoiding repeat testing or providing information regarding the benefit of identifying hepatitis C virus infection for the mother/parent and the baby.

Benefits, Harms, and Costs

Benefits may include identifying those eligible for treatment of hepatitis C virus infection, avoiding interventions that may increase the risk of transmission to the baby during labour and delivery, creating opportunities for appropriate screening of newborns, and reducing the burden of hepatitis C virus infection in line with World Health Organization recommendations. No direct harms are present given the possibility of testing for hepatitis C using the blood samples already included in antenatal screening. Psychological distress may occur with a new diagnosis of hepatitis C virus in pregnancy. The costs of identifying asymptomatic cases, with resulting treatment, outweigh the health care costs of this additional test.

Evidence

Published and unpublished literature was reviewed between 2017 and July 2023 (when the prior hepatitis C guideline: No. 96 The Reproductive care of Women Living with Hepatitis C infection, was last endorsed). OVID Medline, Embase, PubMed, and the Cochrane Library databases were searched for relevant publications available in English for each section of this statement. Unpublished literature, protocols, and international guidelines were identified by accessing the websites of health-related agencies, clinical practice guideline collections, and national and international medical specialty societies (i.e., American College of Obstetricians and Gynecologists, Royal College of Obstetricians and Gynaecologists, and Royal Australian and New Zealand College of Obstetricians and Gynaecologists).

Validation Methods

The evidence was obtained and reviewed by the principal authors with recommendations reviewed by the Infectious Disease Committee of the SOGC (2022). The authors identified these recommendations using a consensus process and rated the quality of evidence and strength of recommendations according to the guidelines developed by the Canadian Task Force on Preventative Health Care (https://canadiantaskforce.ca/methods/; see online Appendix A).

Intended Audience

Health care practitioners providing antenatal care, health care organizations, and provincial and federal governments.

Social Media Abstract

Universal screening for hepatitis C in pregnancy is recommended.

SUMMARY STATEMENTS

• 1.
  Screening for hepatitis C virus in every pregnancy is important (moderate).
• 2.
  Treatment options for hepatitis C virus exist, and diagnosis in pregnancy should result in referral for treatment following delivery (moderate).
• 3.
  Vertical transmission of hepatitis C occurs to newborns and those born to women and persons with hepatitis C in pregnancy, and these infants require follow-up (moderate).

RECOMMENDATIONS

• 1.
  Hepatitis C virus screening in the form of antibody testing should be performed in the first trimester of every pregnancy. If a pregnant woman/pregnant individual has a history of hepatitis C virus infection (treated or untreated), a hepatitis C viral load test should be requested if there is ongoing risk of reinfection or a viral load had not previously been performed to determine the presence of active disease. Repeat hepatitis C virus antibody testing should not be performed, as the result will remain positive. (strong, moderate).
• 2.
  Persons diagnosed with hepatitis C virus through antenatal screening or based on review of prior serology should be made aware of treatment options following pregnancy and linked with available treatment providers. Treatment is not currently recommended during pregnancy and breastfeeding (strong, moderate).
• 3.
  The course of Hepatitis C virus is not expected to worsen due to pregnancy and routine testing of liver function throughout the pregnancy is not required. However, baseline liver function tests should be ordered and an assessment of fibrosis organized prior to referral for treatment following delivery (strong, high).
• 4.
  Although the exact mechanisms of transmission are not known, intrapartum procedures that involve mixing of fetal and maternal blood such as fetal scalp electrodes and fetal blood sampling are not recommended. There is no indication for cesarean delivery or other changes to routine intrapartum care in patients with hepatitis C (strong, high).
• 5.
  There is no contraindication to breast/chest-feeding in patients with hepatitis C virus. Avoidance of feeding in the setting of cracked or bleeding nipples should be advised (strong, high).
• 6.
  Testing of neonates should be deferred until two months of age (strong, moderate).
• 7.
  Prior to discharge from hospital, plans for treatment of hepatitis C virus should be reviewed and appropriate referrals initiated (strong, high).