Maternity Care Calendar and Guidelines: Screening for Hepatitis C

Current MCC Guideline (1998):

No guideline currently given

Literature Search:
EBM reviews including the Cochrane Database of Systematic Reviews (CDSR), ACP Journal Club, Database of Abstracts and Reviews of Effectiveness (DARE) and Cochrane Central Register of Controlled Trials (CCTR) were searched using the keywords hepatitis C and pregnancy. Medline was searched using the MeSH exp Hepatitis C AND mass screening.mp or Mass Screening (keyword and MeSH) AND pregnancy.mp or exp PREGNANCY (keyword and MeSH) limited to English and human from 1993-2003. This search yielded 19 articles. Clinical practice guidelines and review articles and randomized controlled trials were selected. The Canadian Task Force on Preventive Health Care, the US Preventive Services Task Force, the CMA Infobase of Clinical Practice Guidelines and the US National Guideline Clearinghouse were also reviewed for guidelines hepatitis C and pregnancy. The websites for national bodies of obstetricians and gynecologists (ACOG, SOGC, RCOG) were also checked for clinical practice guidelines.

Summary of Evidence:
Presently, there is considerable lack of uniformity in current practice with regards to hepatitis C screening in pregnancy and recommendations for breastfeeding in hepatitis C infected mothers. [1]

A very thorough clinical practice guideline was produced by the Society of Obstetricians and Gynaecologists of Canada (SOGC) in October 2000 on The Reproductive Care of Women Living with Hepatitis C Infection .[2] They used the criteria developed by the Canadian Task Force on Preventive Health for grading the levels of evidence and the recommendations. The full report is available on their website:
http://sogc.medical.org/SOGCnet/sogc_docs/common/guide/pdfs/ps96.pdf

In their review, they found seroprevalence rates during pregnancy varied from 0% in a small study in rural India to 13.7% in Egypt. The only Canadian seroprevalence study done in pregnant women was completed in British Columbia in 1994. The seroprevalence rate was 0.9%. They also reported a wide range in the rate of vertical transmission demonstrated in studies from 0-80%. Merging the data from existing studies, gave a rough estimate of 7.9% for the rate of vertical transmission. The authors note that the risk of vertical transmission is much higher in women co-infected with HIV (up to 60%) and is related to the level of hepatitis C virus (HCV) RNA.

They found no data to suggest that pregnancy alters the course of HCV. Aside from the risk of vertical transmission, there does not appear to be an increased risk of adverse pregnancy outcomes (congenital malformation, fetal distress, still birth or prematurity) in HCV-infected women. Pregnancy is not contraindicated in HCV infected women. (level III B)

There have been cases in Ireland in the late 1970's of hepatitis C infection from contaminated anti-D immune globulin.[3] The currently used preparations (WinRho) have not been associated with the transmission of viral blood-borne pathogens.

With regard to the risk of vertical transmission of HCV through invasive prenatal procedures (amniocentesis, fetal blood sampling, CVS), there is very little data on which to base recommendations. The view of the SOGC panel was that women with undetectable HCV RNA by PCR may not be at risk of transmitting the virus to the fetus during the procedures. In the presence of detectable HCV RNA, the possible risks must be weighed against the benefits. In terms of intrapartum obstetrical procedures, external monitoring is preferred. To date no case of HCV transmission has been linked to the use of a scalp electrode, but the procedure should be avoided unless absolutely necessary for fetal assessment. The panel found no conclusive evidence that Caesarian section lowers the rate of vertical transmission and felt that there was no contraindication to vaginal delivery.

Although HCV RNA and antibodies have both been detected in breast milk, no case of transmission through breastfeeding has been documented.

At present, they found that HCV did not meet the criteria for universal screening. Problems with universal screening include:

The prevalence is relatively low in pregnant populations.
Antibody screening tests do not differentiate between acute and chronic infection.
Response to treatment is neither universal nor sustained in most individuals.
The drugs used to treat HCV are not known to be safe in pregnancy. (ribavirin is a known teratogen).
To date there are no documented interventions known to decrease the rate of vertical transmission.

The SOGC makes the following recommendations:

Universal screening for HCV is not recommended (III B)
Targeted testing should be offered to women at high-risk (with appropriate counseling and informed consent). Risk factors include: injection drug use (even once), hemodialysis, persistent elevated AST, receipt of blood products or organs before 1992 or clotting factors before 1988, exposure to blood of high-risk individual, prison inmates, HIV positivity or tattoos. (III B) They note that targeted screening will miss between 40-60% of infected women.
Ideally preconception or early pregnancy evaluation should include assessment of risk factors for hepatitis C and testing if indicated. (III B)
Breastfeeding is not contraindicated in HCV infected women (II-3 B)

The SOGC recommendations are consistent with those of other authors.[4-7]

In a separate clinical practice guideline regarding the use of amniocentesis in women infected with hepatitis B or C or HIV, the SOGC draws the following conclusions: [8]

"Amniocentesis in women infected with hepatitis C does not appear to significantly increase the risk of vertical transmission, but women should be counselled that very few studies have properly addressed this possibility" (level II-2 evidence, C recommendation)
if amniocentesis is done, care should be taken to avoid inserting the needle through the placenta (level II-1, B recommendation)
noninvasive methods of prenatal risk screening ( nuchal translucency, triple screening, ultrasound) may help in reducing the age-related risk to a level below the threshold for genetic amniocentesis (level II-2, C recommendation)

Recommendations of Others:
Canadian Task Force on Preventive Health Care (CTFPHC):
No review on hepatitis C screening in pregnancy available

U.S. Preventive Services Task Force (USPSTF):
No review on hepatitis C screening in pregnancy available

Centers for Disease Control and Prevention:
In the 2002 Sexually transmitted diseases treatment guidelines, the CDC recommends:

"a test for hepatitis C antibodies (anti HCV) should be performed at the first prenatal visit for pregnant women at high risk for exposure (injection-drug use history, repeated exposure to blood products, prior blood transfusion or organ transplants)[9]

American College of Obstetricians and Gynecologists (ACOG):
In the ACOG publication "Guidelines for Perinatal Care" are the following recommendations:[10]

"Routine serologic testing during pregnancy for HCV is not recommended. Testing should be reserved for those whose history suggests an increased risk of infection, such as from blood transfusion, intravenous drug use, or repeated exposure to percutaneous or mucosal blood."
Maternal HCV infection is not a contraindication to breastfeeding. (mothers should be informed of theoretical risks)

Society of Obstetricians and Gynaecologists of Canada (SOGC):
(See summary of evidence above)

Institute for Clinical Systems Improvement (ICSI):
No guideline on hepatitis C screening in pregnancy available on the website (search terms: hepatitis C AND pregnancy)

Royal College of Obstetricians and Gynaecologists (RCOG):
RCOG lists maternal infection with viral hepatitis as one of the contraindications to fetal scalp sampling in a 2001 clinical practice guideline on electronic fetal monitoring. http://www.rcog.org.uk/resources/pdf/efm_guideline_final_2may2001.pdf

No guidelines on screening for hepatitis C in pregnancy were found on the RCOG website.

Cochrane Collaboration:
No reviews on screening for hepatitis C in pregnancy found

Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases) recently published a guideline entitled "National Guideline on the Management of the Viral Hepatitides A, B & C".
http://www.mssvd.org.uk/PDF/CEG2001/viral%20hepatitides%2007%2002b.PDF
They make the following recommendations with regards to hepatitis C and pregnancy:

There is at present no known way of reducing the risk of vertical transmission. Women should be informed of the potential risk of transmission in pregnancy (IV, C)
Breast feeding: there is no firm evidence of additional risk of transmission except, perhaps in women who are symptomatic with a high viral load (III,B)

Conclusions:
The new guideline on the MCC will be as follows:

offer hepatitis C antibody screening to women with risk factors (IDU, exposure to blood products -medical or occupational, HIV positive, elevated AST, prison inmates, multiple sex partners, tattoos)
plain font
it will be located under "Investigations" suggested for preconception visit (or alternatively, early pregnancy)

Reviewer: Colleen Kirkham, MD, CCFP March 2003

3/30/2005 9:00:00 PM

1. Pembrey, L., M.L. Newell, and P.A. Tovo, European paediatric hepatitis C virus network. Antenatal hepatitis C virus screening and management of infected women and their children: policies in Europe. Eur J Pediatr, 1999. 158(10): p. 842-6.
2. Boucher M, G.A., The reproductive care of women living with hepatitis C infection: SOGC Clinical practice guideline No. 96. Journal SOGC. J Soc Obstet Gynaecol Can, 2000. 22(10): p. 820-44.
3. Kenny-Walsh, E., Clinical outcomes after hepatitis C infection from contaminated anti-D immune globulin. NEJM, 1999. 340: p. 1228-33.
4. Burns, D.N. and H. Minkoff, Hepatitis C: screening in pregnancy. Obstet Gynecol, 1999. 94(6): p. 1044-8.
5. Freitag-Koontz, M.J., Prevention of hepatitis B and C transmission during pregnancy and the first year of life. J Perinat Neonatal Nurs, 1996. 10(2): p. 40-55.
6. Hudson S, M.D., Hepatitis C -Implications in pregnancy. J Soc Obstet Gynaecol Can, 1995. 17: p. 143-151.
7. Moyer, L.A., E.E. Mast, and M.J. Alter, Hepatitis C: Part I. Routine serologic testing and diagnosis. Am Fam Physician, 1999. 59(1): p. 79-88, 91-2.
8. Davies G, W.R., SOGC clinical practice guideline: amniocentesis and women with hepatitis Bm hepatitis C, or human immunodeficiency virus. J Soc Obstet Gynaecol Can, 2003. 25(2): p. 145-8.
9. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep, 2002. 51(RR-6): p. 1-78.
10. Guidelines for Perinatal Care 5th ed. Fifth ed. 2002, Elk Grove Village, Il.: American Academy of Pediatrics, and Washington, D.C.: American college of Obstetricians and Gynecologists: American Academy of Pediatrics, The American College of Obstetricians and Gynecologists.