Although there are no true rates of prenatal HCV known in Canada, it is estimated that one of every 120 Canadian women who gives birth is infected with HCV. Almost half of women living with HCV are thought to be unaware of their infection, meaning that they are not receiving treatment and, if they get pregnant, may pass HCV to their babies. This highlights the importance of screening for HCV in the preconception period.
The recommended test for initial screening is the HCV antibody test, which detects HCV antibodies in the blood. Because HCV antibodies remain in the body for life, a confirmatory HCV RNA polymerase chain reaction test is required if the antibody test is positive to confirm chronic infection. The HCV RNA test is able to distinguish between those with a current infection and those with previous spontaneous or treatment-induced clearance.
Although there have been calls for universal HCV screening of all pregnant women in Canada similar to what is done for HIV, current screening guidelines focus on those with risk factors. These at-risk categories include the following:
The main risk factors for HCV infection in pregnant women in Canada are previous or current injection drug use and being the sexual partner of someone who uses injection drugs. Screening of high-risk women is important for treatment following the pregnancy, in order to reduce the risk of HCV-related liver damage and cancer.
In order to be effective, risk-based screening depends on active assessment of risk factors by healthcare providers and full disclosure from patients. The Society of Obstetricians and Gynaecologists of Canada (SOGC) states that testing should occur following adequate counselling and informed consent of the patient. Any woman who receives a diagnosis of HCV in pregnancy should be referred to a hepatologist or infectious diseases specialist.
None of the antiviral therapies recommended for HCV infection treatment are currently approved for use in pregnancy. Ribavirin-based regimens are particularly not recommended in pregnancy because of their known teratogenic effects (i.e., cause malformations in unborn babies). Because ribavirin can remain in the body for up to 6 months, pregnancy should be avoided in women taking ribavirin and female partners of men using ribavirin until 6 months after completing therapy.
Treatment has improved with the introduction of direct-acting antiviral (DAA) regimens, but it is still unknown whether they are safe to use in pregnancy or during breastfeeding.
How the baby is born (e.g., vaginal versus caesarean section delivery) does not seem to impact HCV transmission. Therefore, the SOGC and others state that women with HCV can deliver vaginally and labour should be left to begin on its own, unless obstetric reasons indicate otherwise. Caesarean section delivery may be recommended for women co-infected with HIV.
It is also recommended that the following procedures be avoided unless deemed absolutely necessary after careful consideration: episiotomy, internal fetal monitoring (e.g., scalp electrodes), and prolonged rupture of membranes. This is because these procedures may result in the mixing of maternal and fetal blood.
Universal precautions should be observed, like in all deliveries, and there is no need to isolate either the mother or infant.
Pregnancy is not contraindicated because of HCV, but women on ribavirin therapy for HCV should not get pregnant while on treatment. The effects of HCV on a woman’s reproductive health depend on the status of her disease. If there is significant liver disease, there may be abnormal menstrual cycles or infertility.
Although there is some research that suggests that HCV infection in pregnancy is associated with higher risk of adverse fetal outcomes, the SOGC states that neither women nor their babies are at increased risk of obstetric or perinatal complications due to HCV infection. They state that there is no report of increased incidence of fetal abnormalities, preterm labour, or fetal distress in the absence of other contributing factors (e.g., limited prenatal care, substance use).
It also appears that pregnancy has very little effect on HCV infection in the majority of women.
Infants born to mothers living with HCV do not show any more neonatal complications than other infants with the same risk factors. However, all infants born to mothers with HCV should be evaluated for HCV themselves. Perinatally acquired HCV becomes chronic in approximately 80% of cases. Most of these cases are asymptomatic, with spontaneous clearance rates being approximately 25%.
All infants born to mothers with HCV will be positive for HCV antibodies at birth. Uninfected infants will clear these antibodies by 12 to 15 months of age, depending on the mother’s levels. Infants are diagnosed with HCV if they receive a positive test on two occasions between 2 and 6 months of age (using HCV RNA polymerase chain reaction) or at 18 months (using serology).
Breastfeeding is not contraindicated for mothers living with HCV unless there are other contraindications (e.g., HIV co-infection). Although there is some evidence of HCV in breast milk, when it has been found it has been at much lower concentrations than in blood and there have been no documented cases of HCV transmission through breastfeeding. However, women with a flare-up of chronic HCV with jaundice postpartum, co-infection with HIV, and those who develop cracked, bleeding nipples should stop breastfeeding. These women should pump and discard their milk until their nipples have healed.
There is no need for caregivers to alter normal childcare routines; the use of gloves, masks, or extra sterilization is unnecessary. Blood is the main source of HCV infection; there is no known risk of transmission by saliva, urine, or stools.
For contraception following birth for women not wishing to become pregnant, use of condoms, intrauterine device, and progesterone-only based contraceptives are all appropriate methods. Combined pills should be avoided by those with cirrhosis because of the potential impact on the liver. The extent of liver disease should be evaluated before women are prescribed hormonal contraception or hormone replacement therapy.
Although there are no true rates of prenatal HCV known in Canada, it is estimated that one of every 120 Canadian women who gives birth is infected with HCV. Almost half of women living with HCV are thought to be unaware of their infection, meaning that they are not receiving treatment and, if they get pregnant, may pass HCV to their babies. This highlights the importance of screening for HCV in the preconception period.
The recommended test for initial screening is the HCV antibody test, which detects HCV antibodies in the blood. Because HCV antibodies remain in the body for life, a confirmatory HCV RNA polymerase chain reaction test is required if the antibody test is positive to confirm chronic infection. The HCV RNA test is able to distinguish between those with a current infection and those with previous spontaneous or treatment-induced clearance.
Although there have been calls for universal HCV screening of all pregnant women in Canada similar to what is done for HIV, current screening guidelines focus on those with risk factors. These at-risk categories include the following:
The main risk factors for HCV infection in pregnant women in Canada are previous or current injection drug use and being the sexual partner of someone who uses injection drugs. Screening of high-risk women is important for treatment following the pregnancy, in order to reduce the risk of HCV-related liver damage and cancer.
In order to be effective, risk-based screening depends on active assessment of risk factors by healthcare providers and full disclosure from patients. The Society of Obstetricians and Gynaecologists of Canada (SOGC) states that testing should occur following adequate counselling and informed consent of the patient. Any woman who receives a diagnosis of HCV in pregnancy should be referred to a hepatologist or infectious diseases specialist.
The likelihood of vertical transmission of HCV from a pregnant woman to her baby depends on the existence of co-factors and other medical conditions. The rate of vertical transmission is approximately 5% in women who are otherwise healthy. Factors found to increase the risk of vertical transmission include:
Maternal coinfection with HIV has been found to be the most important determinant of vertical transmission risk for HCV (i.e., more than double). The use of highly active antiretroviral therapy in pregnant women with HIV appears to lower the increased risk of HCV vertical transmission.
No interventions during pregnancy or at the time of delivery have been proven to reduce the risk of vertical transmission, but the SOGC recommends the following to be of benefit:
Risk reduction strategies are important because women can be infected with multiple strains of HCV.
None of the antiviral therapies recommended for HCV infection treatment are currently approved for use in pregnancy. Ribavirin-based regimens are particularly not recommended in pregnancy because of their known teratogenic effects (i.e., cause malformations in unborn babies). Because ribavirin can remain in the body for up to 6 months, pregnancy should be avoided in women taking ribavirin and female partners of men using ribavirin until 6 months after completing therapy.
Treatment has improved with the introduction of direct-acting antiviral (DAA) regimens, but it is still unknown whether they are safe to use in pregnancy or during breastfeeding.
How the baby is born (e.g., vaginal versus caesarean section delivery) does not seem to impact HCV transmission. Therefore, the SOGC and others state that women with HCV can deliver vaginally and labour should be left to begin on its own, unless obstetric reasons indicate otherwise. Caesarean section delivery may be recommended for women co-infected with HIV.
It is also recommended that the following procedures be avoided unless deemed absolutely necessary after careful consideration: episiotomy, internal fetal monitoring (e.g., scalp electrodes), and prolonged rupture of membranes. This is because these procedures may result in the mixing of maternal and fetal blood.
Universal precautions should be observed, like in all deliveries, and there is no need to isolate either the mother or infant.
Pregnancy is not contraindicated because of HCV, but women on ribavirin therapy for HCV should not get pregnant while on treatment. The effects of HCV on a woman’s reproductive health depend on the status of her disease. If there is significant liver disease, there may be abnormal menstrual cycles or infertility.
Although there is some research that suggests that HCV infection in pregnancy is associated with higher risk of adverse fetal outcomes, the SOGC states that neither women nor their babies are at increased risk of obstetric or perinatal complications due to HCV infection. They state that there is no report of increased incidence of fetal abnormalities, preterm labour, or fetal distress in the absence of other contributing factors (e.g., limited prenatal care, substance use).
It also appears that pregnancy has very little effect on HCV infection in the majority of women.
Infants born to mothers living with HCV do not show any more neonatal complications than other infants with the same risk factors. However, all infants born to mothers with HCV should be evaluated for HCV themselves. Perinatally acquired HCV becomes chronic in approximately 80% of cases. Most of these cases are asymptomatic, with spontaneous clearance rates being approximately 25%.
All infants born to mothers with HCV will be positive for HCV antibodies at birth. Uninfected infants will clear these antibodies by 12 to 15 months of age, depending on the mother’s levels. Infants are diagnosed with HCV if they receive a positive test on two occasions between 2 and 6 months of age (using HCV RNA polymerase chain reaction) or at 18 months (using serology).
Breastfeeding is not contraindicated for mothers living with HCV unless there are other contraindications (e.g., HIV co-infection). Although there is some evidence of HCV in breast milk, when it has been found it has been at much lower concentrations than in blood and there have been no documented cases of HCV transmission through breastfeeding. However, women with a flare-up of chronic HCV with jaundice postpartum, co-infection with HIV, and those who develop cracked, bleeding nipples should stop breastfeeding. These women should pump and discard their milk until their nipples have healed.
There is no need for caregivers to alter normal childcare routines; the use of gloves, masks, or extra sterilization is unnecessary. Blood is the main source of HCV infection; there is no known risk of transmission by saliva, urine, or stools.
For contraception following birth for women not wishing to become pregnant, use of condoms, intrauterine device, and progesterone-only based contraceptives are all appropriate methods. Combined pills should be avoided by those with cirrhosis because of the potential impact on the liver. The extent of liver disease should be evaluated before women are prescribed hormonal contraception or hormone replacement therapy.
The preconception period is an excellent time for screening, diagnosis, and treatment, in an effort to cure HCV before pregnancy occurs. This is beneficial both for the woman’s own health and for reducing vertical transmission of HCV if she becomes pregnant. Because HCV cure rates now exceed 95% and access to treatment is possible in those without fibrosis, both partners should be counselled regarding the benefits of treatment before becoming pregnant. This counselling should include a discussion of reliable birth control during any HCV treatment, as well as 6 months following treatment if the regimen includes ribavirin.
For women who are already pregnant, healthcare providers are in a position to provide women (and their partners) with clear, evidence-based information about HCV during and after pregnancy. For patients to benefit from treatment and care, individuals have to be accessed, identified, educated, and properly treated. Healthcare providers play a vital role in each of these steps.
