Infections During Pregnancy


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    Hepatitis C Infection

    Hepatitis C virus (HCV) is a single-stranded RNA virus in the Flaviviridae family.The average time to seroconversion after exposure to HCV is 8 to 9 weeks. Acutely infected individuals may develop clinically apparent hepatitis with loss of appetite, nausea, vomiting, fever, abdominal pain and jaundice. 60%-70% of patients with acute HCV infection are asymptomatic. [1]

    Injecting-drug use currently accounts for 60% of HCV transmission in the United States.Blood transfusion, is now an uncommon cause of recently acquired infections [1]. Sexual transmission of HCV appears to be inefficient relative to hepatitis B virus (HBV). Transmission between sexual partners of persons with chronic HCV infection with no other risk factors for infection is about 5% (range, 0% to 15%) [1-4] Household contact with an infected person has been associated with a nonsexual transmission rate of 4% (range, 0% to 11%) [2,5,6 ]. Approximately 7-8% of hepatitis C virus-positive women transmit hepatitis C virus to their offspring with a higher rate of transmission seen in women coinfected with HIV [7] .

    Acute HCV infection progresses to chronic HCV infection in most persons (75%--85%). Cirrhosis develops in 10%-20% of persons with chronic hepatitis C and hepatocellualr carcinoma in 1%-5%.[1]. In one small study acute maternal hepatitis (type B or nontype B) had no effect on the incidence of congenital malformations, stillbirths, abortions, or intrauterine malnutrition. However, acute hepatitis did increase the incidence of prematurity [8]. Pregnancy does not appear to be adversely affected by chronic HCV [9,10].

    Who to Test [1]

  • “Persons who ever injected illegal drugs, including those who injected once or a few times many years ago and do not consider themselves as drug users.
  • Persons who received clotting factor concentrates produced before 1987;
  • Persons who were ever on chronic (long-term) hemodialysis; and
  • Persons with persistently abnormal alanine aminotransferase levels.
  • Prior recipients of transfusions or organ transplants, including
    • Persons who were notified that they received blood from a donor who later tested positive for HCV infection;
    • Persons who received a transfusion of blood or blood components before July 1992; and
    • Persons who received an organ transplant before July 1992.
  • Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood.
  • Children born to HCV-positive women. “


    The diagnosis of HCV infection can be made by detecting either anti-HCV by enzyme
    immunoassay (EIA) or HCV RNA using the reverse transcriptase polymerase chain
    reaction (RT-PCR). If the HCV RNA result is negative supplemental testing should be
    performed. The CDC recommends confirmation of a positive EIA with supplemental recombinant immunoblot assay (RIBA TM) or RT-PCR for HCV RNA. (Figure 1). Supplemenatal testing using RIBA TM may be run on the same sample as the EIA.
    However, If RT-PCR is used to confirm anti-HCV results, a separate serum sample will
    need to be collected.

    The present supplemental RIBA TM detects four viral antigens. The test is considered
    positive if at least two antigens are detected. The test is indeterminate if only one antigen is detected. If the RIBA TMis indeterminate , further laboratory testing might include repeating the anti-HCV in two or more months or testing for HCV RNA and ALT
    level.[11] Table1.[1] may be helpful at arriving at a proper diagnosis.


    Table 1: Use of diagnostic tests in hepatitis C

    Chronic hepatitis C Positive PositivePositive Raised
    Hepatitis C carrier Positive Positive Positive Normal
    Recovered HCV infection Positive Positive Negative Normal
    False positive anti-HCV Positive Negative Negative Normal

      ELISA=anti-HCV by enzyme-linked immunoassay; RIBA=anti-HCV by recombinant immunoblot assay; ALT=alanine aminotransferase.
      From Di Bisceglie AM.  Hepatitis C  Lancet 1998; 351: 351-55

    Persons with hepatitis C should be referred to health-care professionals with experience in the treatment of hepatitis C.Current approved therapy for HCV-related chronic liver disease includes alpha interferon alone or in combination with the oral agent ribavirin. Alpha-interferon-2b and ribavirin are the current treatment. Interferon does not appear to have an adverse affect the embryo or fetus. However, the data is limited, and the potential benefits of interferon use during pregnancy should clearly outweigh possible hazards[12-14].Because there are no large studies of ribavirin use during human pregnancy, and ribavirin is teratogenic (causes birth defects) in multiple animal species the use of ribavirin during pregnancy is presently contraindicated [15].

    Pregnant patients with hepatitis C should be advised to

  • Obtain vaccination against hepatitis viruses A and B as indicated.
  • Abstain form alcohol use.
  • Avoid hepatotoxic drugs such as acetaminophen (Tylenol) that may worsen liver damage.
  • Inform the infant’s pediatrician of the mother’s hepatitis C status.
  • Not donate blood, body organs, other tissue, or semen.
  • Not share any personal items that may have blood on them (e.g., toothbrushes and razors).
  • Discuss the low but present risk for transmission with their partner and discuss the need for counseling and testing. However, HCV-positive persons with one long-term, steady sex partner do not need to change their sexual practices. [1]

    Liver enzymes and PCR should be obtained at the beginning of pregnancy, and as needed thereafter [16]

    The following recommendations from The Society of Obstetricians and Gynecologists of Canada may be helpful in counseling women considering amniocentesis.

    SOGC Recommendations [17]

  • “Amniocentesis in women infected with hepatitis C does not appear to significantly increase the risk of vertical transmission, but women should be counseled that very few studies have properly addressed this possibility.
  • In HIV-positive women all noninvasive screening tools should be used prior to considering amniocentesis.
  • For women infected with hepatitis B, hepatitis C, or HIV, the addition of noninvasive methods of prenatal risk screening, such as nuchal translucency, triple screening, and anatomic ultrasound, may help in reducing the age-related risk to a level below the threshold for genetic amniocentesis.
  • For those women infected with hepatitis B, hepatitis C, or HIV who insist on amniocentesis, every effort should be made to avoid inserting the needle through the placenta. “

    Delivery and Postpartum
    The risk of vertical transmission of HCV appears to be related to the level of viremia in the pregnant mother and not to the route of delivery. The virus does not appear to be transmitted when a woman's titer is < 10^6/mL or is negative [18-20]. Although Tejari et al [21] and Conte et al [22] did not find cesarean section to be protective against transmission of HCV to the neonate Gibb et al have found the HCV maternal to child (MTC) transmission rate to be reduced in patient delivered by elective cesarean[23]. The latter study has yet to be confirmed. Elective cesarean to reduce MCT transmission of HCV is not presently recommended by the Centers for Disease Control, American Academy of Pediatrics or the American College of Obstetricians and Gynecologists (ACOG)[1,7,24]. At delivery staff and the baby’s pediatrician should be notified of the mother’s hepatitis C carrier state.

    Breastfeeding does not appreciably increase the risk of transmitting HCV to a neonate [21, 24-26]

    1. CDC Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease MMWR October 16, 1998 / 47(RR19);1-39
    2. Bjoro K, et al. Hepatitis C infection in patients with primary hypogammaglobulinemia after treatment with contaminated immune globulin. N Engl J Med. 1994;331:1607-1611 MEDLINE
    3. Alter MJ, Hadler SC, Judson FN, et al: Risk factors for acute non-A, non-B hepatitis in the United States and association with hepatitis C virus infection. JAMA 264:2231-2235, 1990.MEDLINE
    4. Alter MJ, Coleman PJ, Alexander WJ, et al: Importance of heterosexual activity in the transmission of hepatitis B and non-A, non-B hepatitis. JAMA 262:1201-1205, 1989.MEDLINE
    5. Dienstag JL: Sexual and perinatal transmission of hepatitis C. Hepatology 26:66S-70S, 1997. MEDLINE
    6. Meisel H, Reip A, Faltus B, et al. Transmission of hepatitis C virus to children and husbands by women infected with contaminated anti-D immunoglobulin. Lancet 1995;345:1209-1211 MEDLINE
    7. ACOG educational bulletin. Viral hepatitis in pregnancy. Number 248, July 1998 . American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1998;63:195-202. MEDLINE
    8. Hieber JP, Dalton D, Shorey J, Combes B.Hepatitis and pregnancy. J Pediatr. 1977;91:545-9. MEDLINE
    9. Floreani A, Paternoster D, Zappala F, Cusinato R, Bombi G, Grella P, Chiaramonte M.Hepatitis C virus infection in pregnancy. Br J Obstet Gynaecol. 1996;103:325-9. MEDLINE
    10 Jabeen T, Cannon B, et al.. Pregnancy and pregnancy outcome in hepatitis C type 1b.QJM. 2000 Sep;93(9):597-601. MEDLINE
    11. Guidelines for Laboratory Testing and Result Reporting of Antibody to Hepatitis C Virus* February 7, MMWR 2003 / 52(RR03);1-16
    12. Ozaslan E, Yilmaz R, Simsek H, Tatar G. Interferon therapy for acute hepatitis C during pregnancy. Ann Pharmacother. 2002;36:1715-8.MEDLINE
    13. Hiratsuka M, Minakami H, Koshizuka S, Sato I. Administration of interferon-alpha during pregnancy: effects on fetus. J Perinat Med. 2000;28:372-6. MEDLINE
    14. Briggs GG,Freeman RK, Yaffe SJ, Drugs in Pregnancy and Lactation 5th edition,Baltimore, MD: Williams & Wilkins,1998 p 716-720.
    15. Briggs GG,Freeman RK, Yaffe SJ, Drugs in Pregnancy and Lactation 5th edition,Baltimore, MD: Williams & Wilkins,1998 p 1219.
    16. Paternoster DM, Santarossa C, Grella P, Palu G, Baldo V, Boccagni P, Floreani A. Viral load in HCV RNA-positive pregnant women. Am J Gastroenterol. 2001;96:2751-4. MEDLINE
    17. Davies G et al Society of Obstetricians and Gynaecologists of Canada. Amniocentesis and women with hepatitis B, hepatitis C, or human immunodeficiency virus. J Obstet Gynaecol Can. 2003;25:145-48, 149-52.MEDLINE
    18. Ohto H, Terazawa  et al.Transmission of hepatitis C virus from mothers to infants. The Vertical Transmission of Hepatitis C Virus Collaborative Study Group. N Engl J Med. 1994;330:744-50. MEDLINE
    19. Ferrero S, Lungaro P, Bruzzone BM, Gotta C, Bentivoglio G, Ragni N.Prospective study of mother-to-infant transmission of hepatitis C virus: a 10-year survey (1990-2000).Acta Obstet Gynecol Scand. 2003;82:229-34.MEDLINE
    20. Thomas SL, Newell ML, Peckham CS, Ades AE, Hall AJ. A review of hepatitis C virus (HCV) vertical transmission: risks of transmission to infants born to mothers with and without HCV viraemia of human immunodeficiency virus infection. Int J Epidemiol 1998; 27: 108-17. MEDLINE
    21. Tajiri H, Miyoshi Y, Funada S, Etani Y, Abe J, Onodera T, Goto M, Funato M, Ida S, Noda C, Nakayama M, Okada S. Prospective study of mother-to-infant transmission of hepatitis C virus.Pediatr Infect Dis J. 2001;20:10-4. MEDLINE
    22. Conte D, Fraquelli M, Prati D, Colucci A, Minola E. Prevalence and clinical course of chronic hepatitis C virus (HCV) infection and rate of HCV vertical transmission in a cohort of 15,250 pregnant women.Hepatology. 2000;31:751-5. MEDLINE
    23. Gibb DM, Goodall RL, Dunn DT, et al Mother-to-child transmission of hepatitis C virus: evidence for preventable peripartum transmission. Lancet. 2000 Sep 9;356(9233):904-7. MEDLINE
    24. Hepatitis C virus infection. American Academy of Pediatrics. Committee on Infectious Diseases.
    Pediatrics. 1998 ;101(3 Pt 1):481-5 MEDLINE
    25. Hunt CM, Carson KL, Sharara AI. Hepatitis C in pregnancy. Obstet Gynecol. 1997;89:883-90.MEDLINE
    26. ACOG Committee Opinion: Breastfeeding and the Risk of Hepatitis C Virus Transmission, August 1999Int J Gynaecol Obstet. 1999;66:307-8. MEDLINE


  • Vertical transmission of the hepatitis C virus : current knowledge and  issues
    Canadian Medical Association
  • Hepatitis
    Center for Disease Control and Prevention

    Created: 12/10/2000
    Last update: 11/30/2003
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    Created: 11/17/2000
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