Hepatitis C in Pregnancy | Perinatology.com

Hepatitis C Virus Infection in Pregnancy

Hepatitis C virus (HCV) is a bloodborne RNA virus. In pregnancy, the main clinical priorities are identifying current maternal infection, assessing liver disease and coinfections, reducing avoidable intrapartum exposures, arranging postpartum treatment, and ensuring testing of the exposed infant.

Updated: June 9, 2026. Update based on SMFM Consult #56, CDC 2023 infant testing recommendations, ACOG 2023 Viral Hepatitis in Pregnancy guidance, and AASLD/IDSA HCV Guidance. This page is for clinical education and should not replace individualized medical care or local protocols.

Current recommendations - concise summary

Screen every pregnancy.
Test all pregnant patients for HCV infection during each pregnancy, ideally at the initial prenatal visit.

Use reflex RNA testing.
Start with anti-HCV antibody. If reactive, obtain HCV RNA to determine current infection.

Assess coinfections and immunity.
Screen for HIV, hepatitis B, syphilis, gonorrhea, and chlamydia if not already done. Vaccinate against hepatitis A and B if nonimmune.

No cesarean solely for HCV.
HCV infection alone is not an indication for cesarean delivery.

Reduce intrapartum blood exposure.
Avoid internal fetal scalp electrodes and early artificial rupture of membranes unless clinically necessary.

Test the infant early.
CDC recommends HCV RNA NAT at age 2–6 months for perinatally exposed infants.

Vertical transmission: HCV transmission occurs primarily among pregnant patients with detectable HCV RNA. The overall perinatal transmission risk is approximately 6% to 7%, and risk is higher with poorly controlled HIV coinfection.

Clinical algorithm

Original flowchart created for this page. It avoids reproduction of copyrighted figures and summarizes a practical prenatal-to-postpartum workflow.

1. Initial prenatal visit

Anti-HCV antibody testing in every pregnancy.

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2. If anti-HCV nonreactive

No evidence of prior infection. Repeat later only if new or ongoing risk, recent exposure, or clinical concern for acute infection.

3. If anti-HCV reactive

Order HCV RNA NAT, liver enzymes, platelet count, bilirubin, albumin, INR if clinically indicated, and evaluate for coinfections.

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4. RNA undetectable

No current viremia detected. Document prior cleared or treated infection versus false-positive antibody. Repeat RNA if recent exposure or immunocompromise.

5. RNA detectable

Current HCV infection. Refer/link to hepatology, infectious disease, or HCV treatment program. Assess HAV/HBV immunity and vaccinate if nonimmune.

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6. Pregnancy management

Consider third-trimester fetal growth assessment. Antenatal testing is not indicated for HCV alone. Avoid internal monitors and early AROM unless necessary.

7. Delivery/postpartum

Mode of delivery should be based on obstetric indications. Breastfeed unless nipples are cracked or bleeding. Arrange postpartum HCV therapy.

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8. Infant testing

HCV RNA NAT at age 2–6 months. If detectable, consult pediatric HCV specialist. If undetectable at or after age 2 months, no further HCV follow-up is needed unless clinically warranted.

Screening and diagnosis

Result pattern	Interpretation	Suggested next step
Anti-HCV nonreactive	No HCV antibody detected.	Routine care. Repeat testing if new exposure, ongoing risk, or concern for acute infection.
Anti-HCV reactive + HCV RNA detectable	Current HCV infection.	Assess liver disease, coinfections, HAV/HBV immunity, and arrange HCV treatment linkage.
Anti-HCV reactive + HCV RNA undetectable	No current viremia detected; may represent resolved infection or successfully treated infection.	Repeat RNA if recent exposure, clinical hepatitis, immunocompromise, or concern for intermittent/early infection.

Recombinant immunoblot assay (RIBA) is no longer part of current routine diagnostic algorithms. Current practice uses anti-HCV antibody testing followed by HCV RNA testing when antibody is reactive.

Maternal evaluation after confirmed current infection

Quantitative HCV RNA to document viremia.
Baseline hepatic panel, platelet count, and assessment for advanced liver disease when indicated.
Screen for HIV, hepatitis B, syphilis, gonorrhea, and chlamydia if not already completed.
Assess hepatitis A and B immunity; vaccinate if nonimmune.
Review medications, alcohol use, injection drug use, and harm-reduction needs.
Refer for postpartum HCV treatment planning, or specialist consultation if treatment during pregnancy is being considered.

Antiviral therapy in relation to pregnancy

For patients with known HCV infection and reproductive potential, antiviral therapy is recommended before pregnancy when practical and feasible to improve maternal health and eliminate future perinatal transmission risk.

Direct-acting antiviral therapy during pregnancy is not yet routine. SMFM recommends initiation only in a clinical-trial setting, while AASLD/IDSA guidance allows individualized consideration after patient-physician discussion of risks and benefits. Because evidence remains limited, antepartum treatment should involve specialist input.

Ribavirin is contraindicated in pregnancy because of teratogenicity. Pregnancy should be avoided during ribavirin therapy and for 6 months after exposure, including exposure through a male partner taking ribavirin.

Pregnancy management

Clinical issue	Recommendation
Fetal growth	Third-trimester fetal growth assessment may be performed because HCV has been associated with fetal growth restriction and low birthweight.
Antenatal testing	HCV infection alone is not an indication for routine NST/BPP surveillance.
Intrahepatic cholestasis of pregnancy	Consider viral hepatitis screening when ICP is diagnosed early or bile acids are markedly elevated.
Invasive prenatal diagnosis	If diagnostic testing is requested, counsel that data on transmission risk are reassuring but limited. Amniocentesis is generally preferred over CVS when invasive testing is indicated.

Delivery and breastfeeding

Do not perform cesarean delivery solely to reduce HCV transmission.
Avoid fetal scalp electrode/internal fetal monitoring unless necessary.
Avoid early artificial rupture of membranes unless clinically indicated.
Breastfeeding is not contraindicated solely because of HCV infection.
Temporarily avoid breastfeeding from a breast with cracked or bleeding nipples; resume when healed.

Testing of perinatally exposed infants and children

Child age	Recommended test	Follow-up
2–6 months	HCV RNA NAT	If detectable, consult a clinician experienced in pediatric hepatitis C. If undetectable at or after age 2 months, no further HCV follow-up is required unless clinically warranted.
7–17 months and not previously tested	HCV RNA NAT	Manage based on RNA result; detectable RNA warrants pediatric HCV consultation.
18 months or older and not previously tested	Anti-HCV antibody with reflex HCV RNA if antibody reactive	Detectable RNA indicates current infection and need for pediatric HCV care linkage.

Curative direct-acting antiviral therapy is FDA-approved for children beginning at age 3 years. Early infant testing improves linkage to care and reduces loss to follow-up.

EMR-ready counseling text

HCV-positive pregnancy counseling

Hepatitis C virus infection in pregnancy was reviewed. HCV is a bloodborne infection and vertical transmission occurs primarily when maternal HCV RNA is detectable. The overall risk of perinatal transmission is approximately 6% to 7%, with higher risk reported with poorly controlled HIV coinfection. Cesarean delivery is not recommended solely for HCV infection. During labor, avoidance of internal fetal monitoring and early artificial rupture of membranes is recommended unless clinically necessary. Breastfeeding is acceptable unless nipples are cracked or bleeding.

Recommend documentation of HCV RNA status, assessment for HIV, hepatitis B and other sexually transmitted infections if not already performed, assessment of hepatitis A and B immunity with vaccination if nonimmune, and linkage to hepatology/infectious disease or an HCV treatment program. Direct-acting antiviral treatment is generally planned before pregnancy or postpartum; antepartum treatment should be individualized with specialist input. The pediatric provider should be notified of perinatal HCV exposure. Current CDC guidance recommends infant HCV RNA NAT at age 2–6 months.

References

Dotters-Katz SK, Kuller JA, Hughes BL; Society for Maternal-Fetal Medicine. SMFM Consult Series #56: Hepatitis C in pregnancy-updated guidelines. Am J Obstet Gynecol. 2021;225:B8-B18. Full text.
American College of Obstetricians and Gynecologists. Viral Hepatitis in Pregnancy. Clinical Practice Guideline No. 6. Obstet Gynecol. 2023;142:745-759. ACOG guidance.
Panagiotakopoulos L, Sandul AL, Conners EE, et al. CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023. MMWR Recomm Rep. 2023;72(4):1-19. CDC MMWR.
AASLD-IDSA HCV Guidance Panel. HCV in Pregnancy. Recommendations for Testing, Managing, and Treating Hepatitis C. HCV Guidance.
Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC Recommendations for Hepatitis C Screening Among Adults United States, 2020. MMWR Recomm Rep. 2020;69(2):1-17. CDC screening recommendations.
Owens DK, Davidson KW, Krist AH, et al. Screening for Hepatitis C Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020;323(10):970-975. USPSTF recommendation.
Benova L, Mohamoud YA, Calvert C, Abu-Raddad LJ. Vertical transmission of hepatitis C virus: systematic review and meta-analysis. Clin Infect Dis. 2014;59(6):765-773. PubMed.

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