Lucan · Conditions

Hepatitis C in pregnancy

obstetrics-gynaecology4 free questions

Australian guidance: RANZCOG C-Obs 51 Hep C in Pregnancy (2020) + ASHM

1. Definition and epidemiology

Hepatitis C virus (HCV) infection in pregnancy is a bloodborne viral infection caused by the HCV RNA flavivirus, affecting approximately 1% of women of childbearing age in Australia, though carriage rates reach 80% or higher in high-risk groups such as people who inject drugs. The incidence of new infections is falling, yet overall prevalence is rising as older untreated cohorts accumulate chronic disease burden. Major at-risk groups include people with current or prior injecting drug use, those born in high-prevalence regions (sub-Saharan Africa, the Middle East, Eastern Europe, South Asia), recipients of blood products in Australia before 1990, and those with a history of incarceration or unsterile tattooing.

2. Pathophysiology

HCV is a single-stranded positive-sense RNA virus in the Flaviviridae family. After parenteral inoculation, the virus infects hepatocytes via binding to surface receptors including CD81, SR-B1, claudin-1, and occludin. Viral replication within hepatocytes triggers both direct cytopathic injury and a host CD4/CD8 T-cell response. Inadequate viral clearance in approximately 75 to 85% of acutely infected individuals leads to chronic infection, defined as viraemia persisting beyond 6 months. Chronic immune-mediated inflammation drives progressive portal fibrosis through stellate cell activation, advancing through stages F0 to F4 (cirrhosis) over decades. Cirrhosis develops in 15 to 30% of untreated patients within 20 years, and of those with cirrhosis, approximately 27% develop hepatocellular carcinoma within a further 10 years, making HCV the leading indication for liver transplantation in Australia. In pregnancy, immune modulation does not reliably reduce viral replication, and maternal viraemia is the primary determinant of vertical transmission risk.

3. Clinical presentation and diagnostic criteria

Most women with chronic HCV infection are asymptomatic during pregnancy. When symptoms are present they may include fatigue, right upper quadrant discomfort, or jaundice, though frank jaundice is uncommon without advanced fibrosis. Stigmata of chronic liver disease (spider naevi, palmar erythema, splenomegaly, caput medusae) indicate advanced disease and prompt specialist review. Acute infection, which is rare in pregnancy, may present with nausea, malaise, and transaminase elevation. Diagnostic criteria for chronic HCV require two positive results: a reactive HCV antibody assay confirming past or present exposure, followed by a detectable HCV RNA polymerase chain reaction (PCR) confirming active viraemia. HCV RNA negativity with a positive antibody indicates spontaneous or treated clearance. RANZCOG recommends all pregnant women be screened for HCV to allow risk stratification and perinatal transmission reduction, even though universal screening is not yet mandated nationally.

4. Investigations and AU-specific cutoffs

Initial investigation follows a reflex pathway. Order HCV antibody (Ab) with reflex HCV RNA (qualitative PCR) as a paired request. If HCV Ab is positive, proceed to:

In women requiring invasive prenatal diagnosis (amniocentesis or chorionic villous sampling), HCV RNA status should be established prior to the procedure; if HCV RNA positive, non-invasive prenatal testing (NIPT) should be offered as a preferred alternative given its lower false-positive rate and avoidance of procedural transmission risk.

5. Management

Management during pregnancy is primarily supportive and aimed at reducing mother-to-child transmission (MTCT), as direct-acting antiviral (DAA) treatment is contraindicated in pregnancy and breastfeeding.

Antenatal. Multidisciplinary care involving obstetrics and infectious disease or hepatology is the standard of care. Alcohol minimisation counselling is recommended as alcohol accelerates fibrosis progression. Fetal surveillance follows routine antenatal pathways unless co-morbidities are present.

Intrapartum. Vertical transmission occurs in approximately 5% of HCV RNA positive mothers and is negligible in RNA-negative mothers. Risk is amplified by high viral load, HIV co-infection, prolonged rupture of membranes, and invasive procedures. Fetal scalp electrodes and fetal scalp blood sampling must be avoided where possible. Caesarean section is not recommended as a strategy to reduce perinatal HCV transmission, as evidence does not support a protective effect.

Postpartum neonatal care. The neonate should be bathed prior to any intramuscular injection (including vitamin K) to remove maternal blood and secretions. HCV infection is not a contraindication to breastfeeding; however, if nipples are cracked or bleeding, the woman should express and discard milk until the skin heals to eliminate a potential bloodborne exposure route.

Pre-pregnancy counselling. Given that pangenotypic DAA regimens have been PBS-listed since 2016 with cure rates exceeding 90%, all women planning pregnancy should be offered HCV screening and, if positive, treatment before conception. Treatment is the optimal window to eliminate vertical transmission risk and maternal morbidity.

6. Pharmacology and AU PBS notes

DAA therapy is not recommended during pregnancy or breastfeeding. Ribavirin, used in older interferon-based regimens, is Australian Pregnancy Category X and is absolutely contraindicated; women and their male partners receiving ribavirin must use reliable contraception during treatment and for 6 months after its completion.

First-line postpartum regimens (PBS-listed, ASHM 2023):

Patients with decompensated cirrhosis, prior DAA treatment failure, renal impairment (eGFR less than 50), or HIV co-infection require specialist review before initiation. Check drug interactions at hep-druginteractions.org before prescribing. Sustained virological response at 12 weeks post-treatment (SVR12) confirms cure and is associated with hepatic histological improvement and reduced risk of hepatocellular carcinoma.

7. Complications and monitoring

Maternal complications include progression to cirrhosis (15 to 30% over 20 years), hepatocellular carcinoma (27% of cirrhotic patients within 10 years), portal hypertension, and liver failure. Women with established cirrhosis require:

Vertical transmission surveillance. All infants of HCV-positive mothers must be tested to determine whether perinatal transmission occurred. Timing is critical: maternal HCV antibodies cross the placenta and persist in the infant for up to 18 months, so HCV antibody testing before 18 months is unreliable. The recommended approach is HCV RNA PCR at 2 to 6 months of age (two separate samples if first is positive) or HCV antibody testing after 18 months. Infants with confirmed infection should be referred to paediatric hepatology; spontaneous clearance occurs in approximately 25 to 40% of perinatally infected children.

Occupational exposure. The risk of HCV transmission from a needlestick injury involving an HCV-PCR-positive source is 1 to 3%. All healthcare workers parenterally exposed to the blood or body fluids of an HCV carrier should undergo baseline and 12-week follow-up HCV RNA testing as part of standard occupational health procedures.

Practise this in Lucan

Written for Australian practice and grounded in the guidance named above. Study material only — not medical advice. Always check against current guidelines.