Hepatitis C infection in mothers

Hepatitis C virus (HCV) testing is not part of the routine antenatal screen but testing can be performed during pregnancy to determine HCV status. Indications to consider HCV testing:

• History of IV drug use (self/partner)
• Persistent abnormal ALT
• Recipient of blood products or components prior to 1992
• Sexual partner who is HCV positive
• Received medical (inc. IVF) or dental treatment in a country where infection control may be poor.
• Received exposure to blood (e.g. needle stick injury) from someone known or high suspicion of HCV
• Partner is known positive for any blood borne virus.

Testing for HCV can be performed on antenatal booking blood and requested as additional test on Lothian antenatal screening. Informed consent should be obtained from the woman prior to testing, though written consent is not necessary.

• The HCV test can be performed on serum (9ml White cap tube)
• In Lothian all testing is performed in Specialist Virology Centre, Royal Infirmary Hospital, Edinburgh
• If HCV antibody positive – presence of HCV RNA will automatically be determined on same sample
• It is important to determine the mother’s HCV RNA status during pregnancy, as follow-up of her baby depends on this result. In some instances (e.g where there was insufficient blood in the first sample) an EDTA plasma sample (Red Cap tube) may be required to determine the RNA status with PCR - the lab will ask for this to be done.

Pregnant women who are HCV antibody positive but HCV RNA negative do not pose a risk of transmission to their child:

• Result should be reported to Specialist midwife to ensure LFTs checked referred letter to GP after pregnancy

Pregnant women who are HCV RNA positive:

• The risk of mother-to-child transmission is approximately 5%
• Standard obstetric management (Unless HIV positive as well) is appropriate
• Breast feeding is not contraindicated in maternal hepatitis C
• Result should be sent to specialist midwife (Fiona McNeilage (RIE) and Joyce Christie (St. Johns) to ensure confidentiality
• The specialist midwife would ensure:
  · referral to Liver specialist
  · letter to GP following pregnancy
  · lnfants are followed up at the Royal Hospital for Sick Children (Dr. Laura Jones)

Natural history

Infants born to women who are HCV antibody positive will test positive for HCV antibody at birth. Infants who are not infected become negative for HCV antibody between six and 20 months of age. Around 80% will be negative by 12 months of age.

Positive results for viral RNA may be obtained in the early months of life in children who subsequently become negative and lose HCV antibody. Some infected infants may not become HCV RNA positive until 2 months of age or thereafter. A recent study indicates that the sensitivity of a positive PCR result obtained on two occasions between two and six months of life in predicting infection is 81% (CI 58-97%). In HIV co-infection, infants consistently positive by RNA may have negative HCV antibody tests between 12 and 18 months of age.

Progression to severe hepatitis or cirrhosis in childhood is rare (<5%). There is a slow non-linear progression of fibrosis with age. The mean time to development of cirrhosis in individuals infected as infants is estimated at 28 years.

Potential treatment

Children that are demonstrated to have acquired infection will be followed up by the gastroenterology team and are assessed for the development of liver disease.

Anti-viral treatment is available and response rates to treatment in children are of a similar magnitude, and show the same influences of Hepatitis C genotype, to adults. Combination treatment with interferon and ribavirin renders Hepatitis C nucleic acid negative in 50-60% of cases. There is a potential for effects on thyroid function and growth problems, so in those with mild disease the positives and negatives of treatment must be weighed up

Action depends on the viral status of the mother; it is therefore essential that you ascertain from a reliable source – her notes – whether she is RNA positive or not. This is more important in determining your action than antibody status.

• Infants born to HCV RNA positive mothers should be referred to Dr. Laura Jones ( RHSC)
• Note therefore that infants born to HCV RNA negative mothers do not need testing or follow-up

• Bloods are not required from the infant at birth. It is important to inform the mother of the need to refer to RHSC for follow-up.
• A number of women do not attend their antenatal appointments with Dr Jones so the maternal notes should always be checked to ensure that counselling has been given. Those who have not attended will need counselled on the risks to their baby and the testing process as well as referral to Dr Jones.
• Refer using infectious disease trak referral proforma- see reference library Basics/postnatal ward/referral to paediatic specialities.
• On receipt of the referral, an appointment will be sent to the mother. HCV RNA testing on EDTA plasma would be performed at 3 and 9 months and HCV antibody testing at 18 months.

NHS Lothian Pregnancy Screening Programme Specification and Protocols, 2006.

Scottish Intercollegiate Guidelines Network- Management of hepatitis C – A national clinical guideline, 2006.