At Digestive Diseases Week in May 2022 in San Diego, one abstract reported an alarming increase in pregnancies among individuals with Hepatitis C virus (HCV) infection. This abstract provided strong support for recommendations to screen pregnant individuals for HCV infection with each pregnancy. Over the last couple of years, this recommendation to screen for HCV with each pregnancy came from the American Association for the Study of Liver Diseases and Infectious Disease Society of America guidance panel, the CDC, and the American College of Obstetricians and Gynecologists. These recommendations emerged from rising rates of HCV infection among individuals of childbearing related to the opioid epidemic.
The aims of the DDW abstract by Johnson and colleagues were to estimate the proportion of pregnancies with HCV infection over a two-decade span and to identify adverse maternal and perinatal outcomes associated with HCV infection. The authors utilized the National Inpatient Sample (NIS), which is the largest publicly available all-payer inpatient healthcare database, for the years 1998 through 2018. The NIS contains data from more than seven million hospital stays each year and provides regional and national estimates of inpatient utilization, access, cost, quality, and outcomes. During the study period, all age groups had substantial increases in the proportion of pregnancies with known HCV infection. For the age group 21 to 30 years old, the increase was 30.6-fold, rising to over 0.6% of all pregnancies by 2018. For the age group 31 to 40 years old, the proportion of pregnancies with known HCV infection approached 0.5%. For both age groups, this equates to about one in every 200 pregnancies in the United States. Modeling revealed that individuals with a pregnancy with known HCV infection were more likely to be white, less affluent, report substance abuse, and have more medical comorbidities. When considering outcomes, those with HCV infection had higher rates of Caesarean section (adjusted odds ratio (AOR) 1.25, 95% confidence interval (CI) 1.22-1.29), pre-term delivery (AOR 1.10, 95% CI 1.06-1.15) and fetal intrauterine growth retardation (AOR 1.40, 95% CI 1.32-1.49). The analysis did not reveal an increased risk of spontaneous abortion, gestational diabetes, preeclampsia, or stillbirth. It should be noted that this was an observational study describing associations and not causation. Further research is needed to understand these outcomes in HCV pregnancies.
This study highlights this dramatic increase in pregnancies among those with HCV infection in the United States over the last two decades. These recent guidelines to screen for HCV infection with each pregnancy are critical to identifying mothers and babies with HCV infection. A meta-analysis of 20 studies reported that the risk of vertical transmission of HCV was 5.8% (95% CI 4.2-7.8) with HCV monoinfection and 10.8% (95% CI 7.6-15.2) with HCV/HIV coinfection. While mode of delivery is not associated with HCV vertical transmission, prolonged rupture of membranes greater than six hours and the use of fetal scalp electrodes during delivery have been associated with transmission. Breastfeeding is not associated with HCV transmission, although there is a recommendation to abstain from breastfeeding if the nipples are cracked or bleeding.
HCV antiviral treatment during pregnancy has not been well studied to determine safety, and so HCV treatment cannot be recommended during pregnancy. Individuals identified with HCV infection during pregnancy must be linked to care following delivery to obtain HCV treatment for the parent and child. Antiviral treatment can be administered to children as young as three years old. With solid linkage to care, these highly effective antiviral therapies can offer an excellent chance of cure for both parent and child infected with HCV. This study identified that HCV infection was associated with lower income, substance abuse, and medical comorbidities. HCV infection may not be the highest priority for some individuals battling poverty or other medical challenges, and they may benefit from navigation and other support services. Pregnancy and well child care are times when individuals are more likely to engage in health care services. The first step is to follow these recommendations to screen for HCV with each pregnancy. When we identify pregnant individuals and babies with HCV, we must support them and offer HCV treatment to the parent and any infected children. These findings should also encourage screening and treatment among those of childbearing potential before pregnancy.
Dr. Muir is employed by Duke University. He has received grants from Cymabay, Genfit, Gilead, Novartis, and Pliant.
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