How should you manage children born to hepatitis C-positive women?

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Clinical Inquiries

How should you manage children born to hepatitis C-positive women?

J Fam Pract. 2010 May;59(5):289-290

By

Matthew Powell, MD

Justin Bailey, MD

Lauren A. Maggio, MS(LIS), MA, AHIP

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References

1. Yeung LT, King SM, Roberts EA. Mother-to-infant transmission of hepatitis C virus. Hepatology. 2001;34:223-229.

2. European Paediatric Hepatitis C Virus Network. Three broad modalities in the natural history of vertically acquired hepatitis C virus infection. Clin Infect Dis. 2005;41:45-51.

3. European Paediatric Hepatitis C Virus Network. Effects of mode of delivery and infant feeding on the risk of mother-to-child transmission of hepatitis C virus. BJOG. 2001;108:371-377.

4. Paccagnini S, Principi N, Massironi E, et al. Perinatal transmission and manifestation of hepatitis C virus infection in a high risk population. Pediatr Infect Dis J. 1995;14:195-199.

5. Mast EE, Hwang LY, Seto DS, et al. Risk factors for perinatal transmission of hepatitis C virus (HCV) and the natural history of HCV infection acquired in infancy. J Infect Dis. 2005;192:1880-1889.

6. England K, Pembrey L, Tovo P, et al. European Paediatric Hepatitis C Virus Network. Excluding hepatitis C virus (HCV) infection by serology in young infants of HCV-infected mothers. Acta Paediatr. 2005;94:444-450.

7. Ketzinel-Gilad M, Colodner SL, Hadary R, et al. Transient transmission of hepatitis C virus from mothers to newborns. Eur J Clin Microbiol Infect Dis. 2000;19:267-274.

8. Management of Hepatitis C: 2002. National Institutes of Health Consensus Conference Statement, June 10-12, 2002. Available at: http://consensus.nih.gov/2002/2002HepatitisC2002116html.htm. Accessed August 23, 2009.

9. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 86. Viral hepatitis in pregnancy. Obstet Gynecol. 2007;110:941-956.

10. Dienstag JL, McHutchison JG. American Gastroenterological Association medical position statement on the management of hepatitis C. Gastroenterology. 2006;130:225-230.Available at: www.gastrojournal.org/article/PIIS0016508505022717/fulltext. Accessed on August 23, 2009.

EVIDENCE-BASED ANSWER

FOR STARTERS, don’t be overly concerned with the mode of delivery; it doesn’t influence the rate of transmission of hepatitis C virus (HCV), except in women who are also infected with human immunodeficiency virus (HIV) (strength of recommendation [SOR]: B, consistent retrospective cohort studies).

Avoid internal fetal monitoring and prolonged rupture of membranes (SOR: B, single retrospective cohort study).

Advise patients that it’s OK to breastfeed. Breastfeeding doesn’t affect transmission (SOR: B, consistent prospective cohort studies).

Check HCV RNA and serum anti-HCV on 2 occasions between 2 and 6 months of age and 18 and 24 months of age (SOR: B, consistent prospective cohort studies).

Evidence summary

Perinatal transmission of HCV is rare. It occurs only when serum HCV RNA is detectable; transmission rates may be related to higher levels (>106 copies/mL).¹ HCV is transmitted to 2% of infants of anti-HCV seropositive women and 4% to 7% of infants born to mothers who are HCV RNA-positive at delivery.¹

FAST TRACK

Perinatal transmission of HCV is rare, occurring only when serum HCV RNA is detectable.

Spontaneous clearance of the virus occurs in approximately 20% of infants. Most remain asymptomatic if HCV persists, but have mild elevation of liver function tests.²

Routine screening for HCV in mothers is not recommended, but pregnant women at high risk for HCV infection should be screened for anti-HCV.

Route of delivery: Only a concern for HIV-positive mothers
The mode of delivery doesn’t influence the rate of HCV transmission, except in mothers with HIV. Retrospective analysis of 503 HCV-positive mothers coinfected with HIV showed a decreased risk of transmission during cesarean delivery (odds ratio [OR]=0.36; P=.01; number needed to treat [NNT]=10).³

One study suggested an increased rate of vertical HCV transmission during vaginal delivery compared with cesarean delivery (32% vs 6%; P<.05). The study didn’t account for the percent of mothers coinfected with HIV, however.⁴

FAST TRACK

Routine screening for HCV isn’t recommended, but screen pregnant women at high risk of HCV infection for anti-HCV.

A meta-analysis of 11 studies showed similar rates of transmission for vaginal and cesarean delivery: adjusted rates were 4.3% and 3%, respectively.¹

Internal monitoring is an issue
Avoid internal fetal monitoring to minimize HCV transmission, based on a single retrospective cohort of 244 infants born to HCV-positive mothers (relative risk [RR]= 7.7; 95% confidence interval [CI], 1.9-31.⁶; number needed to harm [NNH]=6).⁷ The same study showed an increased risk with membrane rupture longer than 6 hours (RR=9.9; 95% CI, 1.2-81; NNH=13).⁵

Breastfeeding doesn’t significantly affect HCV transmission. Transmission rates for breastfed and nonbreastfed infants are 3.7% and 3.9%, respectively.¹

Evidence-based answers from the Family Physicians Inquiries Network

How should you manage children born to hepatitis C-positive women?

References

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