HCV and Pregnancy

HCV-RNA levels increase during pregnancy in women with chronic hepatitis C

Wejstal R, Widell A, Norkrans G.      Department of Infectious Diseases, Sahlgrenska University Hospital, Ostra, Goteborg, Sweden.
Scand J Infect Dis 1998;30(2):111-113

Alanine aminotransferase (ALT) levels decline during pregnancy in women chronically infected with hepatitis C virus (HCV). In order to understand further the underlying mechanisms, we prospectively followed 10 chronically infected women before, during and after pregnancy. ALT levels were analysed together with quantification of serum HCV-RNA using the branched DNA technology. As anticipated, the ALT levels significantly declined late in pregnancy and increased again after delivery. HCV-RNA levels, conversely, significantly increased late in pregnancy and returned to baseline levels 1 y after delivery. These findings suggest the importance of immune mediated mechanisms in controlling the viral replication and contributing to the liver injury in chronic hepatitis C.

Decrease in serum ALT and increase in serum HCV RNA during pregnancy in women with chronic hepatitis C

Gervais A, Bacq Y, Bernuau J, Martinot M, Auperin A, Boyer N, Kilani A, Erlinger S, Valla D, Marcellin P.
Service d'Hepatologie, INSERM U481 and Centre de Recherche Claude Bernard sur les Hepatites Virales, Hopital Beaujon, Clichy, France. J Hepatol 2000 Feb;32(2):293-299

BACKGROUND/AIMS: The natural history of chronic hepatitis C infection during pregnancy has not been clearly established, and thus our aim was to assess serum alanine aminotransferase levels and serum HCV RNA levels during pregnancy. METHODS: Twenty-six pregnant women with chronic hepatitis C were studied. Serum alanine aminotransferase was assessed within the 3 months before, monthly during and within the 3 months after pregnancy. In 12 women, serum HCV RNA levels were quantified by the branched DNA assay. Twenty-six age-matched non-pregnant women with chronic hepatitis C were followed up for 1 year, and used as a comparison group.

RESULTS:
During pregnancy, serum alanine aminotransferase levels decreased in the second and third trimesters. The third trimester levels were significantly lower than serum alanine aminotransferase levels before pregnancy (p=0.0001). Seventy-seven percent of the pregnant women with increased pre-pregnancy levels had normalization of serum alanine aminotransferase levels. In the second or third trimesters, serum HCV RNA levels increased. The third trimester serum HCV RNA levels were significantly higher than levels before pregnancy (p=0.01). No significant change in serum alanine aminotransferase or HCV RNA levels was observed in the control group.

CONCLUSION: In pregnant women with chronic hepatitis C, serum alanine aminotransferase levels decrease, and serum HCV RNA levels increase during the second and third trimesters. 

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Should Pregnant Women Be Screened for Hepatitis C?

Factors Warranting Hepatitis C Testing Persons who should be tested routinely for hepatitis C virus: Those who ever injected illegal drugs (even once) Those notified that they received blood from a donor who later tested positive for hepatitis C virus Recipients of transfusions or organ transplants, particularly if received before July 1992 Those who were ever on long-term hemodialysis Those with persistently elevated alanine aminotransferase levels or other evidence of liver disease Persons for whom routine testing is of uncertain need: Recipients of tissue transplants (e.g., corneal, musculoskeletal, skin, sperm, ova) Users of intranasal cocaine or other noninjected illegal drugs Those with a history of tattooing or body piercing Those with a history of sexually transmitted diseases or multiple sexual partners A long-term steady sex partner of a hepatitis C virus­positive person Information from Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR Morb Mortal Wkly Rep 1998;47:1-39.

An estimated four million Americans are infected with hepatitis C, but most are asymptomatic and unaware of their infection. Current treatment options, such as interferon or combinations of interferon and ribavirin, are associated with a positive response in about one half of the patients but have substantial adverse side effects. Over time, up to 90 percent of patients develop chronic hepatitis and, over a period of 20 years, 20 percent develop cirrhosis. An unknown proportion of patients develops hepatic failure or hepatocellular carcinoma. One estimate is that hepatitis C is currently responsible for up to 10,000 deaths per year in the United States, and this could triple over the next 10 to 20 years. If these estimates are accurate, hepatitis C will surpass HIV as a cause of mortality.

In addition to blood-to-blood transmission and sexual contact, hepatitis C can be transmitted vertically from mother to child. This transmission appears to be inefficient, occurring in approximately 5 percent of live births to infected mothers. Factors associated with transmission have not been conclusively identified. Burns and Minkoff reviewed the potential benefit of maternal screening for hepatitis C as a preliminary step in preventing vertical transmission of the virus.

The advantages of screening include the identification of asymptomatic women who might otherwise not present for medical attention until late in the course of the disease, when serious hepatic damage has occurred. These women could be offered therapy and advised to avoid hepatotoxic materials, especially alcohol. Identification of infected mothers would also enable measures to be taken to prevent spread of the virus to household contacts and others, in addition to the unborn child.

Because of the many unknown factors in hepatitis C disease transmission and progression, the Centers for Disease Control and Prevention and the American Academy of Pediatrics currently recommend screening only children born to mothers who are known to have hepatitis C or who have risk factors for the infection. These risk factors include injection of illegal drugs, contaminated blood transfusion, long-term hemodialysis, multiple sexual partners or a sexual partner infected with hepatitis C, and a history of tattooing or body piercing. Routine testing of all pregnant women does not currently appear to be justified (see accompanying table).

ANNE D. WALLING, M.D.

Burns DN, Minkoff H. Hepatitis C: screening in pregnancy. Obstet Gynecol December 1999;94:1044-8.

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