Should All Pregnant Women Get Tested for Hepatitis C?

Guideline groups are at odds over testing every expectant mom.

You can count on having blood work to screen for HIV, hepatitis B, and syphilis as part of your prenatal care. But you probably won't be checked for hepatitis C unless you have a known risk factor.

Now some doctors say it's time to close the gap. They want all pregnant women screened for this potentially liver-damaging infection to ensure proper diagnosis and follow-up care for moms and their babies.

An estimated 1 to 2.5% of pregnant women (and even as many as 4% according to some research) have hepatitis C. The infection passes from mom to baby in 5% of births, on average, and more frequently in women who also have HIV.

The concern is that some women with hep C aren't being identified, and some babies, whose hep C status cannot be confirmed until they're 18 months of age, aren't getting screened at all. "We're missing cases of perinatal hepatitis C infection," says Catherine Chappell, MD, assistant professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of Pittsburgh.

Other clinicians say there's no rationale for singling out pregnant women, at least not at the moment. "If we get to a point where we have a treatment we can offer these women [during pregnancy], then it's a whole different ballgame," says Geeta Swamy, MD, associate professor of obstetrics and gynecology at Duke University and a spokesperson for the Society for Maternal-Fetal Medicine (SMFM).

Sarah Schillie, MD, medical officer in the Division of Viral Hepatitis at the U.S. Centers for Disease Control and Prevention (CDC), confirmed to Health that the agency is reviewing the strength of evidence regarding hepatitis C screening among pregnant women as part of a multistep process for updating recommendations. She wouldn't speculate on the potential outcome of the review.

Health spoke with clinicians, researchers, and public health officials who specialize in infectious disease and maternal-and-child health for insight into the hep C screening debate. Here's what we learned.

Hep C Is Not Just a Baby Boomer Disease

The face of hepatitis C is changing. Young adults, a group that includes women of childbearing age, account for the majority of new cases.

The CDC attributes the spike in infections among 18- to 39-year-olds to the nation's opioid epidemic. Sharing needles and other equipment to inject prescription opioids or heroin puts women (and men) at risk of acquiring this blood-borne infection.

From 2009 through 2014, maternal hepatitis C infections nearly doubled, from 1.8 to 3.4 per 1,000 live births, according to the CDC. The highest rates occurred in the Appalachian region of the U.S.

Screening Guidelines Differ

The American College of Obstetricians and Gynecologists endorses SMFM guidelines calling for risk-based screening in pregnancy. The CDC also recommends testing women at higher risk.

The U.S. Preventive Services Task Force (USPSTF) doesn't single out pregnant women; it recommends screening any person at high risk of hepatitis C infection.

You might be considered "at risk" if you ever—even once—injected illegal drugs, received a tattoo or piercing with unsterile equipment, or engaged in some other activity that may have exposed you to the hepatitis C virus.

But in May 2018, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America recommended that all pregnant women get tested for hepatitis C, ideally at the start of their prenatal care.

Risk-Based Screening Isn't Perfect

Doctors don't always know who's at risk for hepatitis C. Women may not know they've been exposed to the virus or may be reluctant to disclose IV drug use. Some evidence suggests universal screening during pregnancy may be more reliable than risk-based testing as a tool for identifying women with hepatitis C.

Marc Ghany, MD, an investigator in the liver disease branch of the National Institute of Diabetes and Digestive and Kidney Diseases and AASLD's Hepatitis C Virus Guidance co-chair, says not screening women during their prenatal care would be "a missed opportunity" to get hep C-positive moms into treatment post-pregnancy and prevent transmission to future offspring.

"For many of these young women," he says, "this is their only engagement with health care professionals."

Kentucky Is Leading the Charge

Norton Healthcare in Louisville, Kentucky began screening all pregnant women for hepatitis C in May 2016, after doctors started seeing more patients with risk factors.

"It was truly based on clinicians saying, we believe that this is clinically the right thing to do," says Michelle Rose, Norton's infectious disease manager for population health.

Remarkably, 75% of moms testing positive since the initiative began had been unaware of their infection, she tells Health.

Hard hit by the opioid epidemic, Kentucky in 2018 became the first state in the nation to pass legislation requiring hepatitis C screening for all pregnant women.

Study Findings Could Change the Debate

Currently, there are no antiviral medicines for hepatitis C approved for use in pregnancy. Nor are there any evidence-based interventions to prevent mom-to-baby transmission.

In short, screening doesn't change a woman's obstetrical care, says Mona Prasad, DO, assistant medical director for perinatal services at OhioHealth Grant Medical Center in Columbus. At least not now.

Dr. Prasad is the principal investigator for a multi-center trial that may help inform the debate. The observational study, backed by the National Institute of Child and Human Development, will examine risk factors for hepatitis C transmission from mother to child, for example.

Other studies could pave the way for new treatment options. A small preliminary study presented at a scientific meeting this month is the first to examine hepatitis C treatment in pregnant women. Larger studies are needed to confirm whether the use of antiviral regimens in pregnancy is safe and effective.

For now, any woman who thinks she may have been exposed to the hepatitis C virus should talk to her doctor about getting tested. If she has risk factors, "testing is obviously clearly indicated," Dr. Ghany says.

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