What Are the Risks of Passing Hepatitis C to My Baby?

Viral load, stage of pregnancy, co-infection influence risk

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Hepatitis C is a communicable viral disease affecting the liver that is predominantly spread through the shared use of needles and syringes. But that's not the only way that people can get infected. Each year in the U.S., around 40,000 women with hepatitis C give birth, of which 4,000 of their babies will test positive for the hepatitis C virus (HCV).

While fewer than 10 percent will progress to a chronic infection, that’s still enough to cause concern—particularly since there are few, if any, factors that either increase or decrease the risk of transmission from mother to child.

Moreover, the absence of an HCV vaccine, as well as the lack of data regarding the use of hepatitis C drugs during pregnancy, means that prevention options are often limited.

But that’s not to say that there aren’t things parents can do—or questions they can ask—if one or both have hepatitis C and are expecting (or planning to have) a baby.

Hepatitis C Infection by Stage of Pregnancy

While it still common in the developing word for HCV to be passed from mother to newborn through unsterile medical procedures, in the U.S. and other developed countries HCV transmission typically occurs either in the uterus or during labor.

Some studies suggest that the risk increases during the latter stages of pregnancy. This may be due, in part, to a surge in the number of virus during the second and third trimesters, which tends to drops in the weeks following delivery.

Typically speaking, the amniotic fluid itself will not contain any virus.

It is more likely that transmission occurs when the virus enters the placenta and/or epithelial cells that line the uterus. We’re still not entirely sure why this happens in some women and not in others, or which physiological factors contribute to transmission.

While infection can occur during delivery as a result of exposure to maternal blood and bodily fluids, the risk varies significantly based on the intensity of infection in the mother.

Hepatitis C Risk Factor in Pregnancy

The one factor most associated with the mother-to-child transmission of HCV is the level of virus in the mother’s blood and bodily fluids. This is measured by a test called the HCV viral load, which calculates the number of viral particles in a milliliter of blood. The value can range from as little as several thousand viral particles to many millions, with higher values correlating to higher risk.

Another factor associated with increased transmission risk is a co-existing HIV infection. This is particularly important given that HCV/HIV co-infection rates can run as high as 20 percent in some countries.

During pregnancy, an uncontrolled HIV infection can increase the likelihood of HCV transmission by 20 percent, according to research from the National Institutes of Health. Furthermore, mothers co-infected with HCV and HIV are more than twice as likely to transmit HCV to their unborn baby if they are current injecting drug users.

Hepatitis C and Caesarean Section

Oddly enough, no. Numerous studies have shown no statistical difference in the rate of transmission if a mother delivers vaginally or by C-section. But that doesn’t mean to suggest there aren’t considerations to be made when deciding on the mode and timing of delivery.

One factor known to increase transmission risk is the prolonged rupture of membranes during delivery. Ruptures longer than six hours are associated with a 30 percent increased risk, suggesting that every effort should be made to keep the second stage of labor as short as possible. This is especially true if the mother has a high HCV viral load.

Similarly, any invasive medical procedure that enables blood-to-blood exposure may increase the likelihood of transmission. These include amniocentesis, which carries a relatively low risk of transmission, and internal fetal monitoring, which should be avoided during labor.

Hepatitis C and Breastfeeding

There is absolutely no evidence to suggest that breastfeeding can increase the risk of HCV transmission from mother to child. It is for this reason that the Centers for Disease Control and Prevention (CDC) and the American Congress of Obstetrics and Gynecologists (ACOG) endorse breastfeeding for mothers with HCV. With that being said, mothers with cracked or bleeding nipples should consider alternatives, particularly if they have a high viral load. 

Mothers co-infected with HCV and HIV should avoid breastfeeding as there remains a risk of transmitting HIV to the baby. This is especially true for mothers who are not yet on antiretroviral therapy or are unable to achieve undetectable HIV viral loads.

What Happens If a Baby Tests Positive

Nearly all children born to mothers with HCV will show antibodies for the virus. This does not mean that the child is infected. Antibodies are simply immune proteins produced by the body in response to disease-causing agents like HCV.

In newborns, HCV antibodies are usually inherited (meaning they are produced by the mother and passed to the baby). As such, their presence doesn’t mean the child is infected. In most cases, the number of antibodies will decline over time, with anywhere from 90 to 96 percent of children spontaneously clearing the virus between the ages of 18 and 24 months.

As such, it is recommended that children be tested for HCV no sooner than 18 months of age. If earlier testing is required, a test called the HCV RNA assay can be performed after the age of 1-2 months and repeated at a later date to assess whether there is genetic evidence of an infection. While early diagnosis will not typically alter the course of medical care for the child, it may help lower the anxiety for the parents.

If a child is definitively diagnosed with hepatitis C, that does not mean that the child will get sick. Hepatitis C typically progresses far slower in children than in adults, with upwards of 80 percent showing minimal to no liver scarring (fibrosis) by the age of 18.

Furthermore, children and adolescents with HCV tend to respond positively to hepatitis C therapy, if needed, achieving high cure rates and with far fewer side effects than adults.

Preventing Hepatitis C in Pregnancy

If you have chronic hepatitis C and intend to get pregnant, speak with your doctor about available treatment options. Today, direct acting antivirals (DAAs) are achieving cure rates in excess of 95 percent in some populations, with treatment durations lasting as little as 12 to 16 weeks.

The same applies if you don’t have HCV, but your spouse does. While there is no way for a male to directly infect a fetus, there remains a risk of infection to the female partner. (Despite the high cost of HCV therapy, access is widening as insurers recognize long-term savings associated with the prevention of liver cancer and decompensated cirrhosis.)

It’s important to note, however, that HCV therapy is not normally advised in the absence of any other indication for treatment. If liver fibrosis is minimal to non-existent and the viral load is low, it probably wouldn’t be necessary to start treatment. The only exception may be former injecting drug users who agree to use birth control until therapy is completed.

On the other hand, if you have hepatitis C and are already pregnant, be sure to meet with a specialist hepatologist or gastroenterologist to better ensure you avoid many of the risk factors associated with mother-to-child transmission.

Equally important is the immediate treatment of HIV infection, whether you are pregnant or not. By suppressing HIV to undetectable levels, you greatly reduce the chronic inflammation associated with infection. This, in turn, can reduce HCV viral activity during pregnancy and well after birth.

Recent studies have shown that mothers on antiretroviral therapy with undetectable viral loads have the same risk of HCV transmission as mothers who don’t have HIV.

Will Pregnancy Complicate My Hepatitis C?

Probably not. However, current data are often conflicting, with some studies suggesting that pregnancy advances liver fibrosis in women with HCV while others report a slowing of disease progression.

With that being said, women with HCV may be at greater risk of pregnancy complications. One population-based study in Washington showed that infants born to HCV-positive mothers were more likely to have low birth weight, while the mothers themselves had an increased risk for gestational diabetes (usually in association with excessive weight gain).

But these seem to be more the exception than the rule. For the majority of mothers with HCV, pregnancies will be uncomplicated with no worsening of liver disease and no adverse effects to the baby.

Sources:

Dunkelberg, J.; Berkeley, E.; Thiel, K.; et al. “Hepatitis B and C in pregnancy: a review and recommendation for care.” Journal of Perinatology. December 2014; 34(12):882-891.

Pergam, S.; Wang, C.; Gardella, C.; et al. “Pregnancy complications associated with hepatitis C: data from 2003-2005 Washington state birth cohort.” American Journal of Obstetrics. 2008; 199:38(e 1-9).

U.S. Department of Health and Human Services. “Consideration for Antiretroviral Use in Patients with Coinfections: Hepatitis C (HCV)/HIV Coinfections.” Bethesda, Maryland; updated July 14, 2016.

U.S. Department of Health and Human Services. "Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States." Rockville, Maryland; updated May 21, 2013.

Yeung, C.; Lee, H.; Chan, W.; et al. “Vertical transmission of hepatitis C virus: Current knowledge and perspective.” World Journal of Hepatology. September 27, 2014; 6(9):643-651.

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