Women With Chronic Hepatitis C Virus Infection

Recommendations for Clinical Practice

Mary Jane Burton, MD; James B. Brock, MD; Stephen A. Geraci, MD


South Med J. 2013;106(7):422-426. 

In This Article

Pregnancy and Breast-feeding

Women with advanced liver disease are at increased risk for complications during pregnancy, but the effects of maternal HCV infection on natal outcomes are less well defined.[44] Recent evidence suggests that HCV infection may increase the risks for gestational diabetes, low birth weight, and neonatal intensive care unit admission.[45,46] Modifiable risk factors, such as IDU and limited prenatal care, may be more prevalent in patients with HCV,[41] which could confound data on maternal and fetal outcomes.

Pregnancy may improve the natural course of HCV infection. In the second and third trimesters, alanine aminotransferase levels decrease, whereas serum levels of HCV RNA increase.[47] This could imply that decreased hepatocyte damage, possibly related to increased estrogen levels and/or placental interferon production, occurs during pregnancy. Although alanine aminotransferase and HCV RNA serum concentrations return to prepregnancy levels within several months of delivery, women with multiple gestations do exhibit slower disease progression.[21]

Vertical transmission is the major cause of HCV infection in children.[45] Maternal–infant transmission occurs in roughly 5% of cases in which the mother is infected with HCV,[48] but recommendations regarding prevention are limited by insufficient high-quality data. The timing of transmission also is poorly understood; evidence exists for both in utero and transvaginal transmission.[49] Frequently identified risk factors for vertical transmission are high maternal HCV viral load and human immunodeficiency virus (HIV) co-infection.[50,51] Prolonged rupture of membranes (>6 hours) has been associated with more frequent perinatal transmission.[50] In addition, some experts recommend avoiding invasive procedures that promote fetal exposure to maternal blood, such as fetal scalp monitoring.[50,52] Elective cesarean section has been proposed to reduce the risk of vertical transmission;[53] however, this practice is not recommended for women infected with HCV unless they are co-infected with HIV.[52] Some studies have reported that because an elevated serum viral load increases the risk of transmission,[50,51] women who achieve remission from HCV before conception may reduce their risk of transmitting the virus to their fetuses.

Although HCV RNA has been detected in breast milk and colostrum,[54] breast-feeding does not appear to be a primary route of maternal–infant HCV transmission.[50,55] Some experts believe that the quantity of virions in these bodily fluids is insufficient to result in infection and that gastric acid exerts a protective effect.[52] Mothers infected with HCV are encouraged to breast-feed in the absence of other contraindications, such as HIV-1 co-infection, but they should be counseled that there is limited study on this topic.[56] The Centers for Disease Control and Prevention propose temporary interruption of breast-feeding when the mother has cracked, bleeding, or traumatized nipples, which could increase exposure of the infant to HCV.[57]