Risk-based screening misses hepatitis C in many pregnant women

11/04/13

By: DENISE FULTON, Ob.Gyn. News Digital Network

Gyn. News Digital Network

WASHINGTON – Programs to screen pregnant women for hepatitis C infection could go far to reduce a host of adverse outcomes, according to an analysis of a large national sample.

"Targeted HCV screening may overlook many pregnant women with chronic HCV infections, and that may contribute to the underdiagnosis of pediatric hepatitis C in the United States," study investigator Dr. Po-Hung Chen said at the annual meeting of the American Association for the Study of Liver Diseases.

^{Denise Fulton/IMNG Medical Media}

Dr. Po-Hung Chen

"Chronic hepatitis C is associated with adverse maternal/fetal consequences. In light of these findings, there seems to be a need to further evaluate universal hepatitis C screening as a part of antepartum care," he added.

Dr. Chen of the division of gastroenterology at Johns Hopkins University, Baltimore, and colleagues collected data on all births and spontaneous abortions recorded in the National Inpatient Sample between 2003 and 2010.

More than 28,000 of the 32 million deliveries or miscarriages recorded in the National Inpatient Sample were to mothers infected with HCV, he reported.

Of HCV-positive mothers, 72% had no traditional risk factors for the disease.

HCV-positive mothers were significantly more likely to experience obstetric pulmonary embolism (adjusted OR, 3.05), thyroid dysfunction (aOR, 1.37), and maternal death (aOR, 2.49). They also were significantly more likely to be white, less affluent, on Medicaid, substance abusers, and have more comorbidities.

Women who were HCV positive were significantly more likely to have labor before 37 weeks’ gestation (aOR, 1.36), antepartum hemorrhage (aOR, 1.44), and poor fetal growth (aOR, 1.61).

Cost of care and length of stay were significantly greater for mothers who were HCV positive, Dr. Chen said.

Previous analysis using data from the National Health and Nutrition Examination Survey (NHANES) showed that the prevalence of hepatitis C virus infection in women aged 20-39 years was 1%-1.6% in the period between 1999 and 2002. Dr. Chen noted that this could be an underestimation because NHANES is based on home health surveys and therefore does not include prison populations and homeless women, who are at high risk for HCV infection.

Currently, no definitive guidelines exist on how to manage chronic HCV in pregnant women, likely because of a dearth of suitable proven management options, Dr. Chen said, adding that ribavirin is contraindicated in pregnancy, interferon is generally not recommended, and the currently approved protease inhibitors are not options for single-drug management.

The American College of Obstetricians and Gynecologists does not recommend routine prenatal screening for HCV; instead, the college recommends screening only in women who are at high risk based on Centers for Disease Control and Prevention criteria.

Dr. Chen did not report financial conflicts of interest.

dfulton@frontlinemedcom.com

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Successful pregnancies possible for women following liver transplantation

June 7, 2012

New research confirms that successful pregnancies are common for female liver transplant recipients. The study appearing in the June issue of Liver Transplantation, a journal published by Wiley-Blackwell on behalf of the American Association for the Study of Liver Diseases, found miscarriage risk was lower and the live birth rate higher among women following liver transplantation than in the general U.S. population.

In 1978, Walcott et al. documented the first known pregnancy in a liver transplant recipient, which resulted in a successful delivery with both mother and infant in excellent health. Medical evidence reports there are currently 14,000 American women of reproductive age who have received liver transplants and another 500 undergo the procedure each year. While previous studies have documented good reproductive function in women following liver transplant, pregnancy outcomes and maternal-fetal risks assessments are limited.

For the present study, a team led by Dr. Dorry Segev, Director of Clinical Research in Transplant Surgery at Johns Hopkins Medical Institutions in Baltimore, Md., systematically reviewed medical literature articles from 2000 to 2011 to identify studies pertaining to pregnancy outcomes among liver transplant recipients. Maternal complications, delivery outcomes, birth information, and transplant-related data were also analyzed.

Eight studies met the inclusion criteria, which included 450 pregnancies among 306 liver transplant recipients. Following transplantation the live birth rate was 77% compared to 67% in birth in the general U.S. population. The rate was similar to the rate after kidney transplant at 77% and 74%, respectively. Miscarriages among women following kidney (14%) and liver (16%) transplants were lower than the general population (17%).

Rates for preeclampsia, cesarean section and preterm delivery were higher in liver transplant patients at 22%, 45%, and 39% than in the general population at 4%, 21% and 13%, respectively. Liver transplant recipients had lower pregnancy complications than kidney recipients whose rates for preeclampsia, C-section, and preterm delivery were 27%, 54%, and 46%, respectively. Liver transplant patients also had significantly greater delivery outcomes than kidney transplant recipients with the mean gestational age at 37 weeks versus 36 weeks, and infant birth weight at 6 pounds versus 5 pounds.

"Our findings confirm that pregnancy is feasible following liver transplantation, but not without potential complications," said Neha Deshpande, who conducted the literature review. "Women who wish to start families following a liver transplant should work closely with their physicians to minimize risk and to ensure a healthy outcome for themselves and their babies." The authors encourage transplant recipients to report pregnancy outcomes to transplantation centers for data collection.

In a related editorial, Dr. Vincent Armenti from Thomas Jefferson University in Philadelphia, Pa. writes, "Dr Segev and colleagues conclude that live birth outcomes are possible among liver transplant recipients and this favorable trend is consistent on the international level." He also encourages reporting to active registries to monitor pregnancy and births in patients following liver transplantation.

Provided byWiley

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Hepatitis C virus infection during pregnancy and the newborn period – are they opportunities for treatment?

Journal of Viral Hepatitis
Early View (Articles online in advance of print)

M. Arshad 1, S. S. El-Kamary 2,3,4, R. Jhaveri 1,5

Article first published online: 7 JAN 2011
DOI: 10.1111/j.1365-2893.2010.01413.x
© 2011 Blackwell Publishing Ltd

Author Information
1 Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, NC
2 Department of Epidemiology and Public Health
3 Department of Pediatrics
4 Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD
5 Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, USA
* Correspondence: Ravi Jhaveri MD, Division of Pediatric Infectious Diseases, Duke University Medical Center, DUMC 3499, Durham, NC 27710, USA. E-mail: ravi.jhaveri@duke.edu

Abstract

Keywords: hepatitis C virus; infants;pregnancy; treatment; vertical transmission

Summary.  The worldwide prevalence of hepatitis C virus (HCV) infection in pregnant women is estimated to be between 1 and 8% and in children between 0.05% and 5%. While parenteral transmission is still common in children living in developing countries, perinatal transmission is now the leading cause of HCV transmission in developed countries. The absence of an HCV vaccine or approved therapy during pregnancy means that prevention of vertical transmission is still not possible. However, a low vertical transmission rate of 3–5%, a high rate of spontaneous clearance (25–50%) and delayed morbidity have resulted in HCV being overlooked in pregnant women and their infants. Yet a study of the natural history in mothers and children demonstrates that the prognosis of HCV can vary greatly and should be taken seriously. Factors known to increase the risk of perinatal transmission include HIV coinfection and higher maternal viral loads, while elective C-section and withholding breastfeeding have not been demonstrated to reduce vertical transmission. Current guidelines for the diagnosis of persistent perinatal infection require a positive anti-HCV test in infants born to infected mothers after 12 months or two positive HCV RNA tests at least 6 months apart. Current HCV treatment options using pegylated interferon and ribavirin are both unsuitable for use in pregnancy and infancy. However, new agents currently in preclinical phases of development, along with the recently identified association between single-nucleotide polymorphisms within the IL28 gene and treatment response, may serve to create a therapeutic window for these patients

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