The Reproductive Care of Women Living With Hepatitis C Infection
V. Assessing a Woman's Risk For HCV
A. Screening
1. Universal screening
The screening of medical disorders usually requires
that certain conditions be present (Table IX). Although HCV is of
major public health importance, universal screening is not currently
recommended in Canada.2However, this policy may change
with new developments in the field of HCV infection and universal
screening may become invaluable to the general population. 84,105,106 The prevalence remains low in both the general (1-3%) and pregnant
(0.68-4.5%) populations. Antibody screening tests are available
but do not differentiate between acute and chronic infection. Interferon
and ribavirin therapy has shown some encouraging results but the
response to treatment is neither universal nor sustained in the
general population. At the moment there is insufficient data on
the safety of interferon in pregnancy.
Ribavirin is a known teratogen. There are no documented measures
capable of influencing maternal-fetal transmission. However, there
may be great benefit from counselling regarding risk reduction strategies
including abstinence from alcohol consumption, immunization against
hepatitis A and B, and for injection drug users, needle exchange
programmes, alternative routes of administration or methadone maintenance
therapy.
2. Targeted screening
For the above reasons, a targeted screening approach
has been adopted by Health Canada and individuals listed in Table
X should be counselled in favour of screening.2 Similarly,
routine screening is not currently recommended in pregnancy but
women falling into these categories should be offered testing. Even
with this approach, between 40 and 60 percent of infected women
will remain unidentified.
B. Counselling
The health care provider has a unique and integral
role to play in providing women living with HCV with clear, evidence
based information regarding hepatitis C infection.
1. Emotional and psychosocial issues
The emotional and psychosocial impact of a diagnosis
of hepatitis C on a woman and her family should not be underestimated.
Some will take the diagnosis in stride but for others the knowledge
will be devastating and more damaging than the actual disease. The
general lack of knowledge concerning HCV infection among medical
practitioners and the public, and the way in which the "bad news"
is broken, will both influence the subsequent course. There are
many fears that may need to be addressed: about health and life,
about transmission and relationships with loved ones, and about
stigma or discrimination. There may also be a sense of guilt and
feelings of violation.
-
| TABLE IX : CONDITIONS FOR USE
OF A SCREENING TEST |
• Disease must be of public
health importance
• A sensitive and specific test must exist for its detection
• Therapeutic and preventive measures must be available
• Direct and indirect screening costs must be acceptable
to the individual and society |
Prior to testing, the patient's perceived risk
of infection should be established, possible symptoms assessed,
and level of knowledge concerning HCV transmission and prevention
ascertained. The patient should be adequately counselled prior to
testing. The tests should be explained and a discussion of how the
patient might cope with a positive result should take place. Referrals
to support sources should be made and the possible implications
of informing others with respect to relationships, jobs or life
insurance be discussed. Emphasis should be given to the fact that
HCV does not necessarily pose an immediate threat to life. The opportunity
to discuss healthy lifestyles and harm reduction behaviour should
be taken.
The diagnosis should always be delivered personally to the patient
in a sensitive, supportive manner by a well informed health care
provider, allowing sufficient time for questions. Results should
never be communicated by telephone, answering machine or through
a receptionist. During the consultation, the patient's understanding
of a positive diagnosis should be checked. Assurance that shock
is a common reaction should be given. A further discussion of features
of the illness, diagnostic procedures, and medical care may be necessary.
Referrals to support resources in the form of both professional
and self-help organizations will be invaluable, as will written
information.Follow-up appointments should be offered for further
discussion. Partners, family, and friends should be invited to attend
if appropriate.106,107
| TABLE X : INDIVIDUALS TO BE OFFERED
SCREENING FOR HCV |
• Injection drug user—this
should include anyone who has ever injected drugs
• Patient on haemodialysis
• Patient with persistently elevated ALT
• Recipients of clotting factor concentrates before 1988*
• Recipients of blood components or solid organs before
1992*
• Recipients of blood components or solid organs from HCV
(+) individual
• Person with significant exposure to blood of HCV (+)
individual or that of individual at high risk
• Prisoners in correctional facilities
• Infants of HCV infected mothers
• Older children of HCV(+) mothers if there is reason to
believe vertical transmission may have occurred
• HIV positive individuals
• Individuals with tattoos (especially performed in prisons) |
| * applicable dates in Canada |
2. Risk reduction behaviours
These should be discussed with all patients with
HCV as appropriate in a sensitive fashion (Table XI).
3. Gynaecological issues
a) General points:
the effects of HCV on a woman's reproductive health will depend
on the status of her disease. In the absence of significant liver
disease there may be no symptoms. However, if significant liver
disease or cirrhosis are present, abnormal menstrual cycles or infertility
may be seen, secondary to anovulation. If cirrhosis has resulted
in chronic estrogen excess, dysfunctional bleeding or endometrial
hyperplasia may also be seen. Indeed, any of these symptoms may
be a presenting feature of HCV infection.
It may be important at initial diagnosis, especially
if infection is occurring in the context of injection drug users
or multiple partners, to seek out and treat coincident sexually
transmitted pathogens. It is recognized that women on interferon
therapy commonly suffer recurrent yeast infections. Recommendations
for Pap smears remain unchanged.
| TABLE XI : RISK
REDUCTION BEHAVIOURS |
• Current
IV drug users should be offered participation in needle exchange
programmes, treatment programmes, with discussion of needle
sharing, needle cleaning*, etc. Remember that many patients
may not be current users
• Alcohol consumption should be discussed and abstinence
advised
• Recommend vaccination against hepatitis A and B if the
patient is non-immune
• Involvement in a support group is of great value
• Social, educational, and employment activities should
continue as normal
• Encourage safer sexual practices in those with multiple
partners. There is insufficient evidence to recommend changes
in current sexual practice in long-term monogamous
relationships
• Refrain from blood, organ, tissue or semen donation
• The sharing of razors and toothbrushes should be avoided,
although there is no evidence to suggest that general household
contact may lead to transmission.
• Tattooing in unlicensed parlours not adhering to recommended
Health Canada infection control guidelines may carry a small
risk of transmission and should be avoided. |
| * not recommended
as a good preventive measure, a last resort only. |
b)Contraception: there are no contraindications
to barrier methods of birth control or to the intrauterine
device. Couples in exclusive, monogamous relationships should
be advised that sexual transmission is uncommon. In the context
of multiple sexual
partners, condom usage should be encouraged.
Progesterone only based contraceptives would be appropriate
for women with HCV.
Combined pills may be prescribed to most women infected by
HCV with the exception of those with cirrhosis or hepatic failure
when hepatic metabolism may be altered. There is no evidence that
hormonal contraceptives further compromise the infected person who
has a functional liver.
c)Hormone replacement therapy: there is little information
on the effects of hormone replacement therapy on women with HCV.
Oral preparations are metabolized in the liver and the presence
of liver dysfunction may significantly alter pharmacokinetics. Given
that these preparations may be used continuously for many years,
regular evaluation of liver function (as recommended for all HCV
patients) should accompany their use. Consideration could be given
to the use of transcutaneous preparations which avoid the first
pass effect in the liver. Recommendations should be tailored to
the individual based on the need for hormone therapy and the liver
function. Consultation with a colleague with expertise in the management
of liver disease should be sought.
d)Assisted reproduction: women living with HCV who desire
medical or surgical assistance with reproduction will need counselling
regarding the issues related to HCV infection.
All HCV positive women should be offered preconception counselling.
If ovulation induction is required, carefully monitored clomiphene therapy may be considered except in cases of severe liver dysfunction.
The use of gonadotropins for ovulation induction should only
be carried out in consultation with a reproductive endocrinologist,
but would not necessarily be contraindicated in the context of HCV
infection.
In vitro fertilization or intrauterine insemination is not contraindicated for an HCV positive woman. However, ethical
dilemmas arise in discordant couples where the male partner is infected
and the woman is not. As HCV has been detected in semen, and although
purification of the semen with standard sperm washing techniques
appears to decrease the viral load but not eliminate it,108 there is a concern that HCV transmission will occur during the assisted
reproductive process. Unfortunately this particular mode of transmission
has not been well studied and there are no accurate figures to report.
The current Canadian Fertility and Andrology Society guidelines
exclude semen donors who are hepatitis C positive.109 Individual infertility clinics have specific policies regarding
treatment. All women seeking these therapies should be aware of
the risk of becoming infected with HCV and fully informed consent
obtained.
4. Effect of HCV infection on pregnancy
Although there is currently little data on HCV
infection in pregnancy, the available data does not suggest an increased
risk of congenital malformation, fetal distress, stillbirth or prematurity.
Women with HCV and their fetuses are at no greater risk of obstetric
or perinatal complications compared with other women. There is no
contraindication to pregnancy on the grounds of HCV alone.100,110-112
5. Effect of pregnancy on HCV
Very little is reported on the effects of pregnancy
on the course of HCV infection. The majority of women appear to
be unaffected. Fewer than ten percent display elevated transaminases,
and in most cases a decrease in ALT during pregnancy has been noted
with a rebound postpartum.100,112 It is postulated that
endogenous production of interferon by the fetoplacental unit may
play a role in the benign course of disease during pregnancy. Cholestasis
of pregnancy may be more common among HCV infected women.46 Rarely, women may present with advanced liver disease and complications
such as oesophagal varices and coagulopathy, posing risks for bleeding
with delivery and the possibility of variceal rupture. These cases
should be managed in tertiary care settings.
6. Effect on the neonate
Reported rates of vertical transmission vary from
zero to 36 percent, with an average of five to six percent in otherwise
healthy women.4,6,7,63 The risk of transmission in those
also infected with HIV is up to 44 percent (Table VI). Although
the available evidence points to the intrapartum period as the main
time of transmission, the relative importance of intrauterine versus
intrapartum transmission remains to be established. Several studies
have documented a significantly greater risk of vertical transmission
with maternal HCV viral copies above 1,000,000/ml.21,110 A transmission risk of about five percent is generally reported,
but it may be as high as 36 percent in the presence of a high maternal
viral load.21 HCV has not been shown to be teratogenic.
Infants born to HCV positive mothers do not show any more neonatal
complications than other infants with the same risk factors (such
as prematurity, born to injection drug users). Children who become
infected are likely to become chronically so. It should be noted
that all neonates will have detectable maternal antibodies. For
details concerning the testing of infants please see Section VIII.E.2:
Infant testing.
7. Breastfeeding
HCV RNA and anti-HCV antibodies have both been
detected in colostrum and breast milk.36,62However, in
multiple series no case of transmission through breastfeeding has
been documented. Therefore, it is generally felt that breastfeeding
is not contraindicated.
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