RETIRED: The Reproductive Care of Women Living With Hepatitis C Infection

Abstract

I. AbstractObjective: hepatitis C virus (HCV) is an increasingly important public health problem worldwide. Health care workers providing care to women of childbearing age are uniquely placed in their practices to identify a significant proportion of at-risk patients and to provide appropriate screening and counselling. The primary objective of this guideline is to provide accurate, current information to those offering reproductive care to women living with HCVThis document is also intended to raise awareness of HCV in both the medical and general populations.Options: the areas of clinical practice considered in formulating this guideline are disease prevention, targeted screening of individuals at risk of contracting HCV, management of identified patients in the context of reproductive care, and the appropriate referral of patients to those with particular expertise.Outcomes: implementation of these guidelines should facilitate identification of infected individuals. It should also result in improved physical and mental well-being for patients and their families and reduction in transmission rates.Evidence: the literature between 1966 and 2000, including non-English language publications, was extensively searched utilizing Medline. A multidisciplinary group consisting of experts within the fields of obstetrics and gynaecology, infectious diseases, hepatology, and public health convened in Montreal in February 2000. The working group also included a patient and a representative from the Hepatitis C Society of Canada. The level of evidence for the recommendations has been determined using the criteria described by the Canadian Task Force on Periodic Health Examination.Benefits, harms and costs: the public health benefits of increased identification of at-risk individuals, diagnosis, treatment, implementation of risk reduction behaviours, and reduced transmission rates, both on an individual and at the community level, are significant. However, it must be remembered that the diagnosis of a chronic disease may have far reaching effects for the individual patient and her family.Recommendations:a)Screening•Universal screening for HCV is not recommended, although targeted screening should be offered to all women falling into any at-risk category. Testing should take place following adequate counselling and informed consent of the patient. (III B)b)Preconception and early pregnancy care•Ideally, preconception or early pregnancy evaluation should include determination of risk of infection with hepatitis C, counselling, and testing as appropriate. (III B)•Patients aware of their HCV positive diagnosis should be evaluated before embarking on pregnancy for complications that may compromise maternal health during pregnancy. (III B) • Pregnancy is not generally contraindicated on grounds of HCV infection alone. (Although it is contraindicated in the context of ribavirin therapy.) (III B)c)Care during pregnancy•There is a risk of vertical transmission which is greater if the woman is also infected with human immunodeficiency virus (HIV). (II-2 A)•Antenatal care will need to be tailored individually to meet the specific needs of the woman’s medical and obstetrical condition, including the monitoring of liver function. (II-2 A)•Alcohol should be avoided. (II-2 A)•Immunization against hepatitis A and B should be provided as required. (II-2 A)•Routine Caesarean section is not recommended as a specific intrapartum measure to reduce the risk of vertical transmission of hepatitis C. (II-2 D)•Breastfeeding is not contraindicated. (II-3 B)d)Care of infant•All infants born to HCV positive mothers should be evaluated for evidence of hepatitis C infection. (III A)e)Contraception and hormone replacement therapy•Barrier methods should be recommended to those with multiple sexual partners. (II-3 B)•The extent of liver disease should be carefully evaluated before considering the use of hormonal contraception or hormone replacement therapy. (III B)f)Universal precautions•Universal precautions/routine practices and additional precautions are recommended in dealing with all patients for the protection of both health care worker and patient. (II-2 A)Validation: references were collected through Medline searches and comparison made to existing current guidelines for assessment of consistency. External reviewers expert in their field were also consulted.