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NICU guideline identifier

Hepatitis C - maternal infection, vertical transmission and nursing care of baby

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Hepatitis C Virus

  • Single-stranded negative sense RNA virus. 
  • Cytopathic virus, replicating in liver cells and spilling over into blood stream during active infection. 
  • Damage to liver leads to steatosis, fibrosis, cirrhosis and in some cases hepatocellular carcinoma. 
  • Major reason for liver transplantation world-wide. 
  • USA - 0.2% seroprevalence of HCV for children under 12 years of age. 

Epidemiology

  • Currently no tissue culture infectivity assay, so information on distribution of virus based largely on detection of viral RNA. 
  • Transmission still incompletely understood. Up to 40% of infected individuals may have no identifiable risk factors. 
  • >95% of infections thought to be parenteral, with injection of infectious blood the most at risk procedure eg injecting drug users, and (pre-transfusion service screening), haemophiliacs, transfusion recipients. 
  • In Western communities, < 5% of infections linked to sexual transmission or household exposure. 
  • Antibodies not protective against re-infection. 
  • Currently no vaccine available. 

Vertical transmission

  • Infrequent (as opposed to vertical transmission of Hepatitis B in the pre-vaccine era). 
  • Rate approximately 6% in HCV viraemic, non-HIV infected mothers. May increase to ~ 15% in HIV positive mothers. 
  • Majority of infant infections probably acquired during exposure to infectious blood at delivery (infants not viraemic until several weeks post-delivery). However, there are no convincing studies at this time demonstrating that Caesarean section should be recommended. 
  • Transmission from breast milk has not been documented, although virus RNA can be found in breast milk. Currently there are no recommendations concerning breast feeding by HCV positive mothers. This should be discussed with the women but breast feeding is not contraindicated. If the woman has cracked or bleeding nipples breast feeding could be temporarily discontinued - express and discard - until problem resolves. Consider early referral to lactation consultant to minimise the problem. 

Tests

  • Antibody to HCV. Indicates past infection, or passive acquisition of maternal antibody (infants). 
  • HCV RNA. Detects specific HCV genetic sequences by RT-PCV. Usually applied to blood (serum). If positive, indicates ongoing active infection. 
  • Currently there is no reliable HCV antigen test. 

Management of pregnant women

  • Offer testing to all pregnant women at risk of HCV (eg on the methadone programme or attending clinic for substance abuse). 
  • Ensure that the laboratory request is annotated " HCV screening in pregnancy." 
  • All antibody positive women must have HCV RNA tested. 
  • If positive, HIV testing must be offered also. (Note. This may become redundant with the introduction of widespread screening for HIV in pregnancy). 

Management of infants born to HCV positive women

Since essentially no infected infants have been found viraemic at birth, testing of cord blood is not necessary.

At 15 months all infants should be tested for HCV antibody. If negative no further followup is required. If positive need HCV RNA and liver function tests and arrange referral to paediatric Gastroenterology team 

In some situations HCV RNA testing could be considered earlier at 4-6 months if family likely to be lost to follow-up or if high degree of anxiety, but will still require 15 month HCV antibody test.

If infant develops signs of liver dysfunction testing should be done immediately.

Nursing Care of Baby

  1. Standard precautions. 
  2. Gloves worn for all cares where contact with body fluid is anticipated. 
  3. Babies greater than 32 weeks gestation if condition stable, are to be bathed on admission. Vitamin K is given after bath.
  4. Baby can have mother's breast milk provided the mother does not have co-infection (e.g. with HIV) or severe liver failure but Doctor/NS-ANP need to discuss (and document) with mother the theoretical risks. 
  5. To be cautious, an infected mother should avoid breastfeeding if her nipples are cracked and bleeding2
  6. To discuss with Paediatric I.D. team or gastro enterology if any questions.

References

  1. Croxson M et al. Vertical transmission of Hepatitis C virus in New Zealand. NZMJ, 9 May 1997, Vol 110, No 1043:165-7.
  2. Mast E (2004). "Mother-to-infant hepatitis C virus transmission and breastfeeding." Adv Exp Med Biol 554: 211-6. PMID 15384578.

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Document Control

  • Date last published: 08 August 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years