Pregnant patient is positive for hepatitis C
Lisa Taylor is 24, single and in her first pregnancy. She admitted to injecting drugs in the past and after counselling decided to have screening tests. The results show she is HIV and hepatitis B negative but positive for hepatitis C. She asks the registrar whether she should have a termination. Dr Tim Jennings discusses the implications.
What is hepatitis C?
Formerly called non-A non-B, hepatitis C (HCV) is a blood-born virus that causes liver disease. The prevalence in adults is estimated at one in 200.
Acute hepatitis with spontaneous resolution is seen in only 15-20 per cent of patients. The rest will develop chronic hepatitis and remain infectious, with a third having minimal disease, a third moderate and a third developing cirrhosis (and 1-5 per cent at risk of primary liver cancer).
Most people will be unaware of the initial infection with only flu-type symptoms. Few will have acute hepatitis with jaundice to initiate initial investigations. Most people with chronic hepatitis C will have no symptoms while some may suffer chronic malaise which may be misdiagnosed as depression, chronic fatigue or TATT (tired all the time). The severity of symptoms may not equate to the severity of the illness. Progression to cirrhosis may take from five to 50 years. Studies have tried to determine which factors may influence this progression and have strongly linked alcohol consumption to severe liver complications, co-infection with HIV or hepatitis B, male gender, and acquiring HCV at an older age.
Who is at risk?
HCV is carried in the blood of the 80 per cent who become chronically infected. Blood products have been screened since 1991. IV drug use accounts for the vast proportion of cases (92.3 per cent). Sexual transmission is possible but uncommon (less than 5 per cent in regular sexual partners). Mother-to-baby transmission is also uncommon with upper estimates at 6 per cent and breast-feeding appears to be low risk. There is no risk of transmission from everyday social contact.
What tests are performed?
Anti-HCV antibody test may be positive within three months of infection. The test will be needed six months after the last known exposure to rule out infection. A positive test is usually repeated to confirm infection and does not distinguish resolved from established chronic infection.
The most reliable test for current infection is a polymerase chain reaction test. Liver function tests can identify liver damage but can be normal with severe damage. Referral to a liver specialist is indicated and ultrasound guided liver biopsy can determine the extent of liver injury. The rapid mutation of HCV means there is no vaccine.
What counselling should be given before testing?
The patient needs to understand the long-term implications of a positive result and the nature of the test. An assessment needs to be made of the support they have. Confidentiality needs to be assured but the implications for life insurance and possible need for disclosure in certain professions and for future medical care should be discussed.
What happens after a positive result?
Specialist referral is needed to establish current infection and extent of disease and to consider eligibility for therapy under NICE guidelines. The patient will need counselling and support from the GP.
What treatment is there?
Treatment of the acute infection, if detected, is symptomatic only. NICE recommends combination therapy of interferon alpha (subcutaneous injections three times a week) and ribavirin (daily orally) for chronic HCV. This lasts for six to 12 months and is successful no virus was detected six months after cessation of treatment in 38-43 per cent of patients. The guidelines preclude treatment for drug users who continue to inject, for some pre-existing conditions and pregnancy and in children. Where there is significant risk of re-infection or compliance issues each case needs to be considered individually. Side-effects such as fatigue, nausea, depression and headaches can prevent completion of treatment.
On a general level it is recommended to abstain from alcohol, not to donate blood, to practise safe sex and not to share razors or toothbrushes.
How can we help Lisa reach a decision?
She needs referral to determine whether she is one of the lucky 20 per cent in whom the infection has resolved, and if not to determine if she fulfils NICE guidelines for treatment.
She cannot have treatment while she is pregnant but can start after delivery. She needs to understand the low risk of 5-6 per cent of transmission if she has chronic infection and that if this did occur there is no treatment for children as yet. If she had a termination there is no guarantee the infection will be eradicated and she may be in the same position in future pregnancies. She needs counselling about her psychological health and social state to see if there are issues that may influence her decision. The registrar needs to be non-judgmental and supportive.
· One in 200 adults may have HCV
· IV drug use is the main risk factor
· Infection from mother to baby is uncommon
· About a sixth of infected people develop cirrhosis
· Treatment can be successful but must be selective
· Breast-feeding is low risk and normal social contact has no risk
· Counselling pre-test and after a positive result is important