Hepatitis C in Pregnancy Guidelines FINAL July17 Document Control Title Hepatitis C in Pregnancy Guidelines Author Author’s job title Screening Midwife Consultant Medical Microbiologist Directorate Department Women and Children Antenatal Clinic Date Version Status Comment / Changes / Approval Issued 0.1 2012 Draft Reviewed and updated into new Trust Format 1.0 Aug 13 Final Approved at August Maternity Services Guidelines Group 2.0 July 17 Final Approved at August Maternity Services Guidelines Group Main Contact Screening Midwife Tel: Direct Dial – 01271 314037 Ladywell Unit Tel: Internal – 4037 North Devon District Hospital Raleigh Park Barnstaple, Devon EX31 4JB Lead Director Director of Nursing Superseded Documents Not Applicable Issue Date Review Date Review Cycle July 2017 July 2020 Three years Consulted with the following stakeholders: (list all) Senior Midwives Obstetricians and Gynaecologists Paediatricians Women’s and Children’s Directorate Management Microbiology Dept. Contact responsible for implementation and monitoring compliance: Lead Clinician Women and Children’s Specialist Midwife Risk Coordinator Education/ training will be provided by: Practice Development Midwives Approval and Review Process Maternity Guidelines Group Local Archive Reference G:\Compliance Team\Policies and Procedures\Published Polices Local Path Maternity\folder Filename Hepatitis C in Pregnancy Guidelines v2.0 Policy categories for Trust’s internal Tags for Trust’s internal website (Bob) website (Bob) Maternity Services G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Maternity\Hepatitis C in Pregnancy\Hepatitis C in Pregnancy Guidelines v2.0.docx V1.0 10Jul15 Page 1 of 20 Hepatitis C in Pregnancy Guidelines FINAL July17 Midwifery, Antenatal Maternity Services G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Maternity\Hepatitis C in Pregnancy\Hepatitis C in Pregnancy Guidelines v2.0.docx V1.0 10Jul15 Page 2 of 20 Hepatitis C in Pregnancy Guidelines FINAL July17 CONTENTS Document Control........................................................................................................................ 1 1. Introduction ......................................................................................................................... 3 2. Purpose ................................................................................................................................ 3 3. Definition of Terms ............................................................................................................... 3 4. Background .......................................................................................................................... 4 5. Antenatal Care ..................................................................................................................... 6 6. Delivery ................................................................................................................................ 8 7. Breastfeeding ....................................................................................................................... 8 8. Management of Infants Born to HCV Positive Mothers .......................................................... 9 9. Consultation, Approval, Review and Archiving Process ........................................................ 10 10. Monitoring Compliance and Effectiveness ........................................................................... 10 11. Education and Training ....................................................................................................... 10 12. References ......................................................................................................................... 11 13. Associated Documentation ................................................................................................. 12 Appendix A: Flowchart for Hepatitis C Testing in Pregnancy ........................................................ 13 Appendix B: Hepatitis C Patient Information Leaflet .................................................................... 17 Appendix C: Individual Care Pathway - Positive Hepatitis C Screen Result .................................... 20 1. Introduction 1.1. These guidelines have been produced to ensure all women attending antenatal clinics are appropriately screened for Hepatitis C. 2. Purpose 2.1. The purpose of this guideline is to show that the Maternity Service has approved processes to ensure Hepatitis C in pregnancy is appropriately managed. 3. Definition of Terms HCV Hepatitis C virus Genotype Generic type or makeup of the virus IVDU Intravenous drug user/s PCR test Polymerase chain reaction test Viral load Amount of copies of the virus circulating in the blood Anti-HCV Antibodies to HCV (a positive result does not indicate whether the infection is acute, chronic or no longer present) Quantitative PCR viral test Measures the amount of HCV in the blood Qualitative PCR viral test Detects if there is HCV present in the blood CMM Consultant Medical Microbiologist Maternity Services G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Maternity\Hepatitis C in Pregnancy\Hepatitis C in Pregnancy Guidelines v2.0.docx V1.0 10Jul15 Page 3 of 20 Hepatitis C in Pregnancy Guidelines FINAL July17 CHIT Child Health Information Team 4. Background 4.1. HCV is recognized as a worldwide public health problem, the global prevalence of chronic HCV infection is estimated to be approaching 3%, over 170million infected people. Prevalence of HCV in England varies from 0.4 - 0.8%. 4.2. HCV is a blood-borne virus discovered in 1989 that predominantly affects the cells of the liver. This can result in inflammation and significant damage to the liver. It can also affect the liver’s ability to perform its essential functions. Although it has always been regarded as a liver disease - ‘hepatitis’ means ‘inflammation of the liver’ - recent research has shown that HCV affects a number of other areas of the body. These can include the digestive system, the lymphatic system, the immune system and the brain. 4.3. HCV infection can be categorised into two stages. The first stage is acute infection (following initial infection). The second stage is chronic infection. The acute stage refers to the first 6 months of infection and does not necessarily result in any noticeable symptoms. Approximately 20% of those infected with HCV will naturally clear the virus from their body within the first six months. For the remaining 80% a chronic (long-term) infection will develop. 4.4. The course of a chronic hepatitis C infection is extremely varied and unpredictable. Some people experience very few symptoms for as long as a decade. Others can suffer symptoms almost from the start. Some will progress to develop fibrosis and cirrhosis (scarring) of the liver, liver cancer or end stage liver disease, while others experience very little liver damage, even after many years. In cases where there is an absence of symptoms many people do not discover that they have HCV until some time after they have been infected. 4.5. Drug treatment to eradicate the virus has advanced greatly in the last few years. The success rates for genotypes 2 and 3 are now as high as 80%, and 50% for the other genotypes. However, the treatment can have significant side effects and is definitely not suited to everyone. A vaccine remains some time off. 4.6. There are no National or Regional guidelines for management of pregnant women with HCV infection. 4.7. There are various risk factors for contracting HCV, intravenous drug injecting is considered to be the predominant mode of infection in women of childbearing age. Inter-agency co-operation should help ensure that the woman gets the best advice and care. 4.8. Currently neither the National Screening Committee (NSC) nor the National Institute for Clinical Excellence (NICE) support universal screening for HCV in pregnancy. Maternity Services G:\Corporate Governance\Compliance Team\Policies Procedural Documents\Published Policy Database\Maternity\Hepatitis C in Pregnancy\Hepatitis C in Pregnancy Guidelines v2.0.docx V1.0 10Jul15 Page 4 of 20 Hepatitis C in Pregnancy Guidelines FINAL July17 4.9. However, HCV Antibody testing should be offered to women who have been identified with the following main risk factors: a) past or current history of illicit drug use, namely intravenous (IV) drug use, sniffing/ snorting (e.g. cocaine), or sharing smoking paraphernalia e.g. crack pipes. b) partner (current or past) diagnosed with Hepatitis C c) partner (current or past) known drug user (as above) d) other known blood borne virus (HIV, Hepatitis B) e) commercial sex work f) women who consider themselves at risk and ask for testing g) history of receiving transfusion of blood prior to the introduction of blood donor screening in the UK (September 1991) or blood products prior to viral inactivation of blood products in 1985; h) tattoos or ear- or body piercing where infection control measures may not have been adequate; i) potential exposure to infection in other countries e.g. by medical or dental treatment where infection control measures might not have been adequate. 4.10. At booking all women are asked if they use or have used drugs. Blood is routinely screened for maternal infections. Informed consent is requested for Hepatitis B Virus, HIV, Syphilis and Rubella. It follows that all pregnant women who present