Vertical transmission of hepatitis C and congenital syphilis: What you need to know for prevention, treatment, and maternal and child health
Andrew Reynolds @AndrewKnowsHepC

In recent years, we have seen a dramatic rise in vertical (also known as mother-to child) transmission of hepatitis C (HCV) as well as increases in perinatal syphilis, both of which are tied to opioid and other drug use, poor access to prenatal healthcare, stigma, and lack of access to reproductive health, including contraception. These, when combined with other structural factors like poverty and health inequality, have created a perfect storm for an increase in infectious disease transmission overall and from mother to child in particular.

Vertical transmission of HCV is on the rise in the United States. Approximately 29,000 women living with HCV give birth each year, making it the leading cause of pediatric HCV. As the opioid crisis rages on, we have seen increases in HCV as a growing number of younger women of childbearing age acquire the virus. From 2011 to 2016, there has been a 39% increase in HCV-positive pregnant women and a 13% increase in HCV-positive children.

Congenital syphilis rates are also dramatically on the rise. Since 2013, the rates of congenital syphilis have more than doubled, and these rates appear to be increasing. From 2016 to 2017 rates increased by 44%. In 2017 alone, over 900 cases of congenital syphilis were reported to the Centers for Disease Control and Prevention (CDC), the highest number of cases in more than 20 years.

Screening for HCV and congenital syphilis are essential components of prenatal care. This article will provide an overview of both mother-to child transmission of HCV and congenital syphilis to help people understand each condition and help make informed choices for the health of the mother and baby.

What is vertical transmission of hepatitis C?

Just as HIV and hepatitis B can be transmitted from mother to child during pregnancy, so too can HCV. However, unlike HIV and hepatitis B, HCV is not routinely screened for in pregnancy, so it is often missed. The American Association for the Study of Liver Diseases and Infectious Diseases Society of America (AASLD/IDSA) HCV Guidelines call for routine HCV screening for all pregnant women, ideally at the initial visit.

The rate of vertical transmission of HCV is approximately 5.8% among persons with HCV mono-infection, though some studies have found it as high as 15%. There do not appear to be any clear risk factors that increase the chance of transmission, though a higher HCV viral load and HIV/HCV co-infection do appear to play a role in higher rates of infection.

Hepatitis C’s impact on pregnancy outcomes

Pregnancy does not appear to make HCV worse, but there is some evidence that HCV can lead to some problems during pregnancy. Pregnant women with HCV have higher rates of preterm labor and delivery; their babies may be smaller and have lower birthweight, too. There is some debate over whether these effects are the result of HCV or other lifestyle issues, but these problems are found in women even when maternal age, tobacco, alcohol, and drug use are taken into account.

Preventing vertical transmission of HCV

Although there are safe and effective ways to prevent vertical transmission of HIV and HBV, there are no recommended interventions to reduce the risk of transmission of HCV from mother to child. Hepatitis C direct-acting antiviral (DAA) treatment cannot be used to prevent it. An elective cesarean section is not recommended, as it does not decrease the risk of transmission. It is recommended to avoid certain medical procedures such as fetal scalp monitoring during labor, prolonged rupture of membranes, and episiotomies. Avoiding the use of forceps during delivery is also recommended.

Both infectious diseases are on the rise in the U.S., but with proper screening and health education, we can help reverse this trend.

Pregnancy and hepatitis C treatment

Direct-acting antivirals (DAAs) are the current medications for the treatment and cure of HCV. While they are safe and effective to take overall, and there is reason to think that they can be safely taken during pregnancy just like HIV and HBV medications can, they have not been studied for safety for use during pregnancy, so as such they are not recommended at this time.

Ribavirin, a medication that was used more frequently with previous HCV treatment regimens but is rarely used today, cannot be safely taken during pregnancy. Ribavirin can cause serious birth defects or death.

There have been cases where women on HCV treatment became pregnant, or pregnant women were accidentally treated with DAAs, and in these few cases the women have been cured with no negative outcomes for the pregnancy associated with the treatment. This offers hope for treatment options, but more study is needed before recommendations can be made.

Hepatitis C and breastfeeding

Breastfeeding is safe to do for mothers living with HCV, as it is not a risk for transmission of the virus. That said, as HCV is transmitted from blood-to-blood contact, mothers who breastfeed should monitor their nipples for bleeding and should not breastfeed if they are cracked and bleeding.

Just as it is not recommended that pregnant women be treated for HCV, it is not recommended that women who breastfeed be treated with DAAs.

What is congenital syphilis?

Also called perinatal syphilis, congenital syphilis occurs when a mother who has syphilis passes the infection on to her newborn. It is a very serious infection that can lead to a wide range of health problems for the baby. Congenital syphilis can lead to stillbirth (a baby born dead) or a miscarriage (losing the baby during pregnancy) in up to 40% of pregnancies. In addition, congenital syphilis can cause:

•   Premature birth

•   Low birth weight

•   Deformed bones

•   Anemia

•   Brain and nervous system problems, including blindness or deafness

•   Meningitis

•   Enlarged liver and/or spleen

Not all babies born with congenital syphilis will show signs of infection, so testing for it and providing treatment are essential medical interventions to prevent serious problems for the baby.

Testing for syphilis

Testing for syphilis during pregnancy is routine: All women should be tested at their first prenatal visit. Depending upon risk factors and certain conditions, women may get tested more frequently. The CDC recommends that syphilis testing should also occur in the third trimester and again before getting discharged from the hospital. Both the mother and newborn infant should be evaluated for syphilis infection before release.

Treatment for syphilis

Syphilis is treated with antibiotics. In pregnancy, only penicillin is recommended for the treatment of syphilis. If the woman is allergic to penicillin, she will need to be desensitized to it and then treated.

As syphilis is highly contagious between sexual partners, it is also important that all sex partners get evaluated, tested, and preventatively treated for syphilis.

The treatment for syphilis is safe for the unborn child, and indeed it is essential to minimize the risk of complications during pregnancy and to improve the long-term health of the baby.

After treatment is administered, both mother and child should be monitored and tested for at least one year to make sure that both have been cured.

Conclusions

Although vertical transmission of HCV cannot be prevented, universal screening should occur as it is a means of finding HCV in women, and it allows for the proper monitoring and follow-up of babies born to mothers with HCV. Congenital syphilis is preventable, and the timely testing and treatment will have a dramatic impact on the health outcome for the baby. Both infectious diseases are on the rise in the U.S., but with proper screening and health education, we can help reverse this trend, and improve the health of both mother and baby.

What is hepatitis C?

Hepatitis C (HCV) is a viral infection of the liver. It is transmitted by blood-to-blood contact, and it can lead to long-term liver damage over time as it leads to more and more scarring, eventually resulting in cirrhosis. HCV can be an acute infection or chronic, and it is usually asymptomatic. When there are symptoms, they include fever, fatigue, nausea/vomiting, joint pain, or jaundice (yellowing of skin and eyes). HCV can be cured, with newer HCV treatments curing 90–100% of people with mild side effects in as little as 8–12 weeks. For more information about HCV, check out the Positively Aware Hepatitis Drug Guide and our “FAQs of Hepatitis C” article at positivelyaware.com/articles/faqs-hepatitis-c.

What is syphilis?

Syphilis is a sexually transmitted disease. It is passed when someone comes into contact with a syphilis sore during oral, vaginal, or anal sex. It has several stages—primary, secondary, latent, and tertiary—each with different symptoms. These symptoms include, but are not limited to, a painless sore, a rash (especially on the palms of hands and soles of feet), swollen lymph nodes, patchy hair loss, and fatigue. That said, it is easy to miss these symptoms, so the only way to know if you have it is to test for it. If it goes untreated, a person can live with it for years before serious health problems can arise. Fortunately, syphilis is relatively easy to treat with antibiotics such as penicillin. For more detailed information about syphilis, check out cdc.gov/std/syphilis/stdfact-syphilis.htm.