| General Screening | > Offer screening to all pregnant substance users at first visit > For high-risk women, repeat testing q 3 months and/or in third trimester > Screen for Hepatitis A Ab, Hepatitis Bs Ag (HBs Ag) and Ab (anti- Bs), Hepatitis C Ab (HCVAb), HIV, VDRL |
| General Prevention | > Advise women about the risks of sharing needles and drug paraphernalia and benefits of using needle exchanges > Advise women with multiple sexual partners about safer sex practices > Refer women for substance abuse treatment services > Refer women with opiate dependence for opioidreplacement therapy |
 Screening |
> Hepatitis C antibody (HCV Ab) does not distinguish between acute, chronic or resolved infection > If HCV Ab positive, monitor AST and ALT at least once annually > If ALT normal, order HCV RNA to confirm active infection; If HCV RNA is negative, repeat at least once more to confirm spontaneous clearance of virus > For chronic hepatitis C positive patients, recommend hepatitis A and B vaccines to prevent progression to cirrhosis with co-infection |
| Prevention of Vertical Transmission | > No known way to prevent vertical transmission > Limit the use of fetal scalp clips and other manoeuvres that may place baby in contact with mother's blood in labour |
| Transmission | > Long-term sexual partners of carriers have a low risk of infection (1-4%) > Infection rate is ~3-5% for infants born to hepatitis C positive mothers, regardless of vaginal or caesarean delivery |
| Breastfeeding | > No evidence of transmission through breast milk – woman has choice to breastfeed |
| Treatment | > All patients with chronic HCV should be assessed to determine if may benefit from therapy; treatment is contraindicated during pregnancy > Offer treatment after breastfeeding finished |
| Neonatal Testing | > HCV antibody transferred from mother to infant can last up to 18 months and does not indicate neonatal infection; if infection has occurred, RNA can be detected at 1-2 months of age > Test for antibody in infant at 18 months, or RNA at 2 months |
 Screening |
> Screen all pregnant women routinely; check for bothHBsAg (indicates infection) and anti-HBs (immunity) > Repeat testing before delivery in women with continuing high-risk behaviours |
| Immunization | > Canadian Immunization Guide recommends offering Hepatitis B vaccine to all high-risk women during pregnancy > Immunize all susceptible pregnant women (HBsAg and anti- HBs negative) who are at increased risk (injection drug use, high-risk sexual practices) with hepatitis B vaccine (O, 1, and 6 months schedule preferred); an accelerated schedule is also approved (0, 1 and > 2 months) > For alcohol-dependent and chronic liver disease patients (e.g., persons infected with hepatitis C), higher concentration vaccine and periodic monitoring of anti-HBs titres recommended; booster doses should be given followed by re-checking anti-HBstitre > Refer to Canadian Immunization Guide, 7th edition, 2006 for future details (www.naci.gc.ca) |
| Prevention of Vertical Transmission | If mother is Hepatitis B surface antigen (HBsAg) positive, treat newborn with: > Immunoglobulin + vaccine within 12 hours of birth > Booster vaccinations at 1 and 6 months > Test for hepatitis B one month after last vaccination > Order the following markers: HBsAg, HBeAg, anti-HBs, anti-Hbe |
 Immunization |
> Safety in pregnancy unknown ; Canadian Immunization Guide recommendation is to offer women immunization in pregnancy > Immunization recommended for injection drug users and hepatitis C positive women: drugs and paraphernalia may be contaminated with hepatitis A (via fecal-oral route) |
 Screening |
> Offer screening to all pregnant women |
| Prevention of Vertical Transmission |
> HIV Medicine is evolving quickly, please contact local ID expert about appropriate prophylactic antiretroviral therapy for HIV infected pregnant women to decrease perinatal transmission |
| Antenatal Treatment | > Management of HIV-positive pregnant woman is complex and should occur in centre that offers obstetrics, addiction and HIV treatment > Delay treatment until after first trimester to avoidteratogenic effects |
| Intrapartum Treatment | > HIV positive women who received no treatment or had inadequate suppression of viral load should receive prophylactic antiretroviral therapy prior to delivery and should be offered a C-Section to decrease risk of perinatal transmission > No evidence for elective C-section for HIV positive women who have received adequate multiple therapy with significant viral load reduction > Women who tested negative in the past or have unknown HIV status in pregnancy, but continue with high-risk behaviours(e.g., injection drug use, sharing needles, unprotected intercourse with high-risk partner) should be retested and offered perinatalprophylaxis > Refer to guideline in CMAJ 2003; 168(13): 1671-1674 and 1683-1688 (www.cmaj.ca) |
| Postpartum Treatment | > Neonate: offer antiretroviral treatment according to the protocol for perinatal prophylaxis > Mother: resume combination antiretroviral therapy based on immunologic and virologic status > Breastfeeding: contraindicated if HIV positive status > See guideline in CMAJ 2003; 168(13): 1671-1674 (www.cmaj.ca) and contact local ID expert for advice about management |
 Screening |
> Mantoux testing recommended for all patients who use injection drugs, are HIV positive, homeless or imprisoned within the last 12 months |
| INH Prophylaxis | > INH prophylaxis recommended if tuberculin positive onMantoux screening with no evidence of active tuberculosis (Tb) > Can wait until 2-3 months postpartum to treat latent tuberculosis due to increased risk of INH-induced hepatitis in pregnancy (INH not teratogenic) > Breastfeeding should be encouraged (low concentrations in breast milk) > For adults, order baseline liver enzymes (AST, ALT andbilirubin) and monitor ALT, AST for patients with a history of alcohol abuse, age > 35 or pre-existing liver disease > Monthly clinical monitoring is recommended > INH should be given for 9 months at a dose of 300 mg daily > Vitamin B6 (pyridoxine) should be added during pregnancy (dose: 25 mg daily) > Administer under direct observation if woman is highly unstable |
