ABSTRACT
Objective
This revised guideline provides updated information for the care of women with chronic
viral infections who require intrauterine fetal diagnostic testing.
Target Population
Women with chronic viral infections who are pregnant or planning a pregnancy.
Options
Non-invasive screening tests for diagnosis: maternal serum placental analytes with
or without nuchal translucency, sonography, maternal serum cell-free placental DNA;
and intrauterine fetal diagnostic testing: amniocentesis, chorionic villus sampling,
cordocentesis.
Outcomes
The recommendations in this guideline have the potential to decrease or eliminate
morbidity and mortality in women with chronic viral infections and their infants,
which is associated with significant health and economic outcomes.
Evidence
Published literature was retrieved through searches of PubMed, guidelines of national
societies (Society of Obstetricians and Gynaecologists of Canada, American College
of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, other international
societies), and the Cochrane Library using appropriate controlled vocabulary (amniocentesis,
chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical
transmission, fetal and neonatal infection) and keywords (maternal infection or exposure,
hepatitis B, hepatitis C, human immunodeficiency virus). Results were restricted to
systematic reviews, randomized controlled trials or controlled clinical trials (if
available), and observational case-control studies or case series from 2012 to 2019
published in English or French. Studies from 1966 to 2002 were previously reviewed
in the SOGC guideline No. 123: Amniocentesis and Women with Hepatitis B, Hepatitis C, or Human Immunodeficiency
Virus, and those from 2002 to 2012 were previously reviewed in the SOGC guideline No. 309: Prenatal Invasive Procedures in Women With Hepatitis B, Hepatitis C, and/or
Human Immunodeficiency Virus Infections. Updated literature searches were completed regularly through August 2019 and were
incorporated into this guideline.
Validation Methods
The authors rated the quality of evidence and strength of recommendations using the
Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).
Intended Audience
The intended users are maternity care providers and women with chronic viral infections.
This guideline provides information to educate and counsel these women, and to offer
them reproductive options.
RECOMMENDATIONS (GRADE ratings in parentheses)
- 1For women with a chronic infection with hepatitis B, hepatitis C, and/or human immunodeficiency virus (HIV), the use of non-invasive methods of fetal aneuploidy risk assessment is recommended, using screening tests with high sensitivity and low false-positive rates (maternal serum placental analytes with or without nuchal translucency, detailed sonography [dating crown-rump length, first- and second-trimester anatomic] and maternal serum cell-free placental DNA as first- or second-tier screening test) (strong, moderate).
- 2When counselling pregnant women with a chronic infection that can pose a risk of perinatal morbidity regarding intrauterine fetal diagnostic genetic and/or infectious testing:
- •The pregnancy loss rate (spontaneous loss rate and rate due to the procedure) discussed should be based on the gestational age at the time of the procedure (strong, high).
- •The first trimester (when chorionic villus sampling is performed) has an estimated spontaneous pregnancy loss rate of 1.40% (based on a population cohort of maternal age >36 years with normal first-trimester sonographic screening); the second trimester (when amniocentesis is performed) has an estimated spontaneous pregnancy loss rate of 0.65% (based on a population cohort of maternal age >36 years with normal second-trimester sonographic screening) (strong, high).
- •The estimated risk of pregnancy loss due to amniocentesis is 0.35% to 1.00%, based on systematic reviews or meta-analyses, cohort studies with control groups, and randomized controlled trials; the risk varies depending on provider expertise (strong, high).
- •
- 3When performing sonography-guided amniocentesis for women with a chronic hepatitis B, hepatitis C, and/or HIV infection, every effort should be made to avoid the amniocentesis needle going through the placenta or within 1 to 2 cm of the implantation placental edge (strong, moderate).
-
Hepatitis B
- 4Hepatitis B virus DNA load should be evaluated in women with positive hepatitis B surface antigen status who require intrauterine fetal diagnostic testing. A viral DNA load >200 000 IU/mL or >106 copies/mL and positive hepatitis B e antigen status increase the risk of vertical transmission (strong, moderate).
- 5In women with chronic hepatitis B infection and a significant viral load (>200 000 IU/mL or >106 copies/mL), maternal antiviral therapy should be considered in order to decrease the vertical transmission risk. The first-line antenatal antiretroviral agent tenofovir is recommended (strong, moderate).
-
Hepatitis C
- 6In women with chronic hepatitis C infection, amniocentesis is recommended over chorionic villus sampling due to the limited data available on chorionic villus sampling (conditional, low).
- 7Amniocentesis in women with a chronic hepatitis C infection does not appear to significantly increase the risk of vertical transmission of the virus; however, there is limited published cohort data, and this information should be shared with the patient during the informed consent process (conditional, low).
-
HIV
- 8Pregnant women with HIV have reported pregnancy loss rates after amniocentesis of 2.6% to 22% (although only small cohorts have been reported) and vertical transmission rates of 0% to 2.3%. Data evaluating the clinical use of amniocentesis among women with HIV is increasing but still limited, and this information should be shared with women during the informed consent process (conditional, low).
- 9Amniocentesis in women with HIV who are treated with combination antiretroviral therapy appears to pose no increased risk of vertical transmission of HIV, especially if the antiviral therapy reduces the maternal viral load to undetectable levels (strong, high).
Keywords
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Article info
Publication history
No. 409, December 2020 (Replaces No. 309, July 2014)
Footnotes
This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care providers. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that is evidence-based, culturally appropriate, and personalized.
Language and inclusivity: This document uses gendered language in order to facilitate plain language writing but is meant to be inclusive of all individuals, including those who do not identify as a woman/female. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages healthcare providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person's needs.
Copyright: The contents of this document, in whole or in part, cannot be reproduced in any form without prior written permission of the publisher of the Journal of Obstetrics and Gynaecology Canada.
Identification
Copyright
© 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
