Prenatal Invasive Procedures in Women With Hepatitis B, Hepatitis C, and/or Human Immunodeficiency Virus Infections

Objective: To review the risk of in utero infection through prenatal invasive procedures in women with hepatitis B, hepatitis C, and/or human immunodeficiency virus (HIV) infections. Outcomes: Fetal and neonatal morbidity and mortality. Evidence: Published literature was retrieved through searches of Medline, CINAHL, and the Cochrane Library using appropriate controlled vocabulary (amniocentesis, chorionic villus sampling, cordocentesis, fetal and neonatal infection) and key words (hepatitis B, hepatitis C, HIV). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies from 2002 to 2012 published in English or French. (Studies from 1966 to 2002 were previously reviewed in Clinical Practice Guideline No. 123.) Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Recommendations 1. For women infected with hepatitis B, hepatitis C, and/or human immunodeficiency virus, the use of non-invasive methods of prenatal risk assessment is recommended, using tests with high sensitivity and low false-positive rates, such as serum screening combined (or not) with nuchal translucency, anatomic ultrasound, and non-invasive molecular prenatal testing. (III-B) [Graphics] 2. For women infected with hepatitis B, hepatitis C, and/or human immunodeficiency virus undergoing an amniocentesis, every effort should be made to avoid inserting the needle through, or very close to, the placenta. (II-2B) 3. Little information is available on other prenatal diagnostic and therapeutic invasive procedures; the risks and benefits of such procedures should therefore be assessed prior to their use. (III-C) 4. The rate of neonatal hepatitis B infection attributable to amniocentesis ranges up to 1.4% in newborns of mothers positive for hepatitis B surface antigen. However, the rate of neonatal infection attributable to amniocentesis in newborns of mothers with a positive hepatitis B e antigen status may be as high as 16%. Although there is no statistically significant difference between the rates of infection in newborns exposed to amniocentesis or not exposed to amniocentesis in these two maternal populations, knowledge of the mother's hepatitis B e antigen status may be valuable in counselling women about the risks associated with amniocentesis. (II-2A) 5. Amniocentesis in women infected with hepatitis C does not appear to significantly increase the risk of vertical transmission, but women should be counselled that very few studies have properly addressed this possibility (II-2C). More research on this topic is recommended. (III-L) 6. Amniocentesis in women infected with human immunodeficiency virus on combination antiretroviral therapy does not appear to significantly increase the risk of vertical transmission, particularly if the viral load is undetectable, but women should be counselled that data on this issue is limited. (II-2B) 7. For women not on combined antiretroviral therapy, the risk of vertical transmission is increased by performing an amniocentesis. When possible, combined antiretroviral therapy should be initiated and the procedure postponed until the viral load is undetectable. Other case management should be individualized in consultation with infectious diseases specialists and obstetricians. (III-B)