Benha University Hospital, Egypt Delta (Mansura) & Benha Fertility Centers

1. In Egypt: a major health problem

20-40% of the all-viral hepatitis. High prevalence of carrier state. 0.010.1% in the United Kingdom and

Scandinavia to 1726% in Egypt (Wasley & Alter,2000) p to !0% progress to chronic hepatitis " #ith serio s complications
The

infection rate peak among ad!"t aged #0$%

is rising most rapi&ly among patients age& $'( )5 *hi#h *ill eventually lea& to in#rease& in#i&en#e o+ hepatitis C

$" %n#i&en#e

" High ris, groups Obstetricians need to be aware of the risk factors leading to hepatitis C infection 1- Recipients of blood and blood products 2- Intravenous drug abusers 3- Health care workers 4- ial!sis patients "- Organ transplantation recipients

"- Organ transplantation recipients #- Ho$ose%ual &- Infants of carrier $others '- ental surger! (- )attooed
Unsterilized medical equipments is an important factor in Egypt. It is thought that the schistosomiasis

#(* of the pregnant wo$en were newl! diagnosed and &3* had no risk factors for

&'( )*+ ha a" o ,een detected in Sa"iva Urine ,rea t mi"kemen- and men tr!a" f"!id.
Therefore- ,oth e.!a" and vertica" tran mi ion have ,een !gge ted a a"ternative mode for tran mi ion of &'(
(Eriksen, 1999)

-arenteral )ransfusion associated parenteral +eedle sticks and sharp in,uries Co$$unit! ac-uired

.on parenteral /erti#al 0e1ual Hori.ontal /intrafa$ilial 0 1od! secretions 2nknown

1. *eed"e tick and harp in/!rie The incidence 1.0% 1range2 0%337%4 [Alter 1997; CDC 1998b]. 56ne t!dy indicating that tran mi ion occ!rred on"y from ho""o73,ore need"e compared 7ith other harp 5Tran mi ion rare"y occ!r from m!co! mem,rane e.po !re to ,"ood

8anagement2 '!rrent"y no vaccine e.i t to prevent &'( infection- and neither imm!nog"o,!"in nor antivira" therapy i recommended [CDC, 1998]. 59o""o73!p at ,a e"ine and 6 month for eroconver ion. 5+ntivira" given 7hen &'( )*+ fir t ,ecome detecta,"e might prevent the deve"opment of chronic infection.

$" /erti#al (mother(to( in+ant) transmission 3Incidence4 03##%an overa"" ri k of :.2% ( ar!ellin et al., 199")
i "o7er than for &;( infection <different patient pop!"ation- different rate of )*+ po itivity- different a ay to determine neonata" infection=

Timing > 8echani m2 +t conceptionin !teroperinata""y- or d!ring "actation. Timing > 8echani m remain "arge"y !nkno7n. 5 ?t occ!r ?n the perinata" period rather than in !tero 6n"y 7hen er!m &'( )*+ i detecta,"e i.e. "imited to infant 7ho e mother are viremic
(#i$$%n&s,2001).

)he risk of 56 trans$ission is enhanced b!4 High level of HC5 R+7. 1 :titers 6 copies8 $l4 the risk 10 < increased to 3#* copies8$l4 +o 104> trans$ission

No association between V. transmission and 1. Gestational age, 2. Type of delivery, 3. Chorioamnionitis (Ohto et al,1994;
Alter,1995).

4. !.

Subsequent pregnan ies. "reast feeding.

'ontrover ia" point 1. The vira" genotype2 8other infected 7ith a high"y pathogenic &'(. 2. U e of interna" feta" monitoring2 U e of feta" ca"p e"ectrode 1 a''a et al,1998). #. @!ration of r!pt!red mem,rane . 8em,rane r!pt!re A6 ho!r prior to de"ivery ((esti et al., 1998)

Brevention ?n a, ence of materna" treatment to red!ce vira" "oador effective vaccination for neonate - o, tetric (preventive mea !re (#i$$%n&s,2001 . +voidance of inva ive proced!re e.g 'horionic vi""o! ,iop y that damage the integrity of the p"acenta" mem,rane. 9eta" ,"ood amp"ing Sca"p e"ectrode

3. Assisted conception: 5&'( can ,e fo!nd in the emen 1on"y "o7 "eve" of &'( )*+4

Transmission of viral epatitis in assisted reprod!ction is possible" b!t t e ma#nit!de of t e ris$ is !n$nown (ASRM,2004(.

)ecommendation of +S)8 1.Te ting for &'( of high3ri k inferti"e co!p"e eeking ferti"ity therapy. )*% re&+!e t,e -%tential risk .%r trans$issi%n t% an +nin.e!te& -artner, baby, sta.. $e$bers, an& &isease/.ree 0a$etes an& e$bry%s in t,e sa$e lab%rat%ry1 (A#( ,2002).
.

Te ting for &'( of co!p"e. % prior to cryopre ervation of (. emen or em,ryo (A#( ,2002 Semen and em,ryo from.3 &'( patient ho!"d ,e tored in &'( de ignated torage (.tank (A#( ,2002

$. )ed!cing the potentia" ri k of vir! tran mi ion among cryopre erved perm and em,ryo ,y2 a. torage of amp"e in the nitrogen vapor tate in tead of the "iC!id tate. ,. ! e of perm 7a hing techniC!e to red!ce vira" "oad prior to freeDing emen amp"e . c. ! e of a do!,"e3 ea"ing techniC!e for cryocontainer (A#( ,2002).

$. Se.!a" tran mi ion2 controver ia" Incidence4 35er! low6 5m!ch "o7er than that of hepatiti ; or &?(. 5doe not corre"ate 7ith inten ity and d!ration of e.!a" e.po !re. 5&'( ho!"d not vie7ed a ST@ from the per pective of pop!"ation hea"th trategie
(3iles et al, 200")

Breca!tion 2 *o need to avoid c"o e contact 7ith fami"y mem,er or to avoid haring mea" or eating !ten i" . 1. Se.!a" partner of infected patient ho!"d ,e te ted for &'( anti,odie . 2. Safe e.!a" practice 'ondom for tho e not trying to conceive
(A#( ,2002).

minimiDe the e.tent of ,"ood contact 'overing open 7o!nd

2" Effect of pregnancy on H"$

8o t 7omen are a ymptomatic *o de"eterio! effect of pregnancy on the co!r e of &'( infection. Bregnancy doe not adver e"y affect the co!r e of hepatiti '. @!ring the co!r e of pregnancy increa ed prod!ction of different hormone and cytokine might inf"!ence &'( activity and the !nder"ying "iver di ea e (Chard et al., 1986)

1. ?mprovement in ,iochemica" marker of "iver damage <&aemodi"!tion- econdary to a re"ative increa e in circ!"ating ,"ood vo"!me in rd the # trime ter=

10% 7i"" have e"evated tran amina e (4l%reani et al., 1995) +ET "eve" decrea e d!ring the #rd trime ter > ret!rn to "eve" fo!nd ,efore pregnancy hort"y after de"ivery < change in imm!ne re pon e d!ring pregnancy p"ay a ro"e in the ho t3 &'( interaction=.

2. + "inear increa e in &'( viraemia thro!gho!t pregnancy <impaired imm!ne reactivity=. &'(3)*+ "eve" increa e "ate in pregnancy and ret!rn to ,a e"ine "eve" 7ithin 1 yr after de"ivery. <imm!ne3mediated mechani m in contro""ing vira" rep"ication and contri,!ting to "iver in/!ry in chronic hepatiti =

#. The rate of cho"e ta i i ignificant"y higher- and occ!r ear"ier. Ear"y occ!rrence of cho"e ta i of pregnancy may ,e an indication for ero"ogic te ting for &'(.

26 E++e#t o+ HC/ on pregnan#y:

16 Hepatitis C infection does not affect pregnanc! co$plications and outco$es6

2. &epatiti in pregnancy i not a ociated 7ith increa ed a,ortion rate- "o7er ,irth 7eight - ti"",irth or congenita" ma"formation.
#. Bremat!rity eem to ,e increa ed if hepatiti

1. +ntenata" creening 6ene.its %. s!reenin02

5@etect at an ear"y tage a ymptomatic ad!"t - 7ho 7o!"d ,enefit from ed!cation and treatment2

8odify their a"coho" intake- e.!a" ,ehavior and vie7 on ti !e and organ donation. 58other and chi"dren 7ith chronic hepatiti ' ho!"d ,e imm!niDed again t hepatiti + and ;
< !per infection may have a more evere co!r e=

5?dentify chi"dren at ri k of acC!iring &'(

&o72 +nti3&'(- and if po itive &'( )*+ ((%berts, 7e+n0, 2002).

Type 2 1. Univer a"F)o!tine not /! tified in area 7ith "o7 &'( preva"ence e.g. UK. <"ack of mea !re to prevent tran mi ion and to treat the infection efficient"y=. 2. Se"ective2 certain high ri k categorie @i advantage 2 mi more than ha"f of &'( po itive pregnant 7omen.

$" 3reatment Co$bination therap!: I;+- plus ribavirin: has resulted in a better response rate co$pared with $onotherap! and is now considered first-line therap! (%ei&in et

a" 8nter.er%n9

:atients ;it, !,r%ni! ,e-atitis ;,%se t,era-y !an be &elaye& s,%+l& n%t be treate& ;it, inter.er%n W%$en e<-%se& t% inter.er%n ina&=ertently &+rin0 -re0nan!y $ay be en!%+ra0e& t% !%ntin+e -re0nan!y.
:atients ;it, a!+te ,e-atitis C &+rin0 -re0nan!y, t,e +se %. inter.er%n t,era-y s,%+l& be !%nsi&ere& ;it, !l%se $%nit%rin0 (>'aslan et al, 2002).

*,ere ,a=e been 27 in.ants b%rn t% 25 $%t,ers, ;,% ;ere e<-%se& t% 84 al-,a in +ter%. #i< ;%$en (2"?) ;ere a&$inistere& 84 al-,a ina&=ertently &+rin0 -re0nan!y (@irats+ka et al, 2000). 1A?9 -re$at+re. 22?9 8B3( C% 84 al-,a/relate& $al.%r$e& in.ants.

"ack of teratogenicity2 ?9* doe not cro the p"acenta 1'ategory '4 ?9* ! e in pregnancy i not advi ed
(A#( ,2002).

,. )i,avirin2 'ategory G ho!"d not ,e ! ed ,y2 pregnant 7omen7omen attempting pregnancyor their ma"e partner (>,t% et al, 1992)

#. E"ective 'e arean ection i not recommended < )o"e in red!cing vertica" tran mi ion i !ncertain=.

)" Breast +ee&ing HC/ 4.5 #an 6e +oun& in 6reast mil,7 in+e#tion through 6reast+ee&ing has not 6een &emonstrate&" 2" Foun& in tiny amount: Una6le to in+e#t the ne*6orn
(Polywaka et al,1999)

Easily ina#tivate& 6y gastri# 8ui#es" $" 3he integrity o+ the oral an&

%herefore& breastfee'ing is not contrain'icate'

(CDC or the American Academy of ediatric!).

:. Screening in chi"dren
9ost infants delivered to HC5-infected $others /1<# copies8$=0 progress to chronic hepatitis6
*,e A$eri!an A!a&e$y %. :e&iatri!s an& t,e CDC

recommended that a"" chi"dren ,orn to 7omen 7ho are infected 7ith &'( ,e creened for thi vir! . +nti,odie to &'( cro the p"acenta and may per i t in the infant for !p to 1: month . Tran mi ion occ!r in the perinata" period > B') a ay at ,irth are !nhe"pf!" (#i$$%n&s, 2001)

6ptima" creening for &'( in the off pring can ,e done ,y te ting for &'( )*+ at 6312 month of age. Some con ider B') te ting at # month provide the ear"ie t > the mo t conc"! ive evidence for ,oth infection > "ack of infection (3ibb et al, 2000) +"ternative"y- &'( anti,ody creening ! ing a recom,inant imm!no,"ot a ay can ,e performed at 1032$ month ( alom"a et al., 1996). +nti3&'( te ting after the fir t year of "ife i ! ed ,y mo t e.pert .

3## $%&G'('T )*+&'

&,-S( $ositive 4# .13.33/0 $C% 'egative 1# .2!/0 -nfants .1 months after delivery0 $C% $ositive 2 .1.13/0 'egative 22 .43.33/0 $ositive 3# .3!/0 'egative 21# .21.13/0

Table .10 5 Chara teristi s of the study population .n 6 3##0

Range Age Parity Previo"s s"rgery #$ood trans%"sion (istory o% )a"ndi*e (ea$t+ *are ,or-er Dr"gs .ns"$in de/endent dia0etes 1e$$it"s #i$+ar2iasis (e/ato1ega$y 41 17 ! 5 Mean 26.2 1.4 .! 5 1.5 1 SD Median 25 1 1 )&.''( 2! )'.''( 1 )1. ) . (' ( .Positive No )%(

)2.''( 7 ) .''( 1 ) . (

Table .20 5 $C% and &,-S( in relation to ris7 fa tors for 8C9 infe tion
Range Age Parity Previo"s s"rgery #$ood trans%"sion (istory o% )a"ndi*e (ea$t+ *are ,or-er .ns"$in de/endent dia0etes 1e$$it"s #i$+ar2iasis (istory o% +"s0and risRange Mean SD Range Mean SD Range Mean SD )%(Positive )%(Negative )%(Positive )%(Negative )%(Positive )%(Negative )%(Positive )%(Negative )%(Positive )%(Negative )%(Positive )%(Negative P3R )4(ve (n 5 ' ) 1&8'7 5.1 26.5 184 1 1.! 85 9 1.4 2.1 9)56.67( 17 )4'.''( 1' 9)16.67( 5 )!'.''( 25 ) . 9)1 . )& . ) . 9)4 . )6 . ( ( 12 ( 1! ( (' ( 27 )1 . ( ' 9)6 . )4 . 67.SA )4(ve (n 5 4 ) 1&8'7 4.& 27.1 87 1.5 1.! 85 9 1.' 2 ( 24 ( 16

9)12.5 ( 5 )!7.5 ( '5 ) . 9)1 . )& . ) . ( ( (4 ( '6 )1 . ( 4

)1 . ( '

)1 . ( 4 9)'2.5 ( 1' )67.5 ( 27

: Signifi

ant differen e to .;0ve group.

Table .30 5 $C% of infants .1 months after delivery0 P3R )4( ve 67.SA )4( ve

No. o% *ases Positive Positive )%( Negative Negative )%( P S 5 Signifi ant differen e.

' 2 6.67 2! &'.'' (S ) . 2

4 2 5. '! &5. (S ) . 1

Conclusions4 1- )he prevalence of anti-HC5 antibodies a$ong pregnant wo$en was 1363*: whereas confir$ed cases with >CR

2- Hepatitis C virus infection was found $ore a$ong those wo$en with histor! of ?urgical operation: 1lood transfusion: @aundice: Insulin dependant diabetes $ellitus Aith husbands having risk

3- )here was no correlation between the age and parit! and the incidence of hepatitis C infection 4- )he vertical trans$ission rate /detected at # $onths

RBCO99B+ 7)IO+? 1- ?creening of pregnant wo$en at high risk for HC5 antibodies is ,ustifiable in Bg!pt 2- +eonates of >CR positive pregnant wo$en should be

(enha )niversity Hospital *elta +,ans ra- . (enha /ertility "enters Email: elnashar012hotmail.com