For most, CD does not reduce HCV transmission
Nine of the 11 studies found that the mode of delivery did not have a statistically significant impact on the vertical transmission rate of HCV in the total study populations.14,22-29 The remaining 2 studies found that the perinatal transmission rate of HCV was lower with cesarean delivery (CD) than with vaginal delivery.20,21 When considered together, the results of these 11 studies indicate that CD does not provide a significant reduction in the HCV transmission rate in the general population.
Our review confirms the findings of others, including a systematic review by the US Preventive Services Task Force.30 That investigation also failed to demonstrate any measurable increase in risk of HCV transmission as a result of breastfeeding.
Cesarean delivery may benefit 2 groups. Careful assessment of these studies, however, suggests that 2 select groups of patients with HCV may benefit from CD:
- mothers co-infected with HIV, and
- mothers with high viral loads of HCV.
In both of these populations, the vertical transmission rate of HCV was significantly reduced with CD compared with vaginal delivery. Therefore, CD should be strongly considered in mothers with HCV who are co-infected with HIV and/or in mothers who have a high viral load of HCV.
CASE Our recommendation for mode of delivery
The patient in our case scenario has both HIV infection and a very high HCV viral load. We would therefore recommend a planned CD at 38 to 39 weeks' gestation, prior to the onset of labor or membrane rupture. Although HCV infection is not a contraindication to breastfeeding, the mother's HIV infection is a distinct contraindication.