以风险为基础的筛查易遗漏丙肝孕妇

之前利用国家健康与营养调查(NHANES)数据开展的分析显示，在1999~2002年期间，20~39岁女性中HCV感染的患病率为1%~1.6%。约翰霍普金斯大学胃肠病学系的Po-Hung Chen 博士指出，因为NHANES是基于家庭健康的调查，未纳入监狱人群和无家可归的妇女，而这些人群又是HCV感染的高危人群，故上述数据可能低于实际患病率。“慢性丙型肝炎与不良的母体/胎儿结局相关。基于这一结果，似乎有必要在产前检查中进一步评估通用的丙型肝炎筛查。”

Chen医生及其同事收集了2003~2010年间在国家住院样本中记录的所有出生和自然流产的数据。结果显示，在有记录的3200万例分娩或流产中，超过28,000例母体感染了HCV。在HCV阳性的母体中，72%无该疾病的传统危险因素。HCV阳性母体更易发生产科肺栓塞(经校正OR为3.05)和甲状腺功能异常(经校正OR为1.37)，以上结果具有统计学意义。HCV阳性母体还更易发生母体死亡，但无统计学意义(经校正OR为2.49)。此外，HCV阳性母体更多为白人、收入较低、接受医疗救助、药物滥用者以及有较多合并疾病。HCV妇女更多在37周之前发动产程(经校正OR为1.36)、发生产前出血(经校正OR为1.44)和胎儿生长不良(经校正OR为1.61)，上述结果均有统计学意义。HCV阳性母体的治疗费用显著增高，住院时间显著延长。

目前尚无明确的关于如何管理妊娠妇女慢性HCV的指南，可能的原因为缺乏适当、经证实的管理选择。Chen医生还补充道，利巴韦林禁用于妊娠期，一般不建议使用干扰素，且目前经核准的蛋白酶抑制剂不是单药治疗的选择。美国妇产科医师协会也不建议进行常规产前HCV筛查，而是建议仅对根据疾病预防控制中心标准确定的高危妇女进行筛查。

研究者总结认为：“在美国，定向HCV筛查可能遗漏很多慢性HCV感染的妊娠妇女，并可能进而导致对儿童丙型肝炎的诊断不足。”

原文阅读

WASHINGTON – Programs to screen pregnant women for hepatitis C infection could go far to reduce a host of adverse outcomes, according to an analysis of a large national sample.

Targeted HCV screening may overlook many pregnant women with chronic HCV infections, and that may contribute to the underdiagnosis of pediatric hepatitis C in the United States, study investigator Dr. Po-Hung Chen said at the annual meeting of the American Association for the Study of Liver Diseases.

Chronic hepatitis C is associated with adverse maternal/fetal consequences. In light of these findings, there seems to be a need to further evaluate universal hepatitis C screening as a part of antepartum care, he added.

Dr. Chen of the division of gastroenterology at Johns Hopkins University, Baltimore, and colleagues collected data on all births and spontaneous abortions recorded in the National Inpatient Sample between 2003 and 2010.

More than 28,000 of the 32 million deliveries or miscarriages recorded in the National Inpatient Sample were to mothers infected with HCV, he reported.Of HCV-positive mothers, 72% had no traditional risk factors for the disease.

HCV-positive mothers were significantly more likely to experience obstetric pulmonary embolism (adjusted OR, 3.05) and thyroid dysfunction (aOR, 1.37), and more likely to experience maternal death, but not significantly so (aOR, 2.49). They also were significantly more likely to be white, less affluent, on Medicaid, substance abusers, and have more comorbidities.

Women who were HCV positive were significantly more likely to have labor before 37 weeks’ gestation (aOR, 1.36), antepartum hemorrhage (aOR, 1.44), and poor fetal growth (aOR, 1.61).

Cost of care and length of stay were significantly greater for mothers who were HCV positive, Dr. Chen said.

Previous analysis using data from the National Health and Nutrition Examination Survey (NHANES) showed that the prevalence of hepatitis C virus infection in women aged 20-39 years was 1%-1.6% in the period between 1999 and 2002.

Dr. Chen noted that this could be an underestimation because NHANES is based on home health surveys and therefore does not include prison populations and homeless women, who are at high risk for HCV infection.

Currently, no definitive guidelines exist on how to manage chronic HCV in pregnant women, likely because of a dearth of suitable proven management options, Dr. Chen said, adding that ribavirin is contraindicated in pregnancy, interferon is generally not recommended, and the currently approved protease inhibitors are not options for single-drug management.

The American College of Obstetricians and Gynecologists does not recommend routine prenatal screening for HCV; instead, the college recommends screening only in women who are at high risk based on Centers for Disease Control and Prevention criteria.