Dr. Chapa’s OBGYN Clinical Pearls

Episode: No OB Hep C RX: Time For Change

Date: December 8, 2025
Host: Dr. Chapa

Overview

This episode delves into the rapidly evolving landscape of hepatitis C treatment during pregnancy, triggered by a brand-new commentary (“Hepatitis C treatment during pregnancy: Time for a practice change”) out of Thomas Jefferson University, published on December 7, 2025 in AJOG MFM (“the Pink Journal”). Dr. Chapa examines the traditional “no treatment during pregnancy” stance—upheld by major organizations like ACOG (American College of Obstetricians and Gynecologists)—and argues that recent evidence, though not from large RCTs, suggests it’s time to consider shared decision making and possibly treatment with direct-acting antivirals (DAAs) during pregnancy.

Key Discussion Points & Insights

1. Medicine Moves Fast—Guidance Changes Quickly

• Dr. Chapa stresses how clinical guidance may lag behind emerging evidence, likening policy changes to “the Titanic turning around—not always fast enough.”
  • “What we learn one year may be outdated as fast as one or two years after that.” (00:08)

2. Current Standards for Hep C Screening and Treatment

• Universal screening for HCV in pregnancy is standard, but treatment is not currently recommended, per ACOG Clinical Practice Guidance #6 (Sep 2023).
  • “As of right now, according to ACOG's last guidance … there are no standard treatment protocols for Hep C in pregnancy.” (01:39)

3. Recent Expert Commentary: Challenging the 'Hard No'

• New review (Dec 2025) from Thomas Jefferson University calls for a practice change: move from “no” treatment to shared decision-making for DAA therapy in pregnancy.
  • “That was then and this is now. … at least it should be considered part of shared decision making.” (02:48-02:51)
• Other major orgs (SMFM, IDSA) are more conservative, sticking to “no” or “only in a clinical trial,” but the tempo of change is quickening.

4. Why a Change Might Make Sense

• Direct-acting antivirals (DAAs) appear to have increasing safety and efficacy data—though no large RCTs yet exist.
• Analogy to latent TB: If you have a “captive audience” (pregnant person in regular care), it might be the best time to treat.
  • “Pregnancy represents a time when individuals are continuously engaged in care, providing an optimum window for treatment …” (11:44)

5. The Evidence So Far

• Smaller-scale observational studies and systematic reviews suggest that DAAs have high cure rates and no major adverse events in pregnancy (notably, as long as ribavirin is avoided).
  • “98% sustained virological response. Amazing. Good news. There was no serious adverse events reported.” (17:54)
• Risk of vertical (mother-to-child) HCV transmission is 5–9% without treatment, higher with comorbid HIV. HCV also increases risk for cholestasis, preterm delivery, and other complications.
• Ribavirin is contraindicated in pregnancy: teratogenic, can cause defects and should not be used within 6 months prior to conception.
  • “Ribavirin equals no. No in pregnancy. That's a bad one.” (06:34 & 14:54)

6. What the Experts Now Propose

• At minimum, bring up the option in shared decision making with patients (and specialists).
  • “Not that they should be done on everybody, but at least bring it up, let the patient decide. That's all we're trying to say here as part of patient centered care.” (12:53)
• Best DAA combos with safety data:
  • Ledipasvir/Sofosbuvir
  • Sofosbuvir/Velpatasvir
  • “These are the combinations that have been proven in pregnancy.” (13:29)
• Multidisciplinary care: Involve MFM, hepatology, infectious disease when considering DAAs.

7. Official Stances and Divergence

• ACOG & SMFM: “No” except maybe in trials (as of 2023-2025).
• AASLD (liver society) & IDSA (infectious disease): “Case-by-case,” shared decision making may be appropriate (with limitations).
  • “That’s the way it should be.” (18:01)

8. Memorable Quotes & Tone Highlights

• The recurring motif of change:
  • “Well, that was then and this is now.”—a refrain throughout, emphasizing the need to stay current. (e.g., 00:32, 02:48, 09:37, 14:18, 20:22, 21:21)
• Dr. Chapa’s humor and engagement:
  • “There’s 60 immunizations by the time they finish pregnancy. Sarcasm. I’m not anti-vaxx…” (07:50)
  • “If you ask me, I totally talk to my patients about direct acting antivirals…” (20:57)
• Explaining to make it simple:
  • Quote from “Philadelphia”:
    • “All right, explain this to me like I’m a two year old, okay? Because there’s an element to this thing I just cannot get through my thick head.” (05:22)

Timestamps for Key Segments

• 00:08 — Speed of change in medical practice
• 01:32–02:35 — Current screening & treatment standards for HCV in pregnancy
• 03:16–04:28 — Introducing the new commentary and shifting attitudes
• 05:22 — Explaining complicated change simply (“Philadelphia” quote)
• 06:30–09:37 — Reviewing the evidence & rationale for revisiting the “no treatment” stance
• 11:44 — Quoting new expert review: DAAs safe/effective, pregnancy is an optimum time for treatment
• 13:29 — Safe DAA combinations for possible use in pregnancy
• 14:54 — Ribavirin: why it’s absolutely contraindicated
• 17:54 — 2024 Systematic review: 98% virological response, no serious adverse events
• 18:07 — Why “no data” is wrong; time to consider evidence and patient autonomy
• 20:22–21:24 — Dr. Chapa’s approach: moving beyond “hard no,” involving patients and specialists

Conclusion

• The “hard no” against hepatitis C treatment during pregnancy is being questioned based on new evidence and increasing support for shared decision making.
• Official guidelines as of late 2025 are still conservative, but other respected bodies and this new commentary urge clinicians to consider discussing safe DAA options with appropriate patients, especially excluding ribavirin.
• Clinical pearl:
  • “What was acceptable to give as an answer … September of 2023 may not stand two years later.” (13:47)

Notable Quotes (with Attribution & Timestamp)

• Dr. Chapa:
  • “What we learn one year may be outdated as fast as one or two years after that.” (00:08)
  • “That was then and this is now.” (refrain throughout, e.g. 02:48, 14:18, 21:21)
  • “I read the entire expert review, it’s very well written … medicine moves quickly. … There’s a time for a change.” (08:20)
  • “Pregnancy represents a time when individuals are continuously engaged in care, providing an optimum window for treatment of hepatitis C viral infection.” (11:44, quoting expert review)
  • “Not that they should be done on everybody, but at least bring it up, let the patient decide. That’s all we’re trying to say here as part of patient centered care.” (12:53)
  • “Ribavirin equals no. No in pregnancy. That’s a bad one.” (14:54)
  • “98% sustained virological response. Amazing. Good news. There was no serious adverse events reported.” (17:54)
  • “Just for me, I totally talk to my patients about direct acting antivirals … and I let the patient decide.” (20:57)

Bottom Line for Clinicians

• Stay updated!
• Discuss recent data on DAAs with your patients, avoiding ribavirin, especially with support from MFM, ID, and hepatology.
• Honor patient-centered care and shared decision making, even as guidelines catch up.

For references and detailed medication regimens, see the episode show notes.