B (3:13)

Well, that was then and this is now.

A (3:16)

In this episode, we're going to cover this brand new commentary from Thomas Jefferson University and we're going to highlight the data that led to their proposal to at least include this as shared decision versus a hard no. Medicine truly does move fast. This is why we do the episodes. So I would do this whole show because one day you can say, well, we used to say it was contraindicated in pregnancy, but that was then.

B (3:42)

That was then and this is now.

A (3:44)

Because now it's part of shared decision making. That's where we're going. Podcast Avenue. We're going to cover this brand new commentary out of the Pink Journal, ajog MFM under expert review, the title of which is Hepatitis C treatment during pregnancy. Time for a practice change. I love it. Let's get to it.

A (4:28)

This is Dr. Chapa's obgyn no spin podcast.

A (4:53)

Foreign.

A (4:57)

There's a quote from Denzel Washington in the movie Philadelphia that, that I use frequently with the resident whenever I've. I know I've told them something, whether it's a technique that we use or, or a concept. And then I ask them again and they're like, wait, I, I know you told me that, but I forgot. And I always pick up a line from Denzel Washington from the movie Philadelphia because it's so appropriate and fitting.

C (5:22)

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.

A (5:28)

Yep. Many a resident that has heard me say, explain it to me like I'm a 2 year old. Cause I can't get it through my thick head that you don't understand what I've already told you many, many times before. Yes, sometimes I'm that kind of attending. All to say that Philadelphia is highlighted here because we're talking about Thomas Jefferson University, a historic institution. And that is where these two authors come from who wrote in the Pink Journal under expert review, hepatitis C treatment during pregnancy. Time for a practice change. Now, I want to be very clear here. I'm not telling you to do something outside of guidance. I'm not telling you to do something that you know is wild and unsafe. I'm saying that some things in medicine happen before, before it becomes into a guidance. Because practice moves quickly. And the decisions from a big professional society sometimes is literally the Titanic turning around. And sometimes, you know how that goes. It doesn't turn around fast enough. So it's okay. So these authors are saying it's time for a practice change and lay out the data. Even though we're missing large randomized clinical trials, we do have smaller observational studies and even a systematic review that says what we do know. Safety doesn't seem to be an issue. As long as it's not ribavirin. Okay, and we'll touch on that in a minute. Because ribavirin equals no. Ribavirin equals no. No in pregnancy. That's a bad one. You gotta wait. Even if the patient is on it, they wanna get pregnant, they gotta wait for about six months to let that clear the system. Okay, so outside of that, why not? We do have some safety data here, and it's all in what we've been doing lately. I mean, we offer pregnant women so many cares they get, you know, there's 60 immunizations by the time they finish pregnancy. Sarcasm? I'm not anti vaxx. I'm just saying, wow, there's a lot of stuff that we do to these women. And when we do find something that is really worrisome, like hepatitis C that potentially has a. As a risk of transmission, as lowest on a good day of 5% or highest around 9% in the antepartum peripartum interval. And then for things like this, we're like, nah, don't you. Nothing to do, honey. Just. You just got to wear it out. Just, you know, be done with the pregnancy, and then we will take care of it. That's a lot of stress when a patient knows that she has hepatitis C and there's nothing to do. Open the door and enter. Therefore, shared decision making. Now, remember, this comes from the previous guidance from the college, which was viral hepatitis and pregnancy from clinical practice guidance number six, which was September 2023. Okay, so now look how things move fast. We're now two years ahead of that. Two years have passed from that. And now there's this expert review going. No, man, you can't call it just completely no carte blanc. It's a no. Absolutely no. It should be at least shared decision making. If we remind ourselves about hepatitis C. Just as a recap, just so that we all get our brains on this. Remember, it is a enveloped virus, single stranded rna, and there's multiple genotypes of this virus. It's not like you just have one hepatitis C virus. They come in a lot of different flavors, just like HPV does. Okay, a lot of different flavors. And now you can check the genotype because that actually can help give you a prognosis for disease progression. And treatment should be ideally tailored to the genotype. Although in pregnancy we only have, you know, safety data for a few of these hepatitis C antivirals, daas, and not all of them, but you can do genotype testing, which is the right thing to do. Okay, so you screen with an antibody. If it's positive, then you confirm with a pcr. And then these authors are saying, rather than saying there's nothing to do, sorry, you just got to get through pregnancy with a possible transmission rate of 5 up to 9%, maybe we should be doing something different. That's all that they're asking. That's all they're saying. And I read the entire expert review, it's very well written, make some good points here, that medicine moves quickly. And so in the past, even though we said no, we just don't treat, that there's a time for a change.

B (9:37)

That was then and this is now.

A (9:39)

That'S all they're saying, is to consider the data and consider the evidence and let the patient, together with a hepatologist, come up with a plan. So right now, according to acog, quote, currently, there are no treatment options for hepatitis C viral infection diagnosed during pregnancy. Additionally, there are currently no recommended interventions to decrease the risk of perinatal hepatitis C viral transmission. End quote. In other words, I can't give you medicine. I'm not gonna section you either. Now, I'm still gonna do common sense things like try not to rupture you if I don't have to try to minimize internals unless I really have to. That's just common sense. However, there's no specific intervention that's gonna decrease the risk of perinatal hepatitis C. These authors are now saying, not so. Not so, because it is possible, based on some evidence that we have, that even though we need, again, even though we need to prove with more larger trial, randomized clinical trials, what we do have can be an option for these poor patients that are so stressed and don't want to risk a 5 up to 9% possible transmission rate peripartum. Now, if they have HIV, that's an even higher risk of transmission, with some studies saying it's anywhere from 10 to 15%. Okay, so these authors, again, this was released on the 7th of December, 2025, are calling for a change, saying that DAA therapy can be started while the patient is pregnant, ideally in the second or in the third trimester. So all they're saying is consider a shift change here for hepatitis C, according to the authors. I'm going to read this directly because I don't want to misquote. I'm going to read you the main take home point here. And then very quickly we're going to dissect some of the data that made them say this, right? But here's what they say. In recent years, there's been a growing body of evidence that DaaS, direct acting antivirals are safe and effective in pregnancy with similar cure rates as non pregnant adults. Pregnancy represents a time when individuals are continuously engaged in care, providing an optimum window for treatment of hepatitis C viral infection. End quote. Let's stop there for a minute. This is the same argument, guys. When we covered TB in pregnancy, latent TB in pregnancy, why some authors say treat them. You've got them captured here. We know that treatment for TB is safe. Treat them because they're under care now. Once they lose potentially pregnancy benefits or they're gone back into the general population of postpartum, they get lost. So the same argument here, guys. It's not new. This is the same argument used for latent TB treatment in pregnancy, which we covered. We have an episode on this as to why don't wait until postpartum, if the patient agrees, do TB treatment for latent infection during that gestation when you have them, assuming of course, they've not been previously treated. So they go on to say, quote, ob GYN should employ shared decision making surrounding treatment of hepatitis C viral infection during pregnancy, acknowledging the benefits and efficacy of treatment versus the available data on DAA exposure in pregnancy. They go on to say therapy should be initiated during the second or third trimesters with limited but reassuring data on DAA exposure through breast milk. So I'm gonna leave you at this last one here. Okay? So this is all they're saying. 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, quote, multidisciplinary care between maternal fetal medicine, infectious disease and hepatology can help promote access to HCV treatment in pregnancy. That's why we're doing this episode. It's phenomenal. Good for them for being trailblazers. And they list some combinations here that have the most available safety data. Ledepazavir and sofosbuvir and sofosavir and veltisazovir. These are the combinations that have been proven in pregnancy. So the two different medications in two dual combinations. And I'll post the reference in our reference list in our show notes because I am not saying those words again. Good Lord Almighty, I'm just not saying those. So there are two medications in combination, so four medications total that have shown the most data, safety and efficacy during pregnancy. Okay, so that's the whole clinical pearl right here. Is that what was acceptable to give as an answer one day, and in this case, September of 2023 may not stand the two years later.

B (14:18)

Well, that was then and this is now.

A (14:22)

Okay, now it's not wrong. Not wrong to give therapy. Let's just say right here, it's not wrong because that is a current guidance, but it's not all together right either. Because at the heart of patient centered care is letting the patient decide. And as these authors are now saying, Remember as of December 7, 2025. December 7, 2025, let the patient decide. Now, everybody agrees that this can be done, except for ribavirin. Ribavirin in pregnancy is bad. We gotta remember that that is embryocital. It's definitely teratogenic. I mean, there's been limb defects from this thing, craniofacial defects. Anencephaly has been reported, especially in some animal species. And this risk for ribavirin containing regimens can hang out in the body as a metabolite for up to six months. So ribavirin, ribavirin in pregnancy, or six months preconception is a no go. All right? But outside of that, in those combinations that we've discussed, potentially those are options. So again, I know I'm going fast here, guys, because I just wanted us to talk about this. And so somebody asks you, what do we do for hepatitis C in pregnancy? The answer is, well, two years ago that was nothing. But according to some new expert reports, again, that's just expert opinion or category C evidence. There is some data there and maybe we should let the patient decide. But right now, just to be clear, because I don't want to, you know, don't want to misrepresent anybody. ACOG says no. SMFM says no. Ish. In other words, yes, it can be treated if it's part of some kind of clinical trial. So that's maybe a yes. And the Infectious Disease Society of America currently say, you know what, I get it, it may work, but we need more safety data. So very conservative. And there's nothing wrong with that. It's okay to be that conservative because it's true. We don't have large, you know, randomized trials, but we do have some data. Meanwhile, on the other flip Side of that, you do have the American association for the Study of Liver Disease, that is the double A sld, double A S L D, and the Infectious Disease Society of America that say, look, talk to a patient about DA and maybe they can be considered during pregnancy once again on a case by case basis and what is called shared decision making. Man, everybody likes those terms a lot. And this is the perfect, perfect example of where this can be done. Because while there is safety data, while there is efficacy data, it's not on all of the medications. And we definitely, definitely need more large scale randomized trials to do this. Just last year, guys, last year in 2024, there was a systematic review and a meta analysis that took a look at global data using pool sustained virological response rates to treating 74 pregnant women. Now I get it's only 74, but hey, we'll take what data we have 74 pregnant women who were given DAAs during pregnancy and they found a 98%. That's 9, 8. 98% sustained virological response. Amazing. Good news. There was no serious adverse events reported. So this analysis also showed. Look, since we know that hepatitis C virus is associated with increased risk of intrahepatic cholestases of pregnancy, which we've covered on this show in the past, it's associated with preterm delivery, endopartum hemorrhage, and of course vertical transmission, why not, why not offer something that can reduce these known complications versus just saying, nope, sorry, nothing to do.

A (18:07)

You're just screwed. Just gotta deal with it. Now. Yes, we need more data, but this 2024 systematic review is something to consider. With a 98% virological response rate and no serious adverse events. I get it, I get it. We need large, large scale prospective RCTs. Absolutely. But to say that there's no data at all is just incorrect. That's why these authors are making this point. But just to be clear, the A sld, that's the American association for the Study of Liver Disease and the Infectious Disease Society of America both suggest that direct acting antiviral treatment can be considered during pregnancy on a case by case basis. After discussion of the risks and benefits. I love it. That's the way it should be. So just to be clear, as we get ready to wrap up this very brief episode. Guys, I just want to let you know it's hot in press and the reason if I sound a little bit more rushed than usual, although I always have some kind of pressured speech, it's the 12 cups of coffee. I have a day. Anyway. Anyway is because I'm doing this in a little lull. I'm waiting for a patient to arrive for a C section and she hasn't arrived. Everything else is calm. Our residents are on top of things. But. But I emailed our producer. I'm like, hey, rather than doing this tonight because I've got a late dinner meeting, let me go ahead and do this now. So I'm going to send this over to him. Hopefully he'll package this up and we'll get this out. But we are recording this just 24 hours, guys. 24 hours after the Pink Journal released that commentary under expert review titled Hepatitis C treatment during pregnancy, time for a practice change. So while acog, SMFM currently say it's a hard no for them, it's not necessarily a hard no for others. Again, AASLD and IDSA say maybe should be part of shared decision making. Exactly as these two authors stated from Thomas Jefferson University Podcast Family. I think I've said what I'm supposed to say now. My phone's actually been going off. I think our lady may be getting here. But treating hepatitis C in pregnancy used to be a hard no.

B (20:22)

Well, that was then and this is.

A (20:25)

Now now potentially at least consider shared decision making and then we'll see what the ACOG and SMFM if they change based on these calls. And it's not just these two authors, by the way, guys. There's been others who say we just gotta get with the times, man. I mean, these things are pretty safe. And are we really gonna roll the dice here on something that has a perinatal transmission rate of up to 5 to 9%? I'm not comfortable with that. Guys, just for me, I totally talk to my patients about direct acting antivirals with hepatitis C viral infection, especially for those that are brand new. And I let the patient decide. But we also have a hepatologist who's very hip to the data and understands that they would rather do this medicine than expose a child to potential transmission. Very interesting. All right, podcast family, I think we've done what we're supposed to do. Let me give a quick note here to Michael because I'm doing this remotely. Michael, let's wrap this up. Packages up. Gets us out, brother. Let's come on, let's do it. So that was then, this is now.

B (21:21)

Well, that was then and this is now.

A (21:24)

We'll see you on the next episode. Podcast Family of the no Spin Podcast.

A (21:50)

This has been Dr. Chapa Zobetyn no Spin Podcast.

A (21:57)

Podcast family. Thank you for your support. Thank you for listening, and as always, we'll see you on another episode of the no Spin podcast.

A (22:14)

Sam.