Grading: 1C 6.2.2 Liver function tests should be repeated at 2 weeks after commencing cART to detect evidence of hepatotoxicity or IRIS and then monitored throughout pregnancy and postpartum. Grading: 1C In a pregnant HIV-positive woman newly diagnosed with HCV, in addition to referral to the local designated specialist, baseline investigations including the presence (HCV RNA) and level of the virus (HCV viral load), the genotype and subtype, the degree of inflammation and synthetic function (ALT, AST, Trichostatin A in vitro albumin, INR), an assessment of fibrosis, and the exclusion

of additional causes of liver disease (e.g. haemochromatosis, autoimmune hepatitis) are indicated. Additionally, patients should be assessed for the need for HAV (HAV IgG antibody) and HBV (anti-HBs) immunization as well as for HBV co-infection (HBsAg). Liver biopsy and hepatic elastometry (Fibroscan) are contraindicated during pregnancy so that where there is suspicion of advanced liver disease, liver ultrasound scanning should be performed. It is important where cirrhosis is found to be present that there is close liaison with the hepatologist

because of a significantly increased Vorinostat research buy rate of complications [189]. However, in the absence of decompensated disease, most women with cirrhosis do not have obstetric complications from their HCV infection. Because of the risk of ART-related hepatotoxicity and a hepatitis flare from immune reconstitution, it is important to repeat LFTs at 2 weeks post initiation of cART. Through pregnancy, it is routine to monitor LFT results at each antenatal clinic appointment as a marker

for potential obstetric complications (HELLP, pre-eclampsia, acute fatty liver, etc.), particularly in the final trimester. Acute hepatitis C is rare in pregnancy but HCV RNA, the initial test to become positive, should be measured where there is a sudden unexplained increase in transaminsases and/or a history of exposure. Where acute hepatitis C is enough confirmed, HCV viral load should be monitored through pregnancy at 4-weekly intervals. Involvement of a clinician experienced in the management of hepatitis is important both for initial care and post partum when treatment decisions are made. In chronically infected patients there is unlikely to have been significant change in the HCV viral load. However, the prenatal viral load will give some idea as to the risk of MTCT and may be worth repeating near delivery. If pregnancy has occurred during treatment for HCV with pegylated interferon and ribavirin, in addition to immediate discontinuation of treatment, thyroid function test should be included in the routine bloods as thyroid dysfunction occurs in approximately 7% of patients. Finally, it is recognized that a small number of co-infected patients are HCV antibody negative but HCV viraemic. Where there is evidence of liver inflammation or fibrosis, profound immune deficiency, or risk factors, an HCV viral load assay should be performed. 6.2.