Ebola in the United States: Management considerations during pregnancy

Symptoms develop rapidly, starting with fever and malaise, and progressing within a few days to vomiting, diarrhea, loss of appetite, abdominal pain, and rash. Signs include hypotension (due to vasodilation and increased vascular permeability), shock, multisystem organ failure, and coagulopathy (which occurs in 20% of cases due to activation of tissue factor). Leukopenia, thrombocytopenia, transaminitis, coagulation abnormalities, proteinuria, renal failure, and electrolyte abnormalities are commonly seen on laboratory analysis.^10,11 Interestingly, the Ebola virus gains entry into human cells using the Niemann-Pick C1 cholesterol transporter, and cells from patients with Niemann-Pick type C disease are immune to infection with the Ebola virus.¹²

Ebola in pregnancy
Information about the true incidence and complications of Ebola disease is limited. Most infected patients have been cared for in community-based health care facilities in Africa with little access to diagnostic testing and unreliable medical records. The data we do have about risks factors, disease transmission, and mortality rates come mainly from epidemiologic studies conducted in the midst of an Ebola epidemic or from studies in nonhuman primates. Data on Ebola infection in pregnancy are even more limited.

Pregnant women are more vulnerable to and may have more complications as a result of certain infections, including malaria, varicella, and seasonal influenza. While data are limited, pregnant women and their fetuses infected with the Ebola virus also appear to have worse outcomes, with a maternal and perinatal mortality rate that approaches 100%.⁵ Under normal conditions, pregnant women are given priority within the medical system. However, given the overall poor prognosis, their increased infectivity, and concerns about the well-being of health care providers, many pregnant women infected with the Ebola virus during the recent epidemic were set aside and denied basic health care needs, including hospital admission. Whether improved infection control and more intensive medical care would improve the survival rate of infected pregnant women is not clear.

Most of what we know about Ebola infection in pregnancy comes from the 1995 epidemic in the Kikwit area of the Democratic Republic of the Congo (Zaire). Of the 202 people infected during that epidemic, 105 were women and 15 were pregnant (4 in the first trimester, 6 in the second trimester, and 5 in the third trimester). Pregnant women presented with vaginal bleeding and occasionally bleeding from other sites, including gum bleeding, hematemesis, hematuria, and melena. Of note, the diagnosis of Ebola during the Kikwit epidemic was based on clinical examination alone.⁵ Fourteen of these 15 women died, giving a mortality rate of 93.3%, with death occurring within 10 days in all instances. One woman delivered a live-born child, but both she and the baby died within 3 days. The woman who did survivehad a miscarriage in the first trimester.⁵

In the 1976 epidemic centered in Yambuku, Zaire, pregnant women fared slightly better, with a mortality rate of 89% (73/82), which was similar to the mortality rate for the population as a whole of 88%.⁵ Nineteen women (23%) had a spontaneous abortion. Ten women (12%) delivered live-born babies, but all died within 19 days. It is assumed that these infants contracted the Ebola virus, but whether this was indeed the case and when and how they contracted the infection is not known. The combined perinatal and infant mortality rate in these 2 epidemics was 100%.

During the recent epidemic in Guinea, there were 2 pregnant patients, both of whom presented with fetal demise in the third trimester. Their labors were induced and both mothers survived.¹³ During the height of the recent Liberian epidemic (between August and October 2014), 700 infected patients were admitted to the largest treatment center. Four women were pregnant, all in the latter half of gestation. Of these, 3 died (75% mortality rate). The remaining woman survived, but her fetus died.⁹ Taken together, the prevailing evidence suggests that maternal and perinatal outcomes of pregnant women infected with the Ebola virus are dismal, with mortality rates approaching 100%.

Protecting health care workers
Transmission of the Ebola virus to health care workers has emerged as a major concern during the most recent outbreak in West Africa. Frontline health care workers are usually the first to see such patients and are at high risk of exposure to infected bodily fluids. This is especially true of health care professionals working on labor and delivery units, where exposure to blood and amniotic fluid is commonplace at the time of delivery.

Contaminated needles and syringes also may play a role in transmission.^14,15 And, in Africa, a large number of transmissions have been attributed to ritual washing of the body at funerals, since viral load is maximal at the time of death, but this is unlikely to play a significant role in transmission of the virus in developed countries. Ebola virus has been isolated from breast milk.¹⁶ While direct transmission of the virus through breastfeeding has not been documented, breast milk from infected individuals should be disposed of carefully.