Ebola Virus Disease (EVD) and Pregnancy: Guide for Health Workers

By Collins Onyango
Two recent commentaries published in BJOG: An International Journal of Obstetrics and Gynaecology (BJOG) suggests that obstetric interventions during an Ebola epidemic are deeply challenging.  
Health workers in Ebola-hit countries and handling pregnancy related cases have to make life or death decisions for their patients and themselves.

To the midwives, Ebola in pregnancy is a more terrifying phenomena; It is not just a likely a death sentence for the mother and fetus, but  can ravage entire public health systems meant to bring children safely into the world.

World Health Organization reports that pregnant women most often die in child birth from abortion, eclampsia (very high blood pressure leading to seizures), and obstructed labour.

Further more, because of stigma, rumours and fear surrounding Ebola, pregnant women with EVD often seek care only when they are in a critical stage, further challenging the system of prioritizing patients.

Ebola virus has been detected in breast milk, although it is unknown whether it can be transmitted routinely from mothers to infants through breastfeeding. Victims can only spread the virus to others once they have developed symptoms

Guidance for Screening and Caring for Pregnant Women with EVD

 Key Points

• Healthcare providers caring for pregnant women in Ebola-hit areas should be prepared to screen patients for EVD and have a plan in place to triage these patients
• Obstetric management of pregnant women with Ebola, particularly decisions about mode of delivery (for women in labour), risks to the woman, risks of exposure for healthcare providers, and potential benefits to the neonate should be considered beforehand.
• Healthcare workers who are pregnant should not care for patients with Ebola.
• Pregnant PUIs or patients with confirmed EVD should be hospitalized
• Institutional policies and CDC guidance for hospitalized patients under investigation (PUIs) or patients with confirmed EVD should be followed.

Specifically all healthcare providers who care for pregnant women and during labour should:

1. Know the signs and symptoms of Ebola.
2. Obtain history of travel to a Ebola-hit countries or cases in urban settingswith uncertain control measures, or contact with a person with Ebola.
3. Assess patients for fever and other signs and symptoms of Ebola if they have recent travel to a country with widespread Ebola transmission or cases in urban settings with uncertain control measures, or contact with a person with Ebola.

How to Care for Pregnant Women Diagnosed with Ebola

The general medical management of pregnant cases with Ebola should be the same as for any other adult with Ebola. Monitoring and early treatment of hemorrhagic complications should be the focus in obstetric management.

Healthcare providers should be aware of spontaneous abortion and intrapartum hemorrhage that appear to be common among women with EVD, and high perinatal mortality rates among infants of women infected with the haemorrhagic fever.

Restrictions for Pregnant Healthcare Workers

• Pregnant healthcare workers should not provide care for patients with Ebola because of the likely increased maternal and fetal risks.
• Furthermore, the recommended PPE for care of patients with Ebola may be particularly restrictive and uncomfortable for pregnant healthcare workers.

Infection Control Procedures for Labor and Delivery Units

• Always follow CDC guidance for hospitalized PUIs or patients with confirmed EVD
• Hospitalize Pregnant PUIs or patients with confirmed EVD and do  follow ups to limit exposure to large amounts of blood and body fluids (such as amniotic fluid) in a controlled setting
• Uses recommendedPPE when caring for pregnant PUIs or patients with confirmed EVD

Delivery Method to Consider for Patients with Ebola

Even though, little is known about the effect of Ebola on pregnancy, what we do know seems particularly grim. 
The first American with Ebola in US, Thomas Eric Duncan is believed to have contracted the disease after providing obstetric care to a friend and neighbour who was infected with the virus.

19-year-old woman, Marthalene Williams, the source case, was seven months pregnant. Sadly, hours after the prolonged exposure to the virus; Duncan, Williams and her fetus died of overwhelming Ebola infection.

No data exist to suggest that one method of delivery as preferred over others for with respect to maternal or neonatal outcomes or the safety of healthcare workers. As a result, the healthcare team caring for a pregnant patient with Ebola should consider the likelihood of:

1. healthcare worker exposure to large amounts of blood and body fluids during labour and delivery regardless of vaginal or cesarean delivery; the overall physical condition of the patient, particularly the presence of coagulopathy; and the likelihood
2. neonatal survival, especially at early gestational ages. The effectiveness of interventions that result in delivery for the purpose of improving maternal outcomes in patients with Ebola is unknown.

How To Handle Visitors During Labour

Patients on labour should be severely restricted from visitors. Exceptions may be considered on a case-by-case basis—such as for the father of the baby or other “support person” to provide personal support to the laboring woman—after careful consideration of risks and benefits.

1. Hospitals should develop procedures for monitoring, managing, and training visitors, and visits should be scheduled and controlled.
3. Consideration should be given to the use of video conferencing instead of in-person visitation.
4. Visitors should be screened before entering the patient area and should have no direct contact with the patient.
5. Visitors should be trained how to safely put on and take off PPE and should wear the same type of PPE recommended for healthcare workers.
6. Visitors also should be observed at all times, including while taking off PPE, which must be done properly to prevent or reduce the risk of infection
7. The risk exposure should be evaluated and visitors monitored according to the risk category identified if allowed in.  Such persons could have the same or similar risk factors for Ebola as the laboring client.

Breastfeeding Restrictions

Although no conclusive data exist, Ebola virus has been detected in samples of breast milk, but no data when in the course of disease the virus appears in breast milk or when it is cleared.Women with Ebola should therefore not breastfeed.

Women with recent travel to country with widespread Ebola transmission or cases in urban settings with uncertain control measures, had no known exposures to Ebola and have no signs or symptoms of Ebola or who otherwise meet the criteria for low (but not zero) risk based on epidemiologic risk factors and should be advised of the benefits of early initiation of breastfeeding.

 Source

1. Centers for Disease Control and Prevention
2. Ebola in pregnancy: information for healthcare workers
3. Ebola Hemorrhagic Fever and Pregnancy
4. Ebola health workers face life or death decision on pregnant women - experts