Guidance for Screening and Caring for People who are Pregnant with Ebola Virus Disease for Healthcare Providers in U.S. Hospitals
Who this is for: Healthcare providers working in emergency departments and labor and delivery units in U.S. hospitals.
What this is for: Guidance on how to screen people who are pregnant for Ebola virus disease (EVD) and how to care for pregnant women as patients under investigation (PUIs) for or with confirmed EVD, including considerations for pregnant healthcare workers.
How to use: This guidance is intended to help U.S. hospitals develop a plan for screening and treating pregnant PUIs or patients with confirmed EVD.
- Healthcare providers caring for people who are pregnant in U.S. hospitals should be prepared to screen patients for EVD and have a plan in place to triage these patients.
- Obstetric management of people who are pregnant with EVD, particularly decisions about mode of delivery for people in labor, needs to consider risks to the person, risks of exposure for healthcare providers, and potential benefits to the neonate.
- Healthcare workers who are pregnant should not care for patients with EVD.
- Pregnant PUIs or patients with confirmed EVD should be hospitalized, and CDC guidance for hospitalized PUIs or patients with confirmed EVD should be followed.
EVD and Pregnancy
No evidence currently exists to suggest that people who are pregnant are more susceptible to infection from Ebola virus (EBOV) than the general population. Earlier reports suggested that pregnant people are more likely to be at increased risk of severe illness and death when infected with EBOV during pregnancy.1 More recent reviews, however, have suggested that pregnancy is not associated with increased mortality or disease severity in people with EVD.2,3 People who are pregnant with EVD are at an increased risk of adverse pregnancy outcomes, including fetal loss and pregnancy-associated hemorrhage.1-4 In previous outbreaks in Africa, almost all infants born to people with EVD have not survived, but whether EBOV was the cause of death has not always been known.2-4
EBOV can cross the placenta, and pregnant people infected with the virus will likely transmit it to the fetus. Placental tissues from patients with EVD have demonstrated EBOV antigen throughout numerous different types of placental cells on pathological exams.5 EBOV RNA has also been detected in amniotic fluid, placental tissue, fetal meconium, vaginal secretions, umbilical cord, and buccal swab samples from neonates. 2,6-9 Importantly, it should be noted that EBOV RNA can remain detectable in amniotic fluid, breast milk, and fetal tissue after maternal recovery from EVD.2 EBOV RNA has been found in pregnancy-related body fluids and tissues up to 32 days after maternal clearance of viremia.2,6-9 Therefore, proper infection control precautions should be taken when managing convalescent pregnant people.7
- Mupapa K, Mukundu W, Bwaka MA, et al. Ebola hemorrhagic fever and pregnancy. J Infec Dis 1999;179 Suppl 1:S11-2.
- Foeller ME, Carvalho Ribeiro do Valle C, Foeller TM, et al. Pregnancy and breastfeeding in the context of Ebola: a systematic review. Lancet Infect Dis 2020; 20(7):e149-e158.
- Kayem ND, Benson C, Aye CYL, et al. Systematic review and meta-analysis: Ebola virus disease in pregnancy: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2022;116(6):509-522.
- Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen SA. What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention. Obstet Gynecol 2014;124:1005-1010.
- Muehlenbachs A, de la Rosa Vazquez O, Bausch DG, et al. Ebola Virus Disease in Pregnancy: Clinical, Histopathologic, and Immunohistochemical Findings. J Infect Dis 2017;215:64-69.
- Oduyebo T, Pineda D, Lamin M, Leung A, Corbett C, Jamieson DJ. A Pregnant Patient With Ebola Virus Disease. Obstet Gynecol 2015;126:1273-1275.
- Caluwaerts S, Fautsch T, Lagrou D, et al. Dilemmas in Managing Pregnant Women With Ebola: 2 Case Reports. Clin Infect Dis 2016;62:903-905.
- Bower H, Grass JE, Veltus E, et al. Delivery of an Ebola Virus-Positive Stillborn Infant in a Rural Community Health Center, Sierra Leone, 2015. Am J Trop Med Hyg 2016;94:417-419.
- Baggi FM, Taybi A, Kurth A, et al. Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014. Euro Surveill 2014;19.
- Kamali A, Jamieson DJ, Kpaduwa J, et al. Pregnancy, Labor, and Delivery after Ebola Virus Disease and Implications for Infection Control in Obstetric Services, United States. Emerg Infect Dis 2016;22.
- Dornemann J, Burzio C, Ronsse A, et al. First Newborn Baby to Receive Experimental Therapies Survives Ebola Virus Disease. J Infect Dis 2017;215:171-174.
Screening People who are Pregnant at Hospitals
Healthcare providers who care for pregnant people in U.S. hospitals should be prepared to screen patients for EVD and have a plan in place for how to triage these patients.3 Specifically, U.S. healthcare providers should:
- Know the signs and symptoms of Ebola.
- Ask patients about recent travel to a country with widespread Ebola transmission or contact with a person with Ebola.
- Assess patients for fever and other signs and symptoms of Ebola if they have recent travel to a country with widespread Ebola transmission or contact with a person with Ebola.
It is good clinical practice to ask all people who are pregnant who arrive at a hospital for medical care about recent travel and to be familiar with countries or regions that are experiencing outbreaks of infectious diseases. A pregnant person who has a history of travel within 21 days from a country with widespread Ebola transmission, or recent contact (within 21 days) with a person with EVD, should be screened for fever and symptoms of EVD. A patient with signs or symptoms of EVD, should be immediately isolated, and appropriate personal protective equipment (PPE) should be worn by all healthcare workers in physical contact with the patient. The hospital should activate its preparedness plan for Ebola, including notifying the local or state health department. If the patient is clinically stable, and is not vomiting or bleeding, follow the PPE guidance for clinically stable persons under investigation for Ebola.
People who are pregnant who have recently traveled from a country with widespread Ebola transmission but have no fever or symptoms of EVD should be assessed for the presence of other epidemiologic risk factors and their risk of exposure should be ascertained. Asymptomatic pregnant people who have no other epidemiologic risk factors should receive routine obstetric care. Obstetric care for people with risk factors and movement restrictions should be determined on a case-by-case basis in consultation with public health authorities.
Treatment for EVD during Pregnancy
The general medical management of pregnant people with EVD should be the same as for any other adult with EVD. Pregnant patients with EVD should be provided optimal supportive care in consultation with experts in the care of these patients. Obstetric management should focus on the monitoring and early treatment of hemorrhagic complications. In general invasive procedures for fetal indications should be avoided if possible in pregnant people with acute EVD. Healthcare providers should be aware that spontaneous abortion and intrapartum hemorrhage appear to be common among women with EVD, and high perinatal mortality rates among infants of women infected with the Ebola virus have been reported.1, 2, 3
Restrictions for Pregnant Healthcare Workers
Pregnant healthcare workers should not provide care for patients with EVD because of increased fetal risks. Furthermore, the recommended PPE for care of patients with EVD7 may be particularly restrictive and uncomfortable for pregnant healthcare workers and present additional challenges for safe donning and doffing.
Infection Control Procedures for Labor and Delivery Units
Pregnant PUIs or patients with confirmed EVD should be hospitalized, and CDC guidance for hospitalized PUIs or patients with confirmed EVD should be followed. Labor and delivery units are unique in that the birthing process presents a high likelihood of exposure to large amounts of blood and body fluids (such as amniotic fluid) in a setting that is less controlled than many other hospital settings. Recommendations for PPE use by healthcare workers caring for pregnant PUIs or patients with confirmed EVD are the same as those caring for other (nonpregnant) PUIs or patients with confirmed EVD. Training, practice in using, and demonstrated competency with PPE is critical for protecting all healthcare workers against transmission of Ebola virus.
How to Handle Visitors for Laboring Patients with EVD
Visitors for laboring patients with EVD should be severely restricted. Exceptions may be considered on a case-by-case basis—such as for the father of the baby or another “support person” to provide personal support to the laboring patient—after careful consideration of risks and benefits. Hospitals should develop procedures for monitoring, managing, and training visitors, and visits should be scheduled and controlled. Consideration should be given to the use of videoconferencing instead of in-person visitation.
If visitors are allowed, their risk exposure should be evaluated, and they should be monitored according to the risk category identified. Such people could have the same or similar risk factors for EVD as the laboring patient. Visitors should be screened before entering the patient area and should have no direct contact with the patient. Visitors should be trained to safely put on (don) and take off (doff) PPE and should wear the same type of PPE recommended for healthcare workers. 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.
Ebola virus has been detected in samples of breast milk, but no data exist about when in the course of disease the virus appears in breast milk. EBOV has been detected in breast milk for at least 26 days after symptom onset. Therefore, women with EVD and women who recently recovered from EVD should not breastfeed. Where available, testing of breastmilk for the presence of Ebola virus (e.g., detection of Ebola virus genetic material) can help to guide decisions about when breastfeeding can be safely resumed.
- Mupapa K, Mukundu W, Bwaka MA, et al. Ebola hemorrhagic fever and pregnancy. J Infect Dis. 1999;179(suppl 1):S11-S12.
- Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen SA. What obstetrician-gynecologist should know about Ebola: a perspective from the Centers for Disease Control and Prevention. Obstet Gynecol. 2014;124(5):1005-1010.
- CDC’s Ebola (Ebola virus disease). Interim U.S. guidance for monitoring and movement of people with potential Ebola virus exposure. Accessed May 29, 2018.
- CDC’s Ebola (Ebola virus disease). 2014 Ebola outbreak in West Africa – case counts. Accessed May 29, 2018.
- CDC’s Ebola (Ebola virus disease). Signs and symptoms. Accessed May 29, 2018.
- CDC’s Ebola (Ebola virus disease). When caring for patients under investigation or confirmed patients with Ebola. Accessed May 29, 2018.
- CDC’s Ebola (Ebola virus disease). Guidance on personal protective equipment to be used by healthcare workers during management of patients with Ebola virus disease in U.S. hospitals, including procedures for putting on (donning) and removing (doffing). Accessed May 29, 2018.
- CDC’s Ebola (Ebola virus disease). Identify, isolate, inform: emergency department evaluation and management for patients under investigation for Ebola virus disease. Accessed May 29, 2018.
- CDC’s Ebola (Ebola virus disease). Epidemiologic risk factors to consider when evaluating a person for exposure to Ebola virus. Accessed May 29, 2018.Council on Patient Safety in Women’s Health Care. Obstetric Hemorrhage Patient Safety Bundle. Accessed May 29, 2018.
- World Health Organization. Ebola hemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978;56:271-293.
- CDC’s Ebola (Ebola virus disease). Infection prevention and control recommendations for hospitalized patients with known or suspected Ebola virus disease in U.S. hospitals. Accessed May 29, 2018.Bausch DG, Towner JS, Dowell SF, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. J Infect Dis. 2007;196 (suppl 2):S142-S147.
- CDC’s Ebola (Ebola virus disease). Recommendations for breastfeeding/infant feeding in the context of Ebola. Accessed May 29, 2018.
- Kamali A, Jamieson DJ, Kpaduwa J, et al. Pregnancy, Labor, and Delivery after Ebola Virus Disease and Implications for Infection Control in Obstetric Services, United States. Emerg Infect Dis. 2016;22(7). [Epub ahead of print.] DOI: 10.3201/eid2207.160269. http://dx.doi.org/10.3201/eid2207.160269.