Guidance for Screening and Caring for Pregnant Women 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 pregnant women 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 pregnant women 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 pregnant women with EVD, particularly decisions about mode of delivery for women in labor, needs to consider risks to the woman, 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.
How EVD Affects Pregnant Women
No evidence currently exists to suggest that pregnant women are more susceptible to infection from Ebola virus (EBOV) than the general population. Unfortunately, limited evidence does suggest that pregnant women are likely to be at increased risk of severe illness and death when infected with EBOV.1 Pregnant women with EVD also appear to be at an increased risk of fetal loss and pregnancy-associated hemorrhage.1-2 In previous outbreaks in Africa, infants born to mothers with EVD have not survived, but whether EBOV was the cause of death has not always been known.2
EBOV can cross the placenta, and pregnant woman 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.3 EBOV RNA has also been detected in amniotic fluid, fetal meconium, vaginal secretions, umbilical cord, and buccal swab samples from neonates.4-7 Importantly, it should be noted that in pregnant women with EVD, EBOV has been shown to persist in amniotic fluid for an unknown duration of time after negative RT-PCR tests for EBOV in maternal blood.4-7 Therefore, proper infection control precautions should be taken when managing convalescent pregnant women.5
Women who become pregnant after recovery from EVD pose little risk for transmission of EBOV to the fetus. Postpartum testing after normal vaginal delivery in a woman who became pregnant 22 weeks after her last negative EBOV RT-PCR test did not detect EBOV RNA in cord blood, amniotic fluid, vaginal secretions, or placenta.8
There is only one report of neonatal survival in an infant born to a mother with evidence of EVD infection. This infant was born to a 25-year-old previously healthy woman who reported onset of EVD symptoms 8 days prior to delivery. The mother was treated with favipiravir on day 5 of her illness, and died on the eighth day of her illness (hospital day 5) due to severe vaginal bleeding after a spontaneous vaginal delivery. Her infant was treated with monoclonal antibodies (ZMapp), a buffy coat transfusion from an Ebola survivor, and the antiviral GS-5734. Aside from seizure-like activity, the infant had no other symptoms and was discharged home. Subsequent weekly follow-up has demonstrated normal development and growth at 12 months of life.9
- Mupapa K, Mukundu W, Bwaka MA, et al. Ebola hemorrhagic fever and pregnancy. J Infec Dis 1999;179 Suppl 1:S11-2.
- 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.
How to Screen Pregnant Women at Hospitals
Healthcare providers who care for pregnant women 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 who care for pregnant women 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 pregnant women who arrive at a hospital for medical care about recent travel or contact with a person with EVD within the past 21 days—the longest known incubation period for Ebola. If a pregnant woman 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, she should be screened for fever and symptoms of EVD.5 If the patient has signs or symptoms of EVD, she 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.6 If the patient is clinically stable, and is not vomiting or bleeding, follow the PPE guidance for clinically stable persons under investigation for Ebola.
Pregnant women 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.9 CDC has guidance for monitoring people with potential Ebola virus exposure and determining whether their movements should be restricted because of their level of exposure.3 Asymptomatic pregnant women who have no other epidemiologic risk factors should receive routine obstetric care. Obstetric care for women with risk factors and movement restrictions should be determined on a case-by-case basis in consultation with public health authorities.
How to Treat Pregnant Women Diagnosed with EVD
The general medical management of pregnant women with EVD should be the same as for any other adult with EVD. Obstetric management should focus on the monitoring and early treatment of hemorrhagic complications.10 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.1,11
Restrictions for Pregnant Healthcare Workers
Pregnant healthcare workers should not provide care for patients with EVD because of the likely increased maternal and fetal risks. Furthermore, the recommended PPE for care of patients with EVD7 may be particularly restrictive and uncomfortable for pregnant healthcare workers.
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.6 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.7 Training, practice in using, and demonstrated competency with PPE is critical for protecting all healthcare workers against transmission of Ebola virus.
What Method of Delivery to Consider for Patients with EVD
No data exist to suggest that one method of delivery is preferred over others for pregnant women with EVD, with respect to maternal or neonatal outcomes or the safety of healthcare workers. The existing literature is confined to small case series in Africa, and details of these cases are sparse. Risk of spontaneous fetal loss is high, and there have been no known neonatal survivals.1 Causes of neonatal death in these circumstances are not always clear. Whether perinatal deaths are consequences of transplacental viral passage or viral transmission through direct contact, or from other causes, is not known. No data on obstetric outcomes are available from settings with highly developed healthcare systems. As a result, the healthcare team caring for a pregnant patient with EVD will need to consider the likelihood of healthcare worker exposure to large amounts of blood and body fluids during labor and delivery regardless of vaginal or cesarean delivery; the overall physical condition of the patient, particularly the presence of coagulopathy;, and the likelihood of 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 EVD is unknown.
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 other “support person” to provide personal support to the laboring woman—after careful consideration of risks and benefits. Hospitals should develop procedures for monitoring, managing, and training visitors, and visits should be scheduled and controlled.12 Consideration should be given to the use of videoconferencing instead of in-person visitation.
If visitors are allowed, their risk exposure should be evaluated,9 and they should be monitored according to the risk category identified.3 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.7
Breastfeeding Recommendations for Women with Possible Ebola
Ebola virus has been detected in samples of breast milk,13 but no data exist about when in the course of disease the virus appears in breast milk or when it is cleared. 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.
There is no known risk of transmission of Ebola virus via breastfeeding for infants born to women who became pregnant after recovering from EVD.
- Breastfeeding is safe and should be recommended for women who, after recovering from EVD, become pregnant and give birth.
- 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.external icon 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/eid2207.160269external icon.