Ebola Virus Disease Course

A 29-year-old physician from West Africa became ill with EVD in late July 2014. She had contracted the virus from an EVD patient whom she had cared for from July 20th until his death on July 25. On July 29, the woman began feeling unwell, noting arthralgia and myalgia, which she self-treated with antimalarial medications. On August 1, she had fever, and on August 3, she began vomiting and had diarrhea. The woman was admitted to an Ebola treatment center (ETC) and isolated after results of an EBOV real-time reverse transcription PCR (rRT-PCR) were positive for EBOV RNA (cycle threshold unknown). According to the woman, she spent 13 days in the ETC, where she was treated with oral rehydration fluids, acetaminophen, and a second course of antimalarial medications. She was discharged from the ETC on August 16, after showing negative results on 2 EBOV rRT-PCRs. After her recovery, the woman noted some fatigue, anorexia, arthralgia, and alopecia; she did not report any sleep disturbances, headaches, or vision problems. Symptoms resolved 2–3 months later.

Pregnancy, Labor, and Delivery

Eight months before her EVD diagnosis, the patient had had a spontaneous abortion at 10 weeks’ gestation. In January 2015, twenty-two weeks after her last negative EBOV rRT-PCR, she became pregnant again. For this second pregnancy, the estimated date of delivery was established on the basis of an 11.5-week ultrasound that was consistent with the patient’s last menstrual period. The patient received routine prenatal care in West Africa, and at 25 weeks’ gestation, she traveled to Kern County, California, USA, and a detailed anatomy ultrasound was performed in Los Angeles County, California, and demonstrated normal fetal development.

The hospital identified staff members who were willing to assist during labor and delivery for the patient, and at 40 weeks and 1 day of gestation, labor was induced to ensure that those staff members were present. The patient was given 2 vaginal doses of misoprostol, and oxytocin was administered, and labor progressed normally. The patient was given epidural anesthesia for pain control and had a normal vaginal delivery of a female neonate (weight 4,128 g) with Apgar scores of 8 and 9 at 1 and 5 min of age, respectively. The patient had a second-degree perineal laceration, which was repaired.

The patient and her neonate were discharged from the hospital at 36 h postpartum. They returned for routine follow-up 7 days postpartum and were monitored for 6 weeks following delivery, after which they traveled home to West Africa.

Infection Control and Personal Protective Equipment, Public Health Response

Two weeks before the patient’s delivery date, her US obstetrician contacted the California Department of Public Health (DPH; Richmond, CA, USA) and the Centers for Disease Control and Prevention (CDC; Atlanta, GA, USA) to determine if there were any special precautions needed for infection control; the California DPH notified the Los Angeles County DPH (Los Angeles, CA, USA). Because the patient was healthy and had fully recovered from EVD ≈4 months before becoming pregnant, all public health agencies agreed that she presented an extremely low risk for transmission of Ebola virus. Nevertheless, it was deemed appropriate that public health officials play an active role assessing and guiding management of the patient. The Los Angeles County DPH and CDC collaborated with the hospital’s healthcare providers, nursing directors, laboratory director, environmental services staff, anesthesiologists, and hospital administration to address concerns and review the care plan, including plans for any complications, such as the need for cesarean delivery or the development of peripartum fever.

Hospital infection control procedures were reviewed in person with hospital staff. In review of these policies, no additional precautions were recommended above the standard precautions and policies currently used for all deliveries at the hospital. Several hospital staff members not directly involved in patient care expressed discomfort about working while an EVD survivor was admitted. To reassure these staff members, the patient was kept in 1 room during labor and delivery and after delivery. No changes were made to the policies for environmental cleaning or waste disposal.

Hospital staff raised concerns about the possibility of EBOV being harbored in immune-privileged sites (e.g., cerebrospinal fluid) in EVD survivors and, thus, expressed their concerns about a theoretical risk for EBOV transmission (6,14–17). This patient did not show signs or symptoms of CNS involvement during her acute illness or during her pregnancy, which likely indicated a decreased risk of any latent EBOV reservoir in her CNS; thus, it was considered likely that epidural or spinal anesthesia for this patient would not pose an infectious risk to staff. Hospital staff also noted the often imperfect adherence to use of personal protective equipment (PPE) during labor and delivery; thus, they voiced concern over this patient’s history of EVD because large volumes of blood and amniotic fluid are often encountered in typical, uncomplicated vaginal deliveries (25). As a result of these concerns, many discussions were held regarding what PPE should be used during labor and delivery. Standard precautions should always be applied in all medical settings, including labor and delivery; however, neither CDC nor the American College of Obstetricians and Gynecologists had tailored recommendations for PPE specifically for vaginal or cesarean deliveries for any patients. Thus, CDC and Los Angeles County DPH developed a preliminary set of recommendations for the patient’s providers regarding the use of PPE (Tables 1, 2) during and after labor and delivery to ensure that standard precautions were implemented. These PPE recommendations were discussed with the providers in the days before the delivery, and staff members were able to ask for clarification and ensure that materials were readily available. These PPE recommendations did not differ from standard precautions, but they explicitly discussed which PPE to use for casual contact, vaginal examinations, labor and delivery, anesthesia, and postpartum care. Routine hand hygiene, the use of barriers for mucous membrane protection, and the use of double gloves for procedures that involve sharps were emphasized.

Laboratory Assessment

One week before delivery, EBOV rRT-PCR testing was performed on the patient’s blood by the Los Angeles County DPH laboratory and the CDC Viral Special Pathogens Branch; both results were negative. As expected, Ebola serum antibodies were detected by ELISA (IgG >1:1600, IgM negative).

After obtaining written informed consent from the patient, healthcare staff obtained the following during and after delivery: vaginal secretions, amniotic fluid (vaginal pool), cord blood, placenta, umbilical cord, breast milk (colostrum collected 16 h after delivery), and oral and ear swab samples from the neonate. Cord blood, colostrum, amniotic fluid, and swab samples were kept refrigerated until processed or frozen on dry ice for shipment to CDC. A placental sample was frozen in a sterile specimen cup and samples of placenta and umbilical cord were placed in buffered formalin and shipped at room temperature to CDC. EBOV rRT-PCR testing was performed on all of these specimens at the Los Angeles County DPH and CDC laboratories by using assays specific for nucleoprotein and viral protein 40 genes.

Placenta, amniotic fluid, and cord blood samples and ear and oral swab samples from the neonate were negative by EBOV rRT-PCR. Attempts were made to recover virus from placenta, amniotic fluid, cord blood, and colostrum at CDC, but no virus was recovered (Table 3). Amniotic fluid, cord blood, and colostrum were tested by ELISA for IgM and IgG against Ebola virus antigens (26). Cord blood was negative for IgM and had an IgG titer of >1:1600. Amniotic fluid and colostrum were negative for IgM and IgG. The placenta and umbilical cord were histologically normal, and no Ebola virus antigen was detected by immunohistochemistry (27), including in maternal and fetal endothelial cells and leukocytes.