Ebola Kills Pregnant Women, Even if They Don't Have It

November 4, 2014

The outbreak of Ebola in West Africa rightly has become a world health crisis. But there are other casualties of the outbreak that we don't hear much about.

"No good deed goes unpunished," Clare Boothe Luce (1903-1987). Eric Duncan, the so-called "patient zero," was the first person residing in the United States to receive a diagnosis of Ebola haemorrhagic fever (EBH). It's thought that he contracted the virus while helping his 7-months-pregnant 19-year-old friend, who ultimately died. Four days later, he flew to the US, already infected, and has since also died of the disease.

Pregnant Patients With EBH

- EBH virus is transmitted through direct contact with the skin or body fluids of an infected individual, with objects that are contaminated with the virus, or with bodies of those who have died of the disease.

- Generalized symptoms of EBH include fever, chills, fatigue, weakness, vomiting, diarrhea, and abdominal pain.

- Spontaneous abortion, usually accompanied by heavy bleeding, is common in pregnant patients infected with EBH in the first and second trimesters.

- During an EBH outbreak, bleeding pregnant patients should be suspected of being infected, and health care workers should take proper precautions.

- There is a high mortality rate for live neonates born to EBH-infected patients in the third trimester.

- Pregnant patients with EBH should receive supportive care and treatment to prevent hemorrhaging.

The EBH epidemic in West Africa is causing significant human suffering for those who have contracted the disease and their families as well as the health care workers who care for them, many of whom have become victims themselves. The outbreak is also affecting pregnant patients and their maternity care professionals in hard-hit areas-even if they aren't infected.

Because EBH outbreaks in the past have affected relatively small populations of people, there is not much research on how the disease affects pregnant women. One small study of 15 pregnant patients infected with EBH in the Democratic Republic of the Congo in 1999 showed 10 spontaneous abortions and 4 deaths in the third trimester. There was an overall mortality rate of 77% in that particular outbreak but, among these pregnant patients, it was 95.5%.

Pregnancy and the Risks of EBH

In 1976, 11 babies born to mothers during an outbreak also died, and while they did not have typical EBH symptoms, it is suspected that they died of the disease. The exact mode of transmission of EBH from mother to child remains unknown.

The Collateral Damage From Fear and Panic

EBH is clearly a very deadly disease, and not just because it has killed an estimated 55% of those infected. It is also because it has caused panic and the spread of misinformation. Health care workers face an uphill battle as rumors about EBH spread, including that the disease is not real and that it is given through vaccinations, or that it is actually the health care workers that are killing patients. People with symptoms of EBH may be staying away from health care facilities instead of seeking treatment, and some treatment centers and health care workers have come under physical attack. For all these reasons and more, the spread of EBH continues in affected areas, making the infection rates difficult to get under control.

For pregnant patients, EBH also brings the risk of death, even for those who have not been infected themselves or who are not caring for infected family members. It's not thought that pregnancy confers a greater risk of becoming infected. However, in previous outbreaks, women tended to get infected in greater numbers than men, typically as a result of caring for sick relatives. A community ravaged by EBH presents a grim reality for pregnant patients and maternity workers.

The Effect of the Breakdown of the Healthcare System

Pregnant women in the areas hard-hit by EBH may not be receiving the care they need for several reasons. The first is that they may stay away from clinics and hospitals, fearing the possibility of being infected. While nosocomial transmission has occurred, in some cases women might be at a greater risk of pregnancy-related complications than they are from becoming infected.

Pregnant women seek health care more frequently than others in the general population, which puts them at a greater risk for contracting EBH in the health care setting. There is at least one case (in a previous outbreak) of the EBH virus being transmitted via infected needles to pregnant women who presented for routine care. The women living in at-risk areas may be aware of this, and may therefore refuse to receive any injections. In an area where injectable progestin is often used as a form of contraception, this could result in unintended pregnancies.

A decrease in the number of vaccines given to women and children could also occur, leaving the people in the area more susceptible to preventable diseases. This side effect of the epidemic could scar the affected communities for years, with diseases that were on the way to being stamped out becoming more prevalent again because of lowered vaccination rates.

With clinics and hospitals being closed or overrun with patients who either have or are suspected of having EBH, pregnant women are being turned away. There may not be any safe place for pregnant patients to receive care or to give birth. Maternal and infant mortality is already high in the developing world. Without even the most basic support, pregnant women and their babies are at risk for developing complications that could be effectively treated by a trained maternity worker. Women are dying in childbirth, unnecessarily.

The Babies Might Be Most Vulnerable of All

Babies born to EBH survivors may also be at significant risk. In one study, the EBH virus was found in breast milk as long as 40 days after the patient became symptomatic, even after the virus was no longer present in the patient's blood. It's not known if a mother can infect her baby with EBH through breast milk, but the safest course of action might be avoidance of breastfeeding by mothers who have recovered from infection with EBH or who are suspected of being infected.

Breastfeeding is the safest and most effective method of feeding, and some areas may not have alternatives available. Not being breastfed by their mothers leaves infants open to many complications, including diarrhea, respiratory diseases, and even starvation. Even close contact between mother and baby could have risks, but the stress of being apart could negatively impact the emotional well-being of both.

When the Epidemic Ends, What Then?

The healthcare systems in the countries affected by this outbreak were improving, thanks to efforts by the World Health Organization and others, but are still very fragile. They are overwhelmed by this unprecedented outbreak of EBH. Governmental or societal collapse in the areas most affected is now a grave concern. There's now a worry that the next generation could be profoundly negatively affected because of the low survival rate for pregnant women and their babies-whether they have Ebola or not.

References:

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:S142-S147. doi: 10.1086/520545. Available at: http://www.cdc.gov/ncidod/EID/vol9no11/03-0339.htm.

Jamieson DJ, Uyeki TM, Callaghan WM, et al. What obstetrician-gynecologists should know about Ebola: a perspective from the Centers for Disease Control and Prevention. Obstet Gynecol. 8 Sept 2014. doi: 10.1097/AOG.0000000000000533. Available at: http://journals.lww.com/greenjournal/Abstract/publishahead/What_Obstetrician_Gynecologists_Should_Know_About.99324.aspx.

Mupapa K, Mukundu W, Bwaka MA, et al. Ebola hemorrhagic fever and pregnancy. J Infect Dis. 1999;179(Suppl 1):S11–12. Available at: http://jid.oxfordjournals.org/content/179/Supplement_1/S11.long.

World Health Organization. Addressing sex and gender in epidemic-prone infectious diseases. 2007. Available at: http://www.who.int/csr/resources/publications/SexGenderInfectDis.pdf?ua=1.

World Health Organization. Ebola hemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978;56:271-293. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395567/.

World Health Organization. Study warns swift action needed to curb exponential climb in Ebola outbreak. 22 Sept 2014. Available at: http://www.who.int/mediacentre/news/releases/2014/ebola-study/en/.