We report two cases of confirmed Ebola virus disease in pregnant women, who presented at the Médecins Sans Frontières Ebola treatment centre in Guéckédou. Despite the very high risk of death, both pregnant women survived. In both cases the critical decision was made to induce vaginal delivery. We raise a number of considerations regarding the management of Ebola virus-infected pregnant women, including the place of amniocentesis and induced delivery, and whether certain invasive medical acts are justified

Baggi, F. M.

Caro, A. di

Declerck, H.

Decroo, T.

Günther, Stephan

Herp, M. van

Jonckheere, S.

Kurth, Andreas

Taybi, A.

Wölfel, Roman

English

Publication server of the Robert Koch Institute

Management of pregnant women infected with Ebola  virus in a treatment centre in Guinea, June 2014

Baggi, F M

Taybi, A

Kurth, A

Van Herp, M

Di Caro, A

Wolfel, R

Gunther, S

Decroo, T

Declerck, H

Jonckheere, S

MSF Field Research

1www.eurosurveillance.org
Rapid communications
Management of pregnant women infected with Ebola 
virus in a treatment centre in Guinea, June 2014
F M Baggi1, A Taybi1, A Kurth2,3, M Van Herp4, A Di Caro2,5, R Wölfel2,6, S Günther2,7, T Decroo4, H Declerck4, S Jonckheere 
(jonckheeresy@gmail.com)1
1. Médecins Sans Frontières – Operational Centre Brussels, Guéckedou, Guinea
2. European Mobile Laboratory – Hamburg, Germany
3. Robert Koch Institute – Berlin, Germany
4. Médecins Sans Frontières – Operational Centre Brussels, Medical Department, Brussels, Belgium
5. L. Spallanzani National Institute for Infectious Diseases – Rome, Italy
6. Bundeswehr Institute of Microbiology – Munich, Germany
7. Bernhard-Nocht-Institute for Tropical Medicine, WHO Collaborating Centre for Arboviruses and Hemorrhagic Fever Reference 
and Research – Hamburg, Germany
Citation style for this article: 
Baggi FM, Taybi A, Kurth A, Van Herp M, Di Caro A, Wölfel R, Günther S, Decroo T, Declerck H, Jonckheere S. Management of pregnant women infected with 
Ebola virus in a treatment centre in Guinea, June 2014. Euro Surveill. 2014;19(49):pii=20983. Available online: http://www.eurosurveillance.org/ViewArticle.
aspx?ArticleId=20983  
Article submitted on 25 November 2014 / published on 11 December 2014
We report two cases of confirmed Ebola virus disease 
in pregnant women, who presented at the Médecins 
Sans Frontières Ebola treatment centre in Guéckédou. 
Despite the very high risk of death, both pregnant 
women survived. In both cases the critical decision 
was made to induce vaginal delivery. We raise a num-
ber of considerations regarding the management of 
Ebola virus-infected pregnant women, including the 
place of amniocentesis and induced delivery, and 
whether certain invasive medical acts are justified. 
We report two cases of confirmed Ebola virus disease 
(EVD) in pregnant patients who presented and were 
treated at the Médecins Sans Frontières (MSF) Ebola 
treatment centre in Guéckedou. We also raise a number 
of considerations regarding the role of amniocentesis 
and induced delivery in the management of pregnant 
women with EVD.
Description of the cases
Case one
Initial presentation
At the beginning of June 2014, a woman in her late 
20s at seven months gestation presented at the Ebola 
treatment centre in Guékedou, Guinea, with a history 
of seven days of asthenia, fever (self-reported), and 
vomiting. Her past obstetrical history included six vagi-
nal deliveries and no abortions. On admission, physi-
cal examination revealed a temperature of 37.1 °C, mild 
dehydration and the patient reported fetal movement. 
The Ebola virus (EBV) test (real-time reverse transcrip-
tion-polymerase chain reaction (RT-PCR)) was positive.
Clinical course and management
On the same day (day 0), the woman was admit-
ted to the EBV treatment/isolation unit where she 
immediately started receiving supportive treatment, 
including Ringer’s lactate, antipyretics, ceftriaxone (2 
g/day), metoclopramide and omeprazole. The woman 
responded well to this supportive treatment and by day 
six of her admission, she was free from symptoms, and 
reported continuously fetal movements. On day eight 
and 10, the results of the EBV tests came back nega-
tive, and the woman was considered cured. The woman 
remained in the unit for further monitoring.
On day 11, the woman’s temperature rose to 38 °C, and 
further examination revealed that fetal movements and 
heartbeat had stopped. Cervical examination showed 
no uterine contractions, no cervical dilation, no blood 
or other discharge. Intravenous metronidazole was 
added for suspected chorioamnionitis. To evaluate 
the possibility of maternal-to-fetal EBV transmission, 
an amniocentesis was performed. The clear-coloured 
amniotic fluid contained a high Ebola viral load (cor-
responding to a real-time RT-PCR cycle threshold (CT) 
value of 21.29).
On day 15, the patient was afebrile. An assisted deliv-
ery was organised to take place in the high-risk zone 
of the treatment centre. Labour induction with mis-
oprostol resulted in a vaginal delivery of a stillborn 
male fetus (first degree maceration). The placenta 
was complete. No episiotomy was required, uterine bi-
manual massage, oxytocin (10 Units intravenous) and 
ergometrine (one vial of 0.2 mg intramuscular) helped 
obtaining normal uterine retraction and prevented any 
excessive post-partum bleeding. The samples from the 
placenta (maternal and fetal side), meconium, and the 
fetus (intra-cardiac aspiration, throat swab, ear swab, 
umbilical cord) were EBV positive (Table). The patient 
was afebrile after delivery, and was discharged on day 
18. A seven-days post-natal consultation (PNC) showed 
a normal evolution.
2 www.eurosurveillance.org
Case two
Initial presentation
In mid-June 2014 a primipara in her early 20s at seven 
months gestation presented with a history of five days 
of arthralgia, asthenia, diarrhoea, fever (self-reported) 
and headache. The patient presented with a history of 
grade III female genital mutilation (FGM). On admis-
sion, the patient had a temperature of 38.4 °C, and 
reported fetal movements and no contractions.
Clinical course and management
On the next day (day 1), the EBV test and malaria 
rapid test were positive. The patient’s fever wors-
ened (39.5 °C), and she had an onset of haematuria 
and cough. The patient reported fetal movements had 
stopped. Supportive treatment included intravenous 
ampicillin and metronidazole for a possible chorioam-
nionitis, as well as intravenous artesunate (malaria 
treatment) and Ringer’s lactate.
On day five, the patient’s systolic blood pressure 
dropped to 60 mmHg (norm: 90–119) and additional 
fluids were intravenously administered. On day eight, 
the patient presented with symmetrical oedema of the 
lower extremities. Obstetrical examination revealed a 
hypertonic uterus, transverse or breech presentation, 
no fetal heartbeat, cervical dilation of one centim-
eter in diameter, and no discharge. Despite the risk, 
ketamine anaesthesia was provided, external version 
manoeuvres were performed, and the fetus was ren-
dered in cephalic presentation.
Table 
Test results from maternal and fetal samples taken from two pregnant patients during their stay at the Ebola treatment 
centre, Guéckédou, Guinea, June 2014
Timeline Specimen type Ebola virus load result (CT value)
Semi-quantitative 
viral load result Other results
Patient 1
Day 0 (admission) Blood (mother) Positive (21.29)  +  +  + Malaria negative
Day 8 Blood (mother) Negative (-) - IgG positive (≥ 1:1,280)IgM positive (≥ 1:320)
Day 10 Blood (mother) Negative (-) - –
Day 12 Amniotic fluid (amniocentesis) Positive (23.31)  +  +  + –
Day 15 Amniotic fluid (fetal mouth swab) Positive (21.41)  +  +  + –
Day 15 Amniotic fluid (fetal ear swab) Positive (24.78)  +  +  + –
Day 15 Placenta (fetal side) Positive (24,12)  +  +  + –
Day 15 Placenta (maternal side) Positive (19,23)  +  +  + –
Day 15 Fetal blood – sample 1 Positive (16,13)  +  +  + –
Day 15 Fetal blood – sample 2 Positive (23.6)  +  +  + –
Day 15 Fetal meconium (anus swab) Positive (20,32)  +  +  + –
Day 18 Blood (mother) Negative (-) - –
Patient 2
Day 1a Blood (mother) Positive (26.46)  +  + Malaria positive
Day 7 Blood (mother) Positive (25,43)  +  + –
Day 11 Amniotic fluid (mouth swab) Positive (24.10)  +  +  + –
Day 11 Amniotic fluid (fetal ear swab) Positive (28.82)  +  + –
Day 11 Placenta (fetal side) Positive (14.22)  +  +  + –
Day 11 Placenta (maternal side) Positive (19.98)  +  +  + –
Day 11 Fetal meconium (anus swab) Negative (-) - –
Day 16 Blood (mother) Negative (-) - –
Day 18 Blood (mother) Negative (-) - –
CT: cycle threshold; NA: not available; RT-PCR: reverse transcription-polymerase chain reaction.
a Patient 2 first presented at the treatment centre in the afternoon (day 0) so the result of Ebola virus testing was available the next day (day 
1).
Real-time RT-PCR was performed with the Smart Cycler. The obtained CT values correspond with the accumulation of the fluorescent signal 
and are inversely proportional with the viral load. CT values are classified in subsequent categories of 0–25, 25–35 and 35–40 and 
correspond with +  +  + , +  + and + results. 
When the real-time RT-PCR was negative this is indicated for the viral load by a – result.
3www.eurosurveillance.org
On day 10, the patient was disoriented and presented 
with anasarca. On the morning of day 11, the patient 
was found unconscious, with the fetal head intra-
vaginal. Ketamine was administered, an episiotomy 
was performed, and a male stillborn fetus was deliv-
ered vaginally. The placenta was complete. Urinary 
retention complicated uterine retraction, and uterine 
bi-manual massage was employed together with the 
administration of oxytocin (10 U) and ergometrine (1 
vial of 0.2mg). Post-partum haemorrhage only stopped 
after repeatedly (five times) packing the uterus with 
gauze. Due to the FGM, bladder catheterisation was 
unsuccessful. Urine was aspirated through a supra-
pubic bladder paracentesis (the urine was not tested 
for EBV). A final vaginal and uterine exploration 
showed no further complications. The samples from 
the placenta (maternal and fetal side) and the fetus 
(throat swab, ear swab) were EBV positive. The sample 
from the meconium was negative (Table). No pericar-
dial puncture was performed.
On day 12, the patient regained consciousness, and 
spontaneous diuresis resumed after a single dose 
dexamethasone injection. The patient had a tempera-
ture of 40 °C. Gentamicin was added to the treatment. 
Over the next six days the patient improved clinically. 
On day 17, the patient was afebrile. On day 16 and 18, 
EBV tests were negative and the patient was consid-
ered cured. The patient was discharged on day 19. She 
did not attend her scheduled appointment seven-days 
PNC.
Ebola virus outbreak in West Africa
In March 2014, an EVD outbreak was declared in 
Guéckedou, Guinea, following which it spread to 
Liberia, Sierra Leone, Nigeria, Senegal and Mali [1,2]. 
The viral strain responsible for the current outbreak 
has been identified as the Zaire strain, a particularly 
virulent strain associated with mortality rates as high 
as 90% [1]. Overall, by 21 November 2014, 15,351 
individuals have become infected and 5,459 of these 
have died. Among those infected, 588 were healthcare 
workers and 377 of these have died [2]. Patients with 
EVD generally present with a history of contact with 
another person with EVD and an abrupt onset of a non-
specific febrile syndrome. A systemic inflammatory 
response can cause multiple organ failure and shock 
[3,4]. Pregnant women are reported to be at higher risk 
to die [5].
Since the onset of the outbreak in Guinea, MSF has set 
up and is running six Ebola treatment centres – includ-
ing one in Guékédou where the outbreak began.
Discussion
There are very few studies reporting on maternal and 
fetal outcomes of pregnant women infected with EBV. 
We report on two cases of pregnant women infected 
with EBV in Guinea. Despite pregnant women being at 
higher risk of more severe disease and mortality [5], 
both women survived. Both fetuses unfortunately died 
in utero. This case report raises a number of important 
points for discussion regarding the management of 
pregnant women infected with EBV.
Although our findings are based on two cases only, 
they depict a more positive picture of the maternal 
outcomes of EVD during pregnancy. In both cases the 
delivery occurred during the healing phase, when the 
EBV viraemia in the pregnant woman was controlled, 
and when clotting had probably returned to normal. 
During previous outbreaks also caused by the Zaire 
strain, such as in the Democratic Republic of the Congo 
(DRC) 1976 Yambuku outbreak, only nine (11%) of 82 
EBV infected pregnant women were reported to have 
survived [6]. Similarly, during another EBV outbreak in 
the DRC 20 years later (1995 in Kikwit) only one (7%) of 
15 pregnant women was reported to have survived, and 
EBV-infected pregnant women had a notably higher 
mortality rate (93%) than non-pregnant EBV-infected 
women (70%) [5]. For the current outbreak, data on 
pregnancy are not routinely reported so overall figures 
on the survival of pregnant women and their unborn 
children or neonates are not available at this point.
Despite the two women described in this report surviv-
ing, in both cases the fetus died in utero. There is not 
much chance for the fetus to survive EBV infection. A 
massive infection of the fetus is likely to occur through 
the placenta. Furthermore maternal immunoglobulins 
M are poorly transported through placental villi and the 
fetal secretory immune system starts producing immu-
noglobulin M around the 20th week of gestation [7]. 
Fetal and neonate mortality was equally reported high 
in other outbreaks. In Yambuku, 11 live neonates were 
born to EBV-infected women and all died within 19 days 
[6]. In Yambuku and Kikwit, abortion occurred among 
19 of 82 (23%) and 10 of 15 (67%) infected pregnant 
women respectively [5,6]. In Kikwit the only surviving 
pregnant patient had an abortion [5]. In Yambuku, one 
of the nine survivors aborted in the treatment centre. 
Abortions occurred spontaneously, likely because of 
fetal death due to EBV infection. Unfortunately the 
pregnancy outcomes of the other pregnant EVD survi-
vors were not reported [6].
This is the first description of the use of amniocentesis 
to determine the presence of intrauterine EBV infec-
tion. In the case of the first patient, despite her having 
an undetectable viral load and declared cured before 
the demise of the fetus, a subsequent amniocentesis 
revealed a high viral load in the amniotic fluid. For this 
reason, a vaginal delivery was arranged to take place 
in the high-risk zone of the EVD treatment centre. In 
the absence of the amniocentesis, the recovered EBV 
negative patient might have been referred to the local 
maternity for delivery, exposing the maternity staff 
to a very high risk of EBV infection. Alternatively, she 
might have had a spontaneous abortion at home with 
potential risk of subsequent transmission of EBV to 
household contacts. In the second case, an emergency 
4 www.eurosurveillance.org
delivery was required and performed at the EVD treat-
ment centre after the patient was found in shock, with 
intra-vaginal fetal head. This delivery also took place 
in the high-risk zone of the centre and episiotomy was 
justified due to the grade III FGM. Post-partum, an 
amniotic fluid sample was taken from the dead fetus 
through an oral swab and yielded a high EBV viral load.
For both cases, the assisted delivery occurred a few 
days after fetal movement had reportedly stopped. As 
these were the first induced deliveries of EBV infected 
pregnant women, careful planning had to be consid-
ered as well precautionary measures, given the high 
risk of nosocomial transmission to healthcare work-
ers [3]. Moreover, based on previous reports [5,6], it 
was also taken into account that spontaneous abor-
tions could occur shortly after fetal death, limiting the 
need for invasive procedures, and reducing the risk to 
healthcare staff.
During both deliveries, strict barrier nursing tech-
niques were used. Full protective equipment included 
scrubs, waterproof overall, apron, boots, N95 masks, 
head cover, goggles, a double pair of gloves and arm-
length gynaecological gloves (three layers of gloving). 
Absorbent pads were laid underneath the patients to 
absorb a maximal amount of fluids. Two pads were 
laid over the abdomen and the perineal region to 
limit splashing. Biomedical waste was gathered in 
the immediate proximity of the patient, and regularly 
sprayed with 0.5% chlorine solution. None of the five 
healthcare workers who were present during the deliv-
eries reported here became infected.
These two case presentations raise a number of con-
siderations regarding the management of pregnant 
women infected with EBV including the role of amnio-
centesis and induced delivery, and whether certain 
invasive medical procedures are justified, despite the 
inherent risk for healthcare workers.
In conclusion, our case report adds to the scarce body 
of literature on the outcomes of pregnant women 
infected with EBV. We also highlight some important 
considerations in the management of such patients 
and describe, for the first time, the use of amniocente-
sis to detect fetal infection with EBV.
Acknowledgements
We would like to thank Marguerite Ouamouno, Pauline 
Yombouno, Adèle Millimouno and all MSF staff from 
Guékédou for their support in taking care of these and many 
other patients. We acknowledge Rosa Crestani and Katherine 
Harries for their critical review of the manuscript.
Conflict of interest
None declared.
Authors’ contribution
Fernanda Mendez Baggi, Aicha Taybi, Andreas Kurth, and 
Sylvie Jonckheere collected data in the MSF Ebola treatment 
centre in Guéckedou, and wrote the first draft. Michel Van 
Herp, Antonino Di Caro, Roman Wölfel, Stephan Günther, 
Hilde Declerck, and Tom Decroo all reviewed the first draft 
and final version of the paper, and their comments were 
incorporated.
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Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014

Publikationsserver des Robert Koch-Instituts

1www.eurosurveillance.orgRapid communicationsManagement of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014F M Baggi1, A Taybi1, A Kurth2,3, M Van Herp4, A Di Caro2,5, R Wölfel2,6, S Günther2,7, T Decroo4, H Declerck4, S Jonckheere (jonckheeresy@gmail.com)11. Médecins Sans Frontières – Operational Centre Brussels, Guéckedou, Guinea2. European Mobile Laboratory – Hamburg, Germany3. Robert Koch Institute – Berlin, Germany4. Médecins Sans Frontières – Operational Centre Brussels, Medical Department, Brussels, Belgium5. L. Spallanzani National Institute for Infectious Diseases – Rome, Italy6. Bundeswehr Institute of Microbiology – Munich, Germany7. Bernhard-Nocht-Institute for Tropical Medicine, WHO Collaborating Centre for Arboviruses and Hemorrhagic Fever Reference and Research – Hamburg, GermanyCitation style for this article: Baggi FM, Taybi A, Kurth A, Van Herp M, Di Caro A, Wölfel R, Günther S, Decroo T, Declerck H, Jonckheere S. Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014. Euro Surveill. 2014;19(49):pii=20983. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20983  Article submitted on 25 November 2014 / published on 11 December 2014We report two cases of confirmed Ebola virus disease in pregnant women, who presented at the Médecins Sans Frontières Ebola treatment centre in Guéckédou. Despite the very high risk of death, both pregnant women survived. In both cases the critical decision was made to induce vaginal delivery. We raise a num-ber of considerations regarding the management of Ebola virus-infected pregnant women, including the place of amniocentesis and induced delivery, and whether certain invasive medical acts are justified. We report two cases of confirmed Ebola virus disease (EVD) in pregnant patients who presented and were treated at the Médecins Sans Frontières (MSF) Ebola treatment centre in Guéckedou. We also raise a number of considerations regarding the role of amniocentesis and induced delivery in the management of pregnant women with EVD.Description of the casesCase oneInitial presentationAt the beginning of June 2014, a woman in her late 20s at seven months gestation presented at the Ebola treatment centre in Guékedou, Guinea, with a history of seven days of asthenia, fever (self-reported), and vomiting. Her past obstetrical history included six vagi-nal deliveries and no abortions. On admission, physi-cal examination revealed a temperature of 37.1 °C, mild dehydration and the patient reported fetal movement. The Ebola virus (EBV) test (real-time reverse transcrip-tion-polymerase chain reaction (RT-PCR)) was positive.Clinical course and managementOn the same day (day 0), the woman was admit-ted to the EBV treatment/isolation unit where she immediately started receiving supportive treatment, including Ringer’s lactate, antipyretics, ceftriaxone (2 g/day), metoclopramide and omeprazole. The woman responded well to this supportive treatment and by day six of her admission, she was free from symptoms, and reported continuously fetal movements. On day eight and 10, the results of the EBV tests came back nega-tive, and the woman was considered cured. The woman remained in the unit for further monitoring.On day 11, the woman’s temperature rose to 38 °C, and further examination revealed that fetal movements and heartbeat had stopped. Cervical examination showed no uterine contractions, no cervical dilation, no blood or other discharge. Intravenous metronidazole was added for suspected chorioamnionitis. To evaluate the possibility of maternal-to-fetal EBV transmission, an amniocentesis was performed. The clear-coloured amniotic fluid contained a high Ebola viral load (cor-responding to a real-time RT-PCR cycle threshold (CT) value of 21.29).On day 15, the patient was afebrile. An assisted deliv-ery was organised to take place in the high-risk zone of the treatment centre. Labour induction with mis-oprostol resulted in a vaginal delivery of a stillborn male fetus (first degree maceration). The placenta was complete. No episiotomy was required, uterine bi-manual massage, oxytocin (10 Units intravenous) and ergometrine (one vial of 0.2 mg intramuscular) helped obtaining normal uterine retraction and prevented any excessive post-partum bleeding. The samples from the placenta (maternal and fetal side), meconium, and the fetus (intra-cardiac aspiration, throat swab, ear swab, umbilical cord) were EBV positive (Table). The patient was afebrile after delivery, and was discharged on day 18. A seven-days post-natal consultation (PNC) showed a normal evolution.2 www.eurosurveillance.orgCase twoInitial presentationIn mid-June 2014 a primipara in her early 20s at seven months gestation presented with a history of five days of arthralgia, asthenia, diarrhoea, fever (self-reported) and headache. The patient presented with a history of grade III female genital mutilation (FGM). On admis-sion, the patient had a temperature of 38.4 °C, and reported fetal movements and no contractions.Clinical course and managementOn the next day (day 1), the EBV test and malaria rapid test were positive. The patient’s fever wors-ened (39.5 °C), and she had an onset of haematuria and cough. The patient reported fetal movements had stopped. Supportive treatment included intravenous ampicillin and metronidazole for a possible chorioam-nionitis, as well as intravenous artesunate (malaria treatment) and Ringer’s lactate.On day five, the patient’s systolic blood pressure dropped to 60 mmHg (norm: 90–119) and additional fluids were intravenously administered. On day eight, the patient presented with symmetrical oedema of the lower extremities. Obstetrical examination revealed a hypertonic uterus, transverse or breech presentation, no fetal heartbeat, cervical dilation of one centim-eter in diameter, and no discharge. Despite the risk, ketamine anaesthesia was provided, external version manoeuvres were performed, and the fetus was ren-dered in cephalic presentation.Table Test results from maternal and fetal samples taken from two pregnant patients during their stay at the Ebola treatment centre, Guéckédou, Guinea, June 2014Timeline Specimen type Ebola virus load result (CT value)Semi-quantitative viral load result Other resultsPatient 1Day 0 (admission) Blood (mother) Positive (21.29)  +  +  + Malaria negativeDay 8 Blood (mother) Negative (-) - IgG positive (≥ 1:1,280)IgM positive (≥ 1:320)Day 10 Blood (mother) Negative (-) - –Day 12 Amniotic fluid (amniocentesis) Positive (23.31)  +  +  + –Day 15 Amniotic fluid (fetal mouth swab) Positive (21.41)  +  +  + –Day 15 Amniotic fluid (fetal ear swab) Positive (24.78)  +  +  + –Day 15 Placenta (fetal side) Positive (24,12)  +  +  + –Day 15 Placenta (maternal side) Positive (19,23)  +  +  + –Day 15 Fetal blood – sample 1 Positive (16,13)  +  +  + –Day 15 Fetal blood – sample 2 Positive (23.6)  +  +  + –Day 15 Fetal meconium (anus swab) Positive (20,32)  +  +  + –Day 18 Blood (mother) Negative (-) - –Patient 2Day 1a Blood (mother) Positive (26.46)  +  + Malaria positiveDay 7 Blood (mother) Positive (25,43)  +  + –Day 11 Amniotic fluid (mouth swab) Positive (24.10)  +  +  + –Day 11 Amniotic fluid (fetal ear swab) Positive (28.82)  +  + –Day 11 Placenta (fetal side) Positive (14.22)  +  +  + –Day 11 Placenta (maternal side) Positive (19.98)  +  +  + –Day 11 Fetal meconium (anus swab) Negative (-) - –Day 16 Blood (mother) Negative (-) - –Day 18 Blood (mother) Negative (-) - –CT: cycle threshold; NA: not available; RT-PCR: reverse transcription-polymerase chain reaction.a Patient 2 first presented at the treatment centre in the afternoon (day 0) so the result of Ebola virus testing was available the next day (day 1).Real-time RT-PCR was performed with the Smart Cycler. The obtained CT values correspond with the accumulation of the fluorescent signal and are inversely proportional with the viral load. CT values are classified in subsequent categories of 0–25, 25–35 and 35–40 and correspond with +  +  + , +  + and + results. When the real-time RT-PCR was negative this is indicated for the viral load by a – result.3www.eurosurveillance.orgOn day 10, the patient was disoriented and presented with anasarca. On the morning of day 11, the patient was found unconscious, with the fetal head intra-vaginal. Ketamine was administered, an episiotomy was performed, and a male stillborn fetus was deliv-ered vaginally. The placenta was complete. Urinary retention complicated uterine retraction, and uterine bi-manual massage was employed together with the administration of oxytocin (10 U) and ergometrine (1 vial of 0.2mg). Post-partum haemorrhage only stopped after repeatedly (five times) packing the uterus with gauze. Due to the FGM, bladder catheterisation was unsuccessful. Urine was aspirated through a supra-pubic bladder paracentesis (the urine was not tested for EBV). A final vaginal and uterine exploration showed no further complications. The samples from the placenta (maternal and fetal side) and the fetus (throat swab, ear swab) were EBV positive. The sample from the meconium was negative (Table). No pericar-dial puncture was performed.On day 12, the patient regained consciousness, and spontaneous diuresis resumed after a single dose dexamethasone injection. The patient had a tempera-ture of 40 °C. Gentamicin was added to the treatment. Over the next six days the patient improved clinically. On day 17, the patient was afebrile. On day 16 and 18, EBV tests were negative and the patient was consid-ered cured. The patient was discharged on day 19. She did not attend her scheduled appointment seven-days PNC.Ebola virus outbreak in West AfricaIn March 2014, an EVD outbreak was declared in Guéckedou, Guinea, following which it spread to Liberia, Sierra Leone, Nigeria, Senegal and Mali [1,2]. The viral strain responsible for the current outbreak has been identified as the Zaire strain, a particularly virulent strain associated with mortality rates as high as 90% [1]. Overall, by 21 November 2014, 15,351 individuals have become infected and 5,459 of these have died. Among those infected, 588 were healthcare workers and 377 of these have died [2]. Patients with EVD generally present with a history of contact with another person with EVD and an abrupt onset of a non-specific febrile syndrome. A systemic inflammatory response can cause multiple organ failure and shock [3,4]. Pregnant women are reported to be at higher risk to die [5].Since the onset of the outbreak in Guinea, MSF has set up and is running six Ebola treatment centres – includ-ing one in Guékédou where the outbreak began.DiscussionThere are very few studies reporting on maternal and fetal outcomes of pregnant women infected with EBV. We report on two cases of pregnant women infected with EBV in Guinea. Despite pregnant women being at higher risk of more severe disease and mortality [5], both women survived. Both fetuses unfortunately died in utero. This case report raises a number of important points for discussion regarding the management of pregnant women infected with EBV.Although our findings are based on two cases only, they depict a more positive picture of the maternal outcomes of EVD during pregnancy. In both cases the delivery occurred during the healing phase, when the EBV viraemia in the pregnant woman was controlled, and when clotting had probably returned to normal. During previous outbreaks also caused by the Zaire strain, such as in the Democratic Republic of the Congo (DRC) 1976 Yambuku outbreak, only nine (11%) of 82 EBV infected pregnant women were reported to have survived [6]. Similarly, during another EBV outbreak in the DRC 20 years later (1995 in Kikwit) only one (7%) of 15 pregnant women was reported to have survived, and EBV-infected pregnant women had a notably higher mortality rate (93%) than non-pregnant EBV-infected women (70%) [5]. For the current outbreak, data on pregnancy are not routinely reported so overall figures on the survival of pregnant women and their unborn children or neonates are not available at this point.Despite the two women described in this report surviv-ing, in both cases the fetus died in utero. There is not much chance for the fetus to survive EBV infection. A massive infection of the fetus is likely to occur through the placenta. Furthermore maternal immunoglobulins M are poorly transported through placental villi and the fetal secretory immune system starts producing immu-noglobulin M around the 20th week of gestation [7]. Fetal and neonate mortality was equally reported high in other outbreaks. In Yambuku, 11 live neonates were born to EBV-infected women and all died within 19 days [6]. In Yambuku and Kikwit, abortion occurred among 19 of 82 (23%) and 10 of 15 (67%) infected pregnant women respectively [5,6]. In Kikwit the only surviving pregnant patient had an abortion [5]. In Yambuku, one of the nine survivors aborted in the treatment centre. Abortions occurred spontaneously, likely because of fetal death due to EBV infection. Unfortunately the pregnancy outcomes of the other pregnant EVD survi-vors were not reported [6].This is the first description of the use of amniocentesis to determine the presence of intrauterine EBV infec-tion. In the case of the first patient, despite her having an undetectable viral load and declared cured before the demise of the fetus, a subsequent amniocentesis revealed a high viral load in the amniotic fluid. For this reason, a vaginal delivery was arranged to take place in the high-risk zone of the EVD treatment centre. In the absence of the amniocentesis, the recovered EBV negative patient might have been referred to the local maternity for delivery, exposing the maternity staff to a very high risk of EBV infection. Alternatively, she might have had a spontaneous abortion at home with potential risk of subsequent transmission of EBV to household contacts. In the second case, an emergency 4 www.eurosurveillance.orgdelivery was required and performed at the EVD treat-ment centre after the patient was found in shock, with intra-vaginal fetal head. This delivery also took place in the high-risk zone of the centre and episiotomy was justified due to the grade III FGM. Post-partum, an amniotic fluid sample was taken from the dead fetus through an oral swab and yielded a high EBV viral load.For both cases, the assisted delivery occurred a few days after fetal movement had reportedly stopped. As these were the first induced deliveries of EBV infected pregnant women, careful planning had to be consid-ered as well precautionary measures, given the high risk of nosocomial transmission to healthcare work-ers [3]. Moreover, based on previous reports [5,6], it was also taken into account that spontaneous abor-tions could occur shortly after fetal death, limiting the need for invasive procedures, and reducing the risk to healthcare staff.During both deliveries, strict barrier nursing tech-niques were used. Full protective equipment included scrubs, waterproof overall, apron, boots, N95 masks, head cover, goggles, a double pair of gloves and arm-length gynaecological gloves (three layers of gloving). Absorbent pads were laid underneath the patients to absorb a maximal amount of fluids. Two pads were laid over the abdomen and the perineal region to limit splashing. Biomedical waste was gathered in the immediate proximity of the patient, and regularly sprayed with 0.5% chlorine solution. None of the five healthcare workers who were present during the deliv-eries reported here became infected.These two case presentations raise a number of con-siderations regarding the management of pregnant women infected with EBV including the role of amnio-centesis and induced delivery, and whether certain invasive medical procedures are justified, despite the inherent risk for healthcare workers.In conclusion, our case report adds to the scarce body of literature on the outcomes of pregnant women infected with EBV. We also highlight some important considerations in the management of such patients and describe, for the first time, the use of amniocente-sis to detect fetal infection with EBV.AcknowledgementsWe would like to thank Marguerite Ouamouno, Pauline Yombouno, Adèle Millimouno and all MSF staff from Guékédou for their support in taking care of these and many other patients. We acknowledge Rosa Crestani and Katherine Harries for their critical review of the manuscript.Conflict of interestNone declared.Authors’ contributionFernanda Mendez Baggi, Aicha Taybi, Andreas Kurth, and Sylvie Jonckheere collected data in the MSF Ebola treatment centre in Guéckedou, and wrote the first draft. Michel Van Herp, Antonino Di Caro, Roman Wölfel, Stephan Günther, Hilde Declerck, and Tom Decroo all reviewed the first draft and final version of the paper, and their comments were incorporated.References1. Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L, Magassouba NF, et al. Emergence of Zaire Ebola Virus Disease in Guinea. N Engl J Med. 2014;371(15):1418-25. http://dx.doi.org/10.1056/NEJMoa14045052. World Health Organization (WHO). Ebola Response Roadmap. Situation Report Update. 21 November 2014. Geneva: WHO; 2014. Available from: http://apps.who.int/iris/bitstream/10665/144117/1/roadmapsitrep_21Nov2014_eng.pdf3. Feldmann H, Geisbert TW. Ebola haemorrhagic fever. Lancet. 2011;377(9768):849-62. http://dx.doi.org/10.1016/S0140-6736(10)60667-8 PMID:210841124. Leroy EM, Gonzalez JP, Baize S. Ebola and Marburg haemorrhagic fever viruses: major scientific advances, but a relatively minor public health threat for Africa. Clin Microbiol Infect. 2011;17(7):964-76. http://dx.doi.org/10.1111/j.1469-0691.2011.03535.x PMID:217222505. Mupapa K, Mukundu W, Bwaka MA, Kipasa M, De Roo A, Kuvula K, et al. Ebola hemorrhagic fever and pregnancy. J Infect Dis. 1999;179(s1) Suppl 1;S11-2. http://dx.doi.org/10.1086/514289 PMID:99881576. Johnson KM. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978;56(2):271-93. PMID:3074567. Zusman I, Gurevich P, Ben-Hur H. Two secretory immune systems (mucosal and barrier) in human intrauterine development, normal and pathological (Review). Int J Mol Med. 2005;16(1):127-33. PMID:15942689

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Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014

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