Ebola in the United States: Management considerations during pregnancy

Treatment itself is largely supportive, with significant intravascular expansion and treatment of fever, nausea, vomiting, and diarrhea. Patients typically require 5 to 10 L of fluid replacement each day, along with regular electrolyte repletion. The development of coagulopathy is a real concern and should be carefully monitored for and corrected as needed. Since blood is highly infectious, every effort should be made to perform only critical blood tests and to do so at the bedside, if possible. Mobile devices are available that can be stationed in the room and provide basic hematologic and electrolyte measurements, thereby avoiding the need to transport the blood and the risk of potentially contaminating laboratory equipment. Dedicated staff should be trained on the use of such equipment. In all likelihood, radiologic imaging will not be available and management decisions will need to be made on the basis of clinical examination alone.

Treatment of the virus and the conditions it can cause
A number of experimental treatments are under investigation. These include some antiviral agents (such as the CMV antiviral drug brincidofovir and the influenza antiviral favipiravir), immune sera from Ebola survivors, and RNA interference agents (such as TKM-Ebola). Zmapp, a cocktail of 3 anti-Ebola monoclonal antibodies, has been shown to be protective in macaque monkeys in the late stages of the disease and has been given to 4 infected patients in the United States, with variable results.¹⁹ All of these options should be considered on an individual basis.

Some patients may experience renal or respiratory failure requiring advanced life support measures such as dialysis, mechanical ventilation, or cardiorespiratory resuscitation (CPR). The decision of whether or not to proceed with such interventions should be left to the discretion of the attending physician staff. Given the extremely poor prognosis for the patient and the attendant risks to the health care staff and potentially to subsequent patients using these same pieces of medical equipment, it would seem reasonable to withhold such interventions.

Unique considerations during pregnancy. In pregnant patients with Ebola, it may be reasonable to withhold the option of cesarean and offer only vaginal delivery in the event of labor. This is not just a theoretic concern. In 1 case in Zaire in 1995, an entire surgical team was infected after operating on an infected patient, with the infection spreading to outside hospital staff and family members.²⁰

Survival rates are dismal
Reported survival rates are extremely low, especially for pregnant women. Patients who are younger, have lower viral loads, and do not have diarrhea or severe dehydration have a higher likelihood of surviving. Whether survival rates are higher in developed countries with more health care resources has yet to be confirmed. If patients do survive, the recovery period is long, with prolonged weakness, fatigue, and weight loss. While sexual transmission of the Ebola virus has not been documented, the CDC has recommended sexual abstinence for at least 3 months after recovery.^14,15 Ebola survivors are thought to be immune to subsequent infections.

Education is the most important factor for most of us
In November 2014, the American College of Obstetricians and Gynecologists (ACOG) published a practice advisory on the care of obstetric patients during an Ebola virus outbreak.²¹ While the number of Ebola cases in the United States has been, and likely will continue to be low, especially among pregnant women, we should continue to focus on education and screening. Only providers who have undergone Ebola training and have proper PPE should be involved in the care of potentially infected or confirmed cases. The greatest potential for harm is suboptimal obstetric care leading to an adverse event in a patient suspected of having Ebola who subsequently tests negative. Once an Ebola infection has been confirmed, patients—regardless of whether or not they are pregnant—should be hospitalized in institutions with the requisite resources, protocols, and expertise to deal with such highly infectious patients.

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