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Pregnant women and Ebola: NEJM perspective expresses researchers' concerns

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Janet Christenbury

Global knowledge about prevention and treatment of Ebola virus disease (EVD) in pregnancy remains severely limited, despite experience gained from the widespread 2014-16 outbreak in West Africa, researchers assert in a perspective paper in the New England Journal of Medicine (NEJM), Dec. 27, 1918 issue. Emory University gynecology-obstetrics researchers Lisa Haddad, MD, MPH, and Denise Jamieson, MD, MPH, and colleague Sonja Rasmussen, MD, MS, from the University of Florida expressed their concerns about surveillance, pregnancy prevention and the care of pregnant women during Ebola outbreaks.

With the current outbreak of Ebola virus disease in the Democratic Republic of Congo (DRC) -- the 10th global outbreak since the 1976 discovery of the virus -- the public health community and the World Health Organization stepped in quickly to try and control the outbreak, but protocols for pregnancy are still needed, say the perspective authors. This latest outbreak is now the world’s second largest EVD outbreak to date, with both the numbers of cases and deaths increasing.

According to the NEJM perspective, during previous outbreaks surveillance systems have not consistently recorded pregnancy status, which has reduced the capacity for monitoring outcomes in pregnant women and their newborns. Haddad, Jamieson and Rasmussen write that ideally, urine pregnancy testing would be performed on all women of reproductive age who are seen as part of case-investigation and contract-tracing efforts, but that such tests could be challenging to perform in emergency settings. At a minimum, they believe that self-reported pregnancy status should be included.

Even though data are limited, the researchers say available information regarding pregnancy during EVD outbreaks provides reason for concern. Women appear to have higher Ebola infection rates than men and EVD infection during pregnancy threatens the fetus. Research shows that in nearly all cases, EVD in pregnant women has resulted in miscarriage, stillbirth or neonatal death.

The researchers also report that obstetrical units may worsen the spread of EVD, “given the high risks associated with potential massive exposures to body fluids during delivery and delays in virus recognition that result in additional contact exposures.”

“Protocols are needed to reduce the transmission risk of EVD and to improve both maternal and fetal outcomes,” says Jamieson. “Pregnant women have been overlooked in treatment guidelines and there is a need to improve the recommendations on management of their care when diagnosed with EVD. We suggest gathering experts who oversee critical care patients during pregnancy and experts in EVD to review available data and develop consensus guidelines for treating this vulnerable population of patients.”

Pregnant women also have been excluded from nearly all EVD experimental vaccine clinical trials, causing more concern to the three researchers. While the World Health Organization has recommended against vaccinating pregnant women, some clinical trials of experimental treatments on have enrolled pregnant women, providing evidence the women can be safely included in such trials. After discussion of the potential risks and benefits, the researchers believe pregnant women need to be given more opportunity to participate in these clinical trials.

Another area of focus is family planning and contraceptive care in targeted areas, according to the researchers. “Effective family planning services are fundamental in the setting of Ebola to prevent unplanned pregnancies,” says Haddad. “In the DRC, where high fertility rates exist, not having proper contraceptive options could further overwhelm the health care system already struggling with an EVD outbreak.”

“Despite compelling evidence supporting the need to address pregnancy issues when planning for and responding to current and future Ebola outbreaks, many needs remain unmet,” write the authors. “Sadly, we remain unprepared to care for pregnant women in the context of Ebola.” 

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