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Practice Advisory: Care of Obstetric Patients During an Ebola Virus Outbreak

The American College of Ob/Gyn 

November 3, 2014 
(Reaffirmed November 2015)

This is an area of evolving care and practice. Fellows should check periodically for revisions and updates. ACOG will communicate important changes and updates to these guidelines.

Medical management of Ebola virus disease (EVD) presents significant challenges related to the high rates of both case mortality and horizontal transmission of infection to those in contact with infected individuals. Patients are desperately in need of care, yet those who care for them – whether family or health care providers – are themselves at great risk. Care of EVD patients requires facilities with staff schooled and practiced in the use of personal protective equipment (PPE) and with space for isolating infected patients and containing infected materials related to their care.

These realities in the context of the recent Ebola outbreak, beginning in West Africa and now extending with cases in Europe and the Unites States, have led all health care providers to consider how they would care for patients infected with Ebola. While the need to deliver care and support directed at the infection itself is unquestionable, how to treat other concurrent conditions, including pregnancy, is less clear. This document describes an approach to managing pregnancy in women at risk for, suspected of, or diagnosed with EVD. Nevertheless, many details will vary between locations, and because no one document can provide a detailed template for national care, regional coordination with local experts and authorities is necessary.

Box 1: Example of Screening
Questions for EVD

3 screening questions

  1. Have you traveled to West Africa (Liberia, Sierra Leone, Guinea*) in the last 21 days?
  2. Have you had any other contact with an individual with Ebola virus infection?
  3. If yes to either exposure, do you have or have you had:
    • Fever
    • Nausea / vomiting
    • Diarrhea
    • Muscle aches
    • Severe headache
    • Stomach or abdominal pain
    • Bleeding or bruising

* Up to date listing of areas with active Ebola outbreak can be found here.

                      

This document’s guidelines for caring for pregnancy in the context of EVD will be framed by several important principles and observations:

  1. In the United States with few current or, at least in the near future, anticipated cases of EVD, the intersection of pregnancy and EVD should be rare. Therefore, most obstetric providers in the U.S. should be focused on education and screening, leaving the details of care of the few EVD pregnancies to a smaller group with more specialized training.
  2. A central element of providing care during an Ebola outbreak is a three step triage process: Identify/Isolate/Inform
    1. Identify: All providers and centers should develop and operationalize screening tools to identify those at risk for or with suspected EVD (see Box 1).
    2. Isolate: When such patients are identified they should be isolated to avoid the risk of infecting others.
    3. Inform: At the same time, steps should be taken to communicate with local experts to facilitate further evaluation, transfer and care.
  3. Care of patients with EVD should be undertaken only by providers with detailed and specific training, including the vital and complex choreography of donning and doffing needed personal protective equipment.
  4. The need for training and specialized multidisciplinary care argue that pregnant women at risk for or with EVD should be referred to and managed at centers with the required resources, protocols and expertise.

Background

Case Definition: EVD is a severe viral hemorrhagic fever caused by one of five different species of Ebola virus.  It is a zoonotic infection for which the natural reservoir is thought to be fruit bats. Once disease is established in humans, Ebola virus can be transmitted person-to-person through direct contact of skin or mucous membranes with blood or body fluids (including amniotic fluid and breast milk) of infected patients, contaminated equipment or the bodies of those who have died from EVD. The incubation period lasts from 2 to 21 days. The current case definition is detailed in Box 2.

Box 2: Case Definition of EVD

A Person Under Investigation is an individual who has both consistent symptoms and risk factors as follows:

  1. Clinical criteria : fever (subjective or >100.4°F or 38.0°C) ,headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage (e.g., bleeding gums, blood in urine, nose bleeds, coffee ground emesis or melena); AND
  2. epidemiologic risk factors within the past 21 days before the onset of symptoms, such as contact with blood or other body fluids or human remains of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats or non-human primates from disease-endemic areas.

A confirmed case is a Person Under Investigation with laboratory-confirmed diagnostic evidence of Ebola virus infection.

Mortality from EVD: Available data from previous Ebola outbreaks show that case fatality rates from EVD are as high as 90%.  Similar to other viral infections such as influenza, the case fatality rate appears to be higher in pregnancy (95% in one series). The case fatality rate in West Africa for the current outbreak is 55%-75% (reviewed in Jamieson). Case series demonstrate similarly high rates of fetal and neonatal loss. According to Médecins Sans Frontières (MSF) guidance, “The mortality for the foetus and newborn is also (extremely close to) 100%”(1)(2).

It is important to note that these data are drawn from resource-limited settings. It is not known if the maternal and neonatal morbidity and mortality are as high in well-resourced settings given the lack of experience with EVD during pregnancy in those settings. Treatment in all settings at the current time focuses on aggressive fluid replacement, electrolyte management and other elements of supportive care.

Some initial data suggest that early detection and treatment when there is a lower viral load may improve outcomes, an observation that emphasizes the importance of early identification(3).

EVD Triage

A central element of providing care during an Ebola outbreak is a three-step triage process: “Identify/Isolate/Inform.” This process ensures that infected individuals are cared for in the most appropriate place by providers who are most protected from infection.

Identify

The vast majority of women in the U.S., because they have had no relevant exposure, will not be at risk for EVD. Fewer still will have both potential exposure and symptoms suggestive of EVD. Symptoms without exposure are not indicative of possible EVD but rather point to a variety of other causes of fever, such as influenza or chorioamionitis.

Whom to screen

All women who call or present with symptoms of concern should be screened for exposure.  Patients new to a practice should also be screened for exposure and screening established patients at least once seems prudent, as well. Some practices will screen at every patient encounter. In other settings, recognizing that exposure after initial negative screening may be unlikely, providers may choose to educate patients about the need to report travel or any other high-risk exposures e.g. with signs in the office, on practice websites or in pre-printed or pre-recorded materials but choose not to repeat screening at every routine visit.

How to screen

A series of questions to elicit exposure to Ebola and associated symptoms provide the basic components of screening which can be done by telephone or if the patient arrives unannounced (Box 1).

Because at present in the United States, exposure will be less prevalent than symptoms, screening algorithms will be most efficient if patients are first screened for exposures that place them at risk. Patients should be asked if they have traveled recently from West African countries that are affected by the current EVD outbreak (as of 10/27: Liberia, Sierra Leone, Guinea) or have otherwise had contact with a patient with EVD (e.g. providing care to a domestic patient with EVD). If the answer to these questions is “no,” then the patient is not at risk for EVD.

The list of specific countries from which travel presents a risk will change with time, and providers and practices should be aware of updated information as posted on the CDC website.

Symptoms of EVD include fever (subjective or >100.4°F or 38.0°C), headache, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or hemorrhage (e.g., bleeding gums, blood in urine, nose bleeds, coffee ground emesis or melena). For encounters or conversations that begin first with discussion of any of these symptoms, providers should quickly ask about travel to Ebola-affected areas or other contact with individuals with EVD (e.g. rare case of exposure in a health care worker).

Isolate

Women who are at risk based on possible exposure to EVD should be immediately isolated until further evaluation, including evaluation for symptoms and fever, can be undertaken.

  • If they are an outpatient, they should be instructed to remain at home or away from others and expect further direction by telephone.    
  • If they are at a medical facility, they should be asked to put on a mask and directed to a private room.
  • Staff should be instructed to avoid touching the patient and to minimize the patient’s exposure to others.

As efficiently as possible, it is important to begin establishing the diagnosis of Ebola, recognizing that the vast majority of patients will not have the disease. Only essential personnel with designated roles should evaluate the patient and provide care in order to minimize transmission risk. Those evaluating the patient should use PPE appropriate to the patient’s condition (i.e. whether or not symptoms positive for EVD have already been elicited or if blood, vomitus or diarrhea are present. In seemingly well patients who have not yet been asked about symptoms or had their temperature taken, standard precautions (at a minimum mask and gloves) would seem appropriate for providers undertaking these first steps of evaluation.

Inform

Once the process of isolation has begun, providers should consult with EVD experts using a path for consultation that has been determined in advance. Box 3 provides an example of ten questions that can be used to gain additional information that will be important in communication with EVD experts. Such communication can address whether and where further evaluation is recommended, and if recommended, the process for transport to the referral facility.  Until such recommendations are made and relevant facilities prepared, patients should stay where they are. Reflex referral without communication risks unnecessary exposure to patients and staff.

Box 3: Example of Template for Information to Be Used in Communicating with EVD Experts Regarding Patients with Potential EVD*

  • What date was your exposure to Ebola?
  • What was the nature of your exposure to Ebola?
  • How close were you to the EVD infected person?
  • Did you have direct contact with blood or bodily fluid from an EVD infected person?
  • Were you wearing any protective gear when you came into contact with infected secretions?
  • How long were you in contact with the EVD infected person?
  • What is your temperature?
  • Are you having contractions?
  • Have you broken your water?
  • Are you having vaginal bleeding?

*In addition to screening questions (see Box 1)

Follow-Up

After an at-risk or possible case of EVD is referred, local infection control managers and consulted EVD experts can help the referring site consider what measures are needed to clean and decontaminate their facilities and what precautions staff who were in contact with the patient should follow.

Testing to Confirm Ebola Virus Infection

Although decisions regarding the need for testing will not be made, in most cases, by those identifying, isolating and informing, all providers should understand some basic details of such testing. As described by the CDC, virus is generally detectable by real-time RT-PCR from 3-10 days after symptoms appear. Specimens ideally should be taken when a symptomatic patient reports to a healthcare facility and is suspected of having EVD exposure. However, if the onset of symptoms is less than 3 days at the time of testing and the first specimen tests negative, a later specimen may be needed to completely rule out Ebola virus.

Caring for Pregnant Women During Outbreaks of EVD

Treatment of Pregnant Patients Not at Risk for EVD

From the start, it is important to recognize that, especially in areas with a low prevalence of EVD, the overwhelming majority of pregnant patients will not be at risk for EVD. Their care should not change from routine obstetric management. The use of universal precautions including masks, gowns, gloves and other equipment to avoid exposure to blood, amniotic fluid and other maternal fluids is the standard of care.

Care of Women at risk for EVD but without Symptoms to Suggest Infection

Women who have traveled to an Ebola-affected area are at risk for EVD during the next 21 days, but most with such risk will not develop clinical infection. While not endorsing quarantine for asymptomatic individuals, we recognize that quarantines may be legislated or otherwise required by local or state authorities. Therefore, respecting those mandates for limiting contact with others, and in the case of the prenatal setting, especially with other pregnant women, providers should make efforts to defer non-emergent, in-person care of women at risk for EVD until the 21-day incubation period has passed. Much care, however, could be managed with the patient at home, via telephone communication, monitoring of fetal movement as appropriate for gestational age, and other measurement tools to assure patients and providers of ongoing maternal and fetal well-being.

In some cases, clinical concerns or symptoms (e.g. labor) will prompt the need for evaluation. Distinguishing pregnancy-related symptoms from those of EVD may be challenging, as there is significant overlap particularly with symptoms and findings in labor.  Knowledge of the nature of exposure (low or high risk), time since exposure, and associated obstetric events and findings that otherwise explain symptoms may help to refine the probability that a pregnancy-specific cause of symptoms is likely.  Given that some uncertainty is likely to remain, obstetricians should consult with EVD experts to decide where a patient should be cared for, who should care for her, and whether she should be treated as a case of suspected EVD.

Management of Pregnant Women with Confirmed EVD

It is important to emphasize that the care of those with suspected or confirmed EVD should be undertaken only by those with appropriate training in and familiarity with the use of PPE recommended for EVD. Only those who have undergone detailed training in its use and have continued to practice and rehearse the process should be involved in the direct care of EVD patients. Providers who are pregnant should not participate in the care of these patients given the challenges of managing pregnant women with exposure and potentially worse outcomes among pregnant women.

Fulminant EVD presents an extraordinary set of challenges and circumstances that may limit usual obstetric care and management. The maternal mortality and fetal mortality reported in resource-poor settings are dismal. Outcomes in more highly resourced settings like the United States are unknown, but even in such settings, surgery, especially in women with hemorrhagic manifestations, could compromise maternal well-being. It is also not clear if and when in the course of maternal EVD intervention benefits the fetus or neonate.  It is not known, for instance, if maternally derived antibody is protective, thus arguing that supportive care without delivery might improve newborn survival. All these concerns and uncertainties exist alongside the infectious exposures that would be associated with typical management of labor and delivery.  Finally, full PPE involving complete coverage of all provider skin, including a hood and double gloves, is vital to mitigate infectious risk but may preclude the ability to perform surgery and other procedures. Therefore, it may be prudent to avoid the usual obstetric interventions such as fetal monitoring, cesarean delivery, induction, or surgical repair of lacerations in this select group of extremely ill women. Such proscriptions are consistent with other organizations’ protocols for obstetric care in women with EVD(4)(5)(6).

Again, any planning or efforts to care for these patients who are highly infectious should only be done in consultation with those schooled in PPE as well as those expert in the EVD-related care needed for these patients. Decisions here will ideally be shared by maternal-fetal-medicine and infectious disease physicians and appropriate other specialists including, perhaps, ethics consultants.

To be clear, the prohibitions are focused on women with EVD, not women at risk, particularly those felt to be at the lowest level of risk. Further, these limitations in obstetric care should not in any way limit the care and support otherwise recommended for EVD patients.  With such care and support, women may survive EVD, and as they recover and viremia is demonstrated to have cleared, the appropriateness of interventions avoided during the critical phase of infection can be re-evaluated.

Even with the limitations and minimal intervention described above, care of a patient with EVD who is in spontaneous labor requires careful consideration and planning. Centers designated to care for pregnant EVD patients, perhaps in collaboration with professional organizations, should develop detailed protocols for managing spontaneous deliveries or miscarriages. MSF has developed guidelines that may inform such pathways(7)(8).

Management of Patents with Suspected But Not Yet Confirmed EVD

For all women with EVD there will be a window in which EVD is suspected from exposure and symptoms but has not yet been confirmed with laboratory testing. These women should be treated in a similar fashion to that described above for the care of those pregnant women with proven EVD, recognizing that a portion may prove negative. The dilemma of management in this window however, emphasizes the importance of implementing testing protocols with as rapid a turn around time as possible and, at the very least, prioritizing diagnostic testing for pregnant women.

Management of “Early Stage” EVD

There are no data that provide an understanding of the risk of exposure to fluids at early stages of infection or among women who are not, at least not yet, critically ill with EVD.  While it is reasonable to presume that there will be less virus in maternal serum and secretions before symptoms are fulminant, the kinetics of viral replication are not known precisely enough  to accurately delineate a curve of infectious risk.  Nor is it known if treatment and intervention at an earlier stage of infection provides maternal or neonatal benefit. Accordingly, at present it is not known how best to treat these pregnant women. Interventions will need to be considered on a case-by-case basis, considering the unknown risks and benefits to the mother, the fetus and the providers.

Treatment of the Neonate

Pediatricians should develop guidelines for the management of any live born infants of mothers with EVD. Clearly any such newborns would be anticipated to be at great risk for infection with Ebola. In adults, there are recommendations that CPR and other aggressive resuscitation not be undertaken in those with EVD. Regardless of decisions regarding any limits on resuscitation, care directed at comfort should be provided for infants who are live born from mothers with EVD.

Lactation

Breast feeding among those with or who have had EVD is not recommended when there are alternate forms of neonatal nutrition available. This advice is consistent with CDC recommendations.

References

  1. Caluwaerts S, Lagrou D, Van Herp M, Black B, Caluwaerts A, Taybi A, et al. Guidance paper Ebola Treatment Center (ETC): pregnant and lactating women. Brussels: Médecins Sans Frontières; 2014. Retrieved October 30, 2014.
  2. Black B. Principles of management for pregnant women with Ebola: a western context. London; 2014. Retrieved October 30, 2014.
  3. Schieffelin JS, Shaffer JG, Goba A, et al. Clinical illness and outcomes in patients with Ebola in Sierra Leone. N Engl J Med 2014, published online first
  4. Caluwaerts S, Lagrou D, Van Herp M, Black B, Caluwaerts A, Taybi A, et al. Guidance paper Ebola Treatment Center (ETC): pregnant and lactating women. Brussels: Médecins Sans Frontières; 2014. Retrieved October 30, 2014.
  5. Black B. Principles of management for pregnant women with Ebola: a western context. London; 2014. Retrieved October 30, 2014.
  6. Ebola in pregnancy: information for healthcare workers. Public Health England. Retrieved October 30, 2014.
  7. Caluwaerts S, Lagrou D, Van Herp M, Black B, Caluwaerts A, Taybi A, et al. Guidance paper Ebola Treatment Center (ETC): pregnant and lactating women. Brussels: Médecins Sans Frontières; 2014. Retrieved October 30, 2014.
  8. Black B. Principles of management for pregnant women with Ebola: a western context. London; 2014. Retrieved October 30, 2014.

A Practice Advisory is issued when information on an emergent clinical issue (e.g. clinical study, scientific report, draft regulation) is released that requires an immediate or rapid response, particularly if it is anticipated that it will generate a multitude of inquiries. A Practice Advisory is a brief, focused statement issued within 24-48 hours of the release of this evolving information and constitutes ACOG clinical guidance. A Practice Advisory is issued only on-line for Fellows but may also be used by patients and the media. Practice Advisories are reviewed periodically for reaffirmation, revision, withdrawal or incorporation into other ACOG guidelines.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

Publications of the American College of Obstetrician and Gynecologists are protected by copyright and all rights are reserved. The College's publications may not be reproduced in any form or by any means without written permission from the copyright owner. 


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