2 ꟾ CASE PRESENTATION:
On September 27, 2019 the Ebola Treatment Unit (ETU) in Mangina, North Kivu in DRC admitted a 17-year-old adolescent girl who was 32 weeks (approx. 7 and a half months) pregnant, weighing 45 kg, confirmed to have EVD.
Her clinical symptoms included headaches, chills, fever, joint and abdominal pain, nausea and dizziness. Seeking management for her symptoms, which began 7 days before her admission to the ETU, she visited a local health post where a diagnosis of malaria in pregnancy was made. The local health post prescribed 6 days of antimalarial, mono-antibiotic, and antispasmodic therapy without symptomatic improvement, hence her transfer to the ETU.
The patient’s obstetrical history included one living child delivered by cesarean section due to borderline pelvis. This was her second pregnancy. Her last menstrual cycle dated February 17, 2019. Four days before the onset of the symptoms detailed above, she was vaccinated against EVD by Ervebo®, Recombinant Vesicular Stomatitis Virus-Ebola Zaire (rVSV-ZEBOV). At the time of admission, fetal movement was present. Upon admission to the ETU she appeared in ill-health and was bedridden. She was not anaemic nor did she show signs of jaundice. Her blood pressure was 126/62 mmHg, heart rate 98 beats/min, respiratory rate 22 breaths/min with a temperature of 38.5°C and arterial oxygen saturation (SaO2) at 98% on free air.
Her abdomen was enlarged by a gravid uterus with a large longitudinal axis and a large upper end with a median sub-umbilical scar. Fetal heart tones were undetectable due to lack of appropriate equipment. The ETU was not equipped with a Doppler or ultrasound machine. On the day of admission the patient began to experience uterine contractions of low intensity spaced 10 minutes apart. Fetal presentation was cephalic, mobile, and in position II. The vulva was clean, cervix medial, 50% effaced and dilated 2 cm. A borderline pelvis was noted upon physical examination. We confirmed a diagnosis of malaria by the Rapid Diagnostic Test (RDT) and EVD through real-time polymerase chain reaction (RT- PCR) analysis for Ebola virus nucleoprotein with cycle threshold (Ct) values of glycoprotein (GP) 23.7 and nucleoprotein (NP) 19.3 by the GeneXpert® (Cepheid, Sunnyvale, CA, USA). We treated the patient with artesunate, ceftriaxone, albendazole, paracetamol, oral rehydration solution, multivitamins and omeprazole. There was no stock of dexamethasone to support fetal lung development so we were unable to treat the patient with steroids in preparation for preterm delivery. Initiated by the PALM trial [10], all admitted patients were entitled to receive one of the only two available monoclonal antibody treatments, neutralizing monoclonal antibody (mAb114), Ebanga® (Ansuvimab, Ridgepack Biotherapeutics, USA) and a neutralizing monoclonal composed of three antibodies, Regeneron® ( REGN-EB3) . Allocation was done by randomization. Our patient was allocated mAb114 by one time intravenous infusion of 50 mg/kg/hour.
On day 3 of admission, she showed signs of breast tension, bilateral galactorrhea with absence of active fetal movements. We suspected IUGR but were unable to confirm without ultrasound equipment. Her general condition was deteriorating. She developed a fever of 38.9o C and repeat RT- PCR showed Ct values of GP 22.0 and NP 16.9 for Ebola virus, indicating a high viral load. At 2 pm on the same day, the patient had effective uterine contractions, cervical effacement at 80% and dilation of 4 cm. The presentation of the fetus was cephalic and fixed. At 9 pm, after spontaneous rupture of membranes, she gave birth by vaginal delivery to a premature female with Appearance-Pulse-Grimace-Activity-Respiration (APGAR) scores of 3/5/7 at 1, 5 and 10 minutes after birth, weighing 1850 g, head circumference of 29 cm, length of 45 cm without apparent malformations. Her mother died of postpartum hemorrhage 14 hours after delivery.
The newborn’s suckling, swallowing, Moro and grasping reflexes were positive. She had a temperature of 35.6°C, heart rate of 122 beats/minute, respiratory rate of 56 breaths/ minute with an SaO2 of 96% on free air. Blood work revealed hypoglycemia at 17 mg/dl, hemoglobin 12 g/dl, hypo-albuminemia at 2.9 g/dL, transaminases elevation with aspartate aminotransferase (ASAT) at 71 U/L, hyperkalemia at 5.8 mEq/L, without evidence of hemolysis or related clinical signs.The newborn was given intravenous ceftriaxone 100 mg twice daily for 7 days, ampicillin 100 mg thrice daily for 7 days, gentamycin 10 mg daily for 3 days, metronidazole 100 mg thrice daily for 7 days, glucose 10% 20 ml bolus and then a continuous infusion of 120 ml 10% glucose + 1.4 mg KCl + 1 ml magnesium and 2 mg calcium gluconate over 24h and vitamin K1 1 mg daily intramuscularly for 2 days. The mother’s adnexal swab was RT- PCR positive but the newborn’s venous whole and buccal swab were negative for. However, the newborn could not be transferred to a health center with a neonatal care nursery because she was born to an Ebola positive mother. Protocol prescribed that any child born to an EVD positive mother should receive one of the two available monoclonal antibody treatments, despite negative RT- PCR results. Thirteen hours after birth the newborn was given 22.5 ml of Regeneron® (REGN-EB3) by randomization, which was administered in a one-time IV dose of 150 mg/kg. The newborn did not receive breastmilk and received parenteral nutrition with glucose 10% at a rate of 80ml/kg and 5ml/kg of milk ready-to-use infant formula 8 times per day with a gradual increase of 5ml/kg/day, which she tolerated well.
In the absence of an incubator or heating lamp, we set up a makeshift heating system by wrapping cotton blankets over a hot water bottle. At 1 meter above her bed, we installed four 100 Watt electric bulbsto heat the ambient area which could drop to 15°C in the ETU. We introduced a variation of Kangaroo care without direct skin-to-skin contact. Instead, Kangaroo care providers were lightly covered with the Personal Protective Equipment (PPE) ; this was practiced 3 times a day for 2-3 hours for the first ten days by EVD survivors who worked in the ETU. Her evolution was without particularities, and she was discharged after 14 days to the health post nursery outside the Ebola high-risk zone. At 45 days of life, her weight was 3850 g. She was healthy and developing normally at our last follow-up visit at the age of 3 years and 7 months on 23 April 2023.