3 ꟾ DISCUSSION:
This case of neonatal survival of a premature infant born in the acute
phase of EVD during the DRC’s 10th epidemic in a context of limited
resources remains exceptional. During maternal infection with EVD,
pregnancies usually result in either spontaneous abortion or fetal death
in utero (FDIU) . If newborns are born alive, most die within three
weeks of life [11]. In a review of five studies of
EVD (1978-2010), 15 infants born to EVD positive mothers all died within
19 days of birth [12]. These unfavorable outcomes
have multifactorial causes. Factors contributing to mortality are
related to the high concentration of virus particles in the placenta and
amniotic fluid, a delay in the synthesis of maternal immunoglobulins
(IgG) which occurs from the 6th day after onset of
Ebola symptoms [13], the limited passage of
maternal antibodies (IgG) to the fetus, which only starts in the
13th week of gestation [14], and
late gestational development of fetal antibody synthesis, which begins
around the 20th week [13]. Recently, three cases
of neonatal survival during the active phase of EVD have been reported,
including one during the Guinea epidemic and who has born with positive
RT- PCR and two others born with negative RT- PCR tests during the
10th epidemic in DRC[15, 16].
Our patient is therefore the fourth documented case of survival of
newborns born in the active phase of EVD, the third case born in the
active phase of EVD with negative RT- PCR and who did not develop the
infection during hospitalization, and the first case of survival of a
premature newborn born in highly precarious conditions, with no
incubator or other necessary resuscitation equipment and who did not
develop another neonatal infection afterward.
In this case, we believe maternal vaccination and EVD specific
monoclonal treatment administered to her mother a few days before
delivery were possibly sufficient to protect the fetus from
intra-uterine infection.This study remains limited due to a logistical
problem, anti-Ebola antibodies were not measured in the newborn.
According to the literature, some infants who had negative RT- PCR at
birth became positive within five days of life[8]. For this infant, compliance with Infection
Prevention and Control (IPC) measures during and after birth,
administration of monoclonal antibodies to her mother during pregnancy
and to her in the first days of life along with early management of
prematurity, may have contributed to prevention of Ebola virus infection
and neonatal survival. This case challenges current assumptions that
vertical mother to child transmission of EVD is systematic. The results
of this case and those of two other neonates in one study[16], born in the active phase of EVD with
negative RT- PCR and whose mothers also received monoclonal antibodies
before delivery, further support our hypothesis.
The absence of neonatal infection at the time of passage through the
genital tract also remains unique, as risk of infection during vaginal
birth in the active phase of EVD remains very high. Further research may
shed more light on how vertical mother-to-child transmission of EV
infection can be prevented in newborns born to mothers with EVD.