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.