When it could have been prevented: A maternal death from postpartum hemorrhage due to genital tract lesions complicated by urinary fistula in an Ebola treatment unit in DR Congo

Abstract

BACKGROUND: Ebola Virus Disease (EVD) increases the risk for complications to a healthy pregnancy and delivery, notably post-partum hemorrhage. Additionally, successful management of post-partum hemorrhage and resource-intensive clinical interventions are difficult in the low-resourced setting of an Ebola Treatment Unit (ETU). CASE PRESENTATION: This report describes the clinical course of a pregnant adolescent, gravida 2 para 1, with a history of delivery by cesarean section only 12 months before her second pregnancy. She was vaccinated with rVSV-ZEBOV following the death of a family member with confirmed EVD. She was admitted to the ETU 8 days after her vaccination, where a diagnosis of EVD in pregnancy was made, and her RT-PCR results on the blood sample showed a high viral load. At admission, she was 32 weeks pregnant. She was treated with mAb114, a neutralizing monoclonal antibody. In the first two days of her treatment, viral loads were measured, and they progressively declined after the third day of treatment. On day 3 of admission, following the failure of tocolysis, she delivered a preterm live infant. Her delivery was complicated by post-partum hemorrhage, two lateral cervical and vaginal mucosa lesions, with leakage of urine through the vagina, suggesting a genito-urinary fistula due to the extension of these lesions. A manual uterine exploration was required to remove placental debris with the administration of uterotonic drugs. Methylene blue instillation confirmed the vesicovaginal fistula. Due to a lack of obstetrical equipment in the ETU, the full extent of the cervical lesions could not be assessed nor repaired. Despite our resuscitation measures and mechanical cervical compression, she died 14 h after delivery of hemorrhagic shock complicated by coagulopathy with severe acute respiratory distress in the setting of acute EVD infection despite decreasing viral load. CONCLUSION: In cases of Ebola in pregnancy, not all maternal deaths due to post-partum hemorrhage are necessarily due to EVD and, therefore, could be averted with resources to provide specialized obstetric and post-partum care.