Reproductive health sequelae among women who survived Ebola virus disease in Liberia

To estimate the incidence of failed pregnancy and menstrual irregularities among Liberian women who had survived Ebola virus disease (EVD) and to identify host‐specific and disease‐specific factors associated with these outcomes.

Ebola virus can persist in certain immunologically protected parts of the body, including semen, the interior compartments of the eye, and central nervous system. [9][10][11] Ebola virus RNA has been detected in the semen of EVD survivors at more than 2 years after recovery. 11 In addition, sexual transmission of the virus from male survivors to their female sexual partners has been identified as the cause of at least three cases of EVD recrudescence in West Africa. 12 Most studies on the impact of Ebola virus on female reproduction have been limited to women who were pregnant at the time of infection. Fetal or early neonatal death is almost certain to occur among women who were pregnant when they developed EVD. 13,14 Some evidence suggests that Ebola virus could persist in the uteruses of survivors who were pregnant when they became infected. 5 Women who experienced spontaneous abortion after discharge from the Ebola treatment unit (ETU) had negative blood test results for Ebola virus; however, products of conception (i.e. the fetus, placenta, and amniotic sac) have tested positive for Ebola virus RNA. 5 For women who were not pregnant at the time of infection, there is evidence that Ebola virus RNA might remain in the vaginal fluid for up to 1 month after the onset of symptoms. 9 Guidance on the clinical care of EVD survivors released by WHO in April 2016 2 provided anecdotal evidence of stillbirths among women who had conceived after EVD, and warned that such pregnancies should be treated as high-risk for fetal complications. The same guidelines indicated that menorrhagia, metrorrhagia, and amenorrhea had been reported by some EVD survivors. However, little research has examined the ongoing reproductive health of female EVD survivors after recovery from acute infection. 6,15,16 The aims of the present study were to estimate the frequency of adverse reproductive health outcomes (failed pregnancy and irregular menstruation) and to identify factors associated with these outcomes among Liberian EVD survivors.

| MATERIALS AND METHODS
A cross-sectional questionnaire-based study was conducted between All women who met these criteria also had to be willing and able to consent to participation. There were no specific exclusion criteria for the current analysis.

Although participants in the Longitudinal Liberian Ebola
Survivor study attended ELWA Hospital every 3 months, the data used for the present study were cross-sectional. These data were collected from an interviewer-administered questionnaire (Box S1).
All interviews were conducted in Liberian English in a private room at ELWA Hospital.
In the present study, the outcomes 'spontaneous abortion' and 'stillbirth' were self-defined by the participants, rather than using the WHO definition of fetal death occurring before or after 28 weeks of gestation. 17 The term 'failed pregnancy' was used to include both stillbirths and spontaneous abortions.

| RESULTS
A total of 111 women were included in the present study. Their characteristics are outlined in A total of 29 (26.1%) participants reported becoming pregnant at least once after EVD ( Fig. 1 and Table 3). Four (13.8%) of these women had become pregnant twice since ETU discharge; however, the current analysis was limited to the outcomes of the first pregnancy following EVD for each woman. As shown in Figure 1, of the 23 pregnancies continued to terminus for which outcome data were available,  Table 4 shows the association of demographic and EVD-related factors with pregnancy outcomes. In bivariate logistic models, no associations were found between failed pregnancy and any of the factors of interest. In addition, no associations were found between pregnancy outcome and potential factors after adjusting for age of the mother or duration of EVD. Table 5 shows the association of demographic and EVD-related factors with menstruation outcomes. No bivariate associations were found between menstrual irregularities due to unknown reasons and any of the factors of interest. These associations remained null even after adjusting for maternal age.

| DISCUSSION
The present study found high rates of pregnancy failure and irregular menstruation among Liberian survivors of EVD. These findings highlighted the substantial long-term impact of EVD among female survivors after acute infection. As such, they represent an important contribution to the previous literature regarding reproductive health outcomes in this population.
The observed rate of failure of first pregnancy after EVD owing to spontaneous abortion (47.8%) was higher than the reported rate of 15%-20% for spontaneous abortion in general populations 21 ; however, no substantiated data are available for general populations in West Africa. In addition, the current finding that 8.7% of first pregnancies after EVD resulted in stillbirth is also greater than the 36 stillbirths per 1000 live births (3.6%) estimated for pregnancies in Sub-Saharan Africa. 22 A small qualitative study that conducted in-depth interviews among 13 female survivors, who had conceived after EVD and continued to terminus found no cases of spontaneous abortion but three (23%) cases of stillbirth, suggesting that pregnancy failure was increased in this cohort. 16 The present findings were also consistent with another study of female survivors (n=68) in Liberia, which found increased rates of post-EVD pregnancy failure (22.1% for spontaneous abortion and 5.8% for stillbirth). 15 However, the present study included pregnancies that were conceived up to 4 months later in the post-EVD recovery period.
Importantly, the results of the present study potentially indicated a greater frequency of failed pregnancies (>50%) among female EVD survivors than was previously suggested.
The present study found that more than one-quarter of women who reported regular menstruation before EVD had experienced irregular menstruation after EVD. Oligomenorrhea was the most frequently reported type of menstrual irregularity, followed by amenorrhea. The frequency of irregular menstruation found in the present study was higher than the 5%-17% rate estimated for women in low-income settings, 23  Sustained immune activation and/or dysregulation might to contribute to the high incidence of failed pregnancies recorded after EVD. 5 The strong association between immune dysregulation and spontaneous abortion in the general population lends credence to this hypothesis. 25 Inflammation of the placenta has been associated with F I G U R E 2 Study population for analyzing menstrual outcomes. Abbreviation: EVD, Ebola virus disease. stillbirth. 26 Furthermore, ongoing inflammation after infection could provide an etiology for some post-EVD clinical manifestations such as arthritis and uveitis. 5 Irregular menstruation among EVD survivors in the present study could be attributable to multiple underlying factors, including weight loss and stress. 27 Given that survivors would have lost large amounts of weight during the period of acute EVD, 3 and are likely to have experienced high levels of stress after Ebola, it is plausible that these factors (in isolation or in combination) could explain the menstrual changes observed in the present study. Persistent inflammation following EVD might also contribute to irregular menstruation, as menstruation is driven by interactions between ovarian hormones and the immune system. 28 The current analysis had some limitations. The study population comprised only EVD survivors; therefore, the lack of a control group (i.e. reproductive-aged women who had not experienced EVD) limited the findings to descriptive statistics. The present study was susceptible to selection bias in that individuals who access services at the ELWA Hospital Ebola Survivor Clinic might experience more severe post-EVD sequelae than EVD survivors who do not access services at that hospital. Conversely, the sickest EVD survivors might not have been able to travel to ELWA Hospital and so were excluded from the present study. Also, the use of self-reported and self-defined data for the failed pregnancy outcomes could have resulted in some early stillbirths being reported as spontaneous abortions, as the women might not have known how to differentiate between these two outcomes.
One of the greatest limitations was the lack of data on pre-EVD pregnancy history. It was unclear how many of the participants had experienced a failed pregnancy before EVD, thereby placing them at increased risk of failed pregnancy after EVD. 27  Values are given as mean ± SD, unless indicated otherwise. b Model 1 was unadjusted and model 2 was adjusted by maternal age. c Irregular menstruation included no menstruation; light or infrequent menstruation; heavy menstruation; frequent menstruation; and/or abdomen or back pain during menstruation.