in september 2014 , a 40-year - old g11p10 4-month pregnant woman with only term normal births in her history was admitted to an mdecins sans frontires ( msf)-managed ebola treatment center ( etc ) in guckdou , guinea . she complained of several days of abdominal pain and diarrhea and was febrile ( 39c ) . a real - time reverse transcription  polymerase chain reaction ( rt  pcr ) for ebov rna ( l gene , realstar filovirus screen , rt  pcr kit 1.0 , altona diagnostics , hamburg , germany ) on whole blood was positive on 9 september 2014 ( table 1 ) . five days after admission , the ebov rt  pcr on maternal blood was twice negative ( table 1 ) . during admission , she described daily fetal movements . the fetal heart rate was repeatedly checked with doppler sonography and remained within the normal range . as she was afebrile and the rt pcr for ebov rna in maternal blood was twice negative , she was technically eligible for discharge from the etc . however , the treating health workers were concerned about possible ebov persistence in the placenta or amniotic fluid based on previous experience with ebov - positive pregnant women . many women in guinea deliver at home with a traditional birth attendant ( tba ) , so the potential danger of infecting the tba , healthcare workers , or other family members if the amniotic fluid were to remain infectious was critical in development of a delivery plan . one option that the treatment team proposed was to terminate the pregnancy , for public health reasons , in an etc with staff wearing full personal protective equipment in order not to risk her delivering at home or in an inadequately equipped primary healthcare facility . the patient and family declined . as an alternative solution , the team proposed that the patient remain near the etc until delivery . during subsequent weeks , the patient repeatedly reported normal fetal movements . however , on 16 october 2014 , 32 days after maternal blood first tested negative using ebov rt  pcr , the patient started to bleed vaginally . she was transferred back to the etc and had a spontaneous delivery of a 5-month stillborn fetus . ebov rt  pcr on placenta , umbilical cord blood , and amniotic fluid after rupturing of membranes were all highly positive ( table 1 ) . the mother left the etc 1 week later in good condition and with condoms as a component of family planning . table 1.ebola virus real - time reverse transcription  polymerase chain reaction results for case 1date sample taken ( 2014)specimenresult ( cycle threshold value)9 septembermaternal bloodpositive ( 22.3)14 septembermaternal bloodnegative15 septembermaternal bloodnegative6 octobervaginal swab after rupture of amniotic sacpositive ( 28.9)17 octoberamniotic fluidpositive ( 22.2)17 octoberplacental swabpositive ( 18.4)17 octobercord bloodpositive ( 15.8)the lower the cycle threshold ( ct ) value , the higher the virus load . a ct value of 20 roughly corresponds to 10 ebov rna copies / ml of specimen.abbreviation : ebov , ebola virus . ebola virus real - time reverse transcription  polymerase chain reaction results for case 1 the lower the cycle threshold ( ct ) value , the higher the virus load . a ct value of 20 roughly corresponds to 10 ebov rna copies / ml of specimen . on 7 march 2015 , a 22-year - old g3p0 woman approximately 5 months pregnant was admitted from a quarantine home to an msf - managed etc in kissi , freetown , sierra leone . per sierra leone national ebola response policy , the patient 's household had been placed under quarantine for 21 days due to an in - house confirmed ebola death . she denied vaginal bleeding , uterine contractions , or loss of fluid and reported good fetal movement . the patient was initially afebrile but later had a temperature of 38.3c during the first 24 hours of her hospital stay . blood samples were taken on 8 march and 9 march , and rt  pcr for ebov rna ( l gene , realstar filovirus screen , rt  pcr kit 1.0 ) was positive ( see supplementary materials ) . fetal heart rate was auscultated by doppler and found to be within normal range . following a negative rt pcr test on 14 march , the patient and her family were counseled extensively on the risk of a stillbirth and that her fetus , placenta , and amniotic fluid may remain positive for the ebov . the patient opted for expectant management with routine care and initially agreed to remain in the etc for surveillance . on 21 march 2015 the patient requested to leave the etc and was discharged against medical advice to her home , which was still under quarantine . upon discharge , the woman and her family were advised to self - isolate and to call in the event of any abdominal pain , vaginal bleeding , discharge , or leaking of amniotic fluid while at home . the patient was called twice daily by a trained healthcare worker and was asked to present weekly to the etc for an examination by the clinical staff . on 13 april , 3 weeks post - discharge , the patient presented to the etc . the patient expelled the placenta and fetus within the amniotic sac approximately 30 minutes after the second dose of misoprostol . the maternal surfaces of the placenta and amniotic sac were swabbed for the ebov rt  pcr assay ; only the placenta tested positive . maternal blood tested negative for ebov rna on 15 april and 17 april , and the patient was discharged from the etc on 17 april in good condition . the national committee of ethics inmedical research of guinea approved the use of diagnostic leftover samples and corresponding patient data for this study ( permit n11/cners/14 ) . as the samples had been collected as part of the public health response to contain the outbreak in guinea , informed consent was not obtained from patients . these 2 cases highlight several challenges in caring for pregnant women with evd . both patients survived evd and initially had live second trimester fetuses in utero following cure . limited published msf data show a persistence of ebov in amniotic fluid for an unknown duration after negative rt  pcr tests for ebov in maternal blood . thus , at the moment of rupture of membranes , delivery , or in the postpartum , convalescent pregnant women could be possible sources of infection for health staff and those in the community . there is also a paucity of data on duration of fetal survival in utero , and a neonate surviving transplacental evd has not been documented . these cases from guinea and sierra leone also posed difficult ethical dilemmas for the treating healthcare workers . if these patients were to be discharged and subsequently delivered at home or in a health center , they could have infected their family members , tbas , or healthcare providers at the moment of membrane rupture or during delivery . the tba or healthcare provider attending the delivery could have become a source of secondary ebov transmission and enhance the further spread of evd . after long discussions of these 2 cases , one option proposed was termination of the pregnancy for public health reasons . in both cases , the family and the patient declined termination , and other solutions were necessary . in guinea a small wooden house was built next to the etc where the family visited the patient and where the patient remained until her labor started . in sierra leone these 2 cases add to the growing data on ebov persistence in the body for more than 1 month after disappearance of ebov rna from blood . at the beginning of the epidemic , routine pregnancy testing was not standard at etc entry , which meant that some early pregnancies may have passed unnoticed and thus potentially became a risk for infection in the community if a convalescent woman miscarried at home following discharge . research on possible infectivity of amniotic fluid after convalescence of the mother should be prioritized . we strongly urge healthcare workers who care for ebov - positive pregnant women to advocate for delivery in an etc , even after the convalescence of the mother , in order to prevent cross - infection due to ebov persistence in amniotic fluid . consisting of data provided by the author to benefit the reader , the posted materials are not copyedited and are the sole responsibility of the author , so questions or comments should be addressed to the author .
we report 2 cases of ebola viral disease ( evd ) in pregnant women who survived , initially with intact pregnancies . respectively 
 3132 days after negativation of the maternal blood evd - polymerase chain reaction ( pcr ) both patients delivered a stillborn fetus with persistent evd - pcr amniotic fluid positivity .