 So next up we have Severine Cabervet, who is an obstetrician-gynecologist, who's going to tell us something about one of the most difficult aspects, which is about pregnant mothers. Okay, thank you for this nice introduction, John, and thank you for already stating that it's difficult, it is difficult caring for pregnant women in Ebola epidemic, both for the pregnant women confirmed Ebola positive and for the pregnant women just who have the bad luck living in Sierra Leone Guinea or Liberia at the moment of this outbreak. I would like to say also that this presentation is the result of a nice intersectional collaboration, particularly OQBA and OCG were very generous with their data and the million from yesterday that was available for intersectional communication, I think what I would really like to do, maybe it's not so innovative, but it's much needed, I would like to spend it on family planning in the affected countries and I'll come back to that in my presentation why. Yeah, and I called it blood, birthing and body fluids, but I could also have called it difficult dilemmas or double trouble because you have a mother and a fetus or a mother and a baby. So one of the challenges for our teams in the West Africa Ebola epidemic next to a number of hundred other challenges was how to care for Ebola infected pregnant patients and also what are the implications if they are cured and what should we do with the pregnancy, what will happen with the baby, do they remain infectious after cure, all those things were not known. So this research basically started last year in August when we received questions from the field, please help us. We have pregnant patients in our Ebola management centres and we really don't know exactly how we should manage them the best for the mother and for the fetus. So the first thing we did was we went to the literature and the literature is not very promising. There's one large series from 1976, by the way, my year of birth. I'm not afraid to disclose my year of birth. And well, 90% maternal survivors is really very horrible. There's another study from 1999, an outbreak in the Congo. The outbreak was in 1996, but it was published later. And in this study, they mentioned one out of 15 pregnant patients surviving so a mortality of around 95%. In the literature, there are no fetal or neonatal survivors. There are some babies who have been born alive in Congo, but they never survived more than 21 days and they died of presumably trans-percental Ebola. So there's lack of adequate guidelines and the medical staff was very anxious when caring for Ebola pregnant patients exactly because of the blood and the body fluids. So the aim of the research is, first of all, to describe a specific adapted management protocol for caring for pregnant Ebola viral disease positive patients and also to describe the characteristics of the pregnant and postpartum patients who survived Ebola in our Ebola management centers and their neonates. Why adapted management protocol, first of all, for the safety of the health care worker and secondly also because we did not have, especially in the beginning of the epidemic, necessarily gynecologists or midwives working in Ebola management centers. If you were lucky, there was one in the country and this one was then called from five other centers for advice. Thank you also to just mention Fernanda Benjamin and Emma who are obstetricians and who worked in Ebola. But in most of the centers, it was a general doctor who, if we were lucky, had done some deliveries and all of a sudden we challenged him to do deliveries in Ebola positive patients. Thank you also if anyone of you did this, thank you. So what we did was we contacted the teams in the Ebola management centers with many of the teams who were already in contact and we asked to report on all pregnant Ebola patients. What we saw was the survivors were very well reported. The patients who died, they were definitely missing data, probably also because the survivors stay on average longer in the center and they pose more challenges what to do with the fetus if the mother survives. So eight out of nine study sites reported two in Guinea, four in Sierra Leone and two in Liberia. And Macburaka OCA also reported two pregnant patients who unfortunately both died, so they're not included here. And also we got ethical review from the MSF ethical board. So the management protocol, in the meantime, we're busy with a fifth update because all this knowledge became, well, it was also for me in Brussels personally and for my colleagues Eva and Daphne, a very challenging and interesting moment to be actually in the middle of where research was created by our field teams. Initially, we placed main emphasis on protection of healthcare workers. No invasive procedures, certainly no cesarean sections in patients that have already 90% chance of dying. And secondly, also pose a very high risk for the healthcare worker. No suturing, if you have a needle stick injury with the Ebola patient, there is lack of data. But the risk for you to get Ebola is certainly high. And also strict waste management protocols. A fetus is an infected body. And for some reason or another, this virus likes infected bodies. We also changed a bit the standard guidelines. Everything that we could do orally, we did orally. Both for the patient, no hematoma when you give oral tablets, as for the healthcare worker, less risk of needle stick injuries. Later, we added the possibility of life-saving blood transfusion. We transfused in total three patients that we know of, and all three of them survived. And they all got two or more units. They would have died without the blood, not of Ebola, but of bleeding. And one patient with eclampsia was treated with magnesium sulfate. And we stressed the importance of family planning and condom use, not only for the condom for the male survivors, but also for the female survivors. We have some very limited data that also vaginal swaps remain positive at least for a few days after birth. So we have 33 pregnant survivors in Ebola management centers. Nine were in the first trimester, 15 in the second trimester, and nine in the third trimester. There's definitely underreporting of the first trimester pregnancies, because what you would expect is to see more first trimester than second trimester pregnancies, because some of them become abortions before they become second trimester. And also initially, there was no systematic pregnancy testing admission, perfectly understandable if you worked in Monrovia and had 300 patients admitted. I was myself last month in Donka. The maximum we had was 27 confirmed. I don't know how people did it with 300 confirmed. And also in the OKBA management center in Friedan, two first trimester patients arrived already blood PCR negative, but they were managed exclusively for the pregnancy in the Ebola management center. They were quite young. The median age was 22. And between 16 and 35, we have missing data for six patients. And then the fetuses. Basically, what we saw in MSF Ebola management centers confirms exactly what the literature says. We had one fetus more than a mother, because there was a twin. 33 out of 34 were stillbirths of miscarriages. One baby was born alive in Geke-Dugini last year in October. This baby had good outcomes, made a good start. The team did a PCR for Ebola. The PCR was positive, and the baby died two days later. And then what we also did, and the initiative came from the field teams, was we did PCRs of all sorts of body fluids. I just kept the PCRs of the amniotic fluid close to amniotic fluid, if not the PCR of amniotic fluid was done, because in some patients or in some fetuses, five different PCRs were done. People had done an intracardiac aspiration and also a PCR of umbilical cord blood. So what we saw was of the 15 deliveries out of 33 where PCRs were done, seven patients were managed in Guinea, seven patients were managed in Sierra Leone, and one patient was managed in Liberia. Again, data from Liberia are lacking, but full respect for the teams. I mean, I'm not talking about data if you have 300 patients admitted. And then what we saw was one pregnancy was in the first trimester, and the other pregnancies were equally divided between the second and the third trimester. The days between negativation of the blood PCR and the delivery of the mother was between zero and 32 days. I'll explain that a little bit more later. And then the sample was mostly from amniotic fluid. The first trimester pregnancy was a sample taken from the products. Then how do we explain that a PCR was taken from amniotic fluid 32 days after negativation of a maternal PCR because this mother was cured? Well, after the first two patients, the patients from Ghekedu, we knew already that amniotic fluid stays positive also after cure of the mother. It's the same principle as with sperm. The sperm also remains positive. Well, for the sperm, we know it's, well, for some patients at least three months. For amniotic fluid, we still don't know how long, but we knew it was already some days. So we said to send the patient home with an intact pregnancy when she herself is cured is dangerous for her family and for a traditional birth attendant who does the delivery. So what we will do is we will discuss options with the patient and we will propose if she wants and if the family wants a termination of pregnancy in the Ebola management center. We did not have to do this a lot. In most of the cases, nature solved the problems for us. The baby died during admission. The patient started bleeding. We proposed this termination of pregnancy in 506 cases and in two of the cases, the patient did not do what the doctor said. She declined and we learned a lot by those cases. And also I have to say again, thanks to the field teams who really took very well care of those patients. This patient was in the second trimester in Ghekedu. She really wanted a baby. It was an 11th baby and an 11th pregnancy, 10 alive. Very good mother and very good father, I think. And so she was cured, but she really wanted this baby. And the team constructed a wooden hut next to the Ebola management center where the patient stayed for more than one month and the husband came to visit her. And then, well, we were hoping really that we would have the first survivor of Transpacental Ebola in an MSF management center and the team was calling him the next president of Guinea. Yeah, and even in Brussels, I mailed weekly the field, how is he doing? And in Brussels, they asked me, how is this baby doing the next president of Guinea? But then, yeah, reality bites, as very often in Ebola, reality bites, patients started bleeding, was transferred back to the EMC and delivered there at that macerated baby. And as you can see, the PCR, 32 days after negativation of the maternal blood, PCR, was still highly positive. And here, in Kisi, Freetown, it was a bit the same story. The patient did not want the interruption of pregnancy. She lived very close to the Ebola treatment center. And what the team did was, they called her every day by phone to ask how she was doing and she came back a weekly for checkup. I also have to say, they had like five patients admitted, so they did have the time for a nice chat over the phone. And then, she came back for a weekly checkup and said that the baby was not kicking anymore. And then they did an induction of labor in the ETC. And as you can see also, this PCR was still highly positive, more than one month after negativation of the blood PCR. And just one small remark more about the first time as a pregnancy was four days between negativation of the maternal PCR and the PCR taken from the products and also in the first time as the pregnancy it was highly positive. So 15 out of 15 PCRs were positive on amniotic fluid and 13 out of 15 were highly positive. So to conclude, the limitations are definitely that we did not have a systematic data collection. We know that pregnant women can survive Ebola. We need to test for pregnancy at admission and adapt management. As in the literature, 100% of our babies and fetuses died. We did not register any healthcare workers when infections were caring for this specific population, which is good news. And also, PCR and amniotic fluid was highly positive up to 32 days after negativation of the blood of the mother. So there's possibly risk of infection after cure and we need a viral culture. We have not been able yet to do a viral culture but I would love and I think together with the audience to see the result of a viral culture. And so also in our management protocol every pregnant Ebola survivor needs to deliver in a Ebola management center. And this just leads me to thank everybody who reported data and cared for the patients and the field teams from Liberia, Guinea and Sierra Leone and the Luxor operational research unit. Thank you very much. So I think we've got time for just one question, so. Hi, thanks for a very interesting presentation. I just wanted to ask about one group that you haven't mentioned, that's pregnant contacts. So contacts of Ebola cases who are pregnant has been a recent, or in February there was an instance in Sierra Leone in one of the districts where an asymptomatic pregnant woman delivered had a postpartum hemorrhage and subsequently tested positive with the baby testing positive after two initial negative tests. So she was a contact and wouldn't have met any kind of criteria for delivery in an EMC. I'm just wondering have you had any thoughts on? It is extremely complicated. I was by coincidence last year at the moment of the outbreak in Sierra Leone when I was there to do maternal health and it's complicated because in pregnant women the signs are very aspecific. Clinically it's very difficult to distinguish between Ebola and common conditions of pregnancy and fever is not always the first sign in pregnant women. Maybe because their immune suppressed pregnancy is a condition of immune suppression physiologically. Maybe because of other reasons but there's a lot we don't know yet. I would love to talk more but I will leave the floor to someone else. Thank you very much.