Treatment Algorithm Addresses Monkeypox in Pregnancy

The hazards that monkeypox poses to maternal and fetal health prompted experts from several countries to recently propose a clinical management algorithm (decision tree) on isolating and testing after exposure and treating the infection during pregnancy.

Pradi Dashraath, MBBS, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, National University Hospital, Singapore, and colleagues in Singapore, the US, France, French Guiana and Switzerland warn of the risk of severe congenital infection, miscarriage, and maternal morbidity and mortality.

Although the west African clade of monkeypox virus implicated in the current outbreak is associated with milder disease in general than the central African clade, Dashraath and colleagues note that its effects in pregnancy are not yet known. They warn that the experience with monkeypox in the Congo—including miscarriages and stillbirths, as well as the virus DNA confirmed in fetal tissue, umbilical cord and placenta, consistent with vertical transmission—warrants precautions against exposure, isolation and testing if exposed, and prompt treatment if infected.

"Clinicians must maintain a high index of suspicion for monkeypox virus in any pregnant woman presenting with lymphadenopathy and vesiculopustular rash, including rash localized to the genital or perianal region, even if there are no apparent epidemiological links," Dashraath and colleagues advise.

Dashraath and colleagues recommend PCR testing for monkeypox for all pregnant individuals with suspected exposure to monkeypox whether or not they are symptomatic. The medical management decisions then flow from test results, with positive tests in asymptomatic individuals necessitating isolation at home for 21 days, self-monitoring for such symptoms as fever and rash, and considering an orthopox vaccine. The algorithm also recommends ultrasound fetal surveillance, and possible amniocentesis if there are signs of hydrops or hepatomegaly.

A vaccine, the algorithm notes, is optimally used within 4 days of exposure, but can be effective if administered within 14 days in the absence of symptoms. Dashraath and colleagues suggest that a third-generation smallpox vaccine, MVA-BN (Modified Vaccinia Ankara-Bavarian Nordic), recently approved in the US, Canada and the EU, could be safer for the fetus as it contains non-replicating virus and has not demonstrated adverse pregnancy outcomes.

For individuals with apparent symptoms but a negative test for monkeypox, other causes for the symptoms should be determined, and the same period of isolation with self-monitoring should be undertaken. Dashraath and colleagues suggest ruling out varicella, herpes simplex and syphilis, as possible sources of similar symptoms. Repeat testing for monkeypox is recommended if symptoms persist without other causes identified.

For pregnant individuals who are symptomatic and test positive for monkeypox, hospitalization may be clinically indicated, with the algorithm referring to the WHO clinical severity score based on number of skin lesions. Maternal surveillance should include monitoring temperature, heart rate, and blood pressure multiple times a day—along with supportive care and pain management.

For these infected individuals, Dashraath and colleagues indicate that in addition to infection-specific treatment with tecovirimat, vaccinia immune globulin and an othopox vaccine, antibiotics may be necessary to prevent bacterial superinfection. They warn that cidofovir should be considered only in critically ill patients, as it is a known teratogen. Fetal assessments will be necessary, and administration of corticosteriods should be considered for fetal lung maturation, depending on gestational age, according to the algorithm.

Dasbraath and colleagues do not favor cesarean section over vaginal delivery except if genital lesions are present. They do call for PCR testing of the newborn, particularly from suspicious mucocutaneous lesions. They also recommend assessment of monkeypox viral load from umbilical cord and placenta; noting that monkeypox virus is likely to be shed in the amniotic fluid only after approximately 18-21 weeks gestation, when fetal kidneys begin producing sufficient urine.

"Finally, we encourage the reporting of all cases of monkeypox virus in pregnancy to WHO and an international registry for emerging pathogens," Dashraath and colleagues conclude.