The management of monkeypox during pregnancy

By Dr. Chinta SidharthanReviewed by Danielle Ellis, B.Sc.Sep 30 2022

In a recent correspondence published in the American Journal of Obstetrics and Gynecology, the authors responded to and clarified some of the contentions discussed in a letter to the editor about their August 2022 article on forecasting the risks of monkeypox in pregnant women.

Background

In a clinical opinion piece published in the American Journal of Obstetrics and Gynecology, authors Dashraath et al. discussed the potentially heightened risks of monkeypox among pregnant women. Some of the discussed risks included the vertical transmission of the virus and, more importantly, the reduced immunity in reproductive-age women due to depleted population immunity to orthopoxviruses like the smallpox virus.

Furthermore, the authors discussed possible pregnancy outcomes such as miscarriages and congenital infections. They went on to address concerns about receiving the monkeypox vaccine during pregnancy and also proposed strategies to mitigate vertical transmission risks.

A recent letter to the editor written by Mungmunpuntipantip and Wiwanitki contested some of the points discussed by Dashraath et al. and proposed alternative approaches for the management of monkeypox in pregnant women, including focusing on traditional disease prevention strategies.

The response

In the present correspondence, the authors addressed some of the contentions presented by Mungmunpuntipantip and Wiwanitki. Referring to the suggestion that fever and skin lesions are unusual symptoms and may be overlooked by doctors leading to inaccurate diagnoses, the authors responded that while skin lesions might not be obvious, the most reported symptom according to the World Health Organization (WHO) continues to be the appearance of systemic, genital and oral rashes.

They added that the prevalence of asymptomatic patients is currently unknown, and a better understanding of asymptomatic monkeypox cases is needed before recommending universal monkeypox screening for pregnant women.

In response to Mungmunpuntipantip’s and Wiwanitki’s statement about patients with neurological and digestive problems exhibiting only specific symptoms, the authors stated that gastrointestinal symptoms have not so far been included in the WHO’s surveillance reports.

Additionally, the authors reported that the predominant neurological manifestation of monkeypox is generalized or frontal headache, which is common during pregnancy. However, they advised obstetricians to be alert to atypical symptoms of monkeypox virus infection, especially those related to monkeypox-associated encephalomyelitis, such as muscle fatigue, incontinence, and altered mental state. They believe these symptoms in previously healthy individuals could indicate the presence of monkeypox virus in the central nervous system.

Mungmunpuntipantip and Wiwanitki mentioned the issue of cross-contamination and inaccuracy of monkeypox virus tests and the need for good specimen collection methods. In light of these issues, they stressed the necessity to consider atypical symptoms. The authors of the present correspondence indicated that the accreditation and assessment of monkeypox testing laboratories are vital to ensure accurate results and prevent contamination of samples.

Lastly, Mungmunpuntipantip and Wiwanitki referred to smallpox infections and argued that there is negligible evidence of vertical transmission from mother to fetus. They added that the size of the monkeypox virus makes it unlikely to be able to pass through the placenta.

In response, the authors discussed the detection of monkeypox viral deoxyribonucleic acid (DNA) in lesions on the fetus and the placenta during birth using real-time polymerase chain reaction (rt-PCR). Furthermore, they added that the absence of evidence on vertical transmission could be due to socioeconomic hurdles to scientific publishing from countries where the disease was previously endemic.

Conclusion

To summarize, in this correspondence, the authors addressed the critique by Mungmunpuntipantip and Wiwanitki to their previous clinical opinion piece on assessing and managing the risks of monkeypox in pregnant women. The authors reinforced the need for more studies on asymptomatic occurrences of monkeypox to understand the role of carriers in the spread of the disease. Additionally, they cautioned obstetricians to recognize signs of neurological manifestations of monkeypox.

While the problem of cross-contaminations can be addressed with stringent assessments of testing facilities, the authors stated that the risk of vertical transmission of monkeypox could not be dismissed. The correspondence referred to possible pathogenic mechanisms of intrauterine viral transmission.

They concluded by stating that there is strong evidence of the adverse outcomes of monkeypox in pregnant women, including miscarriage, preterm births, and congenital infections, and it poses a significant risk to the fetus and the mother.