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Correspondence| Volume 53, 103622, February 2023

The impact of monkeypox in pregnant patients on obstetric anesthesiology

Published:December 28, 2022DOI:https://doi.org/10.1016/j.ijoa.2022.103622
The impact of monkeypox in pregnant patients on obstetric anesthesiology
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      We write in regard to the 2022 monkeypox virus (Mpox) outbreak and consider the implications of Mpox infection during pregnancy on the practice of obstetric anesthesiology. As of December 5, 2022 there have been 82 062 confirmed cases of Mpox, with over 98% occurring in non-endemic countries.

      CDC. 2022 Monkeypox Outbreak Global Map. Centers for Disease Control and Prevention. Published December 5, 2022. Accessed December 5, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html.

      The Centers for Disease Control and Prevention reported the first case of Mpox in a pregnant person in the USA on July 23, 2022.

      U.S. spots first monkeypox case in a pregnant woman as cases climb. Accessed August 17, 2022. https://www.cbsnews.com/news/monkeypox-pregnant-woman-baby-cases/.

      The newborn received prophylactic immunoglobulin and did not show signs of Mpox infection, and as of July 27, 2022, both mother and newborn were doing well.

      U.S. spots first monkeypox case in a pregnant woman as cases climb. Accessed August 17, 2022. https://www.cbsnews.com/news/monkeypox-pregnant-woman-baby-cases/.

      Data regarding Mpox, albeit limited, suggest the virus can be transmitted transplacentally or via close contact perinatally.

      CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

      There are five reported cases of Mpox infection in pregnant individuals (Table 1). The first was in Zaire in 1983, where a person diagnosed with Mpox at 24 weeks’ gestation delivered a premature infant six weeks later.
      • Jezek Z.
      • Fenner F.
      II. Monkeypox virus.
      Hum Monkeypox. 1988; 17: 6-32https://doi.org/10.1159/000416457
      The infant had a generalized skin rash at birth and died at 6.5 weeks, reportedly from malnutrition.
      • Jezek Z.
      • Fenner F.
      II. Monkeypox virus.
      Hum Monkeypox. 1988; 17: 6-32https://doi.org/10.1159/000416457
      , 

      Human Monkeypox: A study of 2,510 contacts of 214 patients. J Infect Dis. | Oxford Academic. Accessed August 6, 2022. https://academic.oup.com/jid/article-abstract/154/4/551/2190149.

      The remaining four cases were identified during a 2007–2011 observational study in the Democratic Republic of Congo. Three individuals suffered fetal loss, including two first trimester miscarriages and one stillbirth, while the fourth gave birth to a healthy infant.
      • Mbala P.K.
      • Huggins J.W.
      • Riu-Rovira T.
      • et al.
      Maternal and fetal outcomes among pregnant women with human monkeypox infection in the Democratic Republic of Congo.
      J Infect Dis. 2017; 216: 824-828https://doi.org/10.1093/infdis/jix260
      The stillborn infant presented with a diffuse maculopapular skin rash, and Mpox virus DNA was detected in fetal tissue, the umbilical cord and the placenta.

      Guidelines for pregnant individuals with monkeypox virus exposure – The Lancet. Accessed August 6, 2022. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01063-7/fulltext#bib1.

      Although unknown, these historical cases support the possibility of increased Mpox infection severity during pregnancy, risk of transmission to the fetus, and risk for severe infection in newborn.

      CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

      Clinicians should remain vigilant while treating pregnant patients with suspected Mpox infection because the risk factors determining a severe adverse pregnancy outcomes remain unknown. It may be beneficial to perform serial ultrasound surveillance for signs of congenital infection in pregnant people with PCR-confirmed Mpox infection, given this unknown risk to the fetus.
      • Dashraath P.
      • Nielsen-Saines K.
      • Rimoin A.
      • Mattar C.
      • Panchaud A.
      • Baud D.
      Monkeypox and pregnancy: Forecasting the risks.
      Am J Obstet Gynecol. 2022; 227: 849-861https://doi.org/10.1016/j.ajog.2022.08.017
      Ultrasound findings of hepatomegaly, ascites, hydrops, placental calcifications, and fetal growth restriction would raise suspicion of fetal infection and justify amniocentesis with real-time PCR.
      • Dashraath P.
      • Nielsen-Saines K.
      • Rimoin A.
      • Mattar C.
      • Panchaud A.
      • Baud D.
      Monkeypox and pregnancy: Forecasting the risks.
      Am J Obstet Gynecol. 2022; 227: 849-861https://doi.org/10.1016/j.ajog.2022.08.017
      Table 1Reported cases of Mpox virus infection during pregnancy.
      Year,

      Location      		Gestational Age at Time of DiagnosisPregnancy OutcomeTime between Illness Onset and Reported OutcomeClinical Findings
      1983, Zaire

      Human Monkeypox: A study of 2,510 contacts of 214 patients. J Infect Dis. | Oxford Academic. Accessed August 6, 2022. https://academic.oup.com/jid/article-abstract/154/4/551/2190149.

      , 
      • Mbala P.K.
      • Huggins J.W.
      • Riu-Rovira T.
      • et al.
      Maternal and fetal outcomes among pregnant women with human monkeypox infection in the Democratic Republic of Congo.
      J Infect Dis. 2017; 216: 824-828https://doi.org/10.1093/infdis/jix260
      		∼5.5 monthsPreterm birth6 weeksMaternal: initial presentation included fever followed by skin rash



      Newborn: generalized skin rash present at birth, birth weight < 1500 g; subsequent neonatal death due to “malnutrition” at 6.5 weeks old
      2007–2011, DRC

      Human Monkeypox: A study of 2,510 contacts of 214 patients. J Infect Dis. | Oxford Academic. Accessed August 6, 2022. https://academic.oup.com/jid/article-abstract/154/4/551/2190149.

      , 
      • Mbala P.K.
      • Huggins J.W.
      • Riu-Rovira T.
      • et al.
      Maternal and fetal outcomes among pregnant women with human monkeypox infection in the Democratic Republic of Congo.
      J Infect Dis. 2017; 216: 824-828https://doi.org/10.1093/infdis/jix260
      		First trimesterMiscarriage14 daysMaternal: moderate to severe infection



      Miscarriage products were not tested
      2007–2011, DRC

      Human Monkeypox: A study of 2,510 contacts of 214 patients. J Infect Dis. | Oxford Academic. Accessed August 6, 2022. https://academic.oup.com/jid/article-abstract/154/4/551/2190149.

      , 
      • Mbala P.K.
      • Huggins J.W.
      • Riu-Rovira T.
      • et al.
      Maternal and fetal outcomes among pregnant women with human monkeypox infection in the Democratic Republic of Congo.
      J Infect Dis. 2017; 216: 824-828https://doi.org/10.1093/infdis/jix260
      		First trimesterMiscarriage24 daysMaternal: moderate to severe infection



      Miscarriage products were not tested
      2007–2011, DRC

      Human Monkeypox: A study of 2,510 contacts of 214 patients. J Infect Dis. | Oxford Academic. Accessed August 6, 2022. https://academic.oup.com/jid/article-abstract/154/4/551/2190149.

      , 
      • Mbala P.K.
      • Huggins J.W.
      • Riu-Rovira T.
      • et al.
      Maternal and fetal outcomes among pregnant women with human monkeypox infection in the Democratic Republic of Congo.
      J Infect Dis. 2017; 216: 824-828https://doi.org/10.1093/infdis/jix260
      		18 weeksStillbirth21 daysMaternal: MPXV
      Monkeypox virus.
      viremia level rose rapidly upon cessation of fetal movement



      Fetus: diffuse maculopapular lesions, hydrops fetalis, hepatomegaly; virus isolated in fetal tissue and placenta
      2007–2011, DRC

      Human Monkeypox: A study of 2,510 contacts of 214 patients. J Infect Dis. | Oxford Academic. Accessed August 6, 2022. https://academic.oup.com/jid/article-abstract/154/4/551/2190149.

      , 
      • Mbala P.K.
      • Huggins J.W.
      • Riu-Rovira T.
      • et al.
      Maternal and fetal outcomes among pregnant women with human monkeypox infection in the Democratic Republic of Congo.
      J Infect Dis. 2017; 216: 824-828https://doi.org/10.1093/infdis/jix260
      		14 weeksFull-term, live birth6 monthsMaternal: mild infection



      Newborn: no symptoms reported
      2022, United States

      U.S. spots first monkeypox case in a pregnant woman as cases climb. Accessed August 17, 2022. https://www.cbsnews.com/news/monkeypox-pregnant-woman-baby-cases/.

      Data currently unavailable.
      		Live birth
      Data currently unavailable.
      		Maternal: doing well per CDC
      Centers for Disease Control and Prevention.




      Newborn: no signs of infection, received prophylactic immune globulin
      a Monkeypox virus.
      b Centers for Disease Control and Prevention.
      * Data currently unavailable.
      The early diagnosis of Mpox in pregnant individuals is challenging given nonspecific prodromal symptoms (Fig. 1).

      CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

      , 
      • Khalil A.
      • Samara A.
      • O’Brien P.
      • et al.
      Monkeypox and pregnancy: what do obstetricians need to know?.
      Ultrasound Obstet Gynecol. 2022; 60: 22-27https://doi.org/10.1002/uog.24968
      Recent guidelines stress the importance of ruling out varicella, herpes simplex, and syphilis, which may resemble Mpox infection.

      Guidelines for pregnant individuals with monkeypox virus exposure – The Lancet. Accessed August 6, 2022. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01063-7/fulltext#bib1.

      Prevention of Mpox poses additional challenges as prophylactic vaccination with ACAM2000 is contraindicated in pregnancy.

      CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

      While the only FDA-approved vaccine for Mpox, JYNNEOS, can be offered to pregnant individuals, human data are insufficient to determine if there are associated risks in pregnancy.

      CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

      There are additional treatment limitations in pregnant individuals, as antiviral therapies used to treat Mpox infection, such as cidofovir and brincidofovir, show evidence of teratogenicity in animal models.

      CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

      Although there are currently no data on the use of tecovirimat during pregnancy, at present it is recommended as the first-line antiviral for pregnant patients.

      CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

      Counselling on the potential risks of vaccination and therapies in pregnancy will be increasingly important.
      Figure thumbnail gr1
      Fig. 1Symptoms of Mpox virus infection.
      It is essential that obstetric anesthesiologists understand the implications of Mpox infection when formulating anesthetic plans. Patients with Mpox are at increased risk of liver and kidney dysfunction, abscesses, and sepsis.
      • Pastula D.M.
      Two cases of monkeypox-associated encephalomyelitis—Colorado and the District of Columbia, July–August 2022.
      MMWR Morb Mortal Wkly Rep. 2022; : 71https://doi.org/10.15585/mmwr.mm7138e1
      Animal studies have shown that Mpox can lead to acute respiratory distress syndrome, therefore improved understanding can guide management with ventilator settings.
      • Pastula D.M.
      Two cases of monkeypox-associated encephalomyelitis—Colorado and the District of Columbia, July–August 2022.
      MMWR Morb Mortal Wkly Rep. 2022; : 71https://doi.org/10.15585/mmwr.mm7138e1
      Additionally, given the pattern of presentation has primarily been anogenital lesions associated with sexual contact, these lesions, if present, are a likely indication for cesarean delivery: exposure to lesions during vaginal birth may increase the risk of fulminant neonatal sepsis.
      • Dashraath P.
      • Nielsen-Saines K.
      • Rimoin A.
      • Mattar C.
      • Panchaud A.
      • Baud D.
      Monkeypox and pregnancy: Forecasting the risks.
      Am J Obstet Gynecol. 2022; 227: 849-861https://doi.org/10.1016/j.ajog.2022.08.017
      There are currently no data regarding the risk of central nervous system (CNS) infection after neuraxial techniques in patients with Mpox, although neurological complications of Mpox otherwise appear to be rare.
      • Pastula D.M.
      Two cases of monkeypox-associated encephalomyelitis—Colorado and the District of Columbia, July–August 2022.
      MMWR Morb Mortal Wkly Rep. 2022; : 71https://doi.org/10.15585/mmwr.mm7138e1
      The theoretical risk of CNS infection should be weighed against the risks associated with alternative methods of anesthesia. For instance, intubating a patient with oropharyngeal lesions may be more challenging if there is physical obstruction of the airway or if friable tissue leads to bleeding. Similar to most other viral infections (e.g. SARS-CoV-2, human immunodeficiency virus), the benefits of neuraxial analgesia and anesthesia for labor and delivery likely outweigh the risk of CNS complications, although it may be necessary to avoid skin puncture in areas of active rash. It is important to consider the use of povidone-iodine for antiseptic skin and vaginal preparation in patients with widespread rash, given the risk of potentially fatal anaphylaxis following exposure of broken skin and mucosa to topical chlorhexidine.
      • Dashraath P.
      • Nielsen-Saines K.
      • Rimoin A.
      • Mattar C.
      • Panchaud A.
      • Baud D.
      Monkeypox and pregnancy: Forecasting the risks.
      Am J Obstet Gynecol. 2022; 227: 849-861https://doi.org/10.1016/j.ajog.2022.08.017
      Anesthetists should refer to interim guidance on Mpox precautions, including enacting enhanced droplet precautions, consideration of negative pressure rooms for aerosol-generating procedures, and use of adequate personal protective equipment.

      Monkeypox – what to know. Society for Obstetric Anesthesia and Perinatology. Accessed December 6, 2022. https://www.soap.org/monkeypox.

      Clinicians must keep up to date on recommended guidelines for Mpox exposure in pregnant individuals, maintain suspicion of Mpox in those presenting with rash and lymphadenopathy, and ensure adequate precautions, including the use of personal protective equipment, are taken to prevent exposure while performing clinical duties.

      Guidelines for pregnant individuals with monkeypox virus exposure – The Lancet. Accessed August 6, 2022. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01063-7/fulltext#bib1.

      , 
      • Chowdhury S.R.
      • Datta P.K.
      • Maitra S.
      Monkeypox and its pandemic potential: what the anaesthetist should know.
      Br J Anaesth. 2022; 129: e49-e52https://doi.org/10.1016/j.bja.2022.06.007

      Funding

      This work was supported by Foundation for Anesthesia Education and Research (FAER) Mentored Research Training Grant (MRTG) ID: MRTG-08-15-2021-White (Robert) that was received by Dr. Robert White.

      Declaration of interests

      There are no conflicts of interest to report.

      References

      1. CDC. 2022 Monkeypox Outbreak Global Map. Centers for Disease Control and Prevention. Published December 5, 2022. Accessed December 5, 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html.

        View in Article

      2. U.S. spots first monkeypox case in a pregnant woman as cases climb. Accessed August 17, 2022. https://www.cbsnews.com/news/monkeypox-pregnant-woman-baby-cases/.

        View in Article

      3. CDC. Clinical considerations for monkeypox in people who are pregnant or breastfeeding. Centers for Disease Control and Prevention. Accessed August 6, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html.

        View in Article
        • Jezek Z.
        • Fenner F.
        II. Monkeypox virus.
        Hum Monkeypox. 1988; 17: 6-32https://doi.org/10.1159/000416457
        View in Article

      5. Human Monkeypox: A study of 2,510 contacts of 214 patients. J Infect Dis. | Oxford Academic. Accessed August 6, 2022. https://academic.oup.com/jid/article-abstract/154/4/551/2190149.

        View in Article
        • Mbala P.K.
        • Huggins J.W.
        • Riu-Rovira T.
        • et al.
        Maternal and fetal outcomes among pregnant women with human monkeypox infection in the Democratic Republic of Congo.
        J Infect Dis. 2017; 216: 824-828https://doi.org/10.1093/infdis/jix260
        View in Article

      7. Guidelines for pregnant individuals with monkeypox virus exposure – The Lancet. Accessed August 6, 2022. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01063-7/fulltext#bib1.

        View in Article
        • Dashraath P.
        • Nielsen-Saines K.
        • Rimoin A.
        • Mattar C.
        • Panchaud A.
        • Baud D.
        Monkeypox and pregnancy: Forecasting the risks.
        Am J Obstet Gynecol. 2022; 227: 849-861https://doi.org/10.1016/j.ajog.2022.08.017
        View in Article
        • Khalil A.
        • Samara A.
        • O’Brien P.
        • et al.
        Monkeypox and pregnancy: what do obstetricians need to know?.
        Ultrasound Obstet Gynecol. 2022; 60: 22-27https://doi.org/10.1002/uog.24968
        View in Article
        • Pastula D.M.
        Two cases of monkeypox-associated encephalomyelitis—Colorado and the District of Columbia, July–August 2022.
        MMWR Morb Mortal Wkly Rep. 2022; : 71https://doi.org/10.15585/mmwr.mm7138e1
        View in Article

      11. Monkeypox – what to know. Society for Obstetric Anesthesia and Perinatology. Accessed December 6, 2022. https://www.soap.org/monkeypox.

        View in Article
        • Chowdhury S.R.
        • Datta P.K.
        • Maitra S.
        Monkeypox and its pandemic potential: what the anaesthetist should know.
        Br J Anaesth. 2022; 129: e49-e52https://doi.org/10.1016/j.bja.2022.06.007
        View in Article

      Article info

      Publication history

      Published online: December 28, 2022
      Accepted: December 23, 2022

      Identification

      DOI: https://doi.org/10.1016/j.ijoa.2022.103622

      Copyright

      © 2022 Elsevier Ltd. All rights reserved.

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