The monkeypox virus (MPXV) is an orthopoxvirus with features similar to smallpox and variola (Meaney-Delman et al., 2022). The current MPXV outbreak in the United States is evolving rapidly. As of November 4, 2022, there were 28,619 cases reported with 8 deaths (Centers for Disease Control and Prevention [CDC], 2022). Care recommendations for perinatal patients are extrapolated from historic and very limited perinatal data, information from the nonpregnant population, and from known perinatal risks associated with similar viruses.
Isolation and Personal Protective Equipment
Person-to-person transmission is through respiratory droplets, direct contact with lesions, and from contact with infected objects (Dashraath et al., 2022). Incubation period is 3 to 17 days. Initial symptoms usually include fever, malaise, headache, muscle aches, and lymphadenopathy, followed 1 to 4 days later by a deep-seated, well-circumscribed rash comprised of lesions that progress from macules, papules, vesicles, to pustules before scabbing over. Most lesions in current cases have been in the genital, anorectal, or oral areas, and the illness course lasts 2 to 4 weeks (CDC, 2022). Individuals are considered contagious during the prodromal period and when exhibiting symptoms and rash and should be isolated during this time. Lesions should be covered, and a mask worn when leaving isolation (Meaney-Delman et al., 2022). Recommended personal protective equipment (PPE) for clinicians in direct contact includes gloves, surgical cap, NIOSH-approved particulate respirator equipped with N95 filters or higher, fluid-impermeable gown with long sleeves, and goggles or disposable face shield (Dashraath et al., 2022).
Treatment
Pregnant persons and their fetuses are more vulnerable to adverse outcomes from MPXV than nonpregnant persons because of heightened susceptibility to viral infections, lack of cross-protective immunity in persons of reproductive age resulting from cessation of smallpox vaccination, and from vertical transmission from the infected pregnant person to the fetus (Dashraath et al., 2022). If treatment is indicated, tecovirimat is the first-line antiviral recommended in pregnant, recently pregnant, and breastfeeding persons and vaccinia immune globulin (VIGIV) may also be considered (CDC, 2022). Both agents require additional monitoring (Dashraath et al., 2022). The nonreplicating smallpox vaccine (MVA-BN) is recommended for pre- and postexposure prophylaxis in pregnancy (Dashraath et al., 2022).
In most cases, expedited birth is not recommended for infected persons because transplacental transfer of maternal IgG antibodies is thought to occur 7 days after onset of rash, which is protective for the neonate (Dashraath et al., 2022). Patients may be eligible for vaginal birth if they do not have vaginal or anorectal lesions and vaginal and rectal polymerase chain reaction (PCR) tests are negative. Otherwise, experts recommend cesarean birth to avoid neonatal infection from exposure to lesions or infected body fluids or exudates during vaginal birth. There may be important general anesthesia considerations if oropharyngeal lesions are present or neuraxial anesthesia considerations if cutaneous lesions exist near the insertion site (Dashraath et al., 2022).
Neonatal Care and Breastfeeding
Newborn care depends on mode of birth and risk of vertical MPXV transmission. All babies should be monitored for skin, eye, and mucous membrane lesions, irritability, and feeding problems. Treatment may not be indicated for babies born by cesarean; however, those who underwent vaginal birth with high risk of MPXV transmission should have PCR testing with skin, oropharynx, and rectal swabs and consider treatment with VIGIV. Breastfeeding and skin-to-skin contact should be delayed until isolation is complete in low-risk patients. In high-risk neonates with positive PCR, breastfeeding may be considered provided there are no lesions on the patient's breast (Dashraath et al., 2022).
Given the evolving status of MPXV and complexity about care recommendations, consult the references here for more detailed guidance about MPXV.
References