Monkeypox in pregnancy: virology, clinical presentation, and obstetric management.

The 2022 monkeypox outbreak, caused by the zoonotic monkeypox virus, has spread across six WHO regions (the Americas, Africa, Europe, Eastern Mediterranean, Western Pacific and South-East Asia) and was declared a public health emergency of international concern on July 23, 2022. The global situation is especially concerning, given the atypically high rate of person-to-person transmission, suggesting viral evolution to an established human pathogen. Pregnant women are at heightened risk of vertical transmission of the monkeypox virus due to immune vulnerability, natural depletion of population immunity to smallpox among reproductive-age women, and because orthopoxviral cell entry mechanisms can overcome the typically viral-resistant syncytiotrophoblast barrier within the placenta. Pregnancy outcomes following monkeypox infection are scarce but include reports of miscarriage, intrauterine demise, preterm birth and congenital infection. This article aims to forecast the issues maternity units might face and propose management guidelines to protect the health of pregnant women and their fetuses. We review the pathophysiology and clinical features of monkeypox infection and discuss the implications of the unusually high prevalence of anogenital lesions. We describe the use of real-time polymerase chain reaction tests from mucocutaneous and oropharyngeal sites to confirm infection and share an algorithm for the antenatal management of pregnant women with monkeypox virus exposure. Based on the best available knowledge from prenatal orthopoxvirus infections, we discuss the sonographic features of congenital monkeypox and the role of invasive testing in establishing fetal infection. We suggest a protocol for cesarean delivery to avoid the horizontal transmission of the monkeypox virus at birth and address the controversy of mother-infant separation in the postpartum period. Obstetric concerns relating to antiviral therapy with tecovirimat and vaccinia immune globulin, including the risks of QTc prolongation, erroneous blood glucose monitoring and venous thromboembolism, are highlighted. Finally, we discuss the possibility of monkeypox vaccine hesitancy during pregnancy, offer strategies to mitigate these risks and propose research priorities to address knowledge gaps about the impact of monkeypox infection on maternal, fetal, and neonatal health.