Expert Recommendations on Monkeypox (MPX) in Pregnancy, Postpartum and Lactating Women

Abstract

In 2020, Brazil and the whole world faced the COVID-19 pandemic, which caused a high number of deaths. This disease was particularly severe for pregnant and postpartum women and determined a significant increase in the Maternal Death Ratio (MMR). To face the disease and assist health professionals in the qualification of the best care to the maternal-fetal binomial, the Ministry of Health and Febrasgo developed a working group formed by professors and researchers from several universities who worked to establish recommendations for the care of pregnant women and puerperal women by the time of the COVID-19 pandemic. In 2022, while we are still experiencing the COVID-19 pandemic, we are surprised by another disease caused by a virus that has been alarming the population and worrying public health authorities and gynecology and obstetrics societies in Brazil and worldwide. It is the infection that is caused by monkeypox virus (MPXV), which is still a not well-known disease, with many of its characteristics not well determined. The knowledge of this disease is fundamental for health professionals working in Obstetrics to plan forms of prevention, as well as the establishment of the diagnosis and treatment of the monkeypox (MPX) disease, preserving the health of the maternal-perinatal binomial. For this reason, the Brazilian Ministry of Health requested the same working group that acted diligently by the time of COVID-19 to establish recommendations for facing MPX, to provide adequate care for pregnant women and puerperal women. These recommendations, based on the knowledge that exists so far, are what guide these orientations and may change depending on new findings that may be presented over time. The MPXV was named after being identified in laboratory monkeys in 1958. The first case of this virus in humans was recorded in 1970 in a child in Congo and since then has become an endemic disease in West and Central Africa.[1] In 2003, the first cases were registered outside the African continent, in the United States,[2] [3] [4] but that was contained through hygienic measures and stock vaccines. In 2017, there was a major outbreak started in Nigeria and spread to some African countries. In early May 2022, another outbreak of MPXV was identified, this time in several countries outside the African continent, with fast dissemination of cases. As a result, on May 21, 2022, the World Health Organization (WHO) declared the existence of an emerging global outbreak of MPXV infection, and on July 23 has determined that this outbreak constituted a Public Health emergency of international concern. Pregnant women present clinically with similar characteristics to nonpregnant women, but may evolve with greater severity, being therefore considered a risk group. In addition to maternal clinical repercussions, there are also concerns specific to the pregnancy period, such as fetal vitality, the possibility of vertical transmission and perinatal outcome. It has been verified that MPXV infection can lead to adverse results in pregnancy, such as fetal death and spontaneous abortion.[5] [6] A recent publication on the evolution of pregnancy in 4 MPXV-infected women showed spontaneous 1^st trimester abortion in 2 pregnant women, without testing of the conception products; an intrauterine death in the 2^nd trimester, with clinical, histological and laboratory evidence of intrauterine fetal infection evidencing the very probable vertical transmission of the disease, and a pregnant woman with MPXV infection that evolved with full-term delivery of healthy conceptus.[7] Close and prolonged skin-to-skin contact, including during sexual activity, seems to be the main means of transmission of MPXV. There are suspicions of transmission of this virus by droplets and aerosols. There is also transmission through biting of rodent animals or even the ingestion of those animals. In addition, contagion by phositis, especially used clothing, can transmit the disease. The quick identification and isolation of affected individuals is fundamental to prevent the spreading of the disease.[8] Transmission of MPXV occurs in the phase of active skin lesions and only ends when they heal completely, which usually requires isolation of 21 to 28 days.[7] [9] [10] There are doubts as to whether the contagion could be prior to the phase of skin lesions, since viral DNA has already been identified in the blood and respiratory system of patients prior to the lesions.[5] [7] Sexual transmission has been discussed not only by contact, but also because the virus has been identified in seminal material.[5] [11] Patients with MPXV should be isolated in a separate area of their home or in hospital services, especially if they present extensive lesions and/or respiratory symptoms. Skin lesions should be covered (for example, with the use of long sleeves and trousers) to minimize the risk of contact. Everyone should wear a face mask in the presence of an infected person. Sexual abstinence is also recommended in the phase of unhealed lesions and condom use for any form of sexual act (anal, oral, or vaginal) in the 12 weeks following the healing of the lesions.[7] Most patients with MPXV will have mild disease and can be cared for at home, where they should remain isolated. Standard cleaning and disinfection procedures should be performed, taking care of clothes and used objects. The diagnosis of infection can be made by anamnesis and clinical findings, with epidemiological suspicion. The incubation period is, on average, 6 to 13 days, and can be from 5 to 21 days. Next to this, a prodromal period occurs, when fever, sweating, headache, myalgia, fatigue and lymphadenomegaly, which is quite characteristic of the disease, are manifested. About 1 to 3 days later, the rash, which usually affects the face, genitals, and extremities, and has a centrifugal character, appears. The lesion evolves from macules to papules, vesicles, pustules...