When to screen for monkeypox in pregnancy

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New guidelines outline how to test and manage pregnant women exposed to the monkeypox virus.

Clinicians should be testing for monkeypox in any pregnant woman with significant exposure even if they are asymptomatic, according to new clinical guidelines published in The Lancet.

Monkeypox infection in pregnant women poses a significant risk of severe congenital infection, miscarriage, and maternal morbidity and mortality. And with international travel resuming, they also face a higher risk of infection with the virus.

Researchers have produced a clinical management algorithm for treating pregnant women with suspected exposure to monkeypox, including symptoms to be aware of and treatment options.

The guidelines recommend clinicians be on the lookout for monkeypox in any pregnant patient who presents with lymphadenopathy or vesiculopustular rash, including rashes localised to the genital or perianal region, even if these are not clearly linked epidemiologically to the monkeypox virus.

When testing for the virus in pregnant women, other tests should also be carried out, including varicella, herpes simplex, and syphilis. These viruses may resemble symptoms of monkeypox in pregnancy.

If a pregnant patient tests positive for monkeypox, the guidelines recommend foetal ultrasound monitoring be carried out.

Given the considerable risk monkeypox poses to the foetus, researchers recommend testing asymptomatic women who have been in exposure areas and if they test positive, they should also receive a foetal ultrasound follow-up – even if they remain asymptomatic.

Subsequent management of a pregnant patient infected with monkeypox should be based on any anomalies detected by the ultra-sound, such as foetal hepatomegaly or hydrops. If the patient’s illness is severe, clinicians should consider treatment with tecovirimat and vaccinia immune globulin.

When the baby is delivered, researchers recommended assessing the viral load in the umbilical cord blood and placenta, as well as conducting real-time PCR analysis of any specimens obtained from the baby.

The researchers also advise reporting all monkeypox cases in pregnancy to the WHO and an international registry for emerging pathogens.

The guidelines outline the vaccines that are available for pregnant women, stating that the US Centre for Disease Control and Prevention has permitted the use of live smallpox vaccine ACAM2000 in pregnant women if they face a high-risk exposure to the monkeypox virus.

However, researchers emphasised that patients must be counselled on the rare but serious risk of foetal vaccinia from the vaccine, which can cause preterm delivery, stillbirth and neonatal death and well as possible adverse maternal reactions.

These recommendations reflect the Australian Technical Advisory Group on Immunisation’s (ATAGI) clinical guidance for vaccinating against monkeypox, published around the same time.

However, ATAGI declares pregnancy to be absolutely contraindicated to ACAM2000, and clinicians should advise women of child-bearing age to avoid pregnancy for a month after receiving the vaccine.

In the guidance, the ATAGI advised that ACAM2000 can be used for pre and post-exposure prophylaxis in individuals who have a high risk of being exposed to the monkeypox virus and/or those who have a high risk of severe outcomes from illness.  

ATAGI recommends that ACAM2000 be given to healthcare workers who are providing others with the vaccine and have not had a smallpox vaccine in the past, as well as those who are likely to encounter patients with monkeypox, such as primary care workers and hospital staff.

The guidance also declared, however, that specialised training and methods are required for clinicians to be able to administer ACAM2000 and that the vaccine is associated with rare but serious adverse events.

In NSW, there are currently eleven confirmed cases of monkeypox, two of which may have been caused by transmission within Australia. NSW Health is urging residents to look out for any symptoms of the virus.

The Lancet 2022, online June 21

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