Monkeypox

in Pregnancy
dr. Lingga Yudistira, Sp.OG
Dokter Spesialis Obgyn RSUD Cipayung
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• Monkeypox merupakan emerging zoonosis yang disebabkan virus Monkeypox
(anggota genus Orthopoxvirus dalam keluarga Poxviridae).

• Monkeypox pertama kali ditemukan tahun 1958 di Denmark ketika ada dua kasus
seperti cacar pada koloni kera yang dipelihara untuk penelitian, sehingga cacar ini
dinamakan 'monkeypox.

• Sejak Mei 2022, Monkeypox menjadi penyakit yang menjadi perhatian kesehatan
masyarakat global, karena dilaporkan dari negara non endemis

Kemenkes, 2022
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Negara-negara yang melaporkan kasus monkeypox tahun 1970 - 2017

Sebaran Kasus Konfirmasi dan Suspek Monkeypox di Negara Non Endemis 29 Mei 2022
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• The current cases have included uncharacteristic presentations of monkeypox virus infection;
many of the initial patients presented with painful genital and perianal lesions, oral lesions, and
proctitis in the setting of mild or no prodromal symptoms, linked to sexual activity between men

• July 5, 2022, seven cases of monkeypox virus infection have been reported in women and
transgender men in the United States

• Although little is known about monkeypox virus infection and pregnancy, prompt diagnosis,
prevention, and treatment may reduce the risk of adverse outcomes
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According to the CDC, the virus spread through:
• Respiratory secretions passed during kissing, cuddling, sex, or prolonged face-to-face contact
• Direct contact with an infected person’s body fluids, scabs, rash, or belongings that touched their
fluids or lesions
• The placenta of an infected pregnant person to a fetus

• Information about monkeypox virus infection during pregnancy is limited

• Monkeypox virus infection was confirmed by polymerase chain reaction testing in fetal tissues and in the
placenta, with high viral loads detected in several fetal tissues
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Case Report
• From March 2007 to July 2011, 222
symptomatic patients were enrolled, of
whom 81 (36%) were female patients
and 141 (64%) were male patients.

• In all 4 cases, hematological and clinical

chemistry findings were within normal
limits, except for a decreased albumin
level

• During hospitalization, they received

antibiotics (amoxicillin,
chloramphenicol via eye drops, and
erythromycin, as well as gentamycin, if
necessary), paracetamol and
papaverine were given as analgesics,
metronidazole and mebendazole were
administered for giardiasis and other
intestinal parasitic infections, and
quinine as given for malaria.
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Case Report
• Pathologic findings for the stillborn fetus from case 4 consisted of
diffuse cutaneous maculopapillary lesions involving the skin of the
head; the trunk, including the abdomen, back, and chest; and the
extremities, including the palms and soles of the hands and feet

• There were no congenital malformations or deformities

• Extensive postmortem autolysis was present, consistent with

intrauterine fetal demise. Products of conception (excluding the
fetus) showed placental hemorrhages on the maternal cotyledon
surfaces, which were numerous, punctate, and diffuse; no other
gross abnormalities in the placenta, placental membranes, or
umbilical cord were seen

• In anotherreport of a probable (non-laboratory-confirmed) case,

apregnant woman infected at around 24 weeks’ gestationdelivered
a premature infant 6 weeks later. The baby had ageneralized skin
rash consistent with monkeypox diseaseand died of malnutrition 6
weeks later
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Treatment
• Monkeypox virus infection can be self-limited; however, certain populations are at risk for severe
disease and should be considered for treatment, includes all pregnant people with monkeypox
virus infection regardless of trimester of infection and people who are breastfeeding

• This is because of the probable increased risk of severe disease during pregnancy, risk of
transmission to the fetus during pregnancy or to the newborn by close contact during and after
birth, and risk of severe infection in newborns.

• The risks and benefits of treatment should be discussed with the patient using shared decision-
making.
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Tecovirimat (also known as TPOXX or ST-246)
• Tecovirimat should be considered the first-line antiviral for people who are pregnant, recently
pregnant, or breastfeeding.
• There are no available data on the use of tecovirimat in pregnant individuals to evaluate for a
drug-associated risk of major birth defects, miscarriage, and other adverse maternal and fetal
outcomes.
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Brincidofovir
• This medications should not be used to treat monkeypox virus infection in people who are in the
first trimester of pregnancy
• Brincidofovir are present in breast milk still not known, so they should not be used in people who
are breastfeeding due to the potential for serious adverse reactions in the breastfeeding infant
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Vaccinia Immune Globulin Intravenous (VIGIV)

• Vaccinia immune globulin intravenous is licensed by the FDA for the treatment of complications
due to vaccinia vaccination and is also available for the treatment of orthopoxviruses in an
outbreak setting.
• No human or animal data are available for vaccinia immune globulin intravenous during
pregnancy; however, other immunoglobulins have been widely used in pregnancy without
negative side effects
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Prevention
Timing and mode of delivery
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Neonatal care
• The baby shouldundergo viral PCR testing of swab sample from the throator any lesions that are present
• The baby should beisolated at birth from its mother and others, in a singleroom, with carers wearing
appropriate
• The baby should be carefully monitored for signs of compromise ormonkeypox infection
• If the baby tests positive, the motherand baby can be reunited
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Breastfeeding
The patient should be counseled about the risk of transmission and the potential for severe
disease in newborns. If the patient chooses to have contact with the newborn during the
infectious period, strict precautions should be taken, including the following:
• There should be no direct skin-to-skin contact.
• During contact the newborn should be fully clothed or swaddled and after contact occurs the
clothing or blanket should be removed and replaced.
• Gloves and a fresh gown should be worn by the patient at all times, with all visible skin below
the neck covered.
• Soiled linens should be removed from the area.
• The patient should wear a well-fitting source control (e.g. medical mask) during visit.
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• Monkeypox virus infection has been reported in many nonpandemic
countries
• Case have been linked to international travel and close, sustained
contact.
• Most ob-gyns have never seen a case of monkeypox virus infection
and may not be aware of testing, treatment, or preexposure or
postexposure vaccine options
• Raising awarness of risk factors and educating people about measures
they can take to reduce exposure to the viris is the main prevention
strategy