Monkeypox infection during pregnancy: European registry to quantify maternal and fetal risks
Léo Pomar, Guillaume Favre, David Baud
Abstract
On 21 May 2022, the World Health Organization (WHO) declared an outbreak of monkeypox in several regions of the world, including Europe. Monkeypox is endemic in West and Central Africa, where official figures on prevalence and health impact likely represent the tip of the iceberg1. Although monkeypox has a moderate clinical course in most cases, its case fatality rate ranges between 3% and 11%1, 2, and could be higher in vulnerable groups, such as immunocompromised patients, children and pregnant women. An observational study of four women exposed to monkeypox during pregnancy reported one case of severe maternal disease and three cases of adverse fetal outcomes, including two cases of miscarriage in the first trimester and one case of intrauterine fetal demise in the second trimester. In the latter case, the fetus exhibited dermal lesions and maternal–fetal transmission was confirmed by polymerase chain reaction and histological evaluation3. Neonatal demise after a rash consistent with congenital monkeypox infection has also been described4. The related virus smallpox poses a 7-fold higher risk of severe hemorrhagic disease to pregnant women compared with non-pregnant adults5. Smallpox has also been associated with increased rates of adverse obstetric outcomes (miscarriage, stillbirth and preterm delivery)6 and congenital syndromes. As monkeypox continues to spread in Europe and other countries, it is paramount that data are collected and centralized to quantify quickly the risks associated with exposure during pregnancy. For this purpose, we have adapted our international registry for emergent viruses and pregnancy7 to accommodate monkeypox. Data collected include specific variables related to maternal disease, based on the WHO clinical severity score4, and therapeutic options, including tecovirimat, cidofovir (recommended for critically ill pregnant women only due to potential teratogenicity), hyperimmune globulin, smallpox vaccine and antibiotics to prevent bacterial superinfection (systemic amoxicillin and chloramphenicol eye drops). We have also added variables to document skin lesions in the fetus and neonate. The complete case-report form is available in Appendix S1. In addition, the follow-up form after vaccination used for the COVI-Preg registry7 can be used to monitor the safety and effectiveness of monkeypox vaccines in pregnant women8. In recent epidemics, clinicians and researchers have struggled to develop prospective and standardized tools to monitor and quantify adequately the risks associated with the emerging pathogen while taking precautions to mitigate potential selection bias and confounders. Offering this registry to all health professionals implicated in this new outbreak will allow rapid access to secure, coded patient data and reinforce data sharing between teams8, 9. Timely use of this tool could expedite estimation of the risks of maternal, fetal and neonatal adverse outcomes, which are currently unquantified10. Professionals willing to contribute to the monkeypox registry can contact us at [email protected]. Appendix S1 Structured data collection tool for monkeypox infection during pregnancy Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.