In creating a guide to monkeypox for OB/GYNs, Denise J. Jamison, MD, MPH, drew on the research she relied on during another outbreak almost 20 years ago.
Jamison, James Robert McCord Professor and Chair of the Department of Gynecology and Obstetrics at Emory Healthcare in Atlanta, Georgia, was working for the Centers for Disease Control and Prevention (CDC) in 2003 when doctors diagnosed monkeypox in several states.
That year, the virus was mainly transmitted through contact with domestic prairie dogs, including in child care facilities and schools. According to one study, of the approximately 70 suspected and confirmed cases, 55% are women.
Jamison, an obstetrician who specializes in emerging infectious diseases, and her colleagues at the agency published a commentary in the journal Obstetrics and Gynecology highlighting the need for doctors to stay up to date on the virus.
Fast forward to 2022: Jamison – again with co-authors from the CDC – makes a similar post in the same journal about the need for clinicians to be prepared for this virus.
“Most OB/GYNs have never experienced monkeypox virus infection and may not be aware of testing, treatment, or vaccination options before or after exposure,” she and her co-authors wrote in a textbook published online last month.
But if a woman catches the virus, her gynecologist may very well be the first doctor she calls. “We are often the first people, the first doctors, to see and evaluate women with a variety of symptoms,” Jamison said.
Obstetricians and gynecologists need up-to-date information to quickly diagnose, treat and prevent the further spread of monkeypox, they said.
Based on evidence from related viruses such as smallpox, monkeypox may be more severe in pregnant women and carry a risk of poor pregnancy outcomes, Jamison said.
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So far this year, monkeypox has spread predominantly among men who have sex with men. However, cases have occurred in women, some of whom have required hospitalization.
As of July 25, there were 1,373 cases of monkeypox in the US in men and 13 in women, according to the CDC. The total number of confirmed cases exceeded 5,800 as of August 1. The agency recently announced that it plans to make the disease a notifiable disease.
In the United Kingdom, which has been hit hard by the outbreak, researchers are closely monitoring the number of cases among women to assess how the disease is spreading.
At least one case of monkeypox in the United States occurred in a pregnant woman who gave birth. The mother and baby, who received immunoglobulin as a preventive measure, are doing well, health officials said.
“We know that infection can occur through the placenta. In the case we currently know about, it appears that the virus was not transmitted,” said John T. Brooks, MD, CDC’s chief medical officer in the HIV division. prevention, by phone July 23 with clinicians.
While monkeypox can be transmitted in utero and during sexual intercourse, it can also be spread through any close contact with skin lesions or bodily fluids, and possibly through touching contaminated objects such as clothing or bedding, according to the CDC.
One monkeypox vaccine, Jynneos, is preferred for use during pregnancy, while the other, ACAM2000, is contraindicated, the CDC says.
Jynneos can be offered to people who are pregnant or breastfeeding and who are eligible for vaccination based on confirmed or probable exposure, ideally within 4 days of exposure. People at high risk of infection, such as laboratory workers, may receive the vaccine in advance.
Animal developmental toxicity studies found no evidence of harm from the Jynneos vaccine, Jamison said.
However, according to the CDC, ACAM2000 can cause fetal vaccinia and should not be used in pregnant or breastfeeding individuals.
The Society for Maternal and Fetal Medicine notes that if treatment for monkeypox is warranted, tecovirimat should be considered a first-line antiviral for pregnant, recently pregnant, and breastfeeding individuals, in accordance with CDC recommendations.
Current outbreak ‘very different’ but lessons apply
In 2003, some women who contracted monkeypox through contact with infected prairie dogs became pregnant, which is how Jamieson became involved in the outbreak response and studying the virus’ impact on pregnancy.
“When it came out again this year, it certainly got my attention,” Jamison said. Extensive person-to-person transmission and a much higher number of cases today make the current outbreak “very different” from the previous one, she said.
But the key principles of treating the condition and understanding its potential risks during pregnancy—despite relatively limited information—remain the same.
“Whenever you look at an infectious disease, you want to think about whether pregnant women are more susceptible or more prone to severe disease,” Jamison said. Smallpox, similar to orthopoxvirus, “is more severe during pregnancy with a higher fatality rate”, which is one reason for concern about monkeypox in this population.
In terms of pregnancy outcomes, researchers only have a few confirmed cases of monkeypox, Jamison said, making it difficult to draw conclusions. A review of five cases outside the United States in previous years found that three cases resulted in pregnancy termination. One of them led to premature birth of an infant who later died. One child was outwardly healthy and was born at term.
Complement to differential Dx
A separate group of researchers proposed a clinical algorithm for managing pregnant women with suspected monkeypox infection.
“Physicians should maintain a high level of suspicion for monkeypox virus in any pregnant woman with lymphadenopathy and a vesiculo-pustular rash, including rash localized to the genital or perianal area, even if there are no obvious epidemiological links,” Pradeep Dashrat, MBBS, National University. Hospital, Singapore, and co-authors wrote earlier this summer in The Lancet.
Jamison repeated the call for heightened vigilance.
“As OB/GYNs, people may come to us with genital lesions associated with sexually transmitted infections. And it’s important to include monkeypox in our differential diagnosis,” Jamieson said. “We’re trying to get across that this should be part of what you think of when you see a patient with genital ulcers.”
Jamieson added that healthcare workers contract monkeypox through contact with patients or fomites, so clinicians should take appropriate precautions when examining patients who may have monkeypox. Appropriate protective measures include wearing a gown, gloves, eye protection and N95.
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