Box 2.

Knowledge gaps and research priorities for monkeypox in pregnancy

Clinical features
• What is the impact of the timing of maternal monkeypox infection in each trimester of pregnancy on the rate of obstetrical outcomes in a geographically diverse cohort? ○ Miscarriage ○ Stillbirth ○ Preterm births ○ Birthweight ○ Fetal growth restriction ○ Maternal morbidity (including psychological) and mortality • What is the rate of severe maternal infection (based on WHO clinical severity score or MPXV viral load assessment) and the impact of the severity of maternal infection on obstetrical outcomes? ○ What is the rate of asymptomatic or paucisymptomatic infection? ○ Do asymptomatic or paucisymptomatic infections carry risks to the pregnancy?
Maternal–fetal and neonatal transmission
• What is the risk of congenital infection? ○ What is the rate of vertical transmission? ○ In the event of fetal infection, what is the proportion of asymptomatic and symptomatic fetuses? ○ Does the risk of congenital monkeypox correlate with the severity of maternal disease? ○ Does MPXV detected in semen carry any risk to the pregnancy? • What is the mechanism of vertical transmission of monkeypox? ○ Can MPXV be isolated from the placenta or other fetal tissues? ○ What is the sensitivity for the molecular detection of MPXV from amniotic fluid? ○ Is the detection of MPXV from amniotic fluid or fetal tissues only transient (as seen in Zika)? •What is the risk of transmission during breastfeeding? ○ Can MPXV be isolated from breast milk?
Therapeutics and vaccines
• What are the issues from the use of tecovirimat (and other new antivirals) in pregnancy? ○ Are there iatrogenic risks to mother and fetus? ○ Does tecovirimat shorten the duration of illness and MPXV viral shedding in pregnancy? ○ Does tecovirimat reduce the risk of severe disease and mortality in pregnancy? •What are the issues from the use of vaccinia immune globulin in pregnancy? • What are the issues from the use of nonreplicating (MVA-BN) and minimally replicating (LC16) orthopox vaccines in pregnancy? ○ Effectiveness in preventing infection ○ Maternal adverse reactions ○ Immunogenicity of the orthopox vaccine in pregnancy ○ Fetal risks from vaccine exposure (eg, miscarriage and birth defects) ○ Transplacental transfer of maternal antibodies derived from vaccination and protection of the fetus and neonate ○ Breastfeeding concerns (eg, are the vaccine components detected in breast milk and in the neonate?)

MPXV, monkeypox virus; WHO, World Health Organization.

Dashraath. Monkeypox and pregnancy. Am J Obstet Gynecol 2022.