Obstetric Care Considerations for Mpox

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*On November 28, 2022, following a series of consultations with global experts, the World Health Organization (WHO) selected the term “mpox” which will be used as the preferred synonym for monkeypox. For the next year while “monkeypox” is phased out, both names will be used. The Centers for Disease Control and Prevention is also aligning their terminology with this recommendation from WHO. In recognition of the stigma and other associated issues with the term “monkeypox,” ACOG is adopting the term “mpox” in place of “monkeypox” and has updated these FAQs to reflect this preference.

Background

Since early May 2022, cases of mpox have been reported in nonendemic parts of the world and the Centers for Disease Control and Prevention (CDC) and its local health partners are tracking thousands of cases of mpox in the United States. On July 30, 2022, the CDC released a Health Alert Network Health Update summarizing the available recommendations and resources for certain populations, including pregnant and breastfeeding individuals.

Mpox is caused by infection with the Monkeypox virus. Monkeypox virus is part of the same family of viruses as variola virus, the virus that causes smallpox. It is not related to the virus that causes chickenpox, varicella-zoster virus. Mpox symptoms are similar to smallpox symptoms and usually include fever, headache, muscle aches, swollen lymph nodes, respiratory symptoms, and a rash that can look like pimples or blisters or vesicles that can appear on the face, hands, feet, chest, genitals, or anus, or inside the mouth (CDC Clinical Recognition). The rash can be painful. The mortality rate of the currently circulating monkeypox virus clade is low with prompt supportive care. To date, there have been very few deaths worldwide.

Mpox spreads from person to person through direct contact with the infectious rash, scabs, or body fluids; respiratory secretions during prolonged face-to-face contact, or during intimate physical contact (such as kissing, cuddling, or sex); and touching items (such as clothing or linens) that previously touched the infectious rash or body fluids. It is also possible for people to get mpox from infected animals, either by being scratched or bitten by the animal or by preparing or eating meat or using products from an infected animal (CDC Transmission).

Pregnant people can spread the virus to their fetus through the placenta and through close contact with the newborn (CDC Transmission).

Mpox can spread from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. The illness typically lasts 2–4 weeks. Spread of mpox from people without symptoms has not been observed. At this time, it is not known whether mpox can spread through semen, vaginal fluids, or breast milk (CDC Transmission).

For more details on mpox diagnosis, management, treatment, and prevention during pregnancy, see ACOG's Frequently Asked Questions below.

Frequently Asked Questions

General Considerations

Last updated December 8, 2022

The signs and symptoms of mpox infection in people who are pregnant appear similar to those in nonpregnant people with mpox infection, including fever, lymphadenopathy, lethargy, pharyngitis, headache, myalgias, and rash. Rash associated with mpox infection can be found in the anogenital area (most commonly reported location in this current outbreak), trunk, arms, legs, face, and the palms and soles. A wide spectrum of skin lesions has been described, including macular, pustular, vesicular, and crusted lesions, and lesions in multiple phases were present simultaneously (NEJM 2022) (see CDC for common symptoms).
Last updated December 8, 2022

Rash in a person who is pregnant with risk factors for mpox infection needs to be differentiated from other skin conditions during pregnancy. Importantly, mpox lesions can mimic those of other skin infections such as molluscum contagiosum; and during the current outbreak, lesions have been common in the genital region. Therefore, mpox should be a differential diagnosis for any patient presenting with a rash or genital lesion. Patients with rashes initially considered characteristic of more common infections (e.g., varicella zoster or sexually transmitted infections [STIs]) should be carefully evaluated for a mpox rash (see CDC information on clinical recognition and images).
Last updated December 8, 2022

The diagnostic approach to a patient with suspected mpox infection is the same for pregnant and nonpregnant people. If a patient presents with signs and symptoms of mpox infection, diagnostic testing should be considered, especially if the person has risk factors for mpox infection. CDC outlines epidemiological criteria for a suspected case of mpox. Co-infection with monkeypox virus and other STIs has been frequently reported (NEJM 2022). The presence of an STI does not rule out mpox, and clinicians should have mpox on their differential diagnosis when presented with an STI-associated or STI-like rash, even if it is localized and not (yet) diffuse.

Clinicians should consult their infectious disease team and/or infection and control practice in their hospital system, their state health department (State Contacts), or CDC through the CDC Emergency Operations Center (770-488-7100) as soon as mpox is suspected to ensure proper testing and reporting.
Last updated December 8, 2022

There are limited data on mpox infection during pregnancy. It is unknown whether pregnant people are more susceptible to mpox virus or whether infection is more severe in pregnancy. Monkeypox virus can be transmitted to the fetus during pregnancy or to the newborn by close contact during and after birth (CDC). Adverse pregnancy outcomes, including spontaneous pregnancy loss and stillbirth, have been reported in cases of confirmed mpox infection during pregnancy (Meaney-Delman, 2022). Preterm delivery and neonatal mpox infection have also been reported. The risk factors associated with severe infection and adverse pregnancy outcomes are not known (CDC Pregnancy).
Last updated December 8, 2022

Monkeypox virus can be transmitted to the fetus during pregnancy or to the newborn by close contact during and after birth. Adverse pregnancy outcomes, including spontaneous pregnancy loss and stillbirth, have been reported in cases of confirmed mpox infection during pregnancy. Preterm delivery and neonatal mpox infection have also been reported. The frequency and risk factors for severity and adverse pregnancy outcomes are not known (CDC).

Staffing, Personnel, and Hospital Resources

Last updated December 8, 2022

Infection control practices for the care of patients who are pregnant with mpox infection are the same as those for patients who are not pregnant with mpox infection. This includes appropriate isolation of patients with mpox; training for health care personnel on maternity and newborn care units on correct adherence to infection control practices and personal protective equipment (PPE) use and handling; and ensuring sufficient and appropriate PPE supplies are positioned at all points of care.

Furthermore, visitors to pregnant or postpartum patients with mpox should be strictly limited to those essential for the patient’s care and well-being, and should have no direct contact with the patient. Use of alternative mechanisms for patient and visitor interactions, such as video-call applications, should be encouraged for any additional support.

See CDC Guidance on Infection Control for more information.
Last updated December 8, 2022

The CDC outlines infection control recommendations for the prevention of mpox in health care settings. Standard precautions should be applied for all patient care, including for patients with suspected mpox. If a patient seeking care is suspected to have mpox, infection prevention and control personnel should be notified immediately.

Clinicians should don appropriate PPE prior to evaluation of a suspicious rash, which includes gown, gloves, eye shields, and a NIOSH-approved particulate respirator with N95 filters or higher (CDC).

Vaccination

Last updated December 8, 2022

There are currently two available vaccines that have demonstrated efficacy against mpox: JYNNEOS and ACAM2000.

The Advisory Committee on Immunization Practices (ACIP) recommends that people whose jobs may expose them to orthopoxviruses, such as mpox, get vaccinated with either ACAM2000 or JYNNEOS to protect them if they are exposed to an orthopoxvirus. For the current outbreak, individuals, including people who are pregnant, who are exposed to mpox can be vaccinated. Postexposure vaccination is recommended within 4 days from the date of exposure for the best chance to prevent onset of the disease.

JYNNEOS

JYNNEOS can be offered to people aged 18 years and older who are pregnant or breastfeeding who are otherwise eligible for vaccination. The risks and benefits of JYNNEOS should be discussed with the patient using shared decision-making.

JYNNEOS is a live, nonreplicating viral vaccine licensed for prevention of both smallpox and mpox disease. Available human data on JYNNEOS administered to people who are pregnant are insufficient to determine whether there are any vaccine-associated risks in pregnancy, however; studies of JYNNEOS vaccine in animals have shown no evidence of harm to a developing fetus.

The safety and efficacy of JYNNEOS have not been evaluated in people who are breastfeeding or in young children. It is not known whether JYNNEOS is excreted in human milk. Data are not available to assess the impact of JYNNEOS on milk production or the safety of breast milk for children from persons vaccinated with JYNNEOS. However, JYNNEOS vaccine is replication deficient and therefore should not present a risk of transmission to breastfed infants.

For more information, please see Use of JYNNEOS (Smallpox and Mpox Vaccine, Live, Nonreplicating) for Preexposure Vaccination of Persons at Risk for Occupational Exposure to Orthopoxviruses: Recommendations of the Advisory Committee on Immunization Practices— United States, 2022, and The Food and Drug Administration's JYNNEOS Package Insert.

ACAM2000

Vaccination with ACAM2000 is contraindicated in people who are pregnant or breastfeeding because of the risk of pregnancy loss, congenital defects, and vaccinia virus infection in fetuses and newborns and the availability of a nonreplicating viral vaccine.

If an individual is vaccinated with ACAM2000, they should be counseled to avoid becoming pregnant (or getting their partner pregnant) for 4 weeks after vaccination, and until the vaccination site has healed, the scabs have fallen off, and a fresh layer of intact skin has formed.

Persons vaccinated with ACAM2000 should isolate from household contacts with contraindications to vaccination (including pregnant and lactating people) for 4 weeks after vaccination and until the vaccination site has healed, the scab has fallen off, and a fresh layer of intact skin has formed. Precautions should be used to avoid transmitting live vaccinia virus to other household contacts.
Last updated December 8, 2022

JYNNEOS typically may be given at the same time as other vaccines. However, because of the observed risk for myocarditis after receipt of ACAM2000 vaccine and Moderna, Novavax, or Pfizer-BioNTech COVID-19 vaccines and the unknown risk for myocarditis after JYNNEOS, some people might consider waiting 4 weeks after JYNNEOS or ACAM2000 before receiving a Moderna, Novavax, or Pfizer-BioNTech COVID-19 vaccine. If an orthopoxvirus vaccine is recommended for prophylaxis in the setting of an outbreak, orthopoxvirus vaccination should not be delayed because of recent receipt of a Moderna, Novavax, or Pfizer-BioNTech COVID-19 vaccine; no minimum interval between COVID-19 vaccination with these vaccines and orthopoxvirus vaccination is necessary (CDC Mpox Vaccination).
Last updated December 8, 2022

As with all vaccines, adverse events should be reported to the Vaccine Adverse Event Reporting System (VAERS). Reports can be filed by health care professionals or by vaccine recipients. To file an adverse reaction report, please visit www.vaers.hhs.gov or call 1-800-822-7967. VAERS is only for reporting reactions, and VAERS staff members do not give medical advice.

For more information, please see Mpox and Smallpox Vaccine Guidance.

Treatment

Last updated December 8, 2022

Pregnant, recently pregnant, and breastfeeding people should be prioritized for medical treatment if needed. Pregnancy alone is an indication for offering treatment in patients with mpox. Treatment for mpox should be offered to people who are pregnant, recently pregnant, or breastfeeding; however, given the limited data on treatment efficacy, treatment decisions will depend on the stage and severity of illness. Close monitoring for severe disease and pregnancy complications are important. The risks and benefits of treatment should be discussed with the patient using shared decision-making, and the decision to treat and monitor a pregnant person as an outpatient or inpatient should be individualized.
Last updated December 8, 2022

There are several treatment options available for mpox. An overview of available treatments and recommendations for or against their use during pregnancy is outlined below. The CDC is offering assistance to physicians in the diagnosis and management of patients with suspected mpox. If treatment is needed, or additional information is required, physicians can contact the CDC Emergency Operations Center at 770-488-7100, Monday through Friday, 8 a.m. to 4:30 p.m. ET; at other times, call 404-639-2888.

Tecovirimat

If treatment is indicated, tecovirimat should be considered the first-line antiviral for people who are pregnant, recently pregnant, or breastfeeding. There are no human data on the use of tecovirimat in pregnancy and lactation, and information of its impact on reproductive development is limited to animal studies. No specific fetal effects were observed in these studies. It is not known whether treatment with tecovirimat during pregnancy prevents congenital mpox. Tecovirimat was present in breast milk in animal studies, and it is not known whether levels of tecovirimat expressed in breast milk are sufficient for treatment of a breastfeeding child with mpox. As such, if indicated, children with mpox who are breastfeeding should be treated independently.

Cidofovir and Brincidofovir

Although cidofovir and brincidofovir have been considered as alternative antiviral therapies to treat mpox for the general population, animal reproduction studies showed evidence of teratogenicity. As such, these medications should not be used to treat mpox in people who are in the first trimester of pregnancy. Similarly, it is not known whether cidofovir and brincidofovir are present in breast milk, and they should not be used in people who are breastfeeding because of the potential for serious adverse reactions in the breastfeeding infant.

As stated above, tecovirimat should be the first line of treatment in pregnancy. Cidofovir may be considered for critically ill pregnant people in the second or third trimester. An important side effect to be aware of with the use of cidofovir is nephrotoxicity.

Vaccinia Immune Globulin Intravenous (VIGIV)

Animal reproduction studies have not been conducted with VIGIV; therefore, it is not known whether VIGIV can cause fetal harm when administered during pregnancy. However, immune globulins have been widely used during pregnancy for many years without any apparent negative reproductive effects. The risks and benefits of VIGIV administration should be assessed for each individual patient. It is not known whether VIGIV is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when VIGIV is administered to a person who is breastfeeding.

Additional information about mpox treatment can be found on the CDC website.

Prenatal Care

Last updated December 8, 2022

Because of the limited data on mpox and pregnancy, the exact risk to the fetus, when vertical transmission is most likely to occur, and what additional fetal surveillance may be needed are unclear. Additional fetal surveillance may be considered depending upon the gestational age, but data regarding fetal surveillance are extrapolated from other viral infections that have been monitored during pregnancy. Specific evidence-based fetal interventions for mpox are unknown at this time. Recommendations regarding the need for additional antenatal fetal surveillance may evolve as more information becomes available if additional mpox cases during pregnancy are reported during this outbreak.

Intrapartum Care

Last updated December 8, 2022

There is currently no evidence to recommend cesarean delivery in all pregnant persons with a previous or current mpox infection. Data are insufficient to demonstrate that cesarean section reduces the risk of perinatal infection or adverse outcomes. More data are needed to better understand the timing of vertical transmission to the fetus in order to inform delivery mode and timing recommendations. Cesarean delivery may be offered, particularly in the presence of genital lesions that cannot be covered, to reduce the risk of neonatal contact during delivery. Decisions regarding cesarean delivery should be individualized, and clinicians should use shared decision-making with patients, taking into account the current limited knowledge about mpox transmission during pregnancy and delivery. Guidance on timing and mode of delivery may evolve as more data become available.

Postpartum Care

Last updated December 8, 2022

The benefits of skin-to-skin contact and rooming-in on breastfeeding and infant physiology are well known; however, given the risk of neonatal transmission of monkyepox virus with close contact and potential for severe disease in newborns, direct contact between a patient in isolation for mpox and their newborn is not advised until the criteria for discontinuing isolation have been met (i.e., all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed).

See CDC for additional considerations for infant contact.
Last updated December 8, 2022

Breast milk is the best source of nutrition for most newborns, and it provides protection against many illnesses. However, given that mpox virus is spread by close contact and neonatal mpox infection may be severe, breastfeeding should be delayed until criteria for discontinuing isolation have been met (i.e., all lesions have resolved, the scabs have fallen off, and a fresh layer of intact skin has formed) and breast milk should be pumped and discarded during this time.

See CDC and AAP for additional information on infant feeding with breast milk.

Please contact [email protected] with any questions.

Additional Resources

Mpox Guidance (CDC)
Clinical Considerations for Monkeypox in People Who are Pregnant or Breastfeeding (CDC)
Update for Clinicians on Monkeypox in People with HIV, Children and Adolescents, and People who are Pregnant or Breastfeeding (CDC Health Alert Network)
A Primer on Monkeypox Virus for Obstetrician-Gynecologists (Obstetrics & Gynecology)
Society for Maternal-Fetal Medicine Frequently Asked Questions (SMFM)

This document has been developed to respond to some of the questions facing clinicians providing care during the rapidly evolving mpox outbreak situation. As the situation evolves, this document may be updated or supplemented to incorporate new data and relevant information. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

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Obstetric Care Considerations for Mpox*