Reply to the Letter to Editor ‘monkeypox Virus in Pregnancy, Do We Have Sufficient Evidence?’

We thank Dr El-Qushayri for his interest in our article.1D'Antonio F Pagani G Buca D Khalil A Monkeypox infection in pregnancy: a systematic review and metaanalysis.Am J Obstet Gynecol MFM. 2022; 5100747Google Scholar The recent outbreaks of monkeypox infection have highlighted the need for a specific knowledge of the effect of such infection on pregnant individuals and their infants. In May 2022, multiple cases of monkeypox infection were identified in several nonendemic countries, mainly the United Kingdom, and in July 23, 2022, the World Health Organization declared monkeypox a global health emergency. Although the course of monkeypox infection is often self-limiting, there is lack of objective data on its course in pregnancy. Previous data on smallpox infection, a virus belonging to the same family of monkeypox, in pregnancy have suggested a heightened risk of adverse maternal and perinatal outcomes. In our review, we reported a relatively high risk of adverse fetal, but not maternal, outcomes in pregnancies complicated by monkeypox infection. Only 7 cases of pregnant women were included in the review. Regarding the potential inclusion of duplicate cases in the studies by Ogoina et al2Ogoina D Iroezindu M James HI et al.Clinical course and outcome of human monkeypox in Nigeria.Clin Infect Dis. 2020; 71: e210-e214Crossref PubMed Scopus (186) Google Scholar and Yinka-Ogunleye et al,3Yinka-Ogunleye A Aruna O Dalhat M et al.Outbreak of human monkeypox in Nigeria in 2017-18: a clinical and epidemiological report.Lancet Infect Dis. 2019; 19: 872-879Abstract Full Text Full Text PDF PubMed Scopus (309) Google Scholar we contacted the authors before the inclusion of these cases in our review, and we did not receive any information suggestive of duplicate cases in these studies. We acknowledge the fact that the very small number of cases included represents a major limitation of our systematic review. Furthermore, there was no information on other potential causes of fetal death, including chromosomal anomalies, malformation, or placental insufficiency, and all women were hospitalized because of moderate or severe disease, thus potentially overestimating the perinatal risks associated with the infection. Finally, the viral clade of the current monkeypox outbreak is different to that from the studies included in our review and includes older monkeypox variants, and this is likely to affect the risk of the different maternal and perinatal outcomes.4Khalil A Samara A O'Brien P et al.Monkeypox vaccines in pregnancy: lessons must be learned from COVID-19.Lancet Glob Health. 2022; 10: e1230-e1231Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar A recent update on cases of monkeypox in pregnancy during the current break has reported no harmful effect for either the mother or fetus in 10 pregnancies complicated by monkeypox infection. These findings are partially reassuring about the actual risk of adverse maternal and fetal outcomes in pregnant women with monkeypox infection.5Khalil A Samara A O'Brien P et al.Monkeypox in pregnancy: update on current outbreak.Lancet Infect Dis. 2022; 22: 1534-1535Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Nevertheless, we believe that the first aim of a systematic review should be not to provide evidence but to report whether there is evidence on a given clinical question. Our review highlighted the need for a large worldwide registry of monkeypox infection in pregnancy and those individuals’ receiving vaccination or antiviral treatment during pregnancy, to elucidate the actual burden of this disease and the safety of vaccination and/or treatment.