NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date

SUMMARY:

Boelig et al. (AJOG MFM, 2020) provide a helpful (and necessary) overview, including suggestions for managing obstetrical workflows during the COVID-19 pandemic. The focus is not only on MFM practice; the authors also provide multiple proposals that may ease congestion and limit viral spread. Note that the following summary reflects ‘Expert Review’. Professional society and organization COVID-19 guidelines may differ.

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• Patient with Symptoms
• Altering the Standard OB Visit Schedule
• Prenatal Ultrasound
• NSTs and BPPs

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Patient with Symptoms

• Pregnancy alone warrants testing (if influenza negative)
  • “Especially if additional risk factors”
• Triage via telehealth to determine if additional supportive care is required
  • Mild symptoms do not require in-person assessment
  • Self-isolate for 14 days (i.e., assume infection unless confirmed otherwise)
  • Use drive-through testing or stand-alone testing rather than in-person office visits/testing
• If patient does come to the office and is symptomatic, assume infection | CDC recommends that

Patients with suspected or confirmed COVID-19 should be asked to wear a surgical mask as soon as they are identified and be evaluated in a private room with the door closed

Healthcare personnel entering the room should use Standard and Transmission-based Precautions

Altering the Standard OB Visit Schedule

Visits Without Face-to-Face Interactions

• Intake Visit
  • Can be done by telehealth unless urgency to visit
  • In general, the authors recommend taking advantage of telehealth opportunities if possible
• 16, 24 and 34 weeks
  • Use telehealth
• Postpartum
  • Photos can be used to assess wounds and other issues (e.g., mastitis) and uploaded via patient portals

In-Person Antenatal Visit Schedule

• <11 weeks
  • Telephone OB intake
  • Consider earlier if at risk for ectopic
• 11-13 weeks
  • Ultrasound for dating and aneuploidy screening (if not scanned previously | If proven viability, cfDNA (NIPS) could obviate need for ultrasound
  • OB labs
• 20 weeks
  • Structural fetal anatomy ultrasound
• 28 weeks
  • Appropriate labs (e.g., GDM screening) and vaccines
• 32 weeks
  • Ultrasound (if indicated)
• 36 weeks
  • Ultrasound (if indicated)
  • GBS/HIV screen
• 37 weeks until delivery
  • Weekly visits

Additional Considerations

• Use home BP monitoring where possible
• Use low volume blood drawing centers if feasible

KEY POINTS

• The authors provide some general points and suggested abbreviated visit schedules for ultrasound and fetal assessment to limit exposure and protect the health of patients and obstetric professionals
• MFM practices and obstetrical units may alter their routine scheduling patterns for high risk OB patients based on resources and local policies | The authors’ modified schedules can be found in ‘Learn More – Primary Sources’ below

Prenatal Ultrasound

• Dating
  • cfDNA is an option for aneuploidy testing if patient has had an early first trimester ultrasound and viability is established
• Anatomy (Early 2nd trimester to 22 weeks)
  • Consider limiting follow-up views to 4 to 8 weeks vs usual 1 to 2 weeks
  • If only a single view or 2 views are missing (example given: lumbar sacral spine not well seen but posterior fossa is within normal, which would strongly suggest absence of NTD)
  • BMI>40: Schedule later in pregnancy (e.g., 22 weeks) to avoid need for follow up due to missing views
• Additional ultrasound testing
  • Third trimester growth scan: 32 weeks
  • previa/low lying placenta: 34-36 weeks
• Authors suggest using telehealth for ultrasound counseling where possible, especially in the absence of a new onset finding

NSTs and BPPs

• Authors suggest minimizing NST visits or using alternative fetal assessment methods where possible
  • NSTs 2x per week should be limited to IUGR with abnormal Doppler flows
  • NSTs initiated <32 weeks should be avoided when possible
  • Avoid NST and use BPP if a patient is already undergoing an ultrasound assessment
• Kick counts
  • Consider as an alternative to NST in lower risk patients, such as
    • Women age 35 to 39
    • BMI>40 (uncomplicated)
• Gestational hypertension or preeclampsia
  • Weekly office visit and daily home blood pressure monitoring

Learn More – Primary Sources:

MFM Guidance for COVID-19 (Boelig et al. AJOG MFM, 2020)

CDC: Healthcare Professionals Frequently Asked Questions and Answers

SMFM: COVID-19 in Pregnancy: Preparing your Obstetrical Units

ISUOG Webinar: How to prepare your unit for Coronavirus

Social Distancing for Outpatient OB Ultrasonographers and Nurses

Related ObG Topics: