Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss changes to consider in the traditional prenatal visit schedule to reduce risk of COVID-19 exposure
2. Describe key points to consider with respect to fetal assessment in the setting of the COVID-19 pandemic

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 03-23-2020 through 03-23-2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.25 contact hours.

Read Disclaimer & Fine Print

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.

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

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:

Coronavirus and Pregnancy: CDC Guidance and Professional Recommendations

ARDS, Critical Care and COVID-19: ‘Surviving Sepsis Campaign’ Guidelines and Key Points

COVID-19 Guidance: Key Highlights for Healthcare Professionals

ACOG COVID-19 FAQs for Obstetrical Care