NOTE: Guidance has been updated to include the latest ACOG statement regarding gyn patient prioritization. Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date.

SUMMARY:

ACOG has released FAQs that address common questions faced by those healthcare professionals providing gynecologic care. The recommendations in this document reinforce CDC guidance and clarify some issues specific to gynecology. Below are highlighted FAQs from the document (please see ‘Learn More – Primary Sources’ below for link to complete document). ACOG states that

Determining how best to care for patients given the COVID-19 pandemic depends on the patient’s signs and symptoms, the patient’s comorbidities and underlying medical condition, the acuity of the presentation (eg, acute versus chronic condition), available health resources, and other factors

• Patient Prioritization – GYN Office Visits
• Patient Prioritization – GYN Surgeries
• Abortion Services
• NSAIDS
• Antibody Testing
• Breast Imaging & Post-Vaccine Lymphadenopathy

Patient Prioritization – GYN Office Visits

• Change in practice prioritization is based on resource reduction resulting from the current COVID-19 pandemic
• ACOG provides examples (“list is not meant to be exhaustive”)
• In-person appointment
  • Fever risk for gyn infection
  • Ectopic
  • Post-op complications not suitable for phone
  • Heavy vaginal bleeding with signs/symptoms suggestive of anemia
• By telehealth (includes virtual visit or phone)
  • Contraceptive management
  • Asymptomatic ovarian cyst
  • Menopause management
  • Routine gyn or post-op care
  • Routine medication abortion care
  • Mental or behavioral health screening
• “May potentially” defer till after COVID-19
  • Preventive visits
  • Routine screenings for average-risk patients

Patient Prioritization: GYN Surgeries

• ACOG emphasizes that decisions related to surgical triage should be based on disease severity, not necessarily a particular surgical procedure
• ACOG along with multiple other gynecology societies, released a joint statement on the suspension of elective surgeries during the COVID-19 pandemic
  • The joint statement supports the Surgeon General’s statement to modify surgical scheduling if the patient will not be harmed by delay
  • If a delay will impact patient health and cause harm, the surgery should be performed as scheduled
• SGO recommendations
  • Examples of surgeries that could be potentially delayed include
    • Benign-appearing ovarian cysts | Hysterectomy for menorrhagia without evidence of anemia
    • Surgeries for precancerous lesions or low risk for endometrial cancer (especially in healthy patients)
  • Examples of surgeries that should not be delayed
    • Most cancer surgeries
    • Resections of masses that will cause end-organ damage or impair quality of life

KEY POINTS:

Abortion Services

• Due to its time-sensitive nature, ACOG states that “Abortion is an essential component of comprehensive health care”
• Furthermore, ACOG and other gynecology societies released a joint statement supporting access to abortion services during the COVID-19 pandemic
• To decrease risk of exposure and transmission, strategies include
  • Counsel remotely (video or phone)
  • Offer timely referral if practice does not provide service
  • If no risk factors for ectopic pregnancy and patient has regular menses with a known LMP
    • Assess gestational age remotely | Ultrasound not required
  • If uncomplicated, pre-op visit and consent can be done remotely (video or phone)
    • “Routine in-person or video or telephone visits are not necessary after an uncomplicated abortion procedure”
• Medical abortion
  • Assessment, counseling, and consent can be done remotely (by video or telephone)
  • Mifepristone and misoprostol can be self-administered at home
  • Follow-up after an uncomplicated medication abortion can be done remotely (video or telephone) | In-person visit not required
  • Note: ACOG states “The FDA has lifted additional burdens on patients seeking access to and clinicians prescribing mifepristone for pregnancy termination and miscarriage during the COVID-19 public health emergency. As you consider changes to your clinical practice, however, please take several important factors into account. Whether you now have authority to mail mifepristone is a fact-specific, state-specific legal question. We strongly encourage any clinician seeking this relief to consult with a lawyer before making any changes to your clinical practice.”
• Rh testing and RhD immunoglobulin administration
  • Should not be a barrier to the provision of medication abortion
  • Low risk of sensitization

NSAIDS

• No evidence of association between NSAIDs, such as ibuprofen, and COVID-19 exacerbation | Situation may change in the future with further information
• Continue to offer low-dose aspirin and other NSAIDs as medically indicated

Antibody Testing

• Some institutions are testing all patients prior to procedures
• Antigen testing
  • Remains the test of choice for diagnosis
• Antibody (serologic) testing
  • Not diagnostic
  • Can be used to obtain information that may indicate prior exposure
  • At present, it is unclear if antibodies confer immunity
• The document states that antibody testing

…should not be used as the sole basis to diagnose COVID-19, to determine staffing decisions or decisions regarding the need for personal protective equipment (PPE), or to determine if a person has immunity to COVID-19

Breast Imaging and Post-Vaccine Lymphadenopathy

• COVID-19 vaccination may be associated with temporary contralateral or ipsilateral lymphadenopathy
• A Radiology Scientific Expert Panel has addressed this issue, as the nodal enlargement identified on breast imaging may be difficult to distinguish from lymph node enlargement seen with malignancy
  • Vaccination should not be delayed due to imaging needs, including indications related to cancer or screening
  • “The estimated infection fatality risk of COVID-19 is orders of magnitude higher than the estimated mortality reduction achieved through effective cancer screening programs in the general population”
  • If possible, mammograms should be conducted prior to COVID-19 vaccination
• Following vaccination and to avoid complicating interpretation of imaging results  
  • Urgent cancer-related clinical indications (e.g., acute symptoms, short-interval treatment monitoring, urgent treatment planning or complications): Do not delay breast imaging
  • All other indications (routine surveillance, screening, staging): Consider postponing imaging for ≥6 weeks after completion of recommended vaccinations

Note: The Society of Breast Imaging recommends delay of 4 to 6 weeks  

Learn More – Primary Sources:

COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology

ACOG: The FDA’s Decision Lifting the Burdensome Restriction on Mifepristone during the Pandemic: What You Need to Know

Joint Statement on Elective Surgeries

Joint Statement on Abortion Access During the COVID-19 Outbreak

Interim Guidance for Timing of Diagnostic and Treatment Procedures for Patients with Abnormal Cervical Screening Tests (ASCCP)

ASRM COVID-19 Resources  (American Society for Reproductive Medicine)

Surgical Considerations for Gynecologic Oncologists During the COVID-19 Pandemic (Society of Gynecologic Oncology) 

Interim Guidance for COVID-19 and Persons with HIV (National Institutes of Health)

Radiology Scientific Expert Panel: Multidisciplinary Recommendations Regarding Post-Vaccine Adenopathy and Radiologic Imaging

Society of Breast Imaging: Recommendations for the Management of Axillary Adenopathy in Patients with Recent COVID-19 Vaccination

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