NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date. This entry has been updated with CDC recommendations regarding screening for chlamydia and GC during testing kit shortages.

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
• STI Testing During Kit Shortages

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
• 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

STI Testing During Kit Shortages

• Due to increased demand for SARS-CoV-2 testing, there has been a shortage of STI test kits and lab supplies, especially for gonorrhea and chlamydia
• ACOG includes the CDC recommendations regarding STI screening and testing during the shortage
• While “every effort should be made to reinstitute STI screening” in keeping with the 2015 CDC STD Treatment Guidelines, CDC has come forward with considerations for prioritization including

Chlamydia and GC Screening of Asymptomatic Individuals

• Asymptomatic women, especially pregnant women
  • <25 years of age or women > 25 years of age at risk (e.g. those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners or a sex partner who has an STI
  • Genital CT/GC NAAT testing should be prioritized with a vaginal swab, the preferred specimen
  • Extra-genital CT/GC screening is not recommended for women
• Asymptomatic men who have sex with men (MSM)
  • Rectal and pharyngeal CT/GC NAAT testing for men with exposure at these anatomic sites should be prioritized above urethral (or urine-based) testing in order to maximize the detection of infection per below
  • If test kits are severely limited, consider prioritizing rectal testing over pharyngeal testing

Men with Symptomatic Urethritis

• A Gram stain (GS) or methylene blue (MB) stain should be performed as the diagnostic test on urethral specimens at clinical sites with this capacity | Clinics without this capacity should send a urethral GS or MB stain specimen to a laboratory to distinguish between gonococcal urethritis and non-gonococcal urethritis (NGU)

Women with Cervicitis Syndrome or PID

• Empirically treating these syndromes is a priority
  • If CT/GC NAAT kits are available for diagnostic testing, then vaginal swabs for chlamydia and gonorrhea NAAT test are the preferred specimen type | Endocervical swabs can also be considered
  • Tests should be prioritized for women < 25 years of age with cervicitis or PID

Individuals with Proctitis Syndrome

• Empirically treating these syndromes is a priority
  • Therapy for herpes simplex virus may be considered if pain or mucocutaneous lesions are present
  • If rectal CT/GC NAAT test kits are available for diagnostic testing, then obtain a rectal specimen and treat empirically per the 2015 CDC STD Treatment Guidelines

Individuals Taking PrEP

• The frequency of extragenital CT/GC screening in MSM receiving PrEP should be in accord with the current CDC PrEP guidelines
  • If test kits are in short supply, extended extragenital screening intervals may be considered

Contacts to Chlamydia and/or Gonorrhea

• Empirically treat the contact for the appropriate organism
  • If CT/GC NAAT test kits are in short supply, consider forgoing testing

If Urine CT/GC NAAT Test Kits are in Short Supply

• Reserve test kits for men with persistent urethritis.

Learn More – Primary Sources:

COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology

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)

CDC Dear Colleague Letter: STI Screening During Test Kit and Laboratory Supply Shortages

Related ObG Topics: