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 gynecologic office visit prioritization during the COVID-19 pandemic
2. Describe gynecologic surgery prioritization during 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 faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

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 07/15/2021 through 07/15/2023, 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 0.2 contact hours.

Read Disclaimer & Fine Print

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

Related ObG Topics:

COVID-19 Guidance: Key Highlights for Healthcare Professionals

ACOG COVID-19 FAQs for Obstetrical Care

Ultrasound and COVID-19: AIUM and WFUMB Guidance on Transmission Precautions

COVID-19 and NSAIDs: Is There Reason for Concern with Use of Ibuprofen?