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 elements of obstetrical care that may be modified due to the COVID-19 pandemic
2. List the obstetrical practices and procedures where standard guidelines should be followed despite the COVID-19 pandemic

Estimated time to complete activity: 0.5 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 through , 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 0.5 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 0.5 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

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. This entry has been updated with additional information on counseling patients working in a non-healthcare setting.

SUMMARY:

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

• Masks
• Clinical Guidelines that Remain Unchanged
• Monoclonal Antibodies
• SARS-CoV-2 Protease Inhibitors in Pregnancy
• PPH: Use of TXA and Hemabate 
• Visitation Policies During COVID-19

Masks

For Pregnant Women

• Not fully vaccinated
  • Wear a mask or cloth face covering in public and when around people outside of the household
  • ACOG recommends the above particularly when social distancing may not be doable
•  Fully vaccinated
  • Follow CDC guidance | However, some pregnant women may wish to continue using masks and should be supported
• Healthcare settings, schools, public transport
  • Regardless of vaccine status, precautions including mask or cloth face covering should be used
  • CDC specifies cloth vs surgical masks or respirators, which should be reserved for healthcare personnel

Health Care Professionals (CDC Guidance)

• Source control options (prevent spread of respiratory secretions when breathing, talking, sneezing or coughing) for HCP include
  • NIOSH-approved N95 or equivalent or higher-level respirator or
  • A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated) or
  • A well-fitting facemask
• When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through
• If masks used for protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions) then discard after the patient care encounter
  • Healthcare providers should use PPE, including respirators or face masks, goggles, gowns and gloves | N95 respirators should be used for aerosol-generating procedures
  • ACOG states that “COVID-19 infection is highly contagious, and this must be taken into consideration when planning intrapartum care”

KEY POINTS:

Clinical Guidelines that Remain Unchanged

Continue to Manage According to Current Clinical Guidance

• Timing of delivery
  • COVID-19 should generally not impact timing of delivery
  • Exception: If a woman is infected in the third trimester and there are no medical indications to the contrary, “it is reasonable” to try and postpone delivery until there is a negative test result or quarantine lifted
• Induction of labor
• Operative delivery
• Mode of delivery
• Delayed cord clamping
• Antenatal fetal testing
• Antenatal fetal surveillance
  • Detailed mid-trimester anatomy scan “may be considered” after pre-pregnancy or first-trimester maternal infection
  • Interval growth assessments “could be considered depending on the timing and severity of infection”
  • Timing and frequency of ultrasound should take in to account clinical setting and additional maternal risk factors

Antenatal Fetal Surveillance: Additional Considerations

• Antenatal fetal surveillance
  • Detailed mid-trimester anatomy scan “may be considered” after pre-pregnancy or first-trimester maternal infection
  • Interval growth assessments “could be considered depending on the timing and severity of infection”
  • Timing and frequency of ultrasound should take in to account clinical setting and additional maternal risk factors

Anti-SARS-CoV-2 Monoclonal Antibodies

Monoclonal antibodies are recommended by the NIH for use in the following clinical scenarios (see ‘Related ObG Topics’ below for NIH COVID Treatment Guidelines)

• For patients with mild to moderate COVID-19 who are at high risk of clinical progression
  • Start treatment as soon as possible after positive SARS-CoV-2 antigen or NAAT report becomes available and within 10 days of symptom onset
• Post-exposure prophylaxis (PEP) should be considered for inadequately vaccinated individuals who have been exposed to SARS-CoV-2
  • These individuals include those who have had a recent exposure to an individual with SARS-CoV-2 for a cumulative total of ≥15 minutes over a 24-hour period or
  • There is a recent occurrence of SARS-CoV-2 infection in other individuals in the same institutional setting AND are 1) not fully vaccinated or 2) fully vaccinated but may not mount an adequate immune response
• The NIH specifically addresses use of PEP in pregnancy and states

PEP should not be withheld from pregnant or lactating individuals who have been exposed to SARS-CoV-2, especially those with additional conditions that increase their risk of progressing to severe disease

Pregnant or lactating patients and their providers should determine whether the potential benefits of the drugs outweigh the potential risks

• ACOG supports the use of monoclonal antibodies in both clinical scenarios (risk for progression or PEP) and states the following

Pregnancy is included among the conditions that put individuals at high risk for clinical progression

This makes patients with pregnancy as their only risk factor eligible to receive outpatient monoclonal antibodies, according to the EUA (NIH)

Obstetric care clinicians may consider the use of monoclonal antibodies for the treatment of non-hospitalized COVID-19 positive pregnant individuals with mild to moderate symptoms, particularly if one or more additional risk factors are present (eg BMI >25, chronic kidney disease, diabetes mellitus, cardiovascular disease)

Lactation is not a contraindication for the use of monoclonal antibodies

Note: Some monoclonal antibodies that were effective against previous variants have limited effectiveness against Omicron variant and therefore ACOG recommends “physicians should consult their facilities as to which monoclonal antibody therapies against SARS-CoV-2 infection are available for treatment options”

SARS-CoV-2 Protease Inhibitors in Pregnancy

PAXLOVID          

• Oral medication
• Includes nirmatrelvir (SARS-CoV-2 main protease inhibitor) and ritonavir (HIV-1 protease inhibitor and CYP3A inhibitor)
• Available only under emergency use authorization (EUA)
• Recommended for the treatment of outpatients with mild to moderate COVID-19 infection who
  • Have a positive SARS-CoV-2 viral test
  • Are at higher risk of clinical progression
• Pregnancy
  • Pregnancy is a risk factor for clinical progression and therefore meets criteria for use of medication use, particularly if other high risk factors are pregnant (e.g., diabetes)
• Lactation
  • Breastfeeding is not a contraindication to use and can be used as indicated in this population
• Dosage
  • Start as soon as possible following diagnosis and within 5 days of symptoms
  • The dose for patients with normal renal function is nirmatrelvir 300 mg (two 150 mg tablets) plus ritonavir 100 mg (one 100 mg tablet) orally twice daily for 5 days

Note: There is risk for drug interactions including mediations used in pregnancy (e.g., nifedipine) | ACOG recommends that “Prescribing clinicians should consult the full prescribing information prior to and during treatment for potential drug interactions”

Fetal Risks

• Nirmatrelvir
  • Human study data
    • None available but observational data has not demonstrated increased risk for birth defects
  • Animal studies
    • Reduced fetal body weights noted among pregnant rabbits at doses 10 times higher than comparable typical human exposure
• Ritonavir
  • Used commonly for management of HIV during pregnancy, suggesting acceptable safety profile

Note: ACOG states that “short-term exposure to these medications must be balanced against the maternal and fetal risks associated with untreated COVID-19 in pregnancy”

PPH: Use of TXA and Hemabate

TXA

• COVID-19 appears to be a hypercoagulable state
• TXA can be considered for the treatment of PPH in keeping with guidance for non-COVID-19 patients
• However, the document states

Because of the possible additive effect of the increased risk of thrombosis from COVID-19 infection and the hypercoagulative state of pregnancy, it may be prudent to consider this increased likelihood of clotting before adminisitering TXA for postpartum hemorrhage

Hemabate

• While Hemabate is not used in asthma due to risk for bronchospasm, patients with COVID-19 have respiratory symptoms consistent with viral pneumonia
• While there is no data specific to COVID-19 and this medication, “Hemabate is not generally withheld” in patients with viral pneumonia

Visitation Policies During COVID-19

• Visitation policy decisions are ultimately guided by
  • Local facilities and capabilities (e.g., physical space, equipment)
  • Community spread and prevalence
  • Governmental regulations and recommendations at multiple levels
• ACOG recommends that for both inpatient and outpatient
  • Reduce number of visitors to minimum necessary
  • Limit to those individuals “essential for the pregnant individual’s well-being (emotional support persons)”
  • Screen all visitors for symptoms of respiratory illness
    • Patient should be attended to by an asymptomatic visitor
    • A visitor with fever or respiratory symptoms should not accompany the patient
• Additional support persons
  • Encourage the use of alternative forms of interaction (e.g., video-call apps)
• Counseling patients and families regarding restrictive visitation policies
  • Acknowledge value of support persons
  • Explain the temporary nature of the policies and that they are in place to protect everyone’s safety, including the patient, baby and community at large
• Special considerations for underserved communities
  • Support systems including support persons are especially important throughout the delivery journey, including postpartum care
  • ACOG states that

…institutions should be mindful of how restrictions might differentially and negatively affect these communities, which in many areas are also disproportionately affected by COVID-19

Learn More – Primary Sources:

COVID-19 FAQs for Obstetrician-Gynecologists, Obstetrics

Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) | CDC

Related ObG Topics:

NIH COVID-19 Treatment Guidelines

Guidance on COVID-19 Vaccine Including Pregnancy

Managing an Obstetric Office Practice During COVID-19

COVID-19: Category Definitions, Symptoms and Those at Increased Risk

COVID-19: The SMFM/SOAP Guidelines for Labor and Delivery