The World Health Organization (WHO) has declared COVID-19 a global pandemic. Healthcare providers should prepare internal guidelines covering all aspect of the organization in order to have their unit ready as soon as possible. This document addresses the current COVID-19 pandemic for maternal-fetal medicine (MFM) practitioners. The goals the guidelines put forth here are two fold- first to reduce patient risk through healthcare exposure, understanding that asymptomatic health systems/healthcare providers may become the most common vector for transmission, and second to reduce the public health burden of COVID-19 transmission throughout the general population. Box 1 outlines general guidance to prevent spread of COVID-19 and protect our obstetric patients. Section 1 outlines suggested modifications of outpatient obstetrical (prenatal) visits. Section 2 details suggested scheduling of obstetrical ultrasound. Section 3 reviews suggested modification of nonstress tests (NST) and biophysical profiles (BPP). Section 4 reviews suggested visitor policy for obstetric outpatient office. Section 5 discusses the role of trainees and medical education in the setting of a pandemic. These are suggestions, which can be adapted to local needs and capabilities. Guidance is changing rapidly, so please continue to watch for updates

Bellussi, Federica

Berghella, Vincenzo

Boelig, Rupsa C.

Saccone, Gabriele

English

Archivio della ricerca - Università degli studi di Napoli Federico II

MFM Guidance for COVID-19

Clinical PerspectiveMFM guidance for COVID-19Rupsa C. Boelig, MD, MS; Gabriele Saccone, MD; Federica Bellussi, MD; Vincenzo Berghella, MDhe World Health Organization hasBOX 1General guidance for outpatient obstetric practice management insetting of COVID-19General obstetric/MFM COVID-19 recommendations Prevention of spread should be the number 1 priority. Social distancing of at least 6 feet; if not feasible, extended dividers or otherprecautions. Any elective or non-urgent visits should be postponed. Each patient should be called to decide on need for next in-person visit and/or test. Any visit that can be done by telehealth should be done that way. No support person to accompany patient to outpatient visits unless they are an integralpart of patient care.Testing-specific recommendations: Pregnancy alone in the setting of new flu-like symptoms with negative influenza issufficient to warrant COVID-19 testing; test especially if additional risk factors (eg, older,immunocompromised, advanced HIV, homeless, hemodialysis, etc). Symptomatic patients are best triaged via telehealth to assess their need for inpatientsupport or supplemental testing; in general, they should be presumed infected and self-isolate for 14 days. In-person evaluation is not indicated if symptoms are mild. Utilize drive-through testing or stand-alone testing rather than in-office testing whereexposure can spread. Symptomatic patients who nonetheless arrive to hospital or office should be managedas if they are COVID-19 positive; so immediately properly isolated in designated areas,with appropriate (eg, N-95) mask on.T declared coronavirus 2019(COVID-19) a global pandemic.Healthcare providers should prepareinternal guidelines covering all aspect ofthe organization in order to have theirunit ready as soon as possible. Thisdocument addresses the currentCOVID-19 pandemic for maternal-fetalmedicine practitioners.The goals of the guidelines put forthhere are 2-fold: first, to reduce patient riskthrough health care exposure, under-standing that asymptomatic health sys-tems/health care providers may becomethe most common vector for trans-mission, and second, to reduce the publichealth burden of COVID-19 transmissionthroughout the general population.Box 1 outlines general guidance toprevent the spread of COVID-19 andprotect our obstetric patients. Section 1outlines suggested modifications ofoutpatient obstetrical (prenatal) visits.Section 2 details suggested scheduling ofobstetrical ultrasound. Section 3 reviewssuggested modification of nonstress tests(NSTs) and biophysical profiles (BPPs).Section 4 reviews suggested visitor policyfor obstetric outpatient office. Section 5discusses the role of trainees andmedicaleducation in the setting of a pandemic.These are suggestions, which can beadapted to local needs and capabilities.From the Division of Maternal-Fetal Medicine,Department of Obstetrics and Gynecology,Thomas Jefferson University, Philadelphia, PA(Drs Boelig, Bellussi, and Berghella); and theDepartment of Neuroscience, ReproductiveSciences, and Dentistry, School of Medicine,University of Naples Federico II, Naples, Italy (DrSaccone).Rupsa C. Boelig is supported by a PhRMAFoundation Faculty Development Award.The authors report no conflict of interest.Corresponding author: Vincenzo Berghella MD.vincenzo.berghella@jefferson.edu2589-9333/$36.00ª 2020 Elsevier Inc. All rights reserved.https://doi.org/10.1016/j.ajogmf.2020.100106Guidance is changing rapidly, so pleasecontinue to watch for updates.Section 1: Outpatient obstetrical(prenatal) visitsAll new obstetrical intakes should becompleted by telehealth/remotely un-less the patient describes an urgent Designated separate areas should be creapatients: increase sanitization; hand sanitizer aarea; wipe down patient rooms after each patienPractice-specific considerations and recomme Meetings should all be virtual/audio/video. Keep some providers at home, as feasiblhighest risk (eg, >60 years old and/or como Practitioners should be leaders in their unifor each area (eg, L&D, outpatient; ultrasounISUOG; ACOG; WHO; CDC; etc) and adapt tocover every scenario. Use this guidance andmuch as feasible.ACOG, American College of Obstetrics and Gynecology; CDC, Cnavirus 2019; ISUOG, International Society of Ultrasound in Obstetfetal medicine; SMFM, Society for Maternal-Fetal Medicine; WHOBoelig. MFM guidance for COVID-19. Am J Obstet Gynecoproblem, in which case she will beappointed as an urgent in-person visit.The standard timing for in-person en-counters in routine, uncomplicatedpregnancies are described in Table 1.The hope is that necessary laboratorywork and/or ultrasounds can be done atthe same visit.ted in each unit for suspected COVID-19vailable at front desk, throughout waitingt; wipe downwaiting area chairs frequently.ndations:e, with clinical duties, especially those atrbidities).t. COVID-19 leaders should be designatedd). Use this and other guidance (SMFM;your specific situation. No guideline canclinical judgment to avoid any contact asenters for Disease Control and Prevention; COVID-19, coro-rics and Gynecology; L&D,labor and delivery;MFM, maternal-, World Health Organization.l MFM 2020.MAY 2020 AJOG MFM 1TABLE 1Summary of suggested antenatal visit timing in setting of COVID-19pandemicGestational age In-person OB visit Ultrasound Comments<11 weeksa Telephone OB intake11e13 weeksb X X (dating/NT) Initial OB lab tests20 weeks X X (anatomy)28 weeks X Labs/vaccines32 weeks X (if indicated) Telehealth36 weeks X X (if indicated) GBS/HIV screen37 weeks to delivery Weekly telehealthand kick countsPostpartum TelehealthUse of telehealth visits facilitate blood pressure cuff/kick counts at home so that in-person visits are not necessary. Additionalvisits including diabetes control, hypertension, mood disorder, etc may be done remotely with teleheath as well.COVID-19, coronavirus 2019; GBS, group B strep; NT, nuchal translucency; OB, obstetric.a Earlier scan may be indicated if at risk for ectopic; b If viability is previously established, consider skipping 11e13 week scanand offering cell-free DNA.Boelig. MFM guidance for COVID-19. Am J Obstet Gynecol MFM 2020.Clinical PerspectiveConsideration may also be givento having laboratory work performedat lower-volume satellite office sitesin which the ability to accomplishBOX 2General principles for routine ultrasodiagnosis and minimize exposure risDating ultrasound: Combine dating/NT to one ultrasound bas If ultrasound earlier in the first trimester (egof threatened abortion, pregnancy of unknownNT ultrasound and offering cell-free DNA scrscreening. For patients with unknown LMP or EGA >Anatomy ultrasound (20e22 weeks)a Consider follow-up views in 4e8 weeks r Consider serial cervical length for those atotherwise do once with anatomy ultrasound. BMI >40 kg/m2: schedule at 22 weeks tofollow-up.Growth ultrasounds All single third-trimester growth at 32 wee Follow-up previa/low-lying placenta at 34e Begin serial growth at 28 weeks (not 24 w Consider q 6e8 weeks week rather thanNT, nuchal translucency; LMP, last menstrual period; EGA, estimaOr earlier if desired based on state-specific termination laws.bConsider forgoing follow-up ultrasound for 1 or 2 suboptimal viposterior fossa normal).Boelig. MFM guidance for COVID-19. Am J Obstet Gyneco2 AJOG MFM MAY 2020social distancing is more easilyattained, as feasible. Interim tele-health visits can be scheduled at pro-vider discretion (eg, at 16, 24, 34unds to maximize perinatalked on LMP., less than 10 weeks) is indicated becauseanatomic location, may consider forgoingeening for those desiring early aneuploidy14 weeks may schedule as next available.ather than 1e2 weeks.bhighest risk for spontaneous preterm birth,reduce risk of suboptimal views/need forks.36 weeks.eeks) with rare exceptions.q 4 week follow-up for most patients,ated gestational age; BMI, body mass index; q, every.ews (eg, l/s spine not seen well because of fetal position butl MFM 2020.weeks). Reschedule all obstetric visitsusing this paradigm.Tominimize other in-patient visits, allpatients should be instructed to obtainblood pressure cuffs if feasible. Somemore health plans may cover the cost ofblood pressure cuffs in the setting of thecoronavirus pandemic. Consider allother visits by telehealth if feasible.Postpartum evaluation of cesareanwound healing or mastitis concerns maybe optimized through the use of photoupload options available in many elec-tronic medical record patient portalprograms.Section 2: Scheduling of obstetricultrasoundBox 2 summarizes our suggested modi-fications to ultrasound timing. Table 2outlines recommendations for specificantenatal indications. We recognize thatthese recommendations are specific toour practice environment. Maternal-fetal medicine physicians nationally andinternationally should feel empoweredto adjust as needed based on limitationsin capacity and/or higher incidence ofCOVID, which may require further re-strictions for both patient safety andpublic health.In addition to modifying ultrasoundtiming, the routine practice of face-to-face counseling for ultrasounds shouldbe adjusted. In most cases ultrasoundfindings can be reviewed either over thephone/telehealth, or in the setting of anormal routine ultrasound, by the ob-stetric provider at the next visit. Indeed,because of resource limitations, manysites do only have remote communica-tions for ultrasound finding, and thistechnology should be adapted widely tolimit unnecessary patient contact, whichprotects both the patient from getting aninfection and the provider from being avector.Section 3: Scheduling of nonstresstests/biophysical profilesTable 3 illustrates how antenatal sur-veillance with NSTs/BPPs may bemodified in the setting of the COVID-19pandemic and the actual increased riskpatients may face in coming into theTABLE 2Outline of common indications for growth ultrasound and suggested frequency/timing in setting of COVID-19pandemicIndicationFrequencyCommentsOnce q 4 wks q 6e8 wksPregestational diabetes mellitus XChronic HTN on medications X Once if no medsCurrent preeclampsia/gestational HTN XHistory of severe preeclampsia XHistory of IUGR or SGA XCurrent IUGR XSickle cell disease XCKD XMultiples, mono/dia XMultiples, mono/mono XMultiples, di/di XGDMA2 XLupus, no renal dysfunction XPrior unexplained IUFD XOrgan transplant XMaternal cardiac disease XUncontrolled thyroid disease XCurrent tobacco or substance use XAMA (35 y old) XGestational diabetes, A1 XChronic HTN, off medications XAbnormal placentation X At 34e36 wksUterine fibroids >5 cm XSerial growth ultrasound beginning at 28 weeks; 1 time growth at 32 weeks unless otherwise indicated. Practice locations should adjust as needed based on site capacity and risk of COVID exposure.AMA, advanced maternal age; CKD, chronic kidney disease; COVID-19, coronavirus 2019; Di/Di, dichorionic diamniotic; GDMA2, gestational diabetes-A2; HTN, hypertension; ; IUFD, intrauterine fetaldemise IUGR,intrauterine growth restriction; Mono-Di, monochorionic diamniotic; Mono/Mono, monochorionic diamniotic; q, every; SGA, small for gestational age.a Consider every 2 week twin-twin transfusion screening.Boelig. MFM guidance for COVID-19. Am J Obstet Gynecol MFM 2020.Clinical Perspectiveoffice for 30 or more minutes of testing.In general, we suggest the followingprinciples: Twice-weekly NSTs only for intra-uterine growth restriction withabnormal umbilical artery Doppler. Limit NSTs initiated <32 weeks. If concurrent ultrasound, perform aBPP rather than an additional NSTvisit. In lower-risk patients, such asadvanced maternal age 35e39 yearsor body mass index >40 kg/m2 withno other comorbidities, consider kickcounts instead of NSTs.For patients with gestational hyper-tension/preeclampsia, plan a weekly visitin the office with daily blood pressurechecks at home. Weekly visit will includeantenatal testing, blood pressure check,and labwork drawn in the office to mini-mize the need for additional visits. Thesechanges should be relayed to patientswithMAY 2020 AJOG MFM 3TABLE 3Summary of common indications for nonstress tests and how we have modified frequency of testing in setting ofadditional risks related to COVID-19 exposure and transmissionIndicationfor NSTGestationalage to begin1 time/wkGestationalage to begin2 times/wk Comments COVID-19aAMA 36 Fetal kick counts instead of NSTCholestasis DiagnosisDecreased fetal movement Diagnosis One time onlyPregestational diabetes 32 36 Weekly onlyGDMA2 32 36 Weekly onlyChronic HTN 32 36 weeks if no medicationsGestational HTN Diagnosis Weekly with home BP monitoringPreeclampsia Diagnosis Weekly with home BP monitoringCKD 32IUGR Diagnosis Weekly with Doppler. SubstituteBPP when possibleElevated Dopplers DiagnosisSLE 32Fetal arrhythmia DiagnosisMono/Di twins 32Di/Di twins Only if additional indicationObesity/BMI >40 kg/m2 32 Fetal kick counts instead of NSTOligohydramnios DiagnosisPolyhydramnios Diagnosis Diagnosis or at 32 wks if <32 wk diagnosis.Only for AFI >30Prior IUFD 32 1 wk prior to IUFDSickle cell disease 32 Kick counts if well controlledSingle umbilical artery 32 Fetal kick counts if normal growth,normal anatomy, normal genetic screeningAMA, advanced maternal age; BMI, body mass index; BP, blood pressure; BPP, biophysical profile; CKD, chronic kidney diseases; COVID-19, coronavirus 2019; Di/Di, dichorionic diamniotic; GDMA2,gestational diabetes-A2; HTN, hypertension; ; IUFD, intrauterine fetal demise IUGR, intrauterine growth restriction; Mono-Di, monochorionic diamniotic; NST, nonstress test; SLE, systemic lupuserythematosus.a Text in column indicates changes to recommendations in setting of COVID, and no change in practice is suggested if this column is empty.Boelig. MFM guidance for COVID-19. Am J Obstet Gynecol MFM 2020.BOX 3Suggested visitor policy for outpatient officesGeneral outpatient office visitor policy There should be no additional family/friend/partner in any outpatient appointment. Patients are asked not to bring children. Visitor with symptoms at front desk check-in will not be allowed in patient care areasand will be asked to return home. Patients may be asked to reschedule nonurgent care if they or their visitor aresymptomatic.Boelig. MFM guidance for COVID-19. Am J Obstet Gynecol MFM 2020.Clinical Perspective4 AJOG MFM MAY 2020a discussion of the altered risk/benefitbalance of coming to the office for testingin the setting of a global pandemic.Section 4: Visitor policy for obstetricoutpatient officeBox 3 outlines the general guidelines forvisitors. In the setting of a pandemic,consider visitors as something that doesnot benefit patient care but may harmother patients/providers. ExceptionsClinical Perspectivemay be made when the visitor is criticalfor patient care, for example, for youngpatients coming with a parent or some-one with developmental delay who relieson a support person to aid in medicaldecision making.Section 5: Involvement of traineesIn setting of a COVID-19 and the sig-nificant risk of not only trainees’ healthbut also additional health care providersserving as a vector and using limitedprotective equipment, we suggest allnonessential clinical personnel remain athome. This means any nursing, medical,or sonography students should not be inthe office; any other observershipsshould be suspended. Additionally, in anacademic setting in which an attendingphysician is supervising residents or fel-lows, multiple providers providing face-to-face counseling should be limited. -ACKNOWLEDGMENTWe acknowledge the help of other membersof the Maternal-Fetal Medicine Division andObstetric-Gynecology Department at ThomasJefferson University, including Jason Baxter,Amanda Roman, Huda Al-Kouatly, RebekahMcCurdy, Johanna Quist-Nelson, EmilyRosenthal, Emily Oliver, Becca Pierce-Williams, Leen Al-Hafez, Laura Felder, KerriSendek, Alexa Herman, Keith Rychlak, CarolFolcher, and William Schlaff as well as TracyManuck.MAY 2020 AJOG MFM 5

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MFM Guidance for COVID-19

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Archivio della ricerca - Università degli studi di Napoli Federico II

Archivio della ricerca - Università degli studi di Napoli Federico II