High Yield OBGYN: How to Get the Correct Diagnosis with the Fewest Steps

High Yield OBGYN: How to get the correct diagnosis with the fewest steps

Courtney B Martin DO, FACOG Assistant Professor, Department of Gynecology and Obstetrics, Loma Linda University School of Medicine Division Chief, General Obgyn Medical Director Maternity Services, LLUCH Director of Quality, LLUCH

1 High Yield OBGYN Topics:

Abnormal Uterine Bleeding Vaginal Discharge COVID-19 and Pregnancy

2 Faculty Disclosure

It is the policy of the ACOFP Program Committee OMED organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

3 Abnormal Uterine Bleeding (AUB)

. Discuss the differential diagnosis of abnormal uterine bleeding by new FIGO criteria . Discuss the proper and evidence based evaluation of abnormal uterine bleeding . Discuss the different pathology of abnormal uterine bleeding . Understand the methodology of treatment for abnormal uterine bleeding

4 Everyone’s Favorite Cycle

Endometrial Response to Ovarian Steroids

14 350 Menses Proliferative Secretory

12 Progesterone 300 Estradiol 10 250

8 200

6 150 Endometrial Thickness Estradiol (pg/ml) 4 100

Implantation 2 50 Endometrium (mm) Progesterone (ng/ml) Progesterone (mm) Endometrium 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Cycle Day

5 FIGO PALM-COEIN Classification of Abnormal Uterine Bleeding

Abnormal uterine bleeding: • Heavy menstrual bleeding (AUB/HMB) • Intermenstrual bleeding (AUB/IMB)

PALM—structural causes: COEIN—nonstructural causes: Polyp (AUB-P) Coagulopathy (AUB-C) Adenomyosis (AUB-A) Ovulatory dysfunction (AUB-O) Leiomyoma (AUB/L) Endometrial (AUB/E) Submucosal leiomyoma (AUB-LSM) Iatrogenic (AUB-I) Other leiomyoma (AUB-LO) Not yet classified (AUB-N) Malignancy and hyperplasia (AUB-M) Estrogen Terminology

Estrogen withdrawal bleeding • Estrogen above a threshold level (50-100 pg/ml) and time (1-2 weeks) stimulates the endometrium to proliferate-- bleeding occurs when the estrogen is withdrawn Estrogen breakthrough bleeding • Estrogen above a threshold level 50-100 pg/ml) and time (3 weeks) stimulates the endometrium to proliferate--bleeding occurs when the endometrium cannot continue proliferating and begins to break down irregularly

7 AUB Diagnosis

The most efficient management of abnormal bleeding is to arrive at the correct diagnosis with the fewest number of false moves, and to institute the most cost-effective therapy

8 Normal Endometrial Response • Estrogen Proliferation (growth) • Progesterone No effect • P after or with continuing E Arrests growth Causes maturation Secretory changes (glands) Decidual changes (stroma) • General concept Estrogen = “gas”, Progesterone = “brake”

9 How do you know if bleeding is abnormal??

We take the menstrual history and compare our patient’s menstrual story with the definition of normal menses.

10 What is normal menses????

• Interval 21-35 days • Duration 2-8 days • No intermenstrual bleeding • No excessive bleeding Pad or tampon “accidents” Clots Anemia Patient’s perception

11 12 Anovulation=No Progesterone

• Sources of progesterone • Corpus luteum • Placenta • Both require ovulation • So anovulation = unopposed estrogen

13 The Question

AUB/O AUB/PALM-CEIN . Cycle lost . Cycle preserved . Abnormal hormone . Normal hormone stimulus stimulus (no progesterone) (ovulation occurring, luteal P present normally) . (“Normal” uterine response) . Coagulopathy (AUB/C) . “Normal” uterus . Abnormal uterine response – Co-existing uterine pathology may not be responsible for – Pathology responsible bleeding (AUB/PALM) – Cause unclear (AUB/EN) . Iatrogenic (AUB/I)

14 14 The most common mistake….

The most common, and easily preventable error in evaluation/management of AUB-O is to give inadequate progestin to initially control the hyperproliferative endometrium when ovulatory dysfunction (= unopposed E) is the underlying fundamental cause of the bleeding

15 AUB Treatment-Patient is Bleeding Pt bleeding at onset of rx MPA 30 mg daily x 12 days If bleeding is emergently heavy, give large dose of estrogen as well (25 mg conjugated equine estrogens IV) Dose of IV CEE can be repeated in 4 hours x 2-3 times If bleeding has been prolonged and/or heavy, consider adding 5 mg CEE daily x 5 days Normal response Bleeding stops in 24-36 hrs (major slowing in 3-4 hours if IV CEE is given) Bleeding remains stopped for duration of P rx Withdrawal bleeding begins 1-3 days after P stops and is self-limited (amount variable, may be heavy) Re-treatment with CEE (usually 5 mg daily x 5 days is enough) and MPA 30 mg daily x 12 days may be required if the first withdrawal bleed is very heavy Second withdrawal bleed should be normal

16 AUB Treatment- Not Bleeding

Pt not bleeding at onset of rx • MPA 10 mg daily x 12 days • Normal response No bleeding occurs during P rx Withdrawal bleeding begins 1-3 days after P stops and is reasonable in amount and self- limited

17 Patton’s Law

A normal uterus should bleed normally if given (or already receiving) normal estrogen and progesterone hormone stimulation and no coagulopathy is present

18 US Measurement of Endometrial Thickness?

. Premenopause . Postmenopause – Changes with cycle – Bleeding . Even when the endometrium is <5 mm, – Value not established for there is still a 5% chance of abnormal screening for endometrial pathology cancer – Not bleeding . If endometrium <12 mm, chance of endometrial cancer 0.002% . If endometrium >11 mm, chance of endometrial cancer 6.7%*

19 *based on a theoretical cohort—Smith-Bindman, R., et al, Ultrasound Obstet Gynecol 24:558 (2004) 19 Reference

Hemostasis and menstruation: investigation for underlying disorders. www.ncbi.nlm.nih.gov/pubmed/16275228 and www.ncbi.nlm.nih.gov/pubmed/16275227 and www.ncbi.nlm.nih.gov/pubmed/16275229 Adolescent Gynecology, Clinical Expert Series. www.ncbi.nlm.nih.gov/pubmed/19305342 Managment of Anovulatory Bleeding. ACOG Practive Bulletin #14, ACOG. Int Journal Gynaecol Obset 2001; 72(3):263-271 Hysterectomy compared with endometrial ablation for DUB. Green Journal. www.ncbi.nlm.nih.gov/pubmed/18055721 Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3–13. (Level III) Diagnosis of abnormal uterine bleeding in reproductive-aged women. Practice Bulletin No. 128. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:197–206. (Level III) Von Willebrand disease in women. ACOG Committee Opinion No. 451. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1439– 43. (Level III) Polycystic ovary syndrome. ACOG Practice Bulletin No. 108. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:936–49. (Level III) Pellerin GP, Finan MA. Endometrial cancer in women 45 years of age or younger: a clinicopathological analysis. Am J Obstet Gynecol 2005;193:1640–4. (Level III) Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD001895. DOI: 10.1002/14651858.CD001895.pub3. (Level III) Gallos ID, Shehmar M, Thangaratinam S, Papapostolou TK, Coomarasamy A, Gupta JK. Oral progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia: a systematic review and metaanalysis. Am J Obstet Gynecol 2010;203:547.e1–547.10. (Meta-analyis) Moschos E, Ashfaq R, McIntire DD, Liriano B, Twickler DM. Saline-infusion sonography endometrial sampling compared with endometrial biopsy in diagnosing endometrial pathology. Obstet Gynecol 2009;113:881–7. (Level II-3)

Vaginal Discharge: What is wrong down there?

. Describe the vaginal environment . Discuss the epidemiology of Vaginitis . Discuss the most common causes of vaginitis and patient complaints . Discuss the Physical exam findings and diagnostic aids to identify cause . Discuss the treatments of different types of Vaginitis

22 Vaginal Discharge

. Described as a spectrum of conditions that cause symptoms such as itching, burning, and abnormal discharge . The most common cause of Vaginitis is Bacterial Vaginosis (22-50%), Vulvovaginal Candidiasis (17-39%), and Trichomoniasis (4-35%). . In undiagnosed women (7-72%), the symptoms can be from a wide array of conditions, including atrophic vaginitis, dermatologic conditions, and vulvodynia. . Empiric Therapy can be effective, but many suffer from recurrence, making an accurate diagnosis important for successful therapy.

23 The Vaginal Environment A Utopian Society

24 The Vaginal Environment

. Estrogen plays a crucial role in the normal vaginal state . In Pre-pubertal and post menopausal states, the vaginal epithelium is thinned, and the pH of the vagina is usually elevated (4.7 or higher). . During the reproductive years, the presence of estrogen increases the glycogen content in the vaginal epithelium, which encourages the colonization by lactobacilli. . Vaginal Flora is very heterogeneous, and other components of the flora include Gardnerella vaginalis, E. Coli, Group B Streptococci (GBS), genital mycoplasmatales, and Candida Albicans

25 Lactobacillus

. All lactobacilli produce lactic acid.

. Some species also produce H2O2.

. H2O2 is a potent natural microbicide. . Present in 42%–74% of females.

. In vitro, H2O2 is toxic to viruses such as HIV, as well as bacteria.

26 Normal Vaginal Flora

. The vagina is a dynamic ecosystem that contains approximately 109 bacterial colony-forming units. . Normal vaginal discharge is clear to white, odorless, and of high viscosity. . Normal bacterial flora is dominated by lactobacilli – other potential pathogens present. . Lactic acid helps to maintain a normal vaginal pH of 3.8 to 4.2. . Acidic environment and other host immune factors inhibits the overgrowth of bacteria.

27 Evaluation of Vaginitis

. Focused history of the entire spectrum of vaginal symptoms – Change in discharge – Vaginal malodor – Itching, Irritation, Burning, Swelling, Dyspareunia, Dysuria – Location of the symptoms (vulva, vagina, anus) – Duration of the symptoms – Timing with menses – Any prior self treatments – Hygiene habits – Sex Practices

28 Types of Vaginitis

. Vulvovaginal Candidiasis . Bacterial Vaginosis . Trichomoniasis . Atrophic Vaginitis . Desquamative inflammatory vaginitis

29 Differential of Infectious Vaginitis

30 Classification of VVC

Uncomplicated VVC Complicated VVC – Sporadic or infrequent Recurrent vulvovaginal vulvovaginal candidiasis candidiasis (RVVC) or or – Mild-to-moderate Severe vulvovaginal vulvovaginal candidiasis candidiasis or – Likely to be C. albicans or Non-albicans candidiasis or – Vulvovaginal candidiasis in or non-immunocompromised Vulvovaginal candidiasis in women women with uncontrolled diabetes, debilitation, or immunosuppression

31 Treatment of Complicated VVC

. Recurrent VVC (RVVC) – 7–14 days of topical therapy, or – 100 mg, 150 mg , or 200 mg oral dose of fluconazole repeated every 3 days (days 1,4,and 7) – Maintenance regimens . After intensive therapy for 7-14 days to achieve mycological remission, prolonged antifungal therapy with fluconazole 150 mg weekly for 6 months will successfully treat approximately 50% of women. . Ketoconazole higher risk for liver toxicity and not recommended for long term use. . Intermittent topical agents (Clotrimazole 500 mg weekly or 200 mg Twice a Week) . Severe VVC – 7–14 days of topical therapy, or – 150 mg oral dose of fluconazole repeated in 72 hours

32 Treatment of Complicated VVC

. Non-albicans (Glabrata) – Optimal treatment unknown – 7–14 days non-fluconazole therapy (Topical Imidazole cures up to 50%) – 600 mg boric acid in gelatin capsule vaginally once a day for 14 days for recurrences . Compromised host – 7–14 days of topical therapy . Pregnancy – Fluconazole is NOT contraindicated – Data showing birth defects is with high dose 400-800 mg daily – 7-day topical agents or Oral Fluconazole (if after the first trimester)

33 Treatment of BV

CDC-recommended regimens

. Metronidazole 500 mg orally twice a day for 7 days or . Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once or twice a day for 5 days or . Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days

– Both oral and topical metronidazole have risk for disulfram like reaction

34 BV in Pregnancy

. Associated with Low birth weight, PPROM, and prematurity . Standard therapy is effective in pregnancy . No contraindications to Clindamycin or Flagyl . No value in screening asymptomatic pregnant women . Conflicting data on screening those pregnant women with history of PPROM or Preterm delivery

35 Treatment of BV

CDC-recommended regimens

36 Treatment of Trichomoniasis

. CDC-recommended regimen – Metronidazole 2 g orally in a single dose or – Tinidazole 2 g orally in a single dose

. CDC-recommended alternative regimen – Metronidazole 500 mg twice a day for 7 days

. Pregnancy: – CDC-recommended regimen . Metronidazole 2 g orally in a single dose – All symptomatic pregnant women should be treated, regardless of pregnancy stage.

37 Treatment Failure

. A common reason for treatment failure is reinfection. Therefore, it its critical to assure treatment of all sex partners at the same time.

. If treatment failure occurs with metronidazole 2 g orally in a single dose for all partners, treat with metronidazole 500 mg orally twice daily for 7 days or tinidazole 2 g orally single dose.

. If treatment failure of either of these regimens, consider retreatment with tinidazole or metronidazole 2 g orally once a day for 5 days.

. If repeated treatment failures occur, contact the Division of STD Prevention, CDC, for metronidazole-susceptibility testing

38 Estrogen is the fountain of youth for the vagina

Atrophic Vaginitis I cannot have sex with my husband anymore. It hurts too much and nothing seems to help.

39 Atrophic Vaginitis

. Up to 50% of post menopausal women will experience vulvovaginal irritation, soreness, dryness, lower urinary tract problems, and dyspareunia. . The onset of symptoms can occur long after other menopausal symptoms . Even if they do not have visible signs of vulvovaginal atrophy, they can still experience symptoms . Despite use of systemic hormone therapy, 10-25% of users will continue to have atrophic symptoms due to estrogen deficiency

40 Atrophic Vaginitis

. Vulvar tissue becomes increasingly sensitive to irritants as women approach menopause . Without estrogen, the vaginal mucosa becomes this, pale and often dry. . The vaginal secretions decrease, the pH is more alkaline . The vaginal flora is altered . The genitals are increasingly susceptible to trauma, chemical irritants, and bacterial overgrowth . Diagnosis can be made on the presence of an elevated vaginal pH and the presence of parabasal or intermediate cells on microscopy . Whiff test negative

41 Atrophic Vaginitis Treatment

. Low dose topical estrogen is the mainstay of treatment – Estring, tablets, creams – Controversial if progestin needed for women with a uterus – Topical vaginal creams and tablets prescribed for treatment of local urogenital atrophic changes have low levels of systemic absorption but have no detectable effect on coagulation proteins or incidence of venous thromboembolism. . No indication for testosterone cream topically . Lidocaine jelly for severe cases . Water based lubricants for intercourse . Maintaining regular intercourse . Vaginal moisturizers

42 Other Vaginitis: General Considerations

. Biopsy is recommended to rule out carcinoma when lesions are hyper pigmented, exophytic, unresolved, or have changes in vascular patterns . For vulvar lesions that require biopsy, a punch biopsy is the usual preferred method. The leading edge of an ulcerative lesion should be sampled, whereas a biopsy of the thickest portion of hyper pigmented lesions is recommended. . Patients with biopsy-confirmed Paget's disease should undergo further evaluation of the breast, genitourinary tract, and gastrointestinal tract . Dermatitis can be present in 20% to 60% of women with chronic vulvar symptoms. Clinical signs of vulvar dermatitis can vary from mild erythema and swelling to fissures, erosions, and ulcers.

43 Lichen sclerosis

. Lichen sclerosus is most commonly seen on the vulva, and the mean age of onset occurs during the fifth to sixth decade.

. Clinical examination reveals porcelain-white papules and plaques as well as thin, crinkled "cigarette paper" epithelium.

. Women with perianal involvement can have a "figure-of-eight" distribution of skin lesions.

. The crinkled or parchment-like appearance that usually extends around the anal area in a figure of eight or hourglass configuration – atrophy of labia minora – constriction the vaginal orifice – adhesion and telangiectasia

. It can be asymptomatic but the most common presentations are: – intractable itching (pruritus vulvae) – vaginal soreness – dyspareunia . Punch biopsy to confirm diagnosis

44 Lichen Sclerosis

. Lichen sclerosus should be treated with high-potency topical steroids such as clobetasol propionate, which can reduce symptoms in 96% of patients. – Once-daily application of corticosteroid cream is usually sufficient, and long- term maintenance therapy with topical corticosteroids has generally not been associated with significant skin damage. – The decision whether to use maintenance therapy vs as-needed topical therapy is best made on a case-by-case basis. . Women with lichen sclerosus should undergo periodic surveillance of vulvar lesions because there is a 5% incidence of squamous cell carcinoma among these patients.

45 Lichen Planus

. Lichen planus can present in different morphologic states, but the most common form is the erosive form. . Erosive lichen planus promotes deep, painful, erythematous erosions on the posterior vestibule, and these lesions often extend to the labia. . The classic presentation of lichen planus is that of white, reticulate, lacy, or fernlike striae. . The most frequently recommended initial treatments of lichen plus are high-potency topical steroids. . Other treatments include topical or oral cyclosporine, topical tacrolimus, and oral immunosuppressants. . Punch biopsy for confirmation of diagnosis . Although vulvovaginal lichen planus is unlikely to remit spontaneously, treatment options include topical or systemic steroids, topical or oral cyclosporine, topical tacrolimus, hydroxychloroquine, oral retinoids, methotrexate, azathioprine, and cyclophosphamide. . Women should be advised that complete control of lichen planus is unusual, and most patients experience chronic and recurring disease. . This chronic, recurring condition requires long-term maintenance therapy.

46 Contact or Allergic Dermatitis

. Difficult to differentiate between the two types . Typical findings are: – diffuse reddening of the involved skin with excoriation and ulceration. – Secondary infection may occur. – Treatment with antihistamines, topical steroids, avoidance . Topical medications that can also cause allergic or irritant contact dermatitis include anesthetics, antibacterials, antimycotics, corticosteroids, trichloroacetic acid, 5- fluorouracil, podofilox, and podophyllin. . Common vulvar irritants and allergens that may cause allergic or irritant contact dermatitis include: – adult or baby wipes, antiseptics, body fluids, colored or scented toilet paper, condoms, vaginal contraceptives and lubricants, dyes, emollients, detergents and fabric softeners, rubber and latex, female hygiene pads or tampons, soaps and shampoos, tea tree oil, and vaginal hygiene products.

47 References

. Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. Jan 1983;74(1):14-22.

. Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. Ann Clin Microbiol Antimicrob. Feb 17 2006;5:4.

. Hillier SL, Krohn MA, Rabe LK, Klebanoff SJ, Eschenbach DA. The normal vaginal flora, H2O2-producing lactobacilli, and bacterial vaginosis in pregnant women. Clin Infect Dis. Jun 1993;16 Suppl 4:S273-81.

. Anderson MR, Klink K, Cohrssen A. Evaluation of Vaginal Complaints. JAMA 2004; 291:1368-79

. Pandit L, Ouslander JG. Postmenopausal vaginal atrophy and atrophic vaginitis. Am J Med Sci. 1997;314:228–31.

. Handa VL, Bachus KE, Johnston WW, Robboy SJ, Hammond CB. Vaginal administration of low-dose conjugated estrogens: systemic absorption and effects on the endometrium. Obstet Gynecol. 1994;84:215–8.

. CDC 2014 Guidelines for STD treatment

. Sobel JD. Desquamative Inflammatory vaginitis: a new subgroup of purulent vaginitis responsive to 2% Clindamycin therapy. Am J Obstet Gynecol 1994; 171 1215-20

. Gokdemir G, Baksu B, Baksu A, Davas I, Koslu A. Features of patients with vulvar dermatoses in dermatologic and gynecologic practice in Turkey: is there a need for an interdisciplinary approach?. J Obstet Gynaecol Res. Oct 2005;31(5):427-31.

. Powell JJ, Wojnarowska F. Lichen sclerosus. Lancet. May 22 1999;353(9166):1777-83.

. Cooper KD. Atopic dermatitis: recent trends in pathogenesis and therapy. J Invest Dermatol. Jan 1994;102(1):128-37. [

. Lewis FM. Vulval lichen planus. Br J Dermatol. Apr 1998;138(4):569-75.

. ACOG Practice Bulletin: Diagnosis and Management of Benign Vulvar Skin Disorders, Number 93, 2008, Reaffirmed 2013

. ACOG Practice Bulletin: Vaginitis, Number 27, 2006, Reaffirmed 2013

COVID-19 and Pregnancy

50 Basic Biology . Positive sense RNA virus . Same family as common cold AND SARS and MERS . Closest biologically to SARS. Both bind to ACE2 receptor in lungs and gut. . Technically virus is SARS-CoV-2 and clinical illness is COVID19 . Evolving rapidly (mutates every ~20 infections). . https://nextstrain.org/ncov

51 Transmission . Large droplet transmission (similar to Influenza with a 6 ft radius). Only necessitates surgical mask. . Small droplets unclear (airborne requires N95 mask). . For SARS N95 masks were used out of an abundance of caution. . Some guidelines require N95 masks (airborne) at all times (CDC). Canadian and WHO guidelines suggest N95 masks for procedures like intubation. . Overuse of N95 masks may lead to unnecessary depletion of stock.

52 Transmission (cont.) . Incubation period is 1-14 days BUT some reports suggest can be as long as 24 days. . Patient is infectious the first 8 days of the illness (no viable virus has been isolated from swabs after day 8 but they may still be PCR positive). . R0 is 2.5-2.9. Greater than the flu and will show exponential increase without social isolation and quarantines.

53 Basic Principles

. Universal surgical masking for all patients and staff . appropriate PPE for all staff . limiting and screening all visitors – screening questions – temperature checks . masking any visitors

54 The key to COVID 19

– Testing all admissions to limit the number and duration of patients under investigation (PUI) . This stops nosocomial spread . This protects health care workers . This preserves PPE

55 Pathophysiology . ARDS. Diffuse alveolar damage + hyaline membranes. There is direct viral damage to alveolar cells. . Cytokine storm. Florid immune response (marked elevations of CRP and Ferritin which correlate with disease severity) . Kawasaki like disease in children . Rapidly developing understanding

56 57 58 Illness Progression . Replicative stage: rapid virus replication. Mild symptoms. . Adaptive immunity stage: falling virus levels but increase in cytokines which leads to tissue damage  worsening symptoms. . This leads to a management challenge. Initial presentation will be followed by a honeymoon period and finally followed by rapid deterioration. . This suggests antiviral therapy should be deployed early to blunt the secondary response. . Most likely to progress are older patients with comorbidities.

59 COVID 19 Presentation in Pregnancy

• Presentation and clinical findings for COVID-19 pneumonia do not differentiate in pregnant women vs the general population • Typical presentation with COVID-19 includes • Common clinical features: Fever | Fatigue | Dry cough • Lymphopenia (<1.0 × 10⁹ cells per L) • Myalgia • Sore throat • Reports of • Liver involvement (elevated transaminases, coagulopathies) and decreased platelets • Cardiac injury biomarkers • Loss of smell and taste • Conjunctivitis

60 Pregnancy and Lab Values

. procalcitonin is reliable in pregnancy . D Dimer not helpful in pregnancy

. Have seen that COVID infection can mimic atypical HELLP syndrome . Suspected (anecdotal concerns) of increased SAB, IUFD

. Should have normal serologic response as compared to non pregnant population –reminder, IGM does not cross placenta

61 High Risk Conditions in Pregnancy Concerning for COVID 19

♣ Hypertension. ♣ Diabetes. ♣ Asthma. ♣ H I V. ♣ Chronic Heart Disease. ♣ Chronic liver disease. ♣ Chronic kidney disease. ♣ Blood dyscrasia. ♣ Immunosuppressive therapy (chronic steroid use, Plaquenil, biologics, etc.). Note: Neither necessary medications nor diagnostic imaging should be withheld from a pregnant woman because of fetal concerns, although attempts should be made to limit fetal exposure to ionizing radiation and teratogenic medications when feasible.

62 63 Criteria for Admission

♣ Respiratory distress or hypoxemia requiring oxygen supplementation, concerns for sepsis, fetal distress, other pregnancy related conditions o Symptoms of COVID 19, with O2 sat <98% on Room Air, increased work of breathing (tachypnea, accessory muscle use) regardless of 02 sat, abnormal ABG (especially with any pCO2 >30, any lab abnormalities with liver enzymes/platelets, consider low threshold for admission for any pregnant women with high-risk conditions and COVID-19 concerns. ♣ Application of timely, effective and safe supportive therapies is the cornerstone of therapy for patients that develop severe manifestations of COVID-19.

64 Management of COVID-19 Pregnant Inpatient

♣ Closely monitor patients with COVID-19 for signs of clinical deterioration, such as rapidly progressive respiratory failure and sepsis, and respond immediately with supportive care interventions. ♣ In general, a higher level of care should be sought when a patient is clinically unstable (e.g., hypotensive or hypoxemic), at high risk of deterioration (e.g., increasing work of breathing), or overtly needs specialized ICU care such as mechanical ventilation. ♣ Patients hospitalized with COVID-19 require regular monitoring of vital signs and, where possible, utilization of maternal abnormal vitals early warning system BPA that facilitate early recognition and escalation of the deteriorating patient. ♣ Early multi-disciplinary team management with OB, MFM, ICU teams, NICU, medicine.

65 CDC: Obstetric L&D Recommendations

. The following is a summary with key highlights – the full CDC recommendations can be found at the Obstetric Healthcare Settings page (find link below in ‘Learn More – Primary Sources’ as well as link to ACOG Practice Advisory) . Visitors • Visitors should be limited to those required for emotional care support, prioritizing maternal well- being • Depending upon the extent of community-transmission, institutions may consider limiting visitors to one essential support person and having that person be the same individual throughout the hospitalization • All visitors should be screened and, if cleared, should be educated regarding appropriate transmission prevention measures • Visitor screening • Visitors should not be allowed entry if fever or respiratory symptoms are present

66 Severity of Illness in Pregnant Women

• CDC data suggests that pregnant women with COVID-19 may be at higher risk for mechanical ventilation and ICU admission but not mortality • Study has multiple limitations including missing data regarding indication for hospital admission

• Uncertain why some get sicker than others • Ethnic and Socioeconomic disproportion suspected

67 Delivery Planning for Mildly Symptomatic or Asymptomatic Pregnant Patients

• COVID-19-positive status is not an indication for delivery • Timing and mode of delivery should be based on usual obstetrical indications • 37w0d to 38w6d: To limit exposure of healthcare team and neonate (and reduce PPE utilization were supply is limited) consider expectant management until • 14 days after the positive SARS-CoV-2 test result or • until 7 days after onset of symptoms and 3 days after resolution of symptoms • ≥39 weeks • Consider delivery to reduce risk of worsening maternal status

68 Delivery for Patients Who are Critically Ill

• SMFM provides guidance on management of critically ill women who are pregnant • Care needs to be individualized and addition, the document states that – Although data regarding delivery timing and acute respiratory distress syndrome are limited, it is reasonable to consider delivery in the setting of worsening critical illness

69 Mother-infant separation • Current evidence suggests that • Risk of a neonate acquiring SARS-CoV-2 from its mother is low • No difference in risk of SARS-CoV-2 infection to the neonate whether separated or rooming in • There is potential risk of transmission to neonate from contact with infectious respiratory secretions from the mother or others in close contact • Considerations for discussions between mother and healthcare provides include the following benefits of rooming • Helps mothers learn newborn feeding cues, which helps establish breastfeeding • Bonding is facilitated • Promotes family-centered care and can allow for parent education • Discontinuation criteria • Mothers who have met discontinuation criteria should not be considered as posing a potential risk of virus transmission • Mothers who have not met discontinuation criteria: May choose to temporarily separate from their neonates | However, unclear whether temporary separation in hospital will prevent transmission to neonate if after discharge they will not be able to maintain separation • When to consider separation • Mothers who are too ill to care for their infants or who need higher levels of care • Neonates at higher risk for severe illness (e.g., preterm infants, infants with underlying medical conditions, infants needing higher levels of care)

70 Infection control practice if no separation

• Consider using the following controls • Physical barriers (e.g., a curtain between the mother and newborn) • Keeping the newborn ≥6 feet away from the ill mother • Mother (with confirmed COVID-19 or PUI) should use a cloth face covering and practice hand hygiene before each feeding or other close contact with her newborn | Keep face covering in place during contact

71 Breastfeeding when mother is COVID-19 Positive

• Mother is breastfeeding • Wash her hands using soap and water before touching the infant or use hand sanitizer (at least 60% alcohol) if soap unavailable • wear a cloth face covering while feeding at the breast • Mother is expressing • Clean hands as above before touching any pump or bottle parts • Wear a cloth face covering • If possible, expressed breast milk should be fed to the infant by a healthy caregiver, who is not at high-risk for severe illness from COVID-19

72 Discharge Planning

• Patients with COVID-19 can be discharged from the healthcare facility whenever clinically indicated • Meeting criteria for discontinuation of Transmission-Based Precautions is not a prerequisite for discharge

73 Key Points

• Based on prior experience with significant viral infections, diligence is warranted in the management of pregnant women during the COVID-19 pandemic • Testing on labor and delivery • Women with suspected COVID-19 or those who develop related symptoms “should be prioritized for testing” • Universal testing: Consider molecular testing strategies to identify asymptomatic patients, particularly in high prevalence areas • PPE: ACOG reviews CDC guidance • Respirators (e.g., N95 respirators) should be used when caring for patients with confirmed or suspected COVID-19 • Aerosol-generating procedures should be prioritized during shortages • ACOG restates the CDC opinion that second stage is not considered an aerosol-generating procedure and adds the following • Mother-infant separation • ACOG recognizes that multiple organizations do not recommend this separation • ACOG states that because evidence is limited, “the determination of whether to keep patients with known or suspected COVID-19 and their infants together or to separate after birth should be made on a case-by-case basis, using shared decision-making”

74 What about the patient who isn't sick?

. This is likely the majority . need to have proper isolation, to protect staff, other patients etc. . Routine OB care is still important and needs to happen

75 Areas to Consider

. Antepartum Management . Intrapartum Management . Postpartum Management . Neonatal Management

76 Antepartum Management

. Questions to resolve: – pregnant healthcare workers and their risks? – prenatal visit timing, ultrasounds, NSTS? – prenatal milestones affected? – testing outpatient before admission? – timing of delivery for patients? – what if they are positive, but recovered, how to we test and screen them?

77 Intrapartum Management

. Questions to resolve: – Delivery method if COVID 19 positive? – Operative deliveries and FSE/IUPC use? – Doulas and their role? – hemorrhage management and risk? – new onset fever and management?

78 Postpartum Management

. Questions to resolve: – separation of mother and baby? – counseling and support during emotional and stressful time? – breastfeeding support and help?

79 Neonatal Management

. Questions to resolve? – isolation of baby? – testing of baby? – circumcision for baby? – discharge recommendations?

80 ACOG Resource

. https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob- gyns-obstetrics

81 References

1. McIntosh K, Hirsch MS, Bloom A. Coronavirus disease2019 (COVID-19). 2. Qiao J. What are the risks of COVID-19 infection in pregnant women? The Lancet. 2020. 3. Mardani M, Pourkaveh B. A Controversial Debate: Vertical Transmission of COVID-19 in Pregnancy. NeoscriberDemo Publisher. 4. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS,Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and Pregnancy: What obstetricians need to know. American Journal of Obstetrics and Gynecology. 2020. 5. Tavakoli A, Vahdat K, Keshavarz M. Novel CoronavirusDisease 2019 (COVID-19): An Emerging Infectious Disease in the 21st Century. ISMJ. 2020;22(6):432-50. 6. Organization WH. Coronavirus disease 2019(COVID-19) Situation Report – 60 2020 [updatedMarch 16, 2020; cited 2020]. Available from:https://www.who.int/emergencies/diseases/novelcoronavirus-2019/situation-reports/. 7. Yang P, Liu P, Li D, Zhao D. Corona Virus Disease 2019, agrowing threat to children? Journal of Infection. 2020. 8. Yu A, Wang Z, Ren W, Wu Z, Hu Z, Li L, et al. Epidemic analysis of COVID-19 in China after Wuhan wasrestricted.