Volume 66 No 01: Recurrent Pregnancy Loss, January 2021

“Previous studies have demonstrated increased rates of poor obstetrical outcomes including preterm delivery, placental abruption, and intrauterine growth restriction in women with uterine leiomyomas,” wrote the authors. “Currently, preconception myomectomy has not been reported to improve pregnancy rates or pregnancy outcomes in women with subserosal leiomyomas, and the data remain inconclusive for intramural fibroids.”

Although pregnancy rates have been found to improve after the removal of submucosal fibroids, the effect of preconception myomectomy for submucosal fibroids on birth outcomes has yet to be assessed, according to the investigators.

The current study sought to determine whether hysteroscopic excision of submucosal leiomyomas impacts the rate of preterm delivery and other obstetrical outcomes.

The final chart review comprised 62 women from Christiana Care Health System in Newark, Delaware, who were diagnosed with submucosal fibroids and underwent hysteroscopic myomectomy between January 2001 and January 2014. There were also 215 controls of women with submucosal fibroids without hysteroscopic myomectomy (case-to-control ratio, 1:3).

All women delivered a nonanomalous fetus beyond 20 weeks' gestation.

Cases and controls were similar in age, race, body mass index (BMI) and mode of delivery.

Overall, 66% of cases were primiparous vs. 37% of controls (

 = 0.00), whereas 22.6% of cases used assisted reproductive technology to conceive vs. 7.0% of controls (

However, the study revealed no differences in the rate of preterm delivery at <37 weeks' gestation (12.9% cases vs. 13.5% controls) (

 = 0.89); preterm delivery at <34 weeks' gestation (4.84% vs. 6.97%) (

The chart review indicated that the causes of preterm delivery in the control population were hypertensive disorders of pregnancy (31.2%); preterm premature rupture of membranes (PPROM) (18.75%); intrauterine fetal demise (IUFD) (12.5%); nonreassuring fetal heart tracing (NRFHT) (9.3%); vaginal bleeding in the setting of placenta previa (6.25%); spontaneous preterm labor (12.5%); and unknown causes (9.3%).

For cases, the causes included PPROM (14.3%); NRFHT (14.3%); hypertensive disorders of pregnancy (14.3%); spontaneous preterm labor (14.3%); and unknown causes (42.9%).

There were no statistically significant differences in the rates of preterm birth before 34 weeks’ gestation (7.01% cases vs. 4.84% controls; 

 = 012); placental abruption (0% vs. 1.87%; 

 = 0.58); fetal malpresentation (9.7% vs. 7.9%; 

 = 0.66); intrauterine growth restriction (IUGR) (9.7% vs. 17.4%; 

 = 0.59); retained placenta (0% vs. 0.47%; 

 = 0.67); postpartum hemorrhage (3.23% vs. 2.80%; 

 = 1.00); maternal transfusion (0% vs. 1.4%; 

 = 1.00); and the rate of cesarean delivery (54.8% vs. 57.5%; 

“Hysteroscopic myomectomy is considered a low-risk procedure, but the impact on future pregnancies is not fully understood,” wrote the authors. “Based on our findings, it seems that a composite of obstetrical outcomes is not significantly affected by hysteroscopic myomectomy, making it hard to know whether myomectomy should be offered to women with asymptomatic fibroids who are considering pregnancy.”

Fonge YN, Carter AS, Hoffman MK. Obstetrical outcomes are unchanged after hysteroscopic myomectomy in women with submucosal fibroids. 

Articles

Women with submucosal uterine leiomyomas who undergo hysteroscopic removal have comparable birth outcomes to women with submucosal uterine leiomyomas who do not have hysteroscopic removal, according to a retrospective case-control study in the American Journal of Obstetrics & Gynecology MFM.

Hysteroscopic myomectomy for submucosal fibroids

Laparoscopy better than imaging for accurate staging in locally advanced cervical cancer

While no difference was shown in disease-free survival rates between surgical and non-surgical staging methods, laparoscopy benefits patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical cancer. Surgical staging also has a cancer-specific survival benefit, according to a study published in the 

International Journal of Gynecological Cancers

Poll: Have you seen a rise in syphilis in pregnancy during the COVID-19 pandemic?

 featured a peer-reviewed article on syphilis in pregnancy.

Expert answers questions about COVID-19 vaccines

In this video, Senior Editor Angie DeRosa interviews Emily Adhikari, MD, on questions or concerns she and colleagues are hearing from patients surrounding the COVID-19 vaccine.

Frequently Asked Questions: COVID-19 vaccines

This FAQ is a printable reference for ob/gyns. It features information on the COVID-19 vaccines, as well as frequently asked questions and answers for ob/gyns to use when counseling patients.

It was a very busy week for the Contemporary OB/GYN team.

In case you missed it: Jan. 11 to Jan. 15

A practice is only as good as the people who work there but finding and keeping the right people can seem like an insurmountable task. This can be compounded with the uncertainty and increased scrutiny introduced by the COVID-19 pandemic.

In a recent entry in weekly studies performed by the Larry A. Green Center and the Primary Care Collaborative on how COVID-19 has affected primary care practices, 35% of physicians say hiring new staff is a big obstacle to their practice.

With this perennial problem only getting worse, the question remains for physician leaders on how to hire, motivate and retain clinical staff.

Target the talent by looking for candidates from areas similar to those your practice is in. This familiarity can smooth over some of the wrinkles the staff member may feel starting at a new practice.

Another suggestion is to adjust your pay system to reward hard work or to boost the total compensation package. This can take the form of creating bonuses for staff members who meet productivity goals, giving employees a sense of how they can earn more without leaving the practice.

The practice leader can also consider offering staff members growth opportunities such as enabling them to pursue more education through training. Sometimes the cost of training and giving the employee a raise can be lower than the cost of hiring another employee to handle the same new duties.

Personalized benefits, such as flexible hours or more vacation time, can be a good recruitment tool and a motivator for current staff members. Allowing newly hired physicians the ability to hire their own care teams or set their own office hours can increase their motivation.

All these changes should be documented and formalized so that, even if employment packages are individualized, they do not appear to be capricious.

An often-overlooked source for clinical staff is the newest batch of medical school graduates. While millennials may get a bad reputation in the media, they can be a key part of a health care team.

Andrew Hajde, CMPE, assistant director of association content at Medical Group Management Association in Englewood, Colorado, says the health care system is reaching a point where millennial physicians are becoming the only ones left to pick up the slack of retiring boomers and Generation Xers before Generation Z comes of age.

When hiring millennials it is important to remember that the cohort tends to put a premium on work-life balance and the feeling that their work has purpose.

Natasha Bhuyan, M.D., is a family physician and regional medical director with One Medical in Phoenix and a millennial. She says the members of her cohort no longer base their success on the hours they spend in the office or the number of patients seen.

“They’re measuring success based on fulfillment of purpose, based on developing meaningful relationships with patients and having time to connect with patients, improve their behaviors and see health results and outcomes change,” she says.

Millennial physicians are also aware that they need feedback and mentoring and can see the value in picking a senior employee’s brain to help them in their own work.

Bhuyan says this new emphasis on mentorship is closer to coaching than in years past.

“How do we coach physicians to reach the top of their potential and beyond?” she asks. “How do we push people beyond what they think is their best?”

ˆhis article was originally published on 

In a recent survey, Medical Economics® asked their audience what challenges they see for 2021. Hiring and retaining medical staff landed among the top five issues.

How to hire and retain clinical staff 

Medical director of Perinatal Infectious Diseases, Parkland Hospital, and assistant professor of Obstetrics and Gynecology in the division of Maternal-Fetal Medicine at the University of Texas Southwestern Medical Center in Dallas.

Currently, the two available vaccines for coronavirus disease 2019 are messenger RNA (mRNA) vaccines. This type of vaccine teaches cells how to make a protein, starting an immune response that creates antibodies. The antibodies protect us from getting infected when exposed to COVID-19.

The COVID-19 vaccine is different than influenza, or other vaccines, that rely on either live or inactivated virus to create the immune response.

There are two vaccines approved by the FDA. Both were tested to prevent COVID-19 disease.

There is no evidence suggesting risk from mRNA vaccines in pregnant or lactating women, but long-term safety and efficacy studies have not yet been published. That said, there is no biologically plausible evidence to suggest that harm to a pregnant woman or her fetus is possible from these vaccines. The currently available COVID-19 vaccines contain a piece of mRNA delivered within a lipid capsule. This capsule fuses with the cell membrane to deliver the mRNA. This mRNA sends a message to the cell to trigger the immune response and then is quickly degraded, never entering the nucleus or changing DNA in any way.

According to the American College of Obstetricians and Gynecologists (ACOG), the COVID-19 vaccine should not be withheld from pregnant women who meet criteria for vaccination

The vaccine also should be offered to lactating women.

 There is potential for a vaccinated mother to make protective antibodies that are passed to her infant based on experience with other vaccines in pregnancy (such as influenza vaccines), although this has not been completely studied yet for the COVID-19 vaccine.

The recommended considerations for vaccinating a pregnant woman against COVID-19 include the level of community transmission, her personal risks, and anticipated side effects, which are thought to be similar to other vaccines.

If a fever develops, pregnant women may take acetaminophen.

There is no need for a pregnancy test before vaccination.

Once vaccinated, do I need to wear a mask? 

Although the vaccines are highly protective, neither Pfizer nor Moderna vaccines provide 100% efficacy. We need more information to tell whether a vaccinated person can become infected without symptoms, or still pass the virus to others. This is being studied but it means we still have to wear masks after vaccination.

Can I get another vaccine at the same time as the COVID vaccine?

The recommendation is to administer the COVID-19 vaccine alone, with minimal interval of 14 days from other vaccines. If accidentally done, neither vaccine should be re-administered.

What if I miss the window for the second dose?

For either vaccine, if you miss the recommended timeframe for the second dose you should get it at the earliest opportunity. You do not need to restart the series.

No, the two vaccines (Pfizer vs Moderna) are not interchangeable. If inadvertently done, no additional doses should be administered until more is known.

Yes, these vaccines are safe, and they stimulate our body to make antibodies so our cells can fight off the SARS-CoV-2 virus that causes COVID-19 disease. The technology used to create them is not new, and is based on sequencing technology that has been around for years, but has not yet been used as part of a coordinated global effort to address a public health crisis such as this. 

Older vaccines like influenza require large amounts of live virus to be grown in special labs. This takes time and for COVID-19 would require extreme safety measures. 

The mRNA vaccines are not live virus, and are developed based on the sequence of the virus that is known. This makes vaccine development much faster, but still very accurate, and safe.

If I had COVID or was exposed to the virus, should I still get the vaccine?

Yes, even those who had COVID-19 should be vaccinated once they are recovered. We do not yet know how long the immune response to natural infection lasts, and the vaccine has been shown to be effective in preventing infection. 

If you are acutely infected, you should wait until you have recovered to receive the vaccine. 

If you are recently exposed or in quarantine, you should wait until the end of quarantine to avoid exposure to health care workers. 

If I had COVID or was exposed, do I need to get blood work done to look for antibodies before getting the vaccine?

No, there is no need to evaluate for antibodies before vaccination. 

If I have medical conditions, like diabetes or high blood pressure, should I get the vaccine? 

Yes! These medical conditions may result in a more severe infection with COVID-19 so it is important to get vaccinated.

If I am immunocompromised should I get the vaccine?

There is limited data available, but vaccination may provide key protection against the virus in those with suppressed immune systems. The COVID-19 vaccines do not contain live virus.

Does either COVID-19 vaccine cause infertility?

Despite social media chatter, antibodies to the spike protein have not been linked to infertility after COVID-19 infection, and there is no scientific reason to believe this will change after vaccination for COVID-19. 

No other viral infection or vaccination-inducing immunity by similar mechanisms has been shown to cause infertility. 

Women should feel comfortable that this claim has no basis in science.

Does the COVID-19 vaccine cause Bell’s palsy?

This question comes from the side effects reported in the Moderna vaccine trial, which included 30,400 participants. 

Companies track every complaint, regardless of whether linked to vaccination. In the trial,

 participants reported Bell’s palsy symptoms: 3 in the vaccine and 1 in the placebo group. This was not a significant difference and thus was not attributed to the COVID-19 vaccine.

Will the vaccine cause male pattern hair growth?

No, there is no evidence the vaccine causes women to grow beards or mustaches. 

In contrast, COVID-19 illness has been linked to 

Thus, vaccination will not increase undesired hair growth and may prevent undesired hair loss from COVID-19.

How does the vaccination affect testing for COVID-19 disease?

Vaccination will not affect results of nasal, nasopharyngeal, or saliva PCR or rapid antigen tests for diagnosis of acute infection. 

Currently, the antibody tests available in laboratories check for IgM or IgG to either spike or nucleocapsid proteins. 

Positive antibody (IgG) to spike protein could mean evidence of prior infection or vaccination. 

To document prior natural infection with live virus, laboratory evidence of antibody to nucleocapsid protein is needed.

How do I know if symptoms after vaccination are due to the vaccine or COVID-19 infection?

Signs and symptoms unlikely to be from COVID-19 vaccination include: Cough, shortness of breath, rhinorrhea, sore throat, loss of taste or smell; 

Signs and symptoms that may be from either COVID-19 vaccination, SARS-CoV-2 infection,or another infection include: Fever, fatigue, headache, chills, myalgia, and/or arthralgia.

People who have had anaphylaxis or severe allergic reaction to any component of the vaccine.

1. Polack FP, Thomas SJ, Kitchin N, et al. C4591001 Clinical Trial Group. Safety and Efficacy of the BNT162b2 mRNA COVID-19 Vaccine. N Engl J Med. Published online Dec 10, 2020: NEJMoa2034577. doi:10.1056/ NEJMoa2034577. PMID: 33301246; PMCID: PMC7745181.

2. The United States Food and Drug Administration. Vaccines and Related Biological Products Advisory Committee Meeting, Dec. 17, 2020. Accessed Dec. 21, 2020. https://www.fda.gov/media/144434/download

3. The American College of Obstetricians and Gynecologists. Vaccinating Pregnant and Lactating Patients Against COVID-19. Accessed online Dec. 21, 2020.

https://www.acog.org/en/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-Pregnant-and-Lactating-Patients-Against-COVID-19

4. Oliver SE, Gargano JW, Marin M, et al. The Advisory Committee on Immunization Practices’ Interim Recommendation for Use of Pfizer-BioNTech COVID-19 Vaccine - United States, December 2020. MMWR

Morb Mortal Wkly Rep. Dec. 18, 2020;69(50):1922-1924. doi:10.15585/mmwr.mm6950e2. PMID: 33332292.

5. Wambier CG, Vaño-Galván S, McCoy J, et al. Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: The “Gabrin sign”. J Am Acad Dermatol. August 2020;83(2):680-682. doi:10.1016/j.jaad.2020.05.079. Epub May 22, 2020. PMID: 32446821; PMCID: PMC7242206.

This FAQ is a printable reference for ob/gyns. It features information on the COVID-19 vaccines, as well as frequently asked questions and answers for ob/gyns to use when counseling patients. 

The American College of Physicians (ACP) has released a series of recommendations aimed at improving COVID-19 coronavirus vaccine provision, distribution, and payment.

 the recommendations seek to address the role of physicians as vaccinators and informing they and the public about COVID-19 vaccines. They also enforce the importance of communication and collaboration between physicians and other vaccinators to ensure safety and continuity of care.

Using all appropriately trained, state-licensed clinicians to administer the vaccines

Urging the Centers for Disease Control and Prevention, the Food and Drug Administration, vaccine manufacturers, state, and local health departments to distribute all vaccine-related educational materials to all vaccinators including information on adverse effects of the vaccines.

All vaccinators should coordinate, collaborate, and communicate with the patient’s primary care team to ensure safety and continuity of care.

Vaccinators should record the administration data within the patient’s medical record and promptly report the vaccination to the state immunization information system or other designated system.

That insurers be required to provide adequate reimbursement for all vaccines, including the COVID-19 vaccines.

“A vaccine can only be as effective as our ability to turn them into actual vaccinations given to our patients and the public,” Jacqueline W. Fincher, MD, MACP, president of ACP, says in the release.“A coordinated effort is critical to distributing the COVID-19 vaccine to the public and will require communication, collaboration and information sharing among physicians and other vaccinators.”

These recommendations build on previous guidance provided by the ACP on the 

support for the Advisory Committee on Immunization Practices recommendations

 on the use of the COVID-19 vaccines, the release says.

This article was originally published on 

The recommendations address the role of physicians as vaccinators.

Recommendations to improve COVID-19 vaccine provision, distribution and payment

Syphilis, known as the “the great imitator,” is a clinical disease with myriad manifestations and stages. Clinical illness results from infection with the spirochete 

 which enters at sites of sexual contact and by transmission across the placenta during pregnancy.

Poll

The January issue of Contemporary OB/GYN® featured a peer-reviewed article on syphilis in pregnancy.

Definitive chemoradiation should be used in place of radical hysterectomy for cervical cancer patients with intraoperatively discovered lymph node involvement, according to a retrospective analysis. 

The study was conducted by David Cibula, MD, PHD, who is a professor in the Department of Obstetrics and Gynaecology at First Faculty of Medicine at the Charles University and General University Hospital in Prague and collaborating authors.

Researchers noted that the management of cervical cancer patients with intraoperatively discovered lymph node involvement is contentious. “Since all these patients are referred for (chemo)radiation after the surgery, the key decision is whether radical hysterectomy should be completed as originally planned, taking into account an additional morbidity associated with extensive surgical dissection prior to adjuvant treatment,” the authors said.

The analysis examined 515 cervical cancer patients in 19 countries who were treated in 51 institutions between 2005 and 2015. Patients had been referred for primary curative surgery for stage IA-IIB, common tumor types where lymph node involvement was found intraoperatively. Patients were placed into a completed surgical group (361) and an abandoned surgical group (154) and had progression-free survival compared. In the abandoned group, 92.9% of patients were treated with definitive chemoradiation. Adjuvant (chemo)radiation or chemotherapy was given to 91.4% of patients in the completed surgical group.

Study authors reported no significant difference in recurrence risk, pelvic recurrence, or death. They also said no subgroup had a survival benefit from radical hysterectomy. They reported disease-free survival in 381 patients, a rate of 74%, after a median follow up of 58 months. They said prognostic factors between the two groups were balanced.

“FIGO stage and number of pelvic lymph nodes involved were significant prognostic factors in the whole study cohort,” the authors said.

, Cibula said the most significant aspect of the research is the international collaboration that made it possible for the study to represent the largest cohort by far of cervical cancer patients in whom lymph node involvement was detected intraoperatively. He said that the authors “tried to avoid the limitations of some previous smaller studies, excluding patients with positive lymph nodes from pre-operative work-up or from final pathology.”

 that although this was a retrospective study, “it is very unlikely that a prospective study can ever be performed since it would require the screening of more than 7,000 patients with early-stage cervical cancer. It is very unlikely that a significant benefit could be found since our study in well-balanced groups comparing the two different approaches did not reveal even a signal towards better survival or local disease control in any patients´ subgroup.”

Cibula emphasized the analyses’ results in his interview, so that physicians in practice can confidently abandon radical hysterectomy in favor of definitive chemoradiation. “We did not find a survival benefit from the completion of radical hysterectomy in any subgroup of patients, irrespective of histological type, disease stage, or tumor size,” he said.

Cibula D, Dostalek L, Hillemanns P, et al. Completion of radical hysterectomy does not improve survival of patients with cervical cancer and intraoperatively detected lymph node involvement: ABRAX international retrospective cohort study. [published online ahead of print, 2020 Dec 5]. 

. 2020;143:88-100. doi:10.1016/j.ejca.2020.10.037.

Since radical hysterectomy does not improve survival, the procedure should be replaced with definitive chemoradiation, according to the ABRAX study published in the European Journal of Cancer.

No survival benefit found after radical hysterectomy when cervical cancer is discovered in lymph nodes intraoperatively

Surgical staging is superior to imaging staging for disease-free and cancer-specific survival benefits in locally advanced cervical cancer, according to the Uterus-11 prospective international multicenter study. This study was conducted by Simone Marnitz, MD, PhD, of the department of radio oncology and medical faculty at the University of Cologne in Germany and colleagues. It is the only randomized study comparing surgical and non-surgical staging before primary chemoradiation to date.

The study’s purpose was to evaluate how surgical staging prior to treatment, including enlarged lymph node removal, affects disease-free survival in patients with locally advanced cervical cancer. The authors said that while clinical examination, imaging, and potential surgical findings are used for revised staging, imaging is often limited because it can result in understaging.

Two hundred forty patients were randomized 1:1 to an experimental surgical staging group (121 patients) or a control clinical staging group (119 patients). Marnitz and colleagues reported that randomization took place between February 2009 and August 2013. The authors reported that patients in the two groups had comparable characteristics.

Patients with confirmed adenocarcinoma, squamous cell carcinoma, or adenosquamous cancer FIGO 2009 stage IIB-IVA had a gynecological exam and pre-treatment imaging that included abdominal magnetic resonance imaging and/or abdominal computed tomography (CT). They also had chest imaging via X-ray, CT, or positron emission tomography-CT.

Transperitoneal, extraperitoneal, or open transperitoneal laparoscopic methods were used for surgical staging in the experimental group. Suspicious areas were biopsied and frozen. Transperitoneal laparoscopy was used in 96.6% of patients in the surgical staging group.

The authors reported laparoscopy resulted in upstaging in 39 of 120 (33%) patients. Surgical staging is also better than clinical staging when examining disease-free survival (HR 0.51, 95% CI 0.30 to 0.86, p=0.011), the authors said. It was associated with better cancer-specific survival in the post-hoc analysis as well (HR 0.61, 95% CI 0.40 to 0.93, p=0.020).

After a median 90-month follow-up, the authors reported “no difference in disease-free survival between surgical staging and clinical staging in patients with locally advanced cervical cancer,” (p=0.084).

Marnitz and colleagues highlighted several strengths in the study: that this is the largest of its kind, and that nearly all patients received minimally invasive surgical approaches and modern radiation techniques. They also noted strength in long-term follow up and high levels of data completeness. They acknowledged study challenges that included PET-CT scans not being routinely done pre-operatively due to lack of reimbursement funding, and study power being reduced from 80% to 70% due to 102 instead of 129 observed events. In addition, the protocol could not include patients with stage IB2 (FIGO 2009) cervical cancer.

The authors concluded that staging with laparoscopy “was safe, did not delay primary chemoradiation, and led to 33% upstaging in patients with locally advanced cervical cancer.” They also said that after surgical staging, primary chemoradiation was not delayed or associated with higher early complication rates.

As a result of these findings, the authors recommended that “further studies in patients with FIGO stage IIB tumors should be considered. The fact that in cases of recurrence there were >85% distant metastases underlines the need for more effective systemic (maintenance) treatments such as sequential chemotherapy following primary chemoradiation, immunotherapy, or a combination of both.”

Marnitz S, Tieko Tsunoda A, Martus P, et al. Surgical versus clinical staging prior to primary chemoradiation in patients with cervical cancer FIGO stages IIB–IVA: oncologic results of a prospective randomized international multicenter (Uterus-11) intergroup study. 

. 2020;30(12):1855-1861. doi:10.1136/ijgc-2020-001973.

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Nullam in eros pulvinar, tristique velit in, sodales ligula. Nunc semper tempus mi, id vehicula metus sodales eu. Nulla pharetra elementum risus id egestas. In fringilla nibh purus, quis eleifend turpis rutrum nec. Pellentesque tempus dui euismod volutpat vehicula. Sed faucibus est ac sapien lobortis, vitae volutpat purus tincidunt. Proin bibendum risus in maximus lobortis. Donec rhoncus urna vel sapien tincidunt, quis semper lorem volutpat. Curabitur lacinia rhoncus leo sit amet dictum. Sed nibh velit, commodo vitae arcu nec, vulputate bibendum augue. Sed porta malesuada orci in placerat. Donec iaculis nibh vel eros molestie finibus. Etiam ut augue risus. In vulputate nec ligula quis rutrum. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas.

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Nulla bibendum turpis eros, at eleifend eros mollis non. Phasellus sit amet sem aliquet massa aliquam convallis. Maecenas maximus velit quam, ut porta odio molestie at. Aliquam non risus ligula. Sed ac elit metus. Aliquam nulla magna, porta sed porttitor sed, tristique id mauris. Integer non congue nunc, a tempor nulla. Mauris iaculis mauris sit amet enim tincidunt, in lobortis orci elementum. Maecenas ligula nunc, auctor ac finibus eu, posuere quis nisl. Cras mattis leo in nisi hendrerit volutpat id sit amet tellus. Donec congue lacus sed efficitur ultricies. Mauris blandit ante eget nunc mollis fringilla. Duis tincidunt euismod neque, ac eleifend quam bibendum et. Proin rhoncus libero et ultricies fermentum.

While no difference was shown in disease-free survival rates between surgical and non-surgical staging methods, laparoscopy benefits patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical cancer. Surgical staging also has a cancer-specific survival benefit, according to a study published in the International Journal of Gynecological Cancers.

Effective treatment of gynecological cancers must now occur within the framework of COVID-19. Ibrahim Alkatout, of the Department of Obstetrics and Gynecology at University Hospitals Schleswig-Holstein in the Kiel School of Gynaecological Endoscopy in Kiel, Germany, and colleagues have created guidelines for pandemic treatment of gynecological cancers.

Using the keywords COVID-19, SARS, and MERS, along with gynecological cancer terminology, Alkatout and colleagues comprehensively reviewed international databases. These included Science Direct, PubMed, Cochrane Library, Scopus, and Google Scholar. The authors consulted various countries’ early guidelines and expert opinion for additional data due to the pandemic’s limited time frame.

General treatment guidance during the pandemic

The following protocols are for high-risk cancer patients aged 65 and older; patients with pulmonary disease, heart disease, or diabetes of any age; patients receiving systemic chemotherapy; and patients with an Eastern Cooperative Oncology Group status ≥2.

Surgery should be performed if the patient’s survival is expected to be more than 12 months, according to the authors. Surgery should also be done if the patient does not respond to other treatments, and if the patient may not survive if surgery is delayed.

If non-surgical therapies can be used effectively, the authors recommend delaying surgery if the patient has ready access to ICU and other hospital facilities.

Elective surgeries for benign conditions should be cancelled. Patients should be given alternative treatments to reduce symptoms and be advised to stay home, and healthcare providers should direct their attention to patients severely affected by the coronavirus, the authors noted.

Legally, patients and families must be informed about surgery delays and of non-surgical treatment use. These must be included on an informed consent form, the authors added. They said that a multidisciplinary team should make decisions based on weekly tumor boards, and that COVID-19 is a risk for both patients and staff.

Guidelines for outpatient management and gynecological oncology clinics

The authors recommended telephone screenings prior to appointments and temperature checks for patients upon arrival. In addition, they suggest visits be limited to new patients, patients with acute oncologic issues or who are being treated for serious conditions, such as symptomatic patients with cancer recurrence or molar pregnancies.

Patients who live in towns outside their treatment center should have imaging and labs performed locally and have results electronically transmitted. Only one person should accompany the patient to on-site visits. Their companion should be screened to ensure they are not infected and have not been exposed to COVID-19.

Physical distancing in the waiting room and patient flow should be monitored for safety, the authors noted. They also said surveillance/follow up visits should be postponed or completed through telehealth. The authors recommended screenings such as pap smears and mammography be delayed; if the patient needs follow up, outer time limits of 6 months should be followed. “Any intervention that is not absolutely essential should be postponed,” the authors said.

 in its early stages, the authors reported hormone therapy as the best choice, while recommending radiotherapy for this cancer in its later stages.

high-grade squamous intraepithelial lesions 

require immediate treatment after diagnosis. Their guidelines require a minimum of a loop electrosurgical excision procedure and the postponement of major surgery for 10-12 weeks.

 can start immediate radiotherapy in the interim while surgery can be delayed 2-4 weeks, according to the authors.

Alkatout and colleagues said hormone therapy may be prescribed for 2-3 months for patients with 

ovarian masses with negative tumor markers 

if patients have no cancer signs on imaging, a low level of CA-125 in serum, no ascites, and no vegetation or papillary projection in the base of the cyst.

Surgery should be performed quickly, in a maximum of 2-3 weeks, for 

, the authors recommend radiotherapy be given preference for treatment within 10-12 weeks.

, an oncological emergency. Molar pregnancy patients need to be monitored for metastases, the authors also noted.

Alkatout and colleagues said there is little information to help choose between laparoscopic and open surgery. Any patient may be an asymptomatic carrier, so major surgery “should be preceded by chest computerized tomography, with and without contrast medium, in order to detect lung lesions,” the authors said. They noted that evidence for these recommendations is limited, and added that data on ethical debates over treatment delays and approaches that stray from current guidelines are also limited.

“Any delay in gynecological procedures that could exert a negative effect on the patient’s health and safety should be avoided…practitioners should be aware of the unintentional impact of policies regarding COVID-19, including limited access to time-sensitive obstetric and gynecological procedures,” the authors concluded.

Alkatout I, Karimi-Zarchi M, Allahqoli L. Gynecological cancers and the global COVID-19 pandemic. J Turk Ger Gynecol Assoc. 2020; 21(4):272-278. doi:10.4274/jtgga.galenos.2020.2020.0119. Accessed 17 December 2020.

With coronavirus disease 2019 limiting the availability of health resources, research using a comprehensive review and expert opinion has set pandemic treatment protocols for gynecological cancers.

Guidance for treating gynecological cancers during the COVID-19 pandemic

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Guidance for treating gynecological cancers during the COVID-19 pandemic

This week on Contemporary OB/GYN: Jan. 11 to Jan. 15