Volume 66 No 4: April 2021

Hormone therapy for postmenopausal women with nocturia

A prospective observational study found that hormone therapy resulted in a significant reduction in nocturia prevalence and bother in postmenopausal women with two nocturnal voids.

A prospective study to assess the effects of an oral contraceptive containing estetrol and drospirenone on ovarian function found treatment achieved complete ovulation inhibition.

Two experts discuss the goals of treatment and the expanding therapeutic landscape. This article was sponsored by Myovant Sciences.

Reduced Testing, Higher Positivity Rates for Prescription and Illegal Drugs During the COVID-19 Pandemic in 2020

Lower levels of testing and higher positivity rates, higher rates of dangerous drug combination use, and increases in fatal and non-fatal overdoses during the coronavirus disease 2019 (COVID-19) pandemic reveal a need for more resources to address the opioid epidemic in the United States.

Evaluation & Management of COVID-19 in Pregnancy

Treating COVID-19 in pregnant patients brings extra challenges, risks.

Articles

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

In case you missed it: April 5 to April 9

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.

At the writing of this article in February 2021, severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) cases ranging from asymptomatic infection to fatal respiratory illness have affected more than 100 million individuals and led to more than 2.4 million deaths worldwide.

 Although cases and hospitalizations have decreased from their winter peak, emerging variants threaten to intensify the epidemic.

 It is important to review the clinical evaluation and management of coronavirus disease 2019 (COVID-19) in pregnancy.

Although predominantly transmitted via respiratory droplets, SARS-CoV-2 can be transmitted through the air via aerosolized particles under some circumstances, such as during intubation prior to surgery, and in enclosed spaces.

 Asymptomatic or presymptomatic individuals account for 40% to 50% of transmissions.

An estimated 95% of infected individuals have asymptomatic or mild illness, with approximately 5% developing severe or critical illness.

 Pregnant individuals with symptomatic COVID-19 may be at higher risk for intensive care unit admission, invasive ventilation, and death.

 Similar to nonpregnant individuals, obesity and diabetes may be risk factors associated with severe COVID-19 illness in pregnant individuals.

Active maternal infection is diagnosed by molecular (also known as polymerase chain reaction [PCR] tests) or antigen detection in nasopharyngeal, nasal, or saliva specimens. Several commercial PCR and antigen tests are available. Rapid antigen tests are inexpensive but not as effective at detecting infection in asymptomatic individuals. 

Molecular test result interpretation depends on pretest probability, epidemiologic risk factors, and intended use for diagnostic or screening purposes in health care or congregate living settings. Serologic testing for presence of anti–SARS-CoV-2 immune globulin is used for epidemiologic and seroprevalence studies, but it is not useful for diagnosing active infection. At this time, there is no recommendation by the Centers for Disease Control and Prevention (CDC) for using antibody testing following vaccination to verify immunity.

Clinical manifestations of COVID-19 in pregnancy

Symptoms of COVID-19 in pregnant individuals are the same as those in nonpregnant individuals. An incubation period of approximately 5 to 14 days may be followed by fever, respiratory, gastrointestinal, or neurologic symptoms.

 Respiratory symptoms can vary from mild upper respiratory symptoms, such as pharyngitis and sneezing, to lower respiratory illness indicated by cough, dyspnea, tachypnea, and decreased oxygen saturation. 

Severe to critical respiratory illness manifests approximately 8 to 12 days after symptom onset in 5% to 14% of nonpregnant individuals, and approximately 5% of pregnant individuals.

 Acute respiratory failure, including acute respiratory distress syndrome (ARDS), is rare. Gastrointestinal symptoms are less common, although loss of smell (anosmia) and taste (ageusia) are reported in more than half of patients.

Table 1. National Institutes of Health COVID-19 Disease Severity Criteria

Clinical Spectrum of SARS-CoV-2 Infection

The National Institutes of Health (NIH) criteria for classifying the severity of respiratory illness from COVID-19 may generally be applied to pregnant patients, with additional considerations for how pregnancy physiology affects the progression and presentation of symptoms (

). Physiologic changes in the pulmonary function during the third trimester include decreased functional residual capacity by approximately 20% to 30% and increased oxygen consumption by 20%, making lower respiratory infections less well tolerated. 

Because the respiratory rate in the third trimester remains relatively unchanged through gestation (with increased tidal volume accounting for increased minute ventilation), an increased respiratory rate above 30 breaths per minute—even if the oxygen saturation on room air is maintained at or slightly above 95%—is a sign of potentially severe respiratory compromise in symptomatic SARS-CoV-2 infection.

Initial evaluation of respiratory symptoms

Initial evaluation of a pregnant patient with reported mild symptoms such as sore throat or sneezing may be limited and focused. More thorough evaluation is warranted for those with fever, significant respiratory complaints, and systemic symptoms. This includes a thorough history and physical exam with an attempt to understand the timing of symptom onset relative to presentation and progression or improvement of symptoms. 

These details help the clinician determine the potential for worsening—ie, a patient with mild clinical illness improving on day 9 or 10 of symptoms is more likely to be near the end of the illness course, whereas a patient with mild, flulike symptoms at day 4 to 5 of illness may worsen and need to be monitored more closely, depending on maternal comorbidities and gestational age. 

In those with systemic findings or significant respiratory symptoms, auscultation of the lungs and documentation of oxygen saturation are necessary but not sufficient to assess respiratory status. The physician must also assess and document respiratory rate as well as objective signs of respiratory fatigue or respiratory distress, including accessory muscle use, work of breathing, and ability to speak without interruption due to coughing or dyspnea.

Assessment can be performed at rest and after walking in patients reporting significant symptoms but who appear comfortable at rest and without hypoxia. In these circumstances, the clinician may be uncertain about the need for admission.

For nonpregnant adult patients, a 6-minute walk test is a low-cost assessment of functional status in patients with moderate to severe pulmonary disease.

 Although a full 6-minute walk test may not be feasible for nonlaboring obstetric patients, a brief assessment of ambulation may assist the clinician in determining whether the patient warrants closer observation. 

For patients with obvious increased work of breathing, chest pain, or desaturation following minimal ambulation, admission is warranted and supplemental oxygen should be considered. Given that approximately 40% of pregnant patients with initially moderate clinical illness may progress to severe pneumonia, observation for 24 to 48 hours should be considered.

Unlike other respiratory infections such as influenza, clinical decompensation secondary to COVID-19, if it occurs, happens relatively late in the course of illness.

Early acute respiratory failure—ie, impaired gas exchange of oxygen and carbon dioxide—in a pregnant patient with COVID-19 should promptly lead to a consultation of maternal-fetal medicine (MFM) and critical care specialists experienced in treating COVID-19. Respiratory failure may be hypoxemic, defined as partial pressure of oxygen (Pao2) less than 60 mm Hg on room air, correlating approximately to an oxygen saturation (SpO2) of less than 90%; or hypercapnic, defined as partial pressure of carbon dioxide (Pco2)greater than 50 mm Hg. 

Importantly, a compensated respiratory alkalosis is expected in the third trimester of pregnancy, and if arterial blood gas is obtained and reveals a normal or elevated Pco2, this is an ominous sign of hypercapnic respiratory failure. In the case of a pregnant patient without preexisting cardiac or pulmonary disease admitted with severe pneumonia from COVID-19, early respiratory failure is commonly hypoxemic, although ARDS may develop with resultant hypercapnia due to increased alveolar dead space. 

With severe illness, hypoxemia-driven tachypnea (increased respiratory rate) and hyperpnea (increased tidal volume) may lead to more profound hypocapnia (decreased Paco2), which shifts the oxygen-hemoglobin dissociation curve to the left. When this occurs, increased binding affinity for oxygen by hemoglobin results in relative preservation of measured oxygen saturation (Spo2) despite profound hypoxemia (low Pao2). 

Whereas this may manifest clinically as “silent hypoxemia” described in elderly patients with COVID-19,14 hypoxemia in pregnancy is unlikely to remain “silent,” and rapid decompensation may occur despite measured Spo2 greater than 90%. 

Prompt initial evaluation of a pregnant patient with COVID-19 who presents with cough and dyspnea is key so that appropriate triage takes place in coordination with specialists. This includes a thorough assessment of both oxygenation and ventilation, as well as an awareness of the pitfalls of using Spo2 as a single measure of clinical stability when the patient is tachypneic or describing shortness of breath.

Conditions other than COVID-19 (e.g., pulmonary embolus or pulmonary edema related to obstetric, pulmonary, or cardiac etiologies) should be considered in patients with hypoxia but without significant parenchymal opacities on chest radiography. It is unclear to what extent COVID-19 may exacerbate conditions such as sepsis from acute pyelonephritis or preeclampsia-related pulmonary edema.

For patients who are asymptomatic or with upper respiratory symptoms only, laboratory evaluation beyond COVID-19 testing typically is not necessary. For those with significant respiratory symptoms, systemic illness and fever who present to the hospital, laboratory evaluation following history and physical examination to rule out other causes of infection and hypoxia may be warranted. In our experience managing hospitalized, nonlaboring patients with moderate to severe viral pneumonia, measurement of daily C-reactive protein (CRP) aids in determining the clinical trajectory. 

While measurement of CRP performed well in discriminating disease severity and predicting adverse outcomes in nonpregnant patients with COVID-19, the predictive value has not been evaluated in a pregnant population.

Furthermore, the level of CRP normally rises during pregnancy and with other states of inflammation or infection, so it would be considered less helpful in a laboring or recently delivered patient. Daily evaluation of liver function (aspartate aminotransferase, alanine aminotransferase [ALT]) also is warranted for patients hospitalized with severe illness and in those who receive remdesivir (Veklury). 

The Society for Maternal-Fetal Medicine (SMFM) recommends evaluation of ferritin in individuals with fevers higher than 39 °C despite acetaminophen in an effort to identify secondary hemophagocytic lymphohistiocytosis or cytokine storm syndrome, which may have a fulminant course.

For critically ill patients with suspected respiratory failure, arterial blood gas evaluation may be indicated if clinical improvement is not rapid following initial oxygen supplementation. 

During initial evaluation, frequent clinical reassessment with respiratory support titration is more informative than arterial blood gas in awake patients. Obtaining serial arterial blood gas samples may delay escalating care, whereas frequent reassessment of the patient’s initial status and response to oxygen supplementation may help determine whether immediate placement in an intensive care setting or early transfer to a facility with a higher level of care is warranted.

There is no evidence to support measurement of coagulation markers, including D-dimer, in nonhospitalized patients with COVID-19.

 Furthermore, there are limited data supporting the routine use of D-dimer in hospitalized pregnant patients to predict venous thromboembolism (VTE) in the setting of COVID-19, as interpretation may be confounded by physiologic increases during gestation, with certain pregnancy complications, and following delivery.

Institutional protocols may call for the evaluation of certain laboratory indices as part of a standard panel ordered for patients with COVID-19. In this case, it may be helpful to consult with MFM specialists experienced in caring for pregnant patients hospitalized with COVID-19 before acting on abnormal laboratory results. When VTE is clinically suspected in the evaluation of a patient with COVID-19, appropriate diagnostic imaging studies should be considered.

Figure. Chest radiograph of a patient at 33 weeks of gestation with severe COVID-19 pneumonia. There are multifocal bilateral parenchymal opacities.

Photo credit: Parkland Hospital, UT Southwestern Medical Center.

Chest radiography should be performed for patients with moderate to severe respiratory illness, and repeated if oxygen requirement increases, to evaluate the extent of parenchymal lung disease. Imaging indicative of moderate to severe viral pneumonia reveals opacities in a predominantly peripheral distribution, with a diffuse pattern demonstrated in early ARDS (

). CT pulmonary angiography (CTA) should be considered when hypoxia or tachycardia persist despite minimal opacities demonstrated on chest radiography or when clinical suspicion for pulmonary embolism is high. CTA is not routinely indicated for all pregnant patients with COVID-19 and classic symptoms of dyspnea and cough when parenchymal lung disease is demonstrated on chest radiography.

For patients with asymptomatic or mild infection, supportive treatment is appropriate. For moderate illness, inpatient observation may be considered, as up to 40% may progress to severe illness.

 For pregnant patients with severe to critical illness, inpatient treatment involves providing adequate respiratory support, managing comorbid conditions, and coordinating safe delivery in coordination with specialists when indicated.

Table 2. Oxygen Delivery Devices and Parameters for Use

Fio2, fraction of inspired oxygen; RR, respiratory rate; PEEP, positive end expiratory pressure; Spo2, percent oxygen saturation. Adapted from Pacheco, et al.

Traditional (low-flow) nasal cannula may be initiated for patients with hypoxia but normal to mildly increased respiratory rate (

). Frequent reassessment of both maternal oxygenation and ventilation in consultation with critical care specialists is warranted for patients requiring increasing oxygen supplementation. The goal of respiratory support is to maintain an oxygen saturation of 95% or more in pregnancy and at the same time reduce dyspnea and tachypnea; several oxygen delivery devices may be used.

If significant mouth breathing is noted, a Venturi mask or nonrebreather mask may be needed to provide more controlled oxygen delivery. For patients with tachypnea or significant work of breathing despite appropriate oxygen supplementation, noninvasive ventilatory support with high-flow nasal cannula (HFNC) may be needed. 

Limited evidence in critically ill, nonpregnant patients suggests that HFNC may be more comfortable and potentially offer advantages over noninvasive positive pressure ventilation such as continuous positive airway pressure.

 Prone positioning to improve oxygenation with severe COVID-19 pneumonia has been used during pregnancy, though it may not be well tolerated.

Managing dyspnea with intermittent intravenous opioids may be considered in coordination with critical care specialists. This may alleviate air hunger and facilitate oxygenation, potentially avoiding the need for intubation. 

Controlled intubation is considered when respiratory failure persists or worsens despite increasing support of maternal oxygenation and ventilation. This can be recognized as maximal fraction of inspired oxygen of 100% (with or without nonrebreather added) and increasing flow rate above 40 to 50 Liters per minute using an HFNC device.

The efficacy of antiviral and biologic agents for COVID-19 in pregnancy remains unclear, and no clinical trials in pregnancy have been conducted. The decision to use currently available therapeutic agents approved under the US Food and Drug Administration’s Emergency Use Authorization (EUA) is made in consultation with MFM and infectious disease experts and in accordance with institutional protocols following a discussion of potential benefits and risks with the patient.

The NIH recommends that remdesivir, an intravenous nucleotide prodrug of an adenosine analogue, be offered to hospitalized patients with Spo2 of less than 94% on ambient air (at sea level) or those who require supplemental oxygen.

 There currently are no available data to suggest harm in pregnant individuals. SMFM supports offering remdesivir for treatment of COVID-19 in hospitalized individuals who meet criteria, although no clinical trials have demonstrated efficacy in this population.

Institutions may have protocols for use of EUA-approved therapies and compassionate use medications for COVID-19. For pregnant patients who meet clinical criteria and are offered remdesivir following counseling on the limited data available, daily liver function studies should be followed. 

NIH guidelines recommend discontinuing therapy if ALT levels increase to greater than 10 times the upper limit of normal or if signs or symptoms of liver inflammation are observed with ALT increase.

Other COVID-19 therapies, such as antibody therapies and immunomodulators, have not been studied in pregnancy but may be considered in some individuals in consultation with infectious disease and MFM experts. Monoclonal antibodies bamlanivimab and the combination of casirivimab plus imdevimab are available through EUA to treat outpatients with mild to moderate COVID-19 who are high risk for progressing to severe disease or hospitalization.

Finally, dexamethasone has been shown to reduce mortality in nonpregnant, hospitalized patients with COVID-19 who require supplemental oxygen.

The dosing recommended based on the RECOVERY trial (NCT04381936) is 6 mg (intravenous or oral) for 10 days. 

SMFM recommends considering twice-daily dosing for 48 hours initially in patients who have an indication for corticosteroids for fetal lung maturity, followed by up to 10 days of daily dosing.

 Antibiotics for respiratory illness are rarely necessary unless bacterial coinfection is strongly suspected.

There is no evidence to support empiric anticoagulation at therapeutic dosing in individuals without suspected or confirmed VTE.

 There is also little evidence to support prophylactic anticoagulation in individuals with asymptomatic or mild infection, whether inpatient or outpatient, without other indications for chemoprophylaxis. 

That said, clinicians should adhere to institutional protocols when available. There is an increased risk for VTE in patients with COVID-19, but evidence suggests that this risk is concentrated in hospitalized patients with critical illness.

For pregnant or postpartum individuals hospitalized with severe or critical COVID-19 pneumonia, VTE prophylaxis may be provided with either low molecular weight heparin or unfractionated heparin (if concern for potential delivery or at 35 weeks or later). Even in nonintubated patients, ambulation is typically very limited due to fatigue and supplemental oxygen requirement. For patients hospitalized for obstetric indications who have asymptomatic or mild COVID-19 illness, VTE prophylaxis is not routinely provided outside of other standard indications.

Mild or asymptomatic COVID-19 illness is not an indication for delivery. There is no evidence to support inducing early term labor in patients with mild symptoms and no other indication for delivery. Although earlier evidence suggested potentially higher rates of preterm birth in patients with COVID-19,

 these data may be biased toward inclusion of individuals with severe pneumonia requiring hospitalization. Overall, there does not appear to be a risk of adverse pregnancy outcomes such as preterm birth, except in patients with severe or critical illness.

Delivery for maternal indication in individuals with preterm gestations should be considered only if adequate maternal oxygen and respiratory support have been provided. Delivery considerations include gestational age, fetal monitoring capabilities, and a discussion of potential benefits versus harms. SMFM provides guidance for considerations regarding delivery timing in pregnant individuals with COVID-19.

Delivery does not always improve maternal ventilation or prognosis in a critically ill patient, so priority is given to providing adequate respiratory support with frequent reassessment for clinical worsening as long as fetal status is reassuring. If intubation with immediate proning is necessary after maximal noninvasive support is provided without improvement, delivery should be planned for pregnancies at or near term and considered for any patient in the third trimester.

In addition to knowing how to manage COVID-19 illness during pregnancy, clinicians should be prepared to educate patients about evidence-based methods to prevent infection. Nonpharmaceutical interventions such asuniversalmasking, physical distance kept at least 6 feet, and hand hygiene are mainstays for reducing the spread of SARS-COV-2 in both community and health care settings. In health care settings, airborne and contact isolation precautions are used to prevent nosocomial transmission, particularly when invasive procedures are planned.

Available mRNA vaccines appear to be highly protective against clinical disease in nonpregnant adults,26,27 and the American College of Obstetricians and Gynecologists and SMFM recommend that COVID-19 vaccines be accessible to pregnant and lactating individuals. Animal developmental and reproductive toxicity studies are ongoing, and clinical studies on safety and efficacy of vaccination in pregnancy are anticipated. 

As the writing of this article, February 16, 2021, the CDC’s V-safe After-Vaccination Health Checker’s data included more than 30,000 pregnant individuals who have received at least 1 dose of an mRNA vaccine.

 Pregnant and lactating individuals who accept vaccination are counseled that they may experience reactions such as pain, headache, fatigue, myalgia, and low-grade fever. Vaccinated individuals are encouraged to register with V-safe to track local and systemic reactogenicity.

Entering the second year of the pandemic, even with vaccination efforts ongoing and variant strains of SARS-COV-2 becoming more recognized, it is imperative that clinicians remain vigilant and up to date on the evaluation and treatment of a pregnant patient who presents with respiratory symptoms of COVID-19. Clinicians caring for pregnant patients with COVID-19 should be familiar with current CDC guidance and local institutional practices. 

They also should consider early consultation with specialists who are most experienced in managing this dynamic illness in pregnancy. As the virus evolves, so must clinicians’ approach to it; this illness likely will not disappear any time soon.

COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Johns Hopkins University & Medicine. Accessed February 12, 2021. https://coronavirus.jhu.edu/map.html

Walensky RP, Walke HT, Fauci AS. SARS-CoV-2 variants of concern in the United States—challenges and opportunities. 

 Published online February 17, 2021. doi:10.1001/jama.2021.2294

Stadnytskyi V, Bax CE, Bax A, Anfinrud P. The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission. 

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Kimball A, Hatfield KM, Arons M, et al; Public Health – Seattle & King County; CDC COVID-19 Investigation Team. Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility - King County, Washington, March 2020. 

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Adhikari EH, Moreno W, Zofkie AC, et al. Pregnancy outcomes among women with and without severe acute respiratory syndrome coronavirus 2 infection. 

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Villapol S. Gastrointestinal symptoms associated with COVID-19: impact on the gut microbiome. 

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Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. 

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Patel A, Charani E, Ariyanayagam D, et al. New-onset anosmia and ageusia in adult patients diagnosed with SARS-CoV-2 infection. 

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Coronavirus disease 2019 (COVID-19) treatment guidelines. National Institutes of Health. Accessed February 19, 2021. https://www.covid19treatmentguidelines.nih.gov

Agarwala P, Salzman SH. Six-minute walk test: clinical role, technique, coding, and reimbursement. 

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Tobin MF, Laghi F, Jubran A. Why COVID-19 silent hypoxemia is baffling to physicians. 

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Luo X, Zhou W, Yan X, et al. Prognostic value of C-reactive protein in patients with coronavirus 2019. 

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; Professor and Vice-Chair of Obstetrics and Gynecology; Gillette Professorship of Obstetrics and Gynecology; and Chief of Maternal-Fetal Medicine at 

New variants of coronavirus disease 2019 (COVID-19) and slow vaccination rates are prolonging the quarantine, and there is no certain end in sight. Without a clear path to a semblance of normalcy for our careers, families, and communities, it should be no surprise that our well-being is in jeopardy.

From private practice to academic medicine, strategies to proactively address physician wellness are urgently needed. Results from a survey of 1122 academic faculty across the nation reported that individuals feeling very or extremely stressed more than doubled from 2019 (32%) to 2020 (70%), and almost 3 times as many had increased anger (12% vs 35%).

During the same time frame, more than 12,000 physicians surveyed reported their rate of being “somewhat” or “very” happy declined from 82% to 58%,with a similar decline reported for ob/gyn physicians (81% to 57%).

 Female faculty members reported a dramatic increase in feeling stressed, from 34% to 75%, and they experienced stress at higher rates than men, 75% to 59%.

Since May 2020, 40% of women reported symptoms of anxiety or depression (

), which is almost 4 times higher than the 11% reported in 2019.

Figure. Anxiety and Depression in Women and Men: 2020-2021

Given the predominance of female ob/gyns—83% of residents are women—these statistics really hit home. The shift to remote learning and limited child care options have affected these colleagues, as women disproportionally shouldered the burden.

 For women, the dual role of being the family’s primary caregiver and practicing medicine has made the balancing act untenable for many, affecting both their mental health and career.

Many accept—often request—night and/or weekend shifts to maximize time at home to assist with child care and remote learning. In return, they have no down time, time to accomplish academic goals, or opportunity to recharge. Remote working has resulted in busier schedules and often longer hours for many, with fewer breaks as virtual meetings are stacked one on top of another. As eloquently stated in a recent Womxn’s Health Collaborative online post, the effort “comes at the expense of our own health and well-being.”

Solutions are not obvious, especially for ob/gyns. Early responses have been to encourage us to take care of ourselves, but when can we do this? Others have recommended taking time off; this burdens our colleagues and often results in insurmountable amounts of catch-up when we return.

 Physician burnout as a critical topic predates the pandemic. 

The National Academy of Medicine launched a resource repository on clinical burnout and well-being in 2018.

 There is a wealth of information on causes, effects, and solutions for clinical burnout available. Solutions include organizational and individual strategies, such as fostering communication, cultivating teamwork, and practicing mindfulness; however, data demonstrating their effectiveness are limited. Ultimately, system changes to address the inequity are needed to adjust metrics and support women in all roles: career, family, and community.

Physician burnout and the need for wellness will not be resolved once the pandemic is behind us. The American College of Obstetricians and Gynecologists has 5 warning signs of burnout: dread, increased complaining, irritability, lapses in confidentiality, and loosening boundaries.

For ourselves and our colleagues, let’s keep these in mind and work with each other to identify and address burnout proactively. A first step, although clearly not a solution, is having someone to talk to, someone to share the realities of life with. This can help us to address our burnout and provide an outlet. 

Although we cannot eliminate the current emphasis on virtual working, remote learning, and limited child care, we can enhance our support for each other. 

1. On the verge of burnout: COVID-19’s impact on faculty well-being and career plans. Chronicle of Higher Education

https://connect.chronicle.com/rs/931-EKA-218/images/Covid%26FacultyCareerPaths_Fidelity_ResearchBrief_v3%20%281%29.pdf

2. Martin KL. Medscape physician lifestyle & happiness report 2021. January 15, 2021. Accessed March 22, 2021. 

http://www.medscape.com/slideshow/2021-lifestyle-happiness-6013446

3. Martin KL. Medscape obstetrician & gynecologist lifestyle, happiness & burnout report 2021. February 19, 2021. Accessed March 22, 2021. 

http://www.medscape.com/slideshow/2021-lifestyle-obgyn-6013515

4. Anxiety and depression: Household Pulse Survey. Centers for Disease Control and Prevention. Updated March 10, 2021. Accessed March 22, 2021. 

http://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

5.Sevilla A, Smith S.Baby steps: the gender division of childcare during the COVID-19 pandemic. 

. 2020;36(suppl 1):S169-S186. doi:10.1093/oxrep/graa027

6. Johnson C, Thornton H. Bracing for impact. Womxns Health Collaborative. Accessed March 22, 2021. 

https://womxnshealth.medium.com/bracing-for-impact-894b9f13db84

7. Sharing knowledge to combat clinician burnout. Clinician Well-Being Knowledge Hub. Accessed March 22, 2021. 

8. At risk for burnout? Check these 5 warning signs. The American College of Obstetricians and Gynecologists. January 28, 2019. Accessed March 22, 2021. 

http://www.acog.org/news/news-articles/2019/01/at-risk-for-burnout-check-these-5-warning-signs

Rarely a day goes by without a post, article, or email about physician burnout. 

Smoldering

The doctor was Alexander Anderson, and the epidemic was yellow fever, which plagued New York, New York, beginning in 1795 and returning in 1798. He would end up losing 8 of his relatives, including his parents and wife, to the disease, and ultimately he would leave the field of medicine to become an acclaimed engraver.

An astute writer researched the doctor’s diaries, which are housed at the Rare Book & Manuscript Library at Columbia University. The writer, Carolyn Eastman, penned an article about the diaries in the March issue of 

 magazine, taking readers on a trip from the perspective of this young doctor whose life was forever changed by the experience.

We are fortunate to have such diaries to look back on, to see what our fellow humans experienced and what was learned. All of us know how profoundly life-changing the COVID-19 pandemic has been. We will be affected for years to come in ways we do not yet even realize. Yellow fever still exists in the world in parts of Africa and South America. Years from now, COVID-19 still will exist, and we will continue to learn so much from the writings of doctors who bothered to take note during this pandemic time. With today’s technologies, there are many ways to record your experiences, including voice memos, the notes function on an iPhone, or social media postings. There also is old-fashioned note-taking with a pen and paper. Anderson included drawings, and his voice and experience came alive for Eastman, more than 2 centuries later.

In this month’s issue, we are fortunate to have esteemed, peer-reviewed content from Emily H. Adhikari, MD, who writes about evaluating and managing COVID-19 during pregnancy, and the extra challenges and risks it brings. That article begins on page 20. On page 28, ob/gyns from the Albert Einstein College of Medicine in Bronx, New York, also provide insight from their experiences. Erika E. Levi, MD, MPH; Molly Findley, DO, MPH, MS; Alexandra Woodcock, MD; and June Hoi Ka Ng, MD, have written 

Fresh Ideas, Workarounds During Pandemic Can Increase Access to Contraception.”

Separate from the pandemic-related articles, a group of dermatologists have written about skin conditions that can afflict pregnant women. The article begins on page 10 and is part of a new series called Curbside Consults. As always, we ask that you let us know your thoughts on these articles. We appreciate reader feedback, which can be sent to us at COGeditorial@mmhgroup.com. Thank you. 

Chairman and Founder, MJH Life Sciences™

A young general practitioner in New York was on the front lines of an epidemic that was as mysterious in its pathology as coronavirus disease 2019 (COVID-19). Some patients would develop only mild symptoms, but others would get the worst of it, ultimately succumbing to the disease, as medical professionals and other scientists rushed to understand how the disease was being spread. 

Take Note: Lessons from a Doctor

Prescription and illicit drug testing rates declined during the COVID-19 pandemic in 2020, according to a study published in the journal 

Many in-person health services were unavailable following pandemic stay-at-home orders, including in-person drug testing, to prevent the spread of the virus.

Harvey W Kaufman, MD, MBA, FCAP, senior medical director, information ventures and office of chief medical officer at Quest Diagnostics conducted the study along with colleagues. The authors analyzed changes in testing patterns for prescription and illicit drugs at Quest Diagnostics, a national clinical laboratory. Researchers compared data sets from before and during the COVID-19 pandemic by examining urine specimen results from Quest Diagnostics medMATCH® reporting method, which indicates whether provider-prescribed or other drugs are found in the samples.

Study authors used specimens collected between January 1, 2019 and May 16, 2020. Specimens that had no record of age, or that were collected from patients under 18 years of age were excluded. Researchers also excluded specimens with abnormal specimen validity testing results and those that tested negative for drugs. The authors noted that not all specimens were tested for all drugs as choice of test varied among medical providers. A total of 872,762 specimens were used in the study; specimens came from all 50 US States and the District of Columbia.

Kaufman and colleagues said the volume of weekly drug testing declined by 70% from the baseline of January 1, 2019 to March 29, 2020 before rebounding in the following weeks. Testing showed increases in substance use during the pandemic: positive tests for non-prescribed fentanyl rose by 35%, and positive tests for heroin rose by 44%. In addition, the authors reported that “Positivity for non-prescribed fentanyl increased significantly among patients positive for other drugs: by 89% for specimens positive for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (

for all comparisons).”1 There also was an increase in dangerous drug combination use, the authors said. Researchers suggested these rates are a direct result of the COVID-19 pandemic, and said that social distancing, stress, loneliness, depression, and job loss contributed to increases. They also said isolation makes drug use more dangerous during this time, as it decreases the chances of a bystander being present to call for help or administer naloxone in the event of an overdose.

Test positivity rates stayed the same for many other non-prescribed drugs or decreased when compared to patterns seen prior to COVID-19. “Models adjusting for potential confounding variables, including medication-assisted treatment and treatment at a substance use disorder facility indicated that the risk for non-prescribed fentanyl positivity rose by more than 50% during the pandemic,” study authors said.1

They also reported an increase in submissions to the Overdose Mapping Application Program (ODMAP); suspected overdose deaths rose 18% in March, 29% in April, and 42% in May when compared to the same period in 2019. ODMAP also reported an overall 11.4% increase in overdose deaths and an 18.6% increase in non-fatal overdoses in 2020.

In case you missed it: April 5 to April 9

Evaluation & Management of COVID-19 in Pregnancy

Smoldering

Take Note: Lessons from a Doctor

Reduced Testing, Higher Positivity Rates for Prescription and Illegal Drugs During the COVID-19 Pandemic in 2020

Volume 66 No 4: April 2021

Current Management of Uterine Fibroids

LARC in the time of COVID and telehealth: Part 2

Oral contraceptive and ovarian function

Hormone therapy for postmenopausal women with nocturia

Fresh ideas, workarounds during pandemic can increase access to contraception