Vice-Chair, Obstetrics and Gynecology; Gillette Professorship of Obstetrics and Gynecology; Chief, Maternal-Fetal Medicine at UT Southwestern Medical Center in DALLAS, TX.

Catherine Y. Spong, MD

Although reductions in transmission are evident with social distancing, the optimal methods to make social distancing attractive and feasible remain elusive. Research to explain the underlying mechanisms of differing rates and severity of infection in different populations is sorely needed – both for medical importance and to provide a rationale the public needs to continue social distancing. 

Given the duration of the SARS-CoV-2 (COVID-19) pandemic, continued isolation and social distancing coupled with different infection rates and severity of illness have stymied universal adaptation of social isolation. 

Although the promise of vaccines is encouraging, it will be critical to maintain our vigilance in hygiene, masking, social distancing, and infection control as vaccines are administered. Equally critical is the education about the vaccine to facilitate uptake.

Ob/gyns have a robust history treating numerous infectious diseases, from smallpox to now COVID-19 – characterized by outbreaks followed by intensive health department measures to identify new infections and trace potential exposures. 

Pregnancy affords a unique time period for identification and treatment of illness. In addition, pregnancy has the unique concern of vertical transmission to the fetus, with potential concerns for fetal development. Although to date COVID-19 infection in pregnancy has not resulted in demonstrable fetal effects, vertical transmission has been documented.

®, we provide guidance on another infectious disease that has been making a comeback in recent years: syphilis. Although once truly nearing elimination in the U.S., it has again become a rising concern for obstetricians. 

As expertly outlined by Emily Adhikari, MD, all pregnant women should be screened, and for those at high risk, repeat screening in the third trimester and at delivery is recommended. Although there are clinical signs and symptoms in some women, typically diagnosis is initially made via serologic tests. Syphilis progresses across a course – including primary, secondary, latent, and finally, tertiary syphilis— if untreated. 

Importantly, vertical transmission is possible and may manifest in utero or after delivery as early or late congenital syphilis.

Pregnancy and HIV, Viral Hepatitis, STD, & TB Prevention

Importantly, the testing paradigms for syphilis have changed, and it is critical to understand the method your laboratory is using. 

Traditional testing—what I am most familiar with— is the initial nontreponemal test (the RPR) followed by the confirmatory treponemal-specific test. This is in contrast to the reverse sequence algorithm, which starts with a treponemal antibody test. High throughput labs are moving to this reverse screening sequence, as it affords a higher volume and more cost-effective throughput. 

However, the interpretation and additional studies require an understanding of whether the patient was previously diagnosed, using which test, and treated, as outlined by Adhikari.

Infectious diseases stimulate us as physicians to think broadly, identify sources, sleuth answers, and create algorithms to mitigate their spread. As we tackle COVID-19 it is imperative that we do not allow more familiar infectious conditions to take an insidious grip on our patients. 

Articles

With the beginning of 2021, we are eager for a resolution to the pandemic. 

Vigilance is key: Syphilis spreads amidst pandemic

Even so, life for ob/gyns continued unabated – with continued deliveries, delayed elective cases, and a transition to virtual visits. The required changes to provide safety for both our patients and providers have been evaluated as opportunities – in some cases virtual visits are easier for both patients and providers. As much as we can try to look for opportunities in the new normal, we all recognize it is difficult and taking a toll on our and our patients mental health.

 has had a very busy year – covering the pandemic and social movements including the implications for our practices, patients, and providers. We have stayed true to our roots, providing peer-reviewed, evidence-based articles in areas of importance to our readers (Figure 1). We welcomed new editorial board members and the entire editorial team has identified new opportunities – including an increased focus on timely information via videos and podcasts.

We are excited to announce the launch of a new feature in 2021 called “Curbside Consults,” the brainchild of Editorial Board member Christine Isaacs, MD. The series will discuss topics related to ob/gyns obtaining insight from non-ob/gyn physician-authors. Examples include how to prevent keloids in ob/gyn surgery; what to know about dental care in pregnancy; and diagnosis and management of carpal tunnel syndrome. We will develop these with non-ob/gyn experts for added value and insight from other specialties.

We are also working to provide easy-to-use infographics, tables, charts, and summaries within each peer-reviewed article so busy practitioners can access the key information at any time.

We will continue to develop our internet presence – through articles, podcasts, and videos. We are regularly tracking activity to ensure the information we are providing is useful, up-to-date, and clear. Understanding what our audience is interested in is critical for our publication.

The most viewed articles include many that have stood the test of time; We will focus on refreshing them in 2021.

The relationship between placental location and fetal gender, June 14, 2011

Alcohol and breastfeeding: What are the risks? Dec. 7, 2018

First menstruation: Average age/physical signs, Nov. 18, 2011

Hemorrhagic ovarian cyst sonographic perspective, Oct. 9, 2011

Perimenopausal bleeding: What’s normal?, June 21, 2011

COVID-19 pregnancy data in the United States: July 31 Update

A Patient’s Guide: Management of hair loss in PCOS, Oct. 11, 2011

Understanding Gestational Diabetes: Glucose monitoring, July 21, 2011

We have striven for topical and timely episodes, which has parlayed into the top episodes:

Racial justice and health equity in ob/gyn (Washington Hill, MD)

The fellow on the frontlines of COVID-19 (Aleha Aziz, MD)

Providing quality care for transgender and nonbinary patients (Haley Crissman, MD, MPH, Daphna Stroumsa, MD, MPH, MSC)

Our videos have been very popular this year. Videos are useful to explain techniques and complex topics.



Does alcohol impact the ability to conceive?


Laparoscopic excision of endometriosis nodule of the rectum


Laparoscopic excision of multifocal bowel

As we have done in years past, we solicited your insight on trends in the industry with our State of the Industry survey, and we report our findings in this issue. As you will read in this issue, nearly 80% of respondents said that if they had to do it over again, they would choose to specialize in ob/gyn. In addition, nearly 66% said that the reason they chose this specialty was to have the ability to care for women throughout their lives. We repeated certain questions in order to trend data, and asked new, pertinent questions related to the impact of the COVID-19 pandemic on your practice. I hope these data are both useful and interesting.

We continue – and we celebrate – our partnerships with the Society for Maternal-Fetal Medicine (SMFM) and the American Urogynecologic Society (AUGS). We have successfully promoted the professional guidance on cystoscopy at the time of prolapse repair, cesarean scar pregnancies, activity restriction in obstetric management, thromboembolism prophylaxis for cesarean delivery, mesh complications, vaginal energy-based devices, and heavy menstrual bleeding in adolescents.

is your source for topical, timely information on obstetrics and gynecology. If you have suggestions for topics, features, or ideas, we welcome them. As we close out 2020, thank you for your insight, readership, and incredible work ethic to care for our patients.

Dr. Spong, Editor in Chief, is Professor and Vice-Chair in the Department of Obstetrics and Gynecology and Chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology.


What a year 2020 has been! We hope to look back on it and recognize it as an outlier or anomaly—hoping life will at some point return to normal.

Contemporary OB/GYN®: A look back to 2020

My antepartum rounds reflect the impact of the pandemic - women struggling with substance abuse and mental illness fill the beds. 

One patient, wearing her designated green hospital gown that signals “at-risk” status and assigned a one-on-one sitter, explained, (

 thoughts now? I have three kids at home – two I try to make the computer work for so they can attend school, a 1-year-old, and here I am pregnant again. We lost our jobs, tensions are high, we cannot visit or see anyone, we have no help…. At times it all just boils up and I explode. Then I think life is not worth living. I get over it, but yes, I have bad thoughts.”

As demonstrated by my patients, the very measures used to prevent the spread of COVID-19 increase the risk of depression and suicidal thoughts: economic stress, social isolation, decreased access to community, barriers to mental health treatment, and illness.

According to the Centers for Disease Control and Prevention (CDC), the national rates of anxiety increased nearly four-fold from one year ago. In 1999, national rates of anxiety in adults were 8.2%, whereas data from August 19-31, 2020, are 31.4%. 

Similarly, rates for anxiety or depression have increased from 11.0% to 36.4%. All are higher in women, those with less education, and Black, Hispanic, and multiple other races.

A separate survey in June found similar rates of anxiety or depression (30.9%). In addition, 10.7% of the respondents reported “having seriously considered suicide in the prior 30 days” – these were significantly higher among those aged 18-24 (25.5%), minority racial and ethnic groups (Hispanic 18.6%; Black 15.1%) and essential workers (21.7%)(Figure 1).

Beyond its impact on our patients, it is vital to realize its effect on us as caregivers. 

As the impact of the pandemic continues, our ob/gyn practices and families are affected. Eighty-three percent of obstetrics and gynecology residents are female – the highest percentage of any specialty

 – and they are often playing a dual role as the family’s primary caregiver in addition to practicing medicine. 

Setting aside the burden of virtual schooling for both caregivers and children, the effects of social isolation and decreased access

to community are also affecting our children. They also mirror increased rates of anxiety and depression, yet may not have the access or resources for identification and treatment.

So what to do, what to do? In our practices, departments, and families, providing an opportunity for open communication and a safe space to share feelings without judgment is essential.Proactively, one of my colleagues’ practices meets biweekly with a psychologist. All of the providers gather and discuss both practice and personal stressors. Although predating the pandemic, this has been especially beneficial with an ongoing opportunity for open communication to discuss and identify solutions. These sessions help to identify feelings, conflicts, and provide strategies to communicate them effectively. They also allow a platform to discuss complications and poor patient outcomes, serving as a forum to process these deeply traumatizing events and rise, rather than stagnate, or worse, fall. We as physicians need this type of forum in order to heal ourselves.

Our patients and families deserve similar support and we should strive to help them get it. We need to provide opportunities for open communication in a safe space. Referrals to our colleagues in psychiatry and psychology are essential to ensure appropriate care. Although there is always a shortage of therapists, these at-risk populations need to be prioritized. Furthermore, we need to be on the alert for signs and symptoms of anxiety and depression in not only ourselves but also in our colleagues, families, and patients

editor-in-chief, is Professor and Vice Chair in the Department of Obstetrics and Gynecology and Chief of the Division of Maternal-Fetal Medicine at UT Southwestern Medical Center in Dallas. She holds the Gillette Professorship of Obstetrics and Gynecology.

1. Regar MA, Stanley IH, Joiner TE. Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm? 

. Published online April 10, 2020. doi:10.1001/jamapsychiatry.2020.1060

2. Centers for Disease Control and Prevention. National Center for Health Statistics. Accessed Sept. 21, 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

3. Czeisler ME, Rashon I, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020 CDC MMWR Aug 14, 2020 vol 69, No. 32

4. Association of American Medical Colleges. Percentage of Women Residents by Specialty 2018. Accessed Sept. 21, 2020. https://www.aamc.org/sites/default/files/aa-data-reports-state-of-women-residents-specialty-2018_0.jpg

 know what you thought of this month’s cover story?
Feel like telling Dr. Spong what you thought of her editorial or how your practice is responding to COVID-19?

Email Dr. Spong at CSpong@mjhlifesciences.com

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The editors reserve the right to shorten or edit letters and comments.

The very measures used to prevent the spread of COVID-19 increase the risk of depression and suicidal thoughts: economic stress, social isolation, decreased access to community, barriers to mental health treatment, and illness.

Mental health support is critical during pandemic

Many obstetric and gynecologic practices are not based on strong evidence, despite the great strides that we’ve made in the last several decades in identifying therapies

 and providing data to support existing practice recommendations.

We rely on expert opinion and common-sense management strategies for many conditions - in part, due to limited research for pregnant and lactating women.

 We are always in search of a new therapy, a new intervention, and data to support the therapies we provide. 

Often we adopt practices that seem intuitive; however, once evaluated, we find that what seemed to make complete sense at the time is not actually supported by evidence.

As detailed in the September issue, the Society for Maternal-Fetal Medicine (SMFM) is highlighting one of these situations: the role of activity restriction in obstetric management. For decades, activity restriction – from bedrest to reducing daily activities, exercise, and/or work – was recommended with the intent to improve pregnancy outcomes. 

With the concern that activity may increase uterine activity, rest was felt to be important in women with preterm labor and preterm rupture of membranes to reduce the risk of preterm birth (PTB). In the setting of premature cervical dilation, in addition to reducing uterine activity, rest – specifically bed rest or lying down – was used to reduce the “pull of gravity.” 

Finally, the concept that rest might improve placental perfusion underlies recommendations in the setting of fetal growth restriction and hypertension.

Given the widespread implementation of activity restriction, evidence for or against this recommendation has been difficult to obtain. As outlined in the article, research is now available to provide guidance for our practitioners recommending against routine use of activity restriction. Furthermore, the data demonstrating risk of activity restriction – both physiologic and psychologic - are outlined. 

Translating clinical research findings into practice requires a number of steps for implementation, including endorsement by professional organizations. A study that evaluated three practices (antenatal corticosteroids for fetal lung maturity, progesterone for PTB prevention, and magnesium sulfate for neuroprotection) that were endorsed by obstetric professional organizations demonstrated that duration of endorsement was important. 

The longer the practice had been recommended the more likely it was to be administered.4 In addition, the setting was important, as the intervention in the outpatient setting (progesterone) was the least administered. Interestingly, over 90% of providers were satisfied with their knowledge and stated they used all three interventions, yet when eligible patients were identified, 93% were offered antenatal steroids, 71% magnesium sulfate, and 39% progesterone.

The translation of research findings, especially when they go against common opinion, takes decades. 

The initial randomized controlled trials of activity restriction for PTB – demonstrating no benefit – were published 15 and 26 years ago. I am hopeful that 

 will provide the final impetus to put this advice “to rest” – pun intended.

NIH Consensus Statement. Effect of corticosteroids for fetal maturation on perinatal outcomes. 1994; Feb 28- Mar 2;12(2):1-24

TitaATN, Landon MB, Spong C, Lai Y, Leveno KJ, Varner W, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. 

. 2009; 8;360(2):111-20 doi: 10.1056/NEJMoa0803267

Spong, C. Addressing inequalities in women’s health research. 

 SZ, Rice MM, Moss J, Todd A, Rincon M, Mallett G, et al. Use and attitudes of obstetricians toward 3 high-risk interventions in MFMU Network hospitals. 

As detailed in the September issue, the Society for Maternal-Fetal Medicine (SMFM) is highlighting one of these situations: the role of activity restriction in obstetric management. 

Catherine Y. Spong, MD

Articles

Vigilance is key: Syphilis spreads amidst pandemic

Contemporary OB/GYN®: A look back to 2020

Mental health support is critical during pandemic

Putting activity restriction to rest