The guideline, which was formulated by an American Association of Gynecologic Laparoscopists (AAGL) Task Force of U.S. and Canadian gynecologic surgeons, incorporates the five canonical components of every ERAS protocol: preoperative patient education and optimization; multimodal, narcotic-sparing analgesia; nausea, surgical site infection (SSI) and venous thromboembolism (VTE) prophylaxis; maintenance of euvolemia; and liberalization of activity.

When it comes to improving quality and outcomes, it is not enough to ‘simply do a good job in the operating room,’ said senior author Rebecca Stone, MD, an associate professor of gynecologic oncology at Johns Hopkins School of Medicine.

At the 2018 annual AAGL meeting, only a third of attendees surveyed at the inaugural Enhanced Recovery After MIS Surgery (ERAmiS) Panel Session reported using a formal ERAS pathway for perioperative management of patients undergoing minimally invasive endoscopic and vaginal surgery, according to Stone. “This was attributed in part to the lack of formalized ERAS guidelines dedicated to MIGS,” she told 

Several guideline recommendations may be new to clinicians, including a “pathway to surgery” that minimizes missed opportunities to treat the most relevant and common medical comorbidities, such as obstructive sleep apnea, anemia, and diabetes. “The goal is to ensure that the patient is as well prepared as possible, in order to maximize their resilience to the physiological stress of surgery,” Stone said. “The surgeon and patient should partner in tackling risks related to functional status, chronic health and acute physiological deterioration.”

Gabapentinoids (pregabalin and gabapentin) have long been part of enhanced recovery multimodal, narcotic-sparing medication bundles. “However, recent FDA warnings about respiratory depression from gabapentinoids, with particular increased risk in narcotic-naïve older patients and/or those with obstructive sleep apnea, led us to recommend against their routine use in the prevention/treatment of surgical pain,” Stone said.

Intravenous first-generation cephalosporins, most commonly cefazolin, are the preferred prophylactic antibiotics for hysterectomy. “But emerging data indicate that SSI rates are higher when beta-lactam alternatives like clindamycin plus gentamycin are used, so their use should be restricted to those patients with a history of bonafide immunoglobulin E (IgE)-mediated penicillin hypersensitivity reactions, including urticaria, not just rash; angioedema; and anaphylaxis,” Stone said.

Conversion to chlorhexidine gluconate (CHG) for perioperative vaginal preparation also is recommended.

“There is a lot of controversy over the need for extended VTE prophylaxis following MIGS for cancer,” Stone said. “This has resulted in huge practice variation in the prescribing of extended thromboprophylaxis for MIGS, which is inconsistent with the overall ERAS mission of evidence-based care standardization.”

The new guideline modifies the historic Caprini scoring system for VTE risk assessment and prescribing of extended thromboprophylaxis, based on clinical risk factors like cancer stage, grade and extent of lymphadenectomy that now align with the VTE incidence observed during the past 10 years of MIGS in over 10,000 women with gynecologic cancer.

“In general, the guideline provides a real opportunity for us to intensify the known benefits of MIGS, including decreased pain, complications and recovery time,” Stone said. “Another advantage of protocolized perioperative care is reducing clinically inappropriate variability in care. This is important for cost containment and eradicating health inequalities.”

Moreover, the guideline facilitates shared care, encourages multidisciplinary communication and action in general, which is especially critical during the COVID-19 pandemic.

Stone reports no relevant financial disclosures.

Stone R, Carey E, Fader A, et al. Enhanced recovery and surgical optimization protocol for minimally invasive gynecologic surgery: an AAGL white paper. JMIG. Published online August 19, 2020. doi:org/10.1016/j.jmig.2020.08.006.

Articles

AAGL

The first Enhanced Recovery After Surgery (ERAS) guideline for standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery (MIGS) has been published in The Journal of Minimally Invasive Gynecology.

First enhanced recovery after surgery guideline for minimally invasive gynecologic surgery

Findings such as these will be presented Friday, Nov. 13, through Tuesday, Nov. 17, at the American Heart Association’s Scientific Sessions 2020.

The presenter is Ramin Ebrahimi, MD, professor of medicine at the University of California, Los Angeles, and director of interventional cardiovascular research and co-director of the Cardiac Catheterization Laboratory at the Greater Los Angeles VA (Veterans Affairs) Medical Center.

“Previous research has linked PTSD to higher risks of ischemic heart disease, including heart attacks and heart pain or angina. However, most of those studies have been in men,” Ebrahimi said in a recent press release.

To conduct the study, Ebrahimi evaluated medical records of female veterans cared for at all U.S. Veterans Health Administration centers between 2000 and the end of 2017. The research team identified nearly 130,000 female veterans with PTSD and nearly 260,000 without the mental health condition. They assessed records for annual exams, emergency room visits and other exams/hospitalizations for new diagnoses of coronary artery disease, angina or heart attacks.

According to Ebrahimi, they found that women with PTSD had a 44% higher risk of developing ischemic heart disease compared to those without PTSD, and the increased risk was more prominent in younger women, especially those younger than 40 years old (72%).

The increased heart disease risk among female veterans with PTSD was also higher in racial and ethnic minorities, including Black women, non-white women from other racial backgrounds and women of Hispanic and Latinx ethnicity, compared with white female veterans.

"Our results suggest that health care professionals should consider more routine and earlier screening for cardiovascular disorders in women with PTSD,” Ebrahimi said.

Women veterans with PTSD have higher rate of heart disease. November 2020. https://www.eurekalert.org/pub_releases/2020-11/aha-wvw110220.php. Accessed November 13, 2020.

Female veterans with posttraumatic stress disorder (PTSD), especially younger women who are non-white, have an increased risk of developing heart disease. 

Female veterans with PTSD at higher risk of heart disease

Jon I. Einarsson, MD, PhD, MPH, Gaby Moawad, MD, and Robert K. Zurawin, MD. 

Dr. Moawad is on the Speakers Bureau, Intuitive Surgical. Dr. Zurawin is principal medical advisor for Memic Innovative Surgery Ltd., the company that created the Hominis surgical system.

Videos

Three esteemed surgeons discuss technology, weighing the pros and cons of existing and newly developed platforms. 


Surgeons Panel Discussion

“Many surgeons think they understand ‘coaching,’ but it may come as a surprise that teaching, mentoring, and sponsoring are unique from coaching,” said Cara King, DO, director of benign gynecologic surgery at the Cleveland Clinic in Ohio.

Peer surgical coaching entails the development of a partnership between two surgeons to identify goals and engage in self-reflection to implement sustainable improvements in both technical and non-technical skills.

King, who was part of a panel on performance coaching at the American Association of Gynecologic Laparoscopists (AAGL) 2020 Virtual Global Congress, told 

 that coaching can be challenging to implement, due to the limited time of busy practicing surgeons.

“However, there are many specific actions to enhance coaching integration,” King said. “These include consistent video recording of surgical cases, optimization of surgeon and surgeon coach pairing, utilization of a reliable virtual platform, integration into national societies, and replacement of current surgical education endeavors that may have limited long-term impact.”

A significant training and performance gap exists in ob/gyn training and assessment. “Traditional continuing medical education efforts often do not promote sustainable impact and are commonly not in line with adult learning,” said King, noting that the American Board of Medical Specialties (ABMS) supports a more formable, less summative approach to continuing certification.

The one-on-one relationship between a surgeon and a coach aligns with adult learning and provides a sustainable model to improve clinical performance, patient care and well-being, according to King.

Video-based coaching can also improve performance in surgical trainees. “Surgical video review with performance-based assessment has revealed that decreased technical skill is associated with increased complications,” King said.

In addition, video coaching allows further insight into trainee intraoperative decision-making and failure to progress, “which can be difficult to evaluate using traditional models,” she said. Furthermore, data science is being integrated to enhance the coaching relationship.

However, dedicated faculty development is required to teach coaching philosophy and enhance outcomes. “This is not to discount teaching, mentoring and sponsoring as critical components of professional development,” King said. “But true coaching implementation takes training and practice to master.”

The non-profit Academy for Surgical Coaching is a resource for individual surgeons, national societies, and academic centers to integrate surgical coaching models and empower surgeons.

For high-level coaching, a mind shift is essential for the coach: from an expert role into learner, and from advocating to inquiring. “The coaching philosophy should be focused on goal setting, guided inquiry, constructive feedback and action planning,” King said.

Surgical coaching not only enhances performance improvement, but has the potential to decrease burn out, increase well-being and encourage deep relationships. Content may include technical, cognitive, interpersonal and self-regulation strategies.

“Surgical coaching has the potential to bridge the gap in residency training and continuous professional development,” said King, who is associate program director of the Minimally Invasive Gynecologic Surgery (MIGS) Fellowship at the Cleveland Clinic. “The time has arrived to evaluate, disrupt, and strengthen current surgical education and professional development activities.”

King reports no relevant financial disclosures.

Although peer surgical coaching bolsters surgical education and promotes continuous professional development throughout a surgeon’s career, the reality is that few surgeons apply coaching theory or operationalize the concept of coaching.

Maximizing peer surgical coaching

Without strong motivation, it is unlikely that fellows and recently graduated fellows will improve and excel in minimally invasive gynecologic surgery (MIGS).

“What lights you up?” asked Javier Magrina, MD, a professor of ob/gyn at Mayo Clinic Arizona in Phoenix, who was part of a panel on pushing the surgical envelope from dream to reality at the American Association of Gynecologic Laparoscopists (AAGL) 2020 Virtual Global Congress.

“You need to set up clear objectives for yourself and create a path to follow,” Magrina told 

 of fellow and recently graduated fellows.

As part of that path, a good mentor to whom one relates well is essential. “If you do not improve, apply cognitive therapy: keep asking yourself why I am not improving until the answer surfaces,” Magrina said. “Ask your mentor if you do not find an answer.”

However, if you do not trust the mentor, “find another one,” Magrina said. “In sports, private coaches are hired and fired, based on the growth of the athlete.”

Likewise, hands-on courses improve surgical skills, especially when they include cadaver dissections.

Magrina also encourages surgeons to envision surgical techniques in their mind. “Close your eyes and see every tiny aspect of the operation,” he said. “When you have a complete and detailed imaginary video, you will be in the zone during the operation.”

Analyzing plenty of real surgical videos is helpful as well, both one’s own and videos of others’ surgeries to compare techniques.

“In short, excelling in surgery demands unrelenting dedication and never stopping,” Magrina said. “There is always something new to learn from someone and incorporate.”

Magrina said none of the information presented should come as a surprise to recent graduates who wish to excel, other than for those who are content with the training they received.

“It would be an improvement if the American Board of Obstetrics and Gynecology (ABOG) mandated hands-on skills testing for everyone at the time of the written exam and a review of their surgical videos at the time of the oral board exams, followed by re-evaluated performance every 10 years with a review of their surgical videos and hands-on skills,” Magrina said. “But this will take time and a lot of discussion.”

Meanwhile, Magrina believes it is important that surgeons discuss the benefits of knowledge and skills. “You need both to be a good surgeon,” he said. “It is a matter of patient safety.”

Being a safe surgeon entails learning anatomy, diseases, and the surgical technique for each disease.

Committing to the laparoscopic lab or the console three times a week for 20 minutes per session is better than one single hour a week, according to Magrina.

“Remember, never give up,” he said. “Great things take time. Never quit learning.”

Also, surgeons should become highly focused in one area of expertise because “you cannot be an expert in all operations,” Magrina said.

To embark on a new procedure, the surgeon should learn anatomy first, followed by exhaustive preparation, then perform the procedure on a cadaver. “When satisfied, you can proceed to the OR to perform the actual procedure, preferably with an expert,” Magrina said.

Valuable lessons can also be gleaned from major surgical complications. “If you do not learn from a complication, then you have failed,” Magrina said. “In fact, your best teacher is your last complication. You have an opportunity to learn from every complication.”

Lastly, to continue growing in a surgical career, the surgeon needs to determine for himself/herself whether a new technique is valid. “Do not take someone else’s word,” Magrina said.

Magrina reports no relevant financial disclosures.

Homing in on passion, commitment, are key also to maintaining excellence in surgical field.

Mentoring, consistent training essential for reaching surgical excellence

That is the consensus of a panel on fertility surgery at the American Association of Gynecologic Laparoscopists (AAGL) 2020 Virtual Global Congress.

“Although obstetricians and gynecologists are the ultimate advocates of women’s health, the decision to proceed to surgery or in vitro fertilization (IVF) cannot be simply based on empiric evidence,” said moderator Anusch Yazdani, MD, medical director of the Queensland Fertility Group in Brisbane, Australia. “The key is interdisciplinary management, with the focus on the woman and her expectations.”

As with endometriosis, “infertility is not a single defined entity,” Yazdani told 

. “It is a complex interplay of numerous factors, including functional, biological and environmental influences, that cannot be conveniently isolated.

Additionally, the impact of endometriosis on fertility is likely mediated by numerous mechanisms. “Most obviously, as the disease progresses and pelvic damage increases, the passage of gametes and embryos through the reproductive tract is impaired,” Yazdani said.

Endometriosis also alters the pelvic environment, mostly due to endometriosis-associated inflammation. “This change may impair the function of both eggs and sperm, fertilization, embryo development and implantation,” Yazdani said.

Increasing evidence shows that both the quality and quantity of oocytes in women with endometriosis is affected. “However, it is unclear whether this is a direct effect of the disease or if endometriosis is a confounder,” Yazdani said.

Evidence also indicates that in the reproductive tract of woman with endometriosis, the eutopic endometrium displays altered metabolomic and proteomic profiles that change the endocrine response. “Hence there is a reduction in implantation and an increased chance of miscarriage and other obstetric complications,” Yazdani said. “There is no evidence that endometriosis surgery will improve either scenario.”

Laparoscopic surgery to treat mild and moderate endometriosis reduces overall pain and increases spontaneous live birth or ongoing pregnancy rates, according to moderate-quality evidence. “But there is no high-quality evidence that laparoscopic excision and ablation improves the outcomes of assisted reproduction,” Yazdani said.

Similarly, while the treatment of advanced disease is probably linked to an increased chance of spontaneous pregnancy, there is limited evidence to suggest that such therapy improves the success rates of IVF.

Irrespective of the stage of endometriosis, the absolute pregnancy rate per cycle remains low compared to a cycle of IVF. “While the clinical pregnancy rate in women undergoing IVF with endometriosis may be lower than that of other infertility aetiologies, there is no good evidence that this can be improved by surgery,” Yazdani said.

In fact, a history of surgery for endometriosis, including cystic ovarian disease, has been shown to be associated with lower pregnancy rates.

Regardless of whether the endometriomas are surgically stripped or ablated, there is no evidence that such techniques increase live birth rates via IVF. Instead, they have been shown to reduce ovarian reserve as measured by the level of anti-mllerian hormone (AMH), decrease the number of oocytes retrieved, increase gonadotrophin requirements, and reduce peak oestradiol levels.

“This lack of surgical efficacy needs to be balanced against the challenges of diagnosis, ovarian access, pelvic infection, pain and cycle cancellation rates, all of which are more prevalent in women with endometriomata,” Yazdani said.

Dr. Yazdani is a minority shareholder in Virtus Health.

With patient-centered care being the mantra of 21st-century medicine, the decision to proceed with fertility surgery in women with endometriosis should be based on the individual patient, her reproductive expectations, her specific disease pattern, her support, family network, and available health care resources.

Factors to consider for fertility surgery with endometriosis

Augmented reality, a surgical black box, and tissue engineering are three technologies that bode well for the future of endoscopic gynecologic surgery, according to a panel presentation at the American Association of Gynecologic Laparoscopists’ (AAGL) 2020 Virtual Global Congress.

“Improved vision, laparoscopy and endoscopic surgery were made possible by an image revolution,” said Michel Canis, MD, PhD, an ob/gyn from Clermont-Ferrand, France, who chaired the panel. “But new revolutions are coming using augmented reality and fluorescence, which will allow us to see structures which are not now visible. We will also be able to understand and to visualize intraoperative physiology -- an essential tool when deciding intraoperative management. Computer vision will be a major step forward.”

augmented reality is well known, few surgeons understand its exact meaning. “Moreover, very few surgeons are aware that augmented reality may become a surgical tool within the next few months or years,” he said.

Improved vision has always been the main catalyst of endoscopic approaches. “Together with fluorescence, augmented reality will revolutionize the world of surgery,” Dr. Canis said.

On the other hand, a surgical black box will benefit the complex environment of an operating room (OR). “Analyzing this airline technology is something new for the medical field,” Dr. Canis said. “Studies clearly demonstrate that many events which can cause complications in the OR are not noticed by OR personnal, so the ability to analyze these at-risk events by using computers and artifical intelligence (AI) technology will improve our knowledge of what happens in the OR and our ability to improve outcomes, particularly when it comes to safety.”

Tissue engineering is also expected to play a major role in the future, due to an aging population, for which reconstructive surgery such as prolapse surgery will become increasingly important. “The complications related to meshes clearly indicate the risks of foreign materials,” he said. “However, few surgeons are aware that by using three-dimensional (3D) bioprinting and stem cell technology, we will be able to design meshes without any non-organic components, thus likely leading to much fewer complications.”

The ability to produce meshes with biologic components is of major signifance for prolapse surgery because after surgery without meshes, “the risk of recurrence is close to 40%,” Dr. Canis said.

Tissue-engineered technologies will also be used for adhesion prevention and for treating uterine synechia.

Some of these innovations will be easier than others to incorporate into practice. For instance, virtual reality tools will be software that is not very expensive, although preoperative magnetic resonance imaging (MRI) will be required.

A surgical black box is somewhat uncomfortable for surgeons at the beginning, but education will help them to accept the technology, even though most surgeons are afraid of litigation, according to Dr. Canis. “This fear is unwarranted, however, because the data are stored for 6 weeks only,” he said. “Afterward, the data are destroyed, so they are not available for judges and lawyers.”

Lastly, Dr. Canis believes tissue-engineered meshes will be readily embraced by surgeons because they will be happy to implant a mesh without long-term risks.

Dr. Canis takes inspiration from a quote from former First Lady of the United States, Eleonore Roosevelt: “The future belongs to those who believe in the beauty of their dreams.”

Dr. Canis was joined by three experts who have published extensively about the future of surgery: Nicolas Bourdel, MD, PhD, from France; Teodor Grantcharov, MD, PhD, from Canada; and Caroline Gargett, MD, PhD, from Australia.

Dr. Canis is co-founder of SurgAR, a French virtual-reality startup.

“Improved vision, laparoscopy and endoscopic surgery were made possible by an image revolution,” said Michel Canis, MD, PhD, an ob/gyn from Clermont-Ferrand, France, who chaired the panel.

Future of endoscopic gynecologic surgery

Identifying clear anatomical landmarks and incorporating surgical principles for a safe approach when operating on a frozen pelvis in a complex scenario will be highlighted in a panel discussion at the 

American Association of Gynecologic Laparoscopists (AAGL) 2020 Virtual Global Congress

, which is being held Friday, Nov. 6 through Saturday, Nov. 14.

“Operating on a frozen pelvis is probably the most difficult situation a gynecologist can face within his surgical activities,” said moderator Mario Malzoni, Chief of the Endoscopica Malzoni Center for Advanced Pelvic Surgery at the National Center for Endometriosis, in Avellino, Italy, which is a referral center for diagnosing and treating endometriosis and other complex benign and malignant gynecologic diseases.

Frozen pelvis refers to a condition in which pelvic organs are distorted and tethered to each other as a consequence of adhesive processes. “It is commonly seen with endometriosis,” Dr. Malzoni told 

. “Other causes are tumors; infections, including pelvic inflammatory disease; postsurgical adhesions; and post-treatment, such as radiotherapy, which results in fibrotic changes.”

Dr. Malzoni said frozen pelvis can obscure normal anatomical landmarks and surgical planes, thus increasing the risk of intraoperative and postoperative complications. “Frozen pelvis is one of the most challenging situations a surgeon can face,” he said. “There are only a handful of surgeries that require the judgment, rigorous experience, and skill necessary to operate on a frozen pelvis.”

The panel discussion is entitled “The hidden doors and the emergency exits: how can surgical anatomy of the pelvis be your Ariadne’s thread in the distorted anatomy maze.”

“Of course, Ariadne’s thread is not a medical term,” Dr. Malzoni said. “It is an expression that refers to the legend of Ariadne, who was a Cretan princess in Greek mythology. Ariadne gave her lover a ball of red thread to help him solve a vexing problem by multiple means through an exhaustive application of logic to all available routes.”

Because the frozen pelvis is an extremely complex situation in which normal anatomy can be distorted, “the only key to a right approach is to ‘find the way’ by recognizing and opening proper pelvic spaces,” Dr. Malzoni said.

Surgical strategy is crucial and should be appropriately planned and executed to avoid unnecessary and potentially damaging procedures, he said.

“The concept of ‘pelvic surgeon’ is probably the key: a gynecologist with full competence in colorectal, urologic, vascular and neuropelveologic surgical procedures,” Dr. Malzoni said.

In all benign conditions, especially endometriosis, and in many cases of malignancies, functional organ damage can occur with a frozen pelvis. Bowel subocclusion/occlusion or urinary tract impairment requires specific surgical procedures, ranging from bowel nodulectomy (shaving or discoid resection) to segmental resection like ureterolysis/resection, anastomosis or reimplantation, and bladder resection.

“Treatment should be tailored and, when possible, aimed at restoring normal anatomical conditions, along with preservation of visceral innervation by nerve-sparing techniques,” Dr. Malzoni said.

Dr. Malzoni does not believe any of the information being presented will be a surprise to clinicians, but rather reinforce effective and safe approaches. “In this case, safety and efficacy go hand in hand,” he said. “The ability to recognize and preserve ureters and neural fibers are crucial. At the same time, you need competence to avoid vascular injuries, and solve them if they occur.”

The session will take place on Nov. 12 and will demonstrate the secrets for safe and radical anatomical dissections of the pelvis, with the goal of removing the whole disease with the least complications. There also will be numerous surgical videos and schematics of a variety of possible scenarios encountered in daily practice.

 for the schedule-at-a-glance, and register 

Dr. Malzoni reports no relevant financial disclosures.

“Operating on a frozen pelvis is probably the most difficult situation a gynecologist can face within his surgical activities,” said moderator Mario Malzoni, chief of the Endoscopica Malzoni Center for Advanced Pelvic Surgery at the National Center for Endometriosis, in Avellino, Italy. 

Surgical anatomy of the frozen pelvis

Dr. Howell’s presentation focused on the longstanding disparities in maternal morbidity and very preterm birth morbidity and mortality.

Her presentation had an unfortunate recent example of maternal morbidity, with the 

 of Dr. Chaniece Wallace, a Black pediatrician who died on Oct. 24 after dealing with preeclampsia and delivering her first child on Oct. 20.

This article is based on information presented at the American College of Obstetrics and Gynecologists’ (ACOG) 2020 Virtual Conference. For more information, click 

On Friday, Oct. 30, Elizabeth A. Howell, MD, MPP, led a presentation on the intertwined racial and ethnic disparities in maternal and infant health that exist for women and babies of color.

According to Howell’s latest research, Black mothers are more likely to deliver at higher risk-standardized severe maternal morbidity hospitals than are white mothers.

“We have a lot of science around quality improvement. We can apply that science and use it in conjunction with other important strategies to improve the way we care for patients and addressing the issues of bias,” said Dr. Howell, presenter and Chair of the Department of Obstetrics & Gynecology at the Perelman School of Medicine at the University of Pennsylvania.

There is a wide range of factors that contribute to racial and ethnic disparities in maternal and neonatal care, including those of the patient, community/neighborhood, provider, and system. High-performing hospitals, according to Howell, have a stronger focus on standards and standardized care; stronger nurse/physician communication; more awareness of the presence of racism in the hospital; and sharing of performance data with nurses and frontline staff.

To further investigate the racial and ethnic disparities in maternal and neonatal care, Howell first focused on the differences in severe mortality rates in New York City hospitals in which Black and white women deliver. For this analysis, data were collected from a linked 2011-2013 New York City discharge and birth certificate dataset (n=353,773).

Howell’s research team applied a mixed-effects logistics regression with a random hospital-specific intercept to generate risk-standardized severe maternal morbidity rates for each hospital (n=40).1

The research showed that Black women experienced the highest rates of severe maternal morbidity at 4.2%, compared with Latinx at 2.7% and White at 1.5%. Her team concluded that differences in hospital of delivery may account for up to 48% of the Black-White disparity and 37% of the Latinx-White disparity.

The next steps for Howell’s research will include hospital qualitative interviews (high- and low-performing), focus groups to explore patient barriers to receipt of high-quality health care, and dissemination efforts to promote an increase in uptake of best practices.

Howell EA, Egorova NN, Balbierz A, Zeitlin J, Hebert PL. Site of delivery contribution to black-white severe maternal morbidity disparity. 

. 2016;215(2):143-152. doi:10.1016/j.ajog.2016.05.007

ACOG

Racial and ethnic disparities in maternal and infant health

As experts evaluate emerging evidence and the pattern of information that comes about, there is a consistent theme that pregnant women are more severely affected by COVID-19, says infectious disease expert Denise Jamieson, MD, MPH, who is the James Robert McCord Professor and Chair of the Department of Gynecology and Obstetrics at Emory University School of Medicine in Atlanta.

Jamieson delivered the Howard Taylor International Lecture: Global Health Threats – Novel Coronavirus & Beyond, during the American College of Obstetricians and Gynecologists’ (ACOG) 2020 Virtual Annual Meeting. Her career has focused on emerging infectious diseases in pregnancy like influenza, ebola, Zika virus, and maternal immunizations. From 1997 to 2017, she was at the Centers for Disease Control and Prevention, where she held a variety of different leadership positions.

Jamieson acknowledged Sonja A. Rasmussen, MD, MS, who serves in the Department of Pediatrics, College of Medicine, Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville.

“Much of what I am going to present represents the evolution of our joint thinking and ideas over many years,” Jamieson said.

She summarized lessons learned from other outbreaks – monkeypox in 2003; SARS in 2003; influenza (Swine flu) in 2009-10; and Zika in 2015-16 – to see what can be applied to the current pandemic.

Monkeypox was a relatively obscure outbreak, but it taught scientists lessons that are relevant now, she said. It began innocuously when a family from Wisconsin adopted a prairie dog from an exotic animal swap meet. But the prairie dog became ill and bit a 3-year-old child in the home. The child became ill with fever and lesions at the site of the bite. The animal dealer then became ill, as did the mother of the child. As it ends up, Gambian pouched rats that had been shipped from Ghana to Texas were the source of the virus. Although the rats had a level of immunity, American prairie dogs did not.

Some of the infected prairie dogs ended up in homes with pregnant mothers. Therefore, there was concern about how to advise pregnant women. “Although there had been at least one reported case of congenital monkeypox, not much was known specifically about monkeypox in pregnancy. However, extrapolating from another pox virus, we knew there was increased morbidity and mortality among pregnant women with smallpox. We also knew that there had been rare cases of fetal vaccinia, vertical transfer of vaccinia virus, the live virus in the smallpox vaccine. Despite these risks, it was recommended that all close contacts with monkeypox be offered vaccination with the smallpox vaccine, regardless of pregnancy status. In other words, pregnant women were not excluded from emergency use of smallpox vaccine.”

Global threats to health may include zoonotic vectors, and that it’s important to rapidly address pregnancy issues during outbreak including use of mitigation measures.

That outbreak has relevance to the ongoing discussions about potential use of COVID-19 vaccine among pregnant patients, she said. SARS in 2003 highlights the case of a super spreader event. After one person in China became ill with it and stayed at a hotel, the virus spread and became the first pandemic of the 21st century. Due to unprecedented scientific, medical and public health collaboration, the global response to SARS was extraordinarily rapid and effective. By July of 2003, SARS had been contained. 

“The world was lucky with this first coronavirus pandemic,” Jamieson said. “There were characteristics of the virus that made it easier to control but there also was a coordinated, strong and swift public health response, that included measures such as mandatory quarantine, contact tracing, symptom and fever screening, travel bans, strict infection control procedures at hospitals and universal masking in affected countries.”

The lessons learned from SARS included that global travel represents a major risk for disease transmission. “We also learned that a coordinated public health response can be effective at controlling a pandemic,” she said.

During the influenza and H1N1 pandemic in 2009-2010, the second documented death was an otherwise healthy woman who was pregnant, portending the role that pregnant women would play in that pandemic. “Fairly early on it was clear that pregnant women with influenza were at risk for severe disease,” Jamieson said. An early 

 paper summarized the cases reported to the Centers for Disease Control and Prevention (CDC).

“We found that pregnant women were more likely to be hospitalized with influenza compared to the general population,” she said. A later report found that 5% of all H1N1 deaths were among pregnant women,3 which was a disproportionate number of deaths.

“We also confirmed that early antiviral therapy helped prevent severe disease and death,” Jamieson said. “Only one death occurred in a pregnant woman who received treatment within two days of symptom onset.”

The lessons learned with this pandemic included being reminded that pregnant women may be more vulnerable to severe disease from some emerging pathogens, and, specifically from respiratory pathogens.

Jamieson also covered the Zika virus, which first was identified in 1947 in a monkey in the Zika Forest in Uganda. It would not be until 2015 that Zika was first identified in the Americas. An outbreak occurred in Brazil, then 8 to 9 months later there was an increased incidence of microcephaly in infants born there. By April of 2016 enough evidence had accumulated to conclude that Zika virus in pregnancy could cause a congenital syndrome, which included microcephaly.

Lessons learned from Zika included the role of global travel in importing cases to the United States; it underlined the importance of specifically evaluating pregnancy outcomes as part of infectious disease investigation; it also highlighted the need for having surveillance systems specifically tailored for pregnant women.

“Because the national surveillance systems were set up prior to the realization that Zika caused birth defects, the CDC system did not routinely collect pregnancy status or outcomes. Therefore, we set up several different systems in the US and elsewhere to collect this critically important information. 

She ended with a short review of COVID-19 and some of what has been learned so far.

There are key questions, she said, with COVID-19 and pregnancy. Are pregnant women more susceptible to becoming infected with SARS-CoV-2 or at an increased risk for severe disease? Second, is there perinatal transmission? And third, what are the effects of the virus on the pregnancy, including the fetus/neonate?

On susceptibility, “we have no data,” she said. “Once asymptomatic infection was recognized, many labor and delivery units started universal testing of all women admitted for delivery.” 

(See related Figure “Universal screening of pregnant women presenting to labor and delivery in the U.S.)

 “You can see here a wide range of overall prevalence of positive test results, depending on time and place of testing, as well as whether women were symptomatic or asymptomatic. However, since we don’t have reliable estimates of overall prevalence in non-pregnant populations, we cannot conclude anything about susceptibility.”

As regards severity in pregnancy, the best data are from the CDC. Its Morbidity and Mortality Weekly Report (MMWR) summarizes data from the CDC surveillance system, which includes case reports submitted by the 50 states, the District of Columbia, and New York City. 

(See related Figure “Women of reproductive age (WRA) with SARS-CoV-2 infection by pregnancy status – Jan 22-June 7”)

“Although there is a large amount of missing data, I think this report is the best information we’ve had to date about severity of COVID in pregnancy. When adjusted for age and comorbidities, pregnant women were more likely to be hospitalized, admitted to the ICU, and require mechanical ventilation compared to non-pregnant women. There was not an increased risk of death.” 

(See related figure “Hospitalization, ICU admission, mechanical ventilation, and death among pregnant women and nonpregnant WRA with SARS-CoV-2 infection”).

“It will be important to look at updated data from the CDC surveillance system, which should include case reports beyond June 7 and hopefully with more complete information about pregnancy status,” Jamieson said.

In terms of transmission risk of the virus to the fetus (known as vertical transmission), the story of this possibility has been unfolding over time, she said. “There were some initial reports of possible perinatal transmission. There were early reports of infants with elevated IgM at birth. Since IgM does not readily cross the placenta, this suggested possible perinatal transmission. However, there are multiple problems with using IgM assays to diagnose congenital infections, including possible fetal-maternal leakage of IgM and inaccurate test results. There were also some reports of several infants testing positive several days after birth. In these cases, it was hard to sort out intrauterine or intrapartum transmission from postnatal transmission. Therefore, it is important to use carefully defined criteria to address perinatal transmission.”

She cited criteria used by Dean A. Blumberg, MD, and colleagues, from their editorial “Vertical Transmission of SARS-CoV-2: What is the optimal definition?”

“They suggested that you need three things: the mother needs to be positive around the time of birth; you need evidence of early exposure, as well as persistence,” she said. Evidence of early exposure means that virus is detected in any of the following: swab of neonatal respiratory tract in the first 24 hours of life; amniotic fluid; umbilical cord blood; neonatal blood sample in the first 24 hours of life. With persistence, you can have either of the following: swab of the respiratory is positive more than 24 hours after the start of life; or the neonate has a positive SARS-CoV-2 IgM assay in the first 7 days of life.

“I think there are now a handful of cases that meet these criteria, and are likely intrauterine transmission,” she said.

As more data becomes available, the impact to pregnant women will become more and more clear, she said. As she noted, there is a consistent pattern that pregnant women are more severely affected by COVID, although she does not think it is as severe as the other diseases she covered.

One audience member asked if Jamieson thought pregnant women should be offered the COVID vaccine, even if there is no safety data.

Should pregnant women be prioritized? Because they’re at an increased risk for severe disease, and that is that prioritization scheme that is being worked on, whether they should be prioritized. I don’t think we have enough data to really address that piece,” she said. “But the way I would look at it is, ‘Should pregnant women be excluded from the opportunity to be vaccinated based on their pregnancy status? So if you are a pregnant healthcare worker and you’re in the top priority to be vaccinated, should you be categorically excluded from the opportunity to be vaccinated just because you happen to be pregnant? My answer would be, emphatically, no. I think with careful counseling about what we know and what we don’t know about the vaccine and depending on what vaccine is available, pregnant women should be given the opportunity to be vaccinated, with careful counseling about what we know and what we don’t know. And just of note there are some of the vaccine platforms that are in Phase III trials that we know quite a bit about, some we know much less about. But I think whatever the safety and efficacy data is we owe it to our patients to talk to them about the vaccine and to be able to offer the vaccine.”

Editor’s Note: Contemporary OB/GYN will soon publish a fuller article from Jamieson’s presentation, including more related studies.

Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. 

2009; 374(9688): 451-458. doi.org/10.1016/S0140-6736(09)61304-0

Blumberg DA, Underwood MA, Hedriana HL, Lakshminrusimha S. Vertical Transmission of SARS-CoV-2: What is the Optimal Definition? 

. 2020 Jun;37(8):769-772. doi: 10.1055/s-0040-1712457. Epub 2020 Jun 5. PMID: 32503058; PMCID: PMC7356079.

As experts evaluate emerging evidence and the pattern of information that comes about, there is a consistent theme that pregnant women are more severely affected by COVID-19.

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