Heralding new era with timely topics and guidance

Catherine Y. Spong, MD

I am honored and delighted to be writing the first of what I hope will be many editorials for Contemporary OB/GYN.  Honored in part due to the legacy of the magazine – following in the steps of Drs. John T. Queenan and Charles J. Lockwood. As the founding Editor in Chief, Dr. Queenan developed a treasured resource for learners, practitioners, and educators. His successor, Dr. Lockwood, added two decades of success along with national publishing awards. I feel the weight of their incredible foresight and accomplishments in bringing Contemporary OB/GYN to the prominence it holds. Further, in a time of unprecedented national chaos, the opportunity to provide a voice and guidance is humbling.  

I am also honored and delighted as I know Contemporary OB/GYN to be a leader in disseminating practical information to ob/gyns caring for patients. Having the ability to participate in such an endeavor is wonderful. As a past member of Contemporary OB/GYN’s editorial board, I live and believe in the magazine’s guiding principles: to provide concise, clear, and simple information on complex topics, decipher the myriad of new studies and data, and provide context to understand how and if they should change our care and management. I am eager to continue our partnerships with the American College of Obstetricians and Gynecologists and other professional societies to provide a venue through which they can disseminate their guidelines and opinions. 

Vision
My vision for Contemporary OB/GYN is simple: to build on our strengths, adapt to current learners, address topical issues by experts in the field, and expand venues for information dissemination. We will maintain the caliber of the publication – credible peer-reviewed sources providing clear, concise, plain-language insight on topics of daily interest to ob/gyns in day-to-day practice. I am eager to expand our online presence and create multiple modalities for learning. 

As an example of timely topics, this issue features an article by Drs. Sarah Dotters-Katz and Brenna Hughes on COVID-19, the coronavirus – a pandemic and national emergency – that has challenged us in ways unprecedented in our lifetime. The impact on communities has been stark – schools closed, colleges cancelling all in-person classes and moving to remote learning for the next semester, community events, places of worship, and gatherings cancelled. In order to work we are challenged to find care for our children, and many people are not working due to these changes, impacting financial stability.

It is critical that we all keep abreast of the ever-changing guidelines for COVID-19 as we grapple with the pandemic. The Centers for Disease Control and Prevention has classified those at highest risk: older adults and people with serious chronic medical conditions including heart disease, diabetes, and lung disease.¹ We may have patients who are high risk, and equally important, our low-risk patients may be in contact with these individuals.  We recognize that they include some of our patients and – equally importantly – are often in regular contact with our patients. Therefore, preventing disease in all of our patients is essential. Furthermore, although the available studies on COVID-19 in pregnancy do not suggest an increased risk for pregnant women, they are small. The physiologic and immunologic changes in pregnancy are known to be associated with a heightened susceptibility to viral respiratory illnesses and some of those illnesses, such as influenza, are more severe in pregnancy. Thus, extra vigilance for our pregnant women is important.

Tips for treating ob/gyn patients
What should we do? In this time of great risk for so many, we must employ novel and innovative solutions. How COVID-19 is transmitted is not fully understood, but clearly there is person-to-person spread through respiratory droplets, which is what prompted recommendations to limit contacts, avoid groups, and practice “social isolation” – staying 6 feet away from others. Decreasing the number of people in our waiting rooms is a first step. For gynecology patients, routine visits should be cancelled and we should provide a venue for telephone consultations instead of visits for all non-emergent issues. All elective surgeries should be postponed, to reduce transmission and also the burden on hospital systems. 

For our obstetrical patients, the necessity of alternative strategies is even more compelling. Prenatal visits, sonograms, and antenatal testing should be spaced out in pregnancies that are uncomplicated. This can include replacing visits with phone calls and/or video visits and home monitoring of fetal movements and blood pressure – either with home devices or those available at grocery stores/pharmacies – with effective communication concerning values and the ability to contact us with questions. In alignment with World Health Organization recommendations, consideration of five visits in person and three virtual visits is reasonable for low-risk women.²

Although a reduction in in-person visits is best for stemming transmission, it comes with a price as reimbursement may not be available for remote services. A number of professional societies are actively working on ways to address this concern.

Testing
Further compounding the crisis is the lack of available test kits, which increases the burden on the medical system. How many of the patients we treated as presumed flu who were negative for influenza A and B actually had coronavirus? As we navigate the hospital ward, our patients and hospital rounds are more complicated. The medicine service hospitalizes only the most ill and can group providers to mitigate spread. Generally, patients seen by ob/gyns are hospitalized for another reason – delivery, a pregnancy complication, an emergent gynecologic condition. They may also have respiratory symptoms but are not ill enough to be tested. Although monitored for worsening symptoms (such as fever) that might increase suspicion of COVID-19 infection, fewer precautions are taken initially. Given our limited resources – both human and facility – this is logical; however, without testing, we risk exposing others to the disease, problematic because this will not be realized until their disease worsens and testing is obtained. Importantly, we should advocate for our patients. In clinicaltrials.gov there are 51 studies listed aimed at understanding COVID-19 and evaluating therapies for it (search terms: coronavirus or COVID).³ Of these, 34 (66%) exclude pregnant women and 26 (51%) exclude lactating women. Incredibly, pregnant and lactating women are excluded even from observational studies evaluating prognostic factors in patients with COVID-19 (ClinicalTrials.gov Identifier: NCT04292964). Despite federal interest in closing gaps in knowledge and research on safe and effective therapies for pregnant and lactating women with the establishment of the Task Force on Research Specific to Pregnant Women and Lactating Women (https://www.nichd.nih.gov/about/advisory/PRGLAC),⁴ the sole study (ClinicalTrials.gov Identifier: NCT04280705) launched by the National Institutes of Health excludes both pregnant and lactating women. It is an adaptive, randomized, double-blind, placebo-controlled trial to evaluate the safety and efficacy of Remedesivir. However, another study of the same drug (ClinicalTrials.gov Identifier: NCT04292899) does not exclude pregnant or lactating women. We must advocate for inclusion, as not collecting information in our populations prevents accumulation of data to best guide therapies. 

Finally, we all must take responsibility for reducing risk to ourselves and others. Though it seems somewhat trite, the need for frequent and effective washing of our hands – for at least 20 seconds – cannot be overstated. Furthermore, other hygiene essentials – avoid touching your face, sneeze into your elbow -- are important. Even those at low risk must practice these measures to avoid transmission to those in high-risk groups. Avoiding crowds, not touching high-touch surfaces in public places, and cancelling non-essential travel may help flatten the curve of transmission. 

As we enter into this new normal, I am on the journey with you. I welcome your ideas and insights. 

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.

Email her at cspong@mjhlifesciences.com 

References:

• Centers for Disease Control and Prevention. Coronavirus (COVID-19) https://www.cdc.gov/coronavirus/2019-ncov/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2Findex.html Accessed March 17, 2020.

• World Health Organization. WHO Recommendations on antenatal care for a positive pregnancy experience (2016) https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf;jsessionid=ADB5DEAC531BDEFC48F781DE0288E616?sequence=1 Accessed March 17, 2020.

• Clinicaltrials.gov. Accessed March 17, 2020.

• Eunice Kennedy Shriver National Institute of Child Health and Human Development. Task Force on Research Specific to Pregnant Women and Lactating Women ) https://www.nichd.nih.gov/about/advisory/PRGLAC Accessed March 17, 2020.