Implications for the future of Obstetrics and Gynaecology following the COVID-19 pandemic: a commentary

Patient-initiated follow-up in gynaecology: Patient and clinician views

OBJECTIVES

Follow-up appointments in the UK National Health Service account for up to two thirds of outpatient activity, but there is a significant resource impact in providing time fixed follow-up appointments. Increasingly patient initiated follow-up is being used, to make follow-up appointments work better for patients both in terms of timing and necessity, and to reduce unnecessary outpatient activity. The objective of this study was to use a modified questionnaire to evaluate patient and clinician views regarding Patient-Initiated Follow-Up (PIFU) in gynaecology services and identify subgroups suited to this pathway of care.

STUDY DESIGN

Participants including both patients and clinicians were recruited from a gynaecology outpatient department. Patients who have poorer access healthcare (with disabilities and black and ethnic minority background) were purposively targeted so their experiences could be included. Value and burden scores were evaluated using patient and clinician surveys based on a modified QQ-10 questionnaire which assessed perceived value and burden of patient initiated follow-up in gynaecology. Free text comments regarding PIFU were also collected.

RESULTS

305 patients and 30 clinicians were surveyed. Overall response to patient initiated follow-up was positive. Patients and clinicians attributed high value (77.4 % and 81.4 %) and low burden scores (37.5 % and 44.7 %) to PIFU. Patient autonomy was cited as a reason for this by 84.6 % of patients and 93.3 % of clinicians. Patients attending benign gynaecological sub-specialties including endometriosis (84.2), general gynaecology (82.5) and vulval clinics (81.4) attributed the highest value scores. Gynaecology oncology patients attributed the lowest value (64.0) and highest burden score (51.3) of all subgroups. Younger adults (<60) were more likely to express a preference for PIFU (52.9 %) than older adults (≥60) (28.6 %).

CONCLUSIONS

In this study, both patients and clinicians are in favour of selected use of PIFU in gynaecology services. Both questionnaires found younger patients with benign gynaecological conditions were perceived as best suited PIFU. We recommend offering PIFU to select patients who are confident in self-monitoring, factoring patient choice so patients are not disadvantaged by this system. Further evaluation of PIFU in practice is needed before widespread implementation.

The impact of the first wave of the COVID-19 pandemic on hospital admissions and treatment management of ectopic pregnancy

OBJECTIVES

We aimed to evaluate the clinical features and treatment strategies applied to the patients with ectopic pregnancy admitted to our tertiary care center before and during the pandemic.

METHODS

Women aged 18-45 years, who were admitted to the hospital with a diagnosis of ectopic pregnancy in the pre- and postpandemic periods, were included in this case-control study.

RESULTS

A total of 173 patients, 116 patients before the pandemic and 57 patients during the pandemic, were included in the study. The rate of admissions from the emergency department was higher during the pandemic than before the pandemic (P = 0.003). The rupture was detected significantly higher during the outbreak (13/116 [11.2%]) than before the pandemic (16/57 [28.1%]) (P = 0.009). While conservative treatment was applied more frequently in the prepandemic period, it was observed that patients were treated surgically more frequently during the pandemic period (P = 0.003). While laparoscopic surgery was preferred before the pandemic, laparotomy was applied to all patients during the pandemic (P < 0.001).

CONCLUSIONS

In the first wave of the outbreak, there were delays in the diagnosis of ectopic pregnancies, and these patients presented with ruptures more frequently than before the pandemic. Furthermore, surgical treatment methods were used more than conservative therapies during the outbreak.

Perspectives on training in obstetrics and gynaecology during the COVID-19 pandemic: Thematic analysis of trainee responses from a pan-European survey

Background

Coronavirus disease 19 (COVID-19) has affected many aspects of the lives of medical professionals. Postgraduate training has also been affected and mitigation plans are still ongoing.

Objective

To understand the perspectives of trainees in obstetrics and gynaecology (ObGyn) during the pandemic.

Materials and Methods

A cross-sectional exploratory survey conducted electronically from 20th of April 2020 to 1st July 2020.

Main outcome measures

The original questionnaire comprised of 40 questions and a free-text option. The free-text questions covered five main domains: effect of the pandemic on training, worries about training, acquisition of skills during the pandemic, training period and extensions and responsibilities outside training during the pandemic. The responses to these questions in the survey were analysed using pragmatic thematic analysis.

Results

Trainees felt there was lack of training as well as training opportunities. Some took the pandemic as an opportunity to gain new skills. Trainees were also worried about time in training and uncertainty about extensions. Lastly, many had concerns pertaining to patient care, an inability to contribute to departmental organisation, and dissatisfaction with the implemented policies.

Conclusion

The difficulties in Obstetrics and gynaecology training due to the pandemic need to be mitigated. When planning for reshaping the training programmes to accommodate for the discrepancies caused, trainers need to consider the perspectives of trainees and actively involve them in the decision making, designing and executing future plans.

What is new?

Efforts are currently underway to address the training time lost during the pandemic in Europe. Recognising the paramount importance of providing exceptional care for women and children across the continent, it becomes imperative to consider the valuable perspectives and insights offered by those who represent the future generation of specialists in the field.

Maternal and perinatal outcomes in mixed antenatal care modality implementing telemedicine in the southwestern region of Colombia during the COVID-19 pandemic

INTRODUCTION

Contingency measures due to the COVID-19 pandemic limited access to routine prenatal care for pregnant women, increasing the risk of pregnancy complications due to poor prenatal follow-up, especially in those patients at high obstetric risk. This prompted the implementation and adaptation of telemedicine.

OBJECTIVE

We aim to evaluate the maternal and perinatal outcomes of patients who received prenatal care in-person and by telemedicine.

METHODS

We conducted a retrospective observational cohort study of pregnant women who received exclusive in-person and alternate (telemedicine and in-person) care from March to December 20,202, determining each group's maternal and neonatal outcomes.

RESULTS

A total of 1078 patients were included, 156 in the mixed group and 922 in the in-person group. The patients in the mixed group had a higher number of prenatal controls (8 (6-9) vs 6 (4-8) p < 0.001), with an earlier gestational age at onset (7.1 (6-8.5) vs 9.3 (6.6-20.3), p < 0.001), however, they required a longer hospital stay (26 (16,67%) vs 86 (9,33%), p = 0.002) compared to those attended in-person; there were no significant differences in the development of obstetric emergencies, maternal death or neonatal complications.

DISCUSSION

Incorporating telemedicine mixed with in-person care could be considered as an alternative for antenatal follow-up of pregnant women in low- and middle-income countries with barriers to timely and quality health care access.

Knowledge and Expectations of Perinatal Care Among Pregnant Women During the COVID-19 Pandemic

Introduction

This study aimed to investigate the knowledge and expectations of pregnant women on perinatal care during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

A cross-sectional survey was conducted among pregnant women ≥21 years, without a history of confirmed COVID-19, attending antenatal clinics between August and September 2020 via a secure online platform. The survey consisted of 10 questions which evaluated the knowledge and expectations on perinatal and neonatal care during the current pandemic.

Results

A total of 313 pregnant women completed the survey. The mean age of the participants was 30 years (SD 4; range 22–43 years). The median gestational age was 25 weeks (range 4–40 weeks). The participants were predominantly multiparous (54%) and almost all (98%) had completed secondary level education. Majority of participants were aware of the spread of COVID-19 by respiratory secretions and contact (90%), and the importance of prevention strategies (94%). Up to 72% agreed or strongly agreed that in-utero transmission of SARS-CoV-2 was possible. Most were unsure of the optimal mode of delivery (77%) and only 22% believed that breastfeeding was safe in a pregnant woman with active COVID-19. Although 46% were concerned about increased transmission risk with antenatal clinic visits, only 37% were agreeable to teleconferencing of clinic appointments. Maternal age >35 years was significantly associated with agreement with separation of mother-infant after birth [AOR 1.89 (95% CI 1.05, 3.39)], restrictions of visitors during the postnatal period [1.92 (1.05, 3.49)] and having their confinement practices were affected [2.3 (1.26, 4.17)]. Pregnant women who were multiparous disagreed that breastfeeding was safe in women with active COVID-19 [0.42 (0.23, 0.75)].

Conclusions

There was significant uncertainty about the optimal delivery method and safety of breastfeeding with COVID-19 among expectant mothers, along with variable agreement with alterations to routine perinatal care.

Did the COVID-19 pandemic affect mental health, training progression, and fertility planning of obstetrics and gynecology trainees? A survey of London trainees

PURPOSE OF STUDY

To assess impact of COVID-19 pandemic on mental wellbeing, workload, training progression, and fertility planning among London Obstetrics and Gynecology trainees.

DESIGN

An anonymous survey comprising 41 peer-validated questions was sent to London trainees. Anxiety and depression were screened using Generalized Anxiety Disorder Questionnaire 7 (GAD 7) and Patient Health Questionnaire-9 (PHQ-9).

RESULTS

One hundred and seventy-seven trainees completed the questionnaire, of whom 54% were aged 25-34 years, 43% were senior trainees (ST6-7), and 51% classified themselves as Black, Asian, and Minority Asian (BAME). Although the percentage of respondents with "moderate"/"severe" GAD 7 and PHQ-9 scores was two to three times that of UK population estimates, median GAD 7 and PHQ-9 scores were 7 and 6 ("mild"). Sixteen percent deferred their fertility plans and 26% of ST6-7 trainees changed their Advanced Training Skills Modules. Other issues raised ranged from lack of assistance with electronic portfolio, postponement of examinations, poor senior input for mental health, lack of debriefing for redeployed trainees and requests for deferment of annual reviews.

CONCLUSIONS

The pandemic has incurred an impact on mental health, training progression, and fertility planning of London trainees. With recommencement of nonemergency consultations and elective gynecology theater, alongside Royal College of Obstetricians and Gynecologists' Recovery Blueprint to optimize learning opportunities, there is optimism that these challenges can be overcome. Trainers and trainees need to safeguard training opportunities and consider innovative forms of future learning, while anticipating potential effects of subsequent waves.

Birthing under the Condition of the COVID-19 Pandemic in Germany: Interviews with Mothers, Partners, and Obstetric Health Care Workers

BACKGROUND

The COVID-19 pandemic and the necessary containment measures challenge obstetric care. Support persons were excluded while protection measures burdened and disrupted the professionals' ability to care and communicate. The objective of this study was to explore the first-hand experience of the impact of the COVID-19 pandemic on mothers, their partners, and obstetric professionals regarding birth and obstetric care in a university hospital.

METHODS

To answer the descriptive research questions, we conducted a qualitative content analysis using a data triangulation approach. We carried out 35 semi-structured interviews with two stratified purposive samples. Sample one consisted of 25 mothers who had given birth during the pandemic and five partners. Sample two included 10 obstetric professionals whose insights complemented the research findings and contributed to data validation. Participants were recruited from the study sample of a larger project on patient safety from two German university hospitals from February to August 2021. The study was approved by two ethics committees and informed consent was obtained.

RESULTS

Mothers complied with the rules, but felt socially isolated and insecure, especially before transfer to the delivery room. The staff equally reported burdens from their professional perspective: They tried to make up for the lack of partner and social contacts but could not live up to their usual professional standards. The exclusion of partners was seen critically, but necessary to contain the pandemic. The undisturbed time for bonding in the maternity ward was considered positive by both mothers and professionals.

CONCLUSION

The negative effects of risk mitigation measures on childbirth are to be considered carefully when containment measures are applied.

Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic

OBJECTIVE

To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management.

RESULTS

There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020.

CONCLUSIONS

No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Midwives' perception of advantages of health care at a distance during the COVID-19 pandemic in Switzerland

OBJECTIVE

To explore midwives' perceptions of the advantages of telemedicine during the COVID-19 pandemic in Switzerland.

DESIGN

Cross-sectional study based on an online survey using quantitative methods.

SETTING

Midwives working in Switzerland.

PARTICIPANTS

Self-selected convenience sample of 630 members of the Swiss Federation of Midwives.

MEASUREMENT

Open questions on advantages of health care at a distance and workrelated characteristics were used in the online questionnaire. The information was coded and integrative content analysis was applied.

FINDINGS

A good half of the respondents associated telemedicine with either an advantage beyond the pandemic ("Reduced workload", "Improved health care provision", "Greater self-care of clients"), while the others saw a pandemic-related advantage ("Protection from COVID-19", "Maintaining care/counseling in an exceptional situation"), or no advantage at all. Older, more experienced midwives were less likely to see an advantage beyond the pandemic. The motive "Reduced workload" was positively associated with professionals aged younger than 40 years and midwives with up to 14 years of professional experience, and "Protection from COVID-19" was more likely cited by midwives aged 50 and more and by midwives working solely in hospitals. Midwives who stated "Maintaining care" and "Improved health care provision" as motives to embrace telemedicine were more likely to experience health care at a distance as a positive treatment alternative.

KEY CONCLUSION

Midwives' perceptions of the advantages of health care at a distance vary substantially with age and years of professional experience, as well as workrelated characteristics. Further research is necessary to acquire a sound understanding of underlying reasons, including the sources of the general attitudes involved.

IMPLICATION FOR PRACTICE

Understanding the differences in perceptions of health care at a distance is important in order to improve the work situation of midwives and the health care they provide to women and families. Different sensitivities represent an important source in the ongoing discussion about the future use of telemedicine in health care.

The impact of disasters on contraception in OECD member countries: a scoping review

OBJECTIVES

Review evidence is lacking about how contraception is affected by severe social disruption, such as that caused by the COVID-19 pandemic. The purpose of this scoping review was to explore the impact of natural and man-made disasters on contraception in OECD member countries.

METHODS

Manual searches and systematic searches in six electronic databases were conducted with no language restrictions. All articles were screened by at least two researchers. The data were analysed thematically.

RESULTS

108 articles were included. Most focussed on the Zika virus outbreak (n = 50) and the COVID-19 pandemic (n = 28). Four key themes were identified: importance of contraception during disasters, impact of disasters on contraceptive behaviour, barriers to contraception during disasters and ways of improving use of contraception during disasters. Despite efforts to increase access to contraception including by transforming ways of delivery, barriers to use meant that unmet need persisted.

CONCLUSIONS

To prevent adverse health outcomes and reduce health costs as a result of failure to have access to contraception during disasters, there is a need to intensify efforts to remove barriers to use. This should include increasing access and information on methods of contraception and their side effects (e.g., menstrual suppression) and making contraception freely available.

Which ethical values underpin England's National Health Service reset of paediatric and maternity services following COVID-19: a rapid review

OBJECTIVE

To identify ethical values guiding decision making in resetting non-COVID-19 paediatric surgery and maternity services in the National Health Service (NHS).

DESIGN

A rapid review of academic and grey literature sources from 29 April to 31 December 2020, covering non-urgent, non-COVID-19 healthcare. Sources were thematically synthesised against an adapted version of the UK Government's Pandemic Flu Ethical Framework to identify underpinning ethical principles. The strength of normative engagement and the quality of the sources were also assessed.

SETTING

NHS maternity and paediatric surgery services in England.

RESULTS

Searches conducted 8 September-12 October 2020, and updated in March 2021, identified 48 sources meeting the inclusion criteria. Themes that arose include: staff safety; collaborative working - including mutual dependencies across the healthcare system; reciprocity; and inclusivity in service recovery, for example, by addressing inequalities in service access. Embedded in the theme of staff and patient safety is embracing new ways of working, such as the rapid roll out of telemedicine. On assessment, many sources did not explicitly consider how ethical principles might be applied or balanced against one another. Weaknesses in the policy sources included a lack of public and user involvement and the absence of monitoring and evaluation criteria.

CONCLUSIONS

Our findings suggest that relationality is a prominent ethical principle informing resetting NHS non-COVID-19 paediatric surgery and maternity services. Sources explicitly highlight the ethical importance of seeking to minimise disruption to caring and dependent relationships, while simultaneously attending to public safety. Engagement with ethical principles was ethics-lite, with sources mentioning principles in passing rather than explicitly applying them. This leaves decision makers and healthcare professionals without an operationalisable ethical framework to apply to difficult reset decisions and risks inconsistencies in decision making. We recommend further research to confirm or refine the usefulness of the reset phase ethical framework developed through our analysis.

Indirect effects of COVID-19 in referring women to gynecologic oncology, perinatology and gynecology clinics in Iran

Purpose

COVID-19 has captured the world. We hypothesized that this pandemic reduced referral of other non-COVID-19 patients to the hospitals or clinics, including gynecological and perinatological referrals. Women can be at risk in limited use of health services.

Methods

In this retrospective study, referrals from gynecologic oncology, perinatology, and gynecology clinics in a large teaching hospital of Tehran University of Medical Sciences (TUMS) were compared from February 20 to May 20, 2020, with the same period in 2019. Finally, referral trends in 2020 were compared with the COVID-19 admission pattern.

Results

Total admissions to all three clinics declined 63% in 2020 compared to 2019. There was a significant relationship between the number of visits to three clinics during these2  years (p < 0.001). The reduction in referrals to the gynecology clinic was more than gynecologic oncology and perinatology. The COVID-19 referral pattern was conversely linked to gynecology-related admissions.

Conclusion

As the pandemic situation makes patients hesitant to go to the hospitals or not, health policymakers should consider other non-COVID issues, including maternal and fetal concerns. Providing safe places for other patients to visit is a goal that can be achieved through developing guidelines for nosocomial hygiene and training informed healthcare staff. Moreover, non-urgent visits should be avoided or postponed. This issue calls for new strategies, including telemedicine in situations similar to the current pandemic to both identify and manage such conditions.

Diagnosis and resection of a giant ovarian cyst presenting in a young patient with contralateral back pain and lower limb deep vein thrombosis

We present a case of a giant ovarian cyst in a 20-year-old woman who presented atypically at our Emergency Department with left-sided back pain followed by acute left leg swelling. Blood tests showed significantly raised C-Reactive Protein and D-Dimer. CT-Abdomen-Pelvis demonstrated a large mass in the region of the right ovary with suspicious heterogeneous filling defects in the left external iliac vein, confirmed as a left-sided deep-vein thrombosis on ultrasound Doppler. MRI revealed the lesion to be cystic and the deep venous thrombosis was treated with twice-daily Clexane. Prior to removal of the cyst, an Inferior Vena Cava Filter was placed to reduce thromboembolic risk. The cyst was resected without complication and the postoperative period was uneventful. This case occurred while face-to-face services were limited by COVID-19 and illustrates the need for robust systemic measures to safeguard patients against the emergency sequelae of insidious gynaecological pathology.

Framework for obstetrics and gynecology department change management in response to COVID-19 pandemic: A tertiary center experience

Coronavirus (cov) disease 2019 pandemic caused by severe acute respiratory syndrome cov 2 has imposed significant demands on healthcare systems across the world. These demands were more significant on obstetrics and gynecology (obgyn) patients, who required services that had to continue despite the closure of other services. This paper describes the change management of an obgyn department at a tertiary health-care center. That experience resulted in a complete management shift in the institution and the formation of an infectious disease epidemic plan for respiratory infections. Description of the change management performed, difficulties encountered, and achievements obtained can assist other departments change management when they face similar situations.