key: cord-0065740-v3gym0es
authors: nan
title: Covid 19 in women's health - Volume 73 multiple choice answers
date: 2021-07-13
journal: Best Pract Res Clin Obstet Gynaecol
DOI: 10.1016/j.bpobgyn.2021.07.002
sha: 28db321aede42133095e22f75c8e9d523136ac9a
doc_id: 65740
cord_uid: v3gym0es

nan

Mortality among pregnant women, including those with COVID-19, is low. However, large retrospective studies found that mortality in pregnant women with COVID-19 was significantly higher than in pregnant women without . Several studies and systematic reviews found that ICU admission rates in pregnant women with COVID-19 are higher than rates in pregnant women without COVID-19. Current literature does not report that pregnant women with COVID-19 are at increased risk of psychosis. Studies from several countries have reported that, compared to pregnant women without COVID-19, pregnant women with the disease are more likely to admitted to ICU and require mechanical ventilation. Studies have reported that pregnant women with COVID-19 have presented with complications including pulmonary embolus and other thromboembolic and haemostatic complications. Other studies found that the rates of venous thromboembolism and myocardial infarction were higher in pregnant women with COVID-19 compared to pregnant women without COVID-19.

Current research has shown that pregnant women with COVID-19 are not at increased risk of developing gestational diabetes. Several studies indicate that pregnant women with COVID-19 are at increased risk of caesarean delivery. However, in many studies the indication for caesarean section was not specified. Currently, there are no studies that have suggested that pregnant women with COVID-19 are at increased risk of placental abruption or obstetric cholestasis. A small cohort study has shown that pre-eclampsia is associated with severe COVID-19. However, it is not possible to differentiate the presentation of pre-eclampsia from worsening COVID-19 as their presentations are very similar. Larger studies have not confirmed that COVID-19 increases the risk of pre-eclampsia.

Inferences regarding the impact of COVID-19 on miscarriage from previous SARS and MERS outbreaks have been made. However, there is a lack of research around the topic of miscarriage in pregnant women with COVID-19. Current evidence does not suggest any causal link. Smaller single centre studies have shown an increase in the rate of stillbirth. However, data from a larger systematic review found no increase in stillbirths among women with COVID-19. Current literature has not

Obstetrics and Gynaecology identified an increased risk of microcephaly or cardiac defects in the fetuses of women with COVID-19 during pregnancy. Many studies reported higher rates of preterm birth in pregnant women with COVID-19. The vast majority of these are iatrogenic and not due to spontaneous preterm labour. Although the absolute rates of preterm birth vary from country to country, with American studies demonstrating lower rates (12%) than European (19%) or Chinese studies (17%), this effect of COVID-19 is consistent.

A body mass index of 30kg/m 2 or higher was associated with COVID-19 severity. Risk factors for severe COVID-19 in pregnancy have been identified by several studies as including Black, Asian and Minority Ethnic (BAME) backgrounds. Studies have reported that advanced maternal age is associated with an increased risk of severe COVID-19. Parity has not been identified as a risk factor of severe COVID-19. Pre-existing diabetes was noted by many studies as a factor associated with severe COVID-19.

In the living systematic review and meta-analysis, Allotey et al. (2020 Allotey et al. ( , updated 2021 showed that pregnant women with chronic hypertension and pre-existing diabetes mellitus had a higher risk of intensive care admission, invasive ventilation and maternal death when admitted to hospital with COVID-19. In the systematic review update published in 2021, gestational diabetes was also found to be a risk factor for adverse outcomes. In the same review, asthma was not found to increase the risk. Individuals with sickle cell disease have been advised by both UK Government and the Centers for Disease Control (USA) that they are extremely vulnerable to the effects of COVID-19, but so far, observational studies of COVID-19 affecting pregnant women have not studied this as a risk factor. This is likely because of the rarity of this co-morbidity.

Gupta et al. (2020) summarised the evidence on COVID-19 myocardial injury and commented that this is seen in individuals without co-existent cardiac disease. It has also been noted affecting pregnant women. COVID myocardial injury has a varied phenotype which includes symptoms of acute coronary syndrome, arrhythmia, cardiogenic shock and myocarditis, although the pathophysiology is inflammatory, distinct from the typically obstructive pathology of acute coronary syndrome. COVID-19 myocardial injury is typically seen with high elevated troponin T or I, with or without elevated BNP. The troponin may also be elevated without symptoms.

COVID-19 typically causes thromboembolism in the pulmonary microvasculature but is also associated with hospital-acquired venous thromboembolism. D-dimer has lower specificity in pregnant women than non-pregnant individuals because of a higher rate of false positive tests, regardless of COVID-19. D-dimer is often raised as a normal physiological response to pregnancy and should not be used as a rule-out screening test for thrombo-embolism in pregnant women. CT-pulmonary angiogram (CT-PA) is the first line radiological examination for individuals who have other chest pathology, such as the bilateral pulmonary infiltrates often seen with severe COVID-19. CT-PAs deliver a lower fetal dose but a higher maternal dose of radiation than ventilation:perfusion (V:Q) scans, however V:Q scans cannot be reliably interpreted in the context of other pulmonary pathology and are unlikely to be useful for a woman with severe COVID-19. Self-isolation with or without COVID-19 is likely to reduce a pregnant woman's mobility, this is a single risk factor for venous thromboembolism and should be interpreted in the context of other risk factors, particularly in the third trimester when the risk of thromboembolism is highest. The UK National Institute for Health and Care Excellence recommend doubling the dose of thromboprophylaxis for individuals requiring advanced respiratory support, there is no reason that this should be contra-indicated in pregnant women.

A recently published meta-analysis found that peak viral load levels were achieved within five days of symptom development, indicating that patients could reach a peak of infectivity prior to being diagnosed with COVID-19. Aerosols, and not droplets, evaporate and result in lighter droplet nuclei that can remain suspended in the air. Respiratory droplets are broadly larger and frequently quoted as >5mm, compared to aerosols (5 mm), although realistically the two exist along a continuum. There is debate as to whether the primary mode of transmission of COVID-19 is via respiratory droplets or aerosols. The former spreads the virus when an infected droplet contacts the mucous membranes of a non-infected person (such as in the nose, mouth or conjunctiva). Experimental data shows that SARS-CoV-2 could be transmitted via aerosols and that both droplets and aerosols are generated during speech, sneezing and coughing with a span of approximately 7e8 m. Although SARS-CoV-2 positive air samples do not equate to viable virus and higher infection risk, the evidence in support of airborne transmission is rising. SARS-CoV-2 within droplets has been found to remain viable on various surfaces: for 4 hours on copper, 24 hours on cardboard, 72 hours on plastic and stainless steel and 84 hours on glass, indicating infection via fomite transmission is plausible. However, the probability of SARS-CoV-2 transmission in this way is unknown; this is due to inconclusive reports where respiratory transmission was unable to be excluded. However, thorough and regular cleansing of surfaces is likely to help reduce viral transmission. There is evidence to suggest that handwashing does reduce bacterial, not viral, load on the skin with 90% reduction of contamination after a 15 second handwash, and 99% after 30 seconds, but not 100%. Drying hands with paper towels helps too, and surpasses electric handdryers for removal of micro-organisms.

Surgical facemasks are worn for two reasons: to prevent the spread of one's own respiratory secretions and to protect the wearer against respiratory secretions from others. When worn for the former reason, for example when talking, the facemask need only be changed when it becomes soiled, damaged or hard to breathe through. Facemasks should be changed between patients when used as protection from the respiratory secretions of others, for example if there is a splash risk. Eye protection, the most effective of which is tight-fitting goggles or face visors, is reusable but should be cleaned between uses with soap and water, followed by disinfection with sodium hypochlorite 0.1% or 70% ethanol. Not all PPE is single-use needing to be changed after attending every single patient, in particular face masks and eye protection, unless soiled by splashes of bodily fluids. However, all other PPE should be single use. Due to the risk of contamination during the doffing of PPE, trusts should provide adequate training in proper donning and doffing technique to minimise this. Prescription glasses provided no additional protection in a simulation model and were comparable to no eye protection at all, however, many goggles fit over prescription glasses.

Women with ovarian cancer may well present with vague abdominal symptoms and making a new diagnosis of irritable bowel is unsafe, particularly in postmenopausal women. Persistent symptoms require attention with an abdominal examination and a CA125 level. Those women with a significantly high level should be referred as a matter of urgency for an urgent CT scan as part of the 'straight-to test' strategy as advised by the BGCS. Women with symptoms of lichen sclerosus generally respond well to topical high dose steroid ointment, such as clobetasol, in combination with a moisturising wash and general advice about vulval care. Those who do not respond after a few weeks of treatment should be referred, but only on the suspected cancer pathway if cancer is actually suspected. Women with unscheduled bleeding on HRT are at lower risk of endometrial cancer than women not taking HRT therefore a telephone consultation may suffice to establish the exact context of the bleeding and discuss modification of their HRT to minimise subsequent bleeding. However, those who do not respond to modified treatment warrant an ultrasound scan of their endometrium and where significantly thickened (the actual thickness threshold depends upon the HRT type) offered further endometrial assessment (Joint RCOG, BSGE, BGCS guideline). Not all women with PMB during the pandemic need to be seen in person, in particular those least at risk of endometrial cancer. Triage of the '2-week wait'/fast track referral letters can identify women who are within two years of the menopause, are not obese (BMI <30) and have experienced a period-like bleeding perhaps preceded by pre-menstrual symptoms. The likely cause of bleeding in this situation is residual ovarian activity and the woman can be reassured that investigation can be safely deferred, with the 'safety-net' advice that should the bleeding recur, investigations would be indicated. Women with a normal appearing cervix on speculum examination with a current negative cervical smear excludes cervical cancer. However, it is important that the woman is seen and examined and, besides testing for a sexually transmitted disease, a cervical smear should be performed if overdue. Further investigation will be necessary if the cervix looks obviously malignant or if the cervical smear test indicates colposcopy is appropriate (Joint RCOG, BSGE, BGCS guideline).

In order to avoid a face-to-face encounter, women should be offered oral progestogens as first line treatment instead of the more usual LNG-IUS. Treatment should be given either for 21 days on a cyclical basis, (so a 'long' and not 'short' 10-day course), or on a continuous basis. The haemoglobin should be checked, possibly using a local drive-in phlebotomy service, to identify anaemia. Patients who respond poorly to oral progestogens may require additional treatment. Women who find that despite treatment their menstrual loss is unmanageable, should be seen within 30 days, particularly if they have significant anaemia. The risk of an endometrial abnormality is small, but should be considered for women with risk factors, such as PCOS, morbid obesity, obesity and over 40 years of age, and Lynch syndrome. It is recognised that menopausal services are still required. A remote consultation may be sufficient to establish the history, convey information about treatment options and prescribe treatment (BMS guideline). The advice from BSUG is that there is no need for urgent assessment of a woman with a new procidentia. However, she should be seen within 30 days if there are bowel or bladder problems, but if the problem is causing minimal inconvenience the clinic visit can be safely deferred until the pandemic has eased. At the time of writing the SARS-CoV-2 vaccination for women who are to receive fertility treatment is only just a consideration, but this may change.

Negative pressure ventilation reduces the risk of infection from patients to staff caring for them. Development of virtual care pathways and clinics allows continuation of care without the risk of infection; these clinics should be recorded in the clinical notes as a consultation and the patient should know how to access care in between scheduled visits. Regular daily meetings between clinicians and hospital management will allow for a dynamic and flexible response to the changing situation and emerging new knowledge that is characteristic of a pandemic. Regular electronic newsletters to all hospital staff are an effective way to clearly communicate with staff in the setting of a rapidly changing clinical and management environment. While much clinical care can occur in the community, with appropriate hospital restructuring, patients who require hospital care can safely access it when required.

The coronavirus (SARS-CoV-2) responsible for COVID-19 is known to be transmitted through the respiratory tract and spread by fomites, contaminated surfaces on to which the virus has fallen and aerosols (particles less than 5m that evaporate in the air leaving droplet nuclei that are able to remain in the air for hours). SARS-COV-2 viral RNA has been detected in faeces in up to 67% of COVID-19 cases, however live infectious particles have only been described in a small number of cases. There have been no reports of the virus being transmitted through the vaginal secretions. A theoretical source of transmission is through aerosolisation of peritoneal fluid during surgery and through smoke plumes generated by the multitude of energy generating devices. Evidence is inconclusive as it is believed that the CO 2 pneumoperitoneum required for laparoscopic procedures resulted in the stagnation of contaminants, including viral particles, that could subsequently become aerosolised during the release of CO 2 such as during the removal of trocars port or specimens.

In the surgical environment the highest risk of transmission is from aerosol generation at intubation and extubation during general anaesthesia (GA) due to the high viral load in respiratory secretions. The next greatest risk is through aerosol generating procedures (AGP) specific to surgical procedures. Dampening transmission of SARS-CoV-2 is achieved firstly by the wearing of appropriate PPE and handwashing. Frontline staff are largely at risk of becoming infected when undertaking AGP and also via direct contact with patients where PPE and social distancing have not been appropriately utilised. Minimising the number of personnel in theatres especially during aerosol generation at intubation and extubation during general anaesthesia will reduce risk of transmission to theatre staff. Mechanical filters capture smoke close to the source of production minimising exposure to health care practitioners in the theatre environment and maintain a clear operating field. Suction devices, smoke evacuation filters, retrieval devices and swabs should be used to prevent aerosol transmission. They remove smoke, aerosol and the CO 2 pneumoperitoneum during surgery and avoid explosive dispersion of body fluids when removing trocars and retrieving specimens. There is a theoretical risk of viral particles within smoke plumes so reducing surgical smoke production minimises this risk.

All patients should undergo SARS-CoV-2 virology screening, using standard oropharyngeal and nasal swabs, in keeping with national guidance. Tests should be done from 3 days before admission, in accordance with local test result turnaround times. Patients testing positive for SARS-COV-2 should have surgery deferred for at least 14 days from the onset of symptoms and only when asymptomatic. All patients should be advised to follow comprehensive social distancing and hand hygiene measures, as per UK government guidance for 14 days before planned admission. Patients testing negative for SARS-COV-2 but with a temperature of >/ ¼ 37.7 C on the day of admission or screen positive on questioning should be considered a suspected COVID-19 case.

The CovidSurg Collaborative published results on the global experience of operating on patients with a peri-operative SARS-CoV-2 infection. It highlighted a significantly high overall mortality of 23.8% quoting 19.1% and 26% mortality in elective and emergency surgery respectively. Of those with peri-operative SARS-CoV-2 infection, 51.2% developed a pulmonary complication namely Adult Respiratory Distress Syndrome (ARDS), pneumonia and the unexpected need for post-operative ventilatory support. The added risks may be proportional to age, sex, surgical complexity and patient comorbidities. Implementing interventions to establish a safe theatre environment is thought to reduce transmission. Such interventions include a negative pressure environment, high frequency of filtered air exchanges and high efficiency particulate air filters. Watson and colleagues looked at 100 patients with a pre-test probability of 80% and with a RT-PCR test sensitivity of 70% and specificity of 95%, 56% of patients would be true positives, 19% would be true negatives whilst one person who tests positive will not have COVID-19 and 24% would be negative, but have COVID-19. This illustrates that when screening patients prior to surgery PCR testing alone will not identify all patients thus the test needs to be combined with a detailed history and temperature checks in RT-PCR negative patients and should be applied for all emergency patients even if they test negative. "COVID free" staff, should be screened daily using an appropriate questionnaire as well as undergoing rapid PCR antigen testing if symptomatic. Regular swab testing to ensure asymptomatic COVID infection is not missed is also recommended and lateral flow testing is being rolled out NHS wide. COVID-19-free pathways are crucial for patient safety during the COVID-19 pandemic, as they appear to lead to lower SARS-CoV-2 infection rates and complications.

Droplet transmission, through close or direct contact with an infected person, is considered to be the primary route of transmission. If it occurs, vertical transmission is rare. The course of infection in neonates is mild. A systematic review found that the likelihood of transmission appears not to be affected by mode of birth, method of feeding or whether the woman and baby are cared for together. A symptomatic individual with mild-moderate disease is likely to be infectious for 24e48 hours prior to symptom onset. At 10 days following the onset of symptoms, 94% of individuals are no longer infectious. Transmission of SARS-CoV-2 occurs most often in poorly ventilated, enclosed spaces where people have frequent close contact with others. In such settings, droplet transmission, aerosol transmission and contact with infected surfaces are all enabled.

Both increased BMI (being overweight or obese) and the presence of diabetes have been shown in cohort studies of pregnant women, and larger cohort studies of whole populations, to be risk factors for hospitalisation with, and severe illness including ICU admission and death, from COVID-19. Increased risk of severe illness and death is strongly associated with increased age. Women from Black, Asian and other minority ethnic backgrounds have been shown to be at increased risk of morbidity and death from COVID-19. Social deprivation has been shown to be associated with severe illness from COVID-19. There is no evidence to suggest parity is associated with a woman's risk of severe illness or death from COVID-19.

Ovarian torsion is a priority 1A procedure and should be carried out within 24 hours. A delay in intervention can impair ovarian function. The inspection±biopsy of the endometrium for suspected hyperplasia is a priority 2 procedure, to be performed within 4 weeks. In order to avoid repeated hospital visits a 'see and treat approach' (such as fitting an intrauterine system at time of biopsy) should be considered and discussed with the patient. This procedure is priority 4, permitting a wait of longer than three months. Cysts that are unilocular or contain isolated septa have a low-risk of malignancy even when they are larger than 5cm. This also holds true for postmenopausal women. These patients are priority 3 and surgery should be carried out within 3 months. The impact of uncontrollable pain on the quality of life of endometriosis patients can be devastating. Prolongation of pain processes can lead to a higher risk of pain memory, longer postoperative recovery in the future, sexual dysfunction and poor mental health. Hysteroscopy for a suspected endometrial polyp is a priority 3 procedure e the risk of malignancy is low.

The framework considers what an acceptable time period for assessing or treating any specific condition would be. It was developed during the pandemic as a guide to get gynaecological services restored. The prioritisation framework organises the procedures or assessment according to clinical priority and not length of time. It aims to restore services but also consider opportunities for change

It encourages a multi-disciplinary approach to patient care and focuses on maintaining safety. 21. a) T b) T c) T d) F e) F

With rising cases of COVID-19, the redeployment of staff to support critical care areas was more common as well as the rate of staff sickness. This hindered the restoration of non-essential gynaecology care services. Early pregnancy services, abortion care and gynaecological oncology are the core gynaecological services that have continued throughout the COVID-19 pandemic. Medical abortion at home have been made legal up to 10 weeks' gestation