ISUOG Consensus Statement on rationalization of early‐pregnancy care and provision of ultrasonography in context of SARS‐CoV‐2

Abstract

In view of the challenges of the current coronavirus (SARS-CoV-2) pandemic and to protect both patients and healthcare providers (physicians, sonographers, allied healthcare professionals), the International Society of Ultrasound of Obstetrics and Gynecology (ISUOG) has compiled the following evidence and expert-opinion-based guidance for the management of early-pregnancy complications. This statement provides proposals and options for managing patients referred for assessment by early-pregnancy healthcare practitioners during the coronavirus disease 2019 (COVID-19) pandemic. Transvaginal ultrasonography is a crucial part of clinical decision-making in early pregnancy. However, appropriate triage is now essential to allow prioritization of use of this resource by pregnancies at high risk of complications, mainly ectopic pregnancy, in which hospital visits will be safer than remote consultation. Temporarily reducing physical patient throughput will reduce the risk of SARS-CoV-2 transmission between patients and between patients and healthcare professionals. Clinicians carrying out ultrasound scans are in close proximity to patients for a significant period of time and have been shown to be at high risk of being infected by SARS-CoV-21. This consensus statement focuses on women contacting their local early-pregnancy support services (e.g. early-pregnancy unit, emergency rooms with ultrasound, ultrasound clinic) with common complaints. Our proposed recommendations can be adapted to individual sites based on their resource availability and infrastructure, in order to continue to use ultrasound when indicated whilst reducing its use to the essential minimum. Guidance on rationalization of gynecological ultrasound services in the context of the COVID-19 pandemic has been provided in a separate document2. Recommendations on triage of early-pregnancy scans based on onset of symptoms and on findings during previous ultrasound assessments are outlined in Tables 1 and 2, respectively. Justification for these is provided within this document. Referrals from urgent-care centers, emergency rooms, primary care Quantify pain using visual analog score (1–10) Referrals from urgent-care centers, emergency rooms, primary care Bleeding score 3–4 Referrals from urgent-care centers, emergency rooms, primary care Referrals from urgent-care centers, emergency rooms, primary care Bleeding score 2 Telephone consultation with experienced clinician Ask patient to take UPT in 1 week - Negative result: no follow-up - Positive result: offer scan Referrals from urgent-care centers, emergency rooms, primary care Bleeding score 3–4, now resolved Telephone consultation with experienced clinician Ask patient to take UPT in 1 week - Negative result: no follow-up - Positive result: offer scan Telephone consultation with experienced clinician No routine scan Telephone consultation with experienced clinician No routine scan Referrals from urgent-care centers, emergency rooms, primary care Bleeding score 1 Quantify pain using visual analog score (1–10) Telephone consultation with experienced clinician No routine scan All women in need of care should be triaged based on their symptoms and infection status. Ideally, this should be carried out over the phone by a senior healthcare practitioner prior to an appointment. However, in the event that the patient is first seen in the clinic, the healthcare professional undertaking triage should wear appropriate personal protective equipment (PPE). Triaging for common symptoms, such as cough and fever3, is critical before a patient gains access to a clinical area for an ultrasound scan or consultation. Screening for travel, occupation, contact and cluster (TOCC) risk factors should also be implemented (Appendix S1). If the local prevalence of SARS-CoV-2 increases, a policy of managing all patients as high risk may need to be implemented at some point. We also recommend that senior healthcare practitioners acquire and consider the details of the clinical history of the women to determine whether they need to attend the hospital or clinic. Any woman with probable or confirmed COVID-19 should be asked not to attend the unit. If assessment is required, they should be seen in a designated COVID-19 area. Only screen-negative patients or patients with probable COVID-19 who need to be reviewed without delay should be asked to attend the unit. If an ultrasound scan is required, we recommend that one ultrasound machine and room is designated for patients with probable or confirmed COVID-19, if possible. It is important to clean the equipment according to safety guidelines4. If a patient with suspicion of COVID-19 is stable, they should be sent home to self-isolate for 7 days, if clinically appropriate. Ideally, any patient who is cohabiting with someone who shows possible symptoms of COVID-19 should self-isolate for 14 days; however, in the context of early-pregnancy care, this is unlikely to be practical. Any rooms or areas in the department in which the patient was present will require deep cleaning. If the patient requires admission to the hospital, the location will depend on the reason for admission and availability of a side room until SARS-CoV-2 testing confirms their status. Any patient with a suspicion of possible SARS-CoV-2 infection must be highlighted immediately to all healthcare team members. Referrals from urgent-care centers, emergency rooms, midwives and primary-care practitioners to early-pregnancy support services should be made via a dedicated phone number, if available, in order to allow telephone-based triage of both early-pregnancy symptoms and risk of COVID-19 by an experienced member of the team. If this is not possible due to logistic limitations or legal requirements, then the clinician on call to cover emergency gynecology should be contacted directly for discussion and advice. A standardized proforma should be completed to screen the patient for TOCC risk factors and symptoms. The form includes three patient-specific details (name, date of birth, unique patient identifier); if a unique patient identifier is not available, then recording the patient's address is advised (Appendix S1). This proforma can also be used to record the discussion accurately and in detail, and will determine if the patient requires urgent review or if advice can be provided remotely. This proforma is a medical record of the consultation and can be kept with the patient's records. A basic requirement in all cases is that the woman should have a positive urine pregnancy test (UPT) in order for them to be considered for referral to early-pregnancy services. Cases of gynecological emergency, such as suspected ovarian torsion, should be discussed with the senior clinician on call. Referrals should be made to the clinician on call covering emergency gynecology (if possible via telephone). This applies to out-of-hours primary-care practitioners as well as healthcare personnel working in the emergency room. The most common presenting complaints are vaginal bleeding with or without pelvic pain. Objective measures of vaginal bleeding include a pictorial blood-loss assessment chart (Figure 1)5. A visual analog score ranging from 0 to 10 (0 indicating no pain and 10 severe pain) can be used to document the level of pelvic pain. It is important to note that, if a woman presenting with vaginal bleeding and/or pelvic pain has had a previous ultrasound scan showing a normally sited pregnancy (ongoing or failed), they should first have a telephone consultation with an experienced clinician as soon as is practical, before being considered for ultrasound assessment. When carrying out telephone triage, clinical judgment must always be used, and if there are concerns about the patient's clinical condition, provision should be made for immediate review. The patient should not be offered further ultrasound scans, unless it is deemed necessary clinically. Patients with a pregnancy of unknown viability can be asked to perform a UPT in 2 weeks' time. A blood test should be taken as per local protocol, measuring β-human chorionic gonadotropin (β-hCG) with or without progesterone. The most sensitive validated method of interpreting these results is via a two-step protocol (Figure 2) comprising initial serum progesterone level and the M6 risk-prediction model, which utilizes initial β-hCG, initial progesterone and 48-h β-hCG levels7, 8. In units in which measurement of progesterone is not part of the standard protocol, the version of the model using β-hCG alone can be used. Patients can then be managed in accordance with the model outcome and local policy. The M6 model is available to use for free online (http://earlypregnancycare.co.uk/). The patient should be assessed over the phone and advised regarding antiemetics. A validated screening tool for pregnant patients with nausea and vomiting is provided in Appendix S4 and a list of recommended antiemetic medications is provided in Appendix S5, as derived from UK guidance (and may be amended according to country or practice), for discussion over the phone9. Prescriptions can be sent to primary-care practitioners or directly to the patient, if possible. If intravenous hydration is required, ambulatory departments would be an ideal location10. The rare possibility of a molar pregnancy should be considered in patients with hyperemesis gravidarum and other symptoms, such as vaginal bleeding. In the event of routine dating ultrasound assessments being delayed as the clinical burden of the pandemic heightens, women should be offered assessment in early-pregnancy support services if gestational trophoblastic disease is suspected. Patients should be managed in accordance with local protocols, with an emphasis on conservative management, if possible. Accurate diagnosis of an ectopic pregnancy is critical for guiding management; thus, ultrasound scans should be reviewed by the most senior clinician available. In the event that a senior clinician is at home self-isolating or not in the hospital, consideration should be given to allow review of ultrasound images online, with appropriate security. All recommendations from local infection-control departments should be followed, including: T. Bourne, Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK; Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Development and Regeneration, Leuven, Belgium C. Kyriacou, Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK A. Coomarasamy, Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK M. Al-Memar, Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK M. Leonardi, Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia E. Kirk, Early Pregnancy and Acute Gynaecology Unit, Royal Free NHS Foundation Trust, London, UK C. Landolfo, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy M. Blanchette-Porter, Larner College of Medicine at University of Vermont Obstetrics, Gynecology, and Reproductive Sciences Division, Reproductive Medicine and Infertility Burlington, VT, USA R. Small, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Bordesley Green East, Birmingham, UK G. Condous, Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia D. Timmerman, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Development and Regeneration, Leuven, Belgium Appendix S1 Checklist for COVID-19 symptoms and TOCC Appendix S2 Flowchart summarizing recommended rationalization of early-pregnancy management including ultrasound scans (USS), based on symptoms, in context of COVID-19 pandemic Appendix S3 Flowchart summarizing recommended rationalization of early-pregnancy follow-up based on initial ultrasound scan (USS) findings, in context of COVID-19 pandemic Appendix S4 Early pregnancy hyperemesis rapid-assessment tool Appendix S5 Recommended medication for management of nausea and vomiting in early pregnancy Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Topics & Concepts