The COVID-19 pandemic has uniquely affected outpatient prenatal care, which depends on frequent assessment of a pregnant mother and her fetus. At the start of the pandemic, the outpatient prenatal care program at Brigham and Women’s Hospital increased the use of virtual visits, allowing patients to regularly meet with their providers safely.
“However, we soon learned that virtual visits couldn’t always provide the same level of care as in-person visits for pregnant patients,” says Khady Diouf, MD, division director of Ambulatory OBGYN Division at the Brigham. “So, we needed to find ways to oversee healthy pregnancies while still reducing the time pregnant patients spent at the hospital.”
Integrating Telehealth into Prenatal Care
To ensure that pregnant patients are safely monitored during the pandemic, the Department of Obstetrics and Gynecology developed a schedule for pregnant patients to alternate between virtual and in-person visits. During virtual visits via video or phone calls, the patient and provider discuss the baby’s movements and any noticeable changes. In-person visits allow OBs to do blood work, ultrasounds and non-stress tests.
Early in the pandemic, the outpatient OB clinics at Brigham started a program to provide blood pressure (BP) cuffs to all pregnant patients. Led by Audra R. Meadows, MD, MPH, this program allowed mothers to monitor their BP at home and report their values to providers during virtual visits. This was especially important for patients at risk of developing hypertension or preeclampsia during pregnancy. Some patients also purchased their own fetal doppler probe, which measures the baby’s heartbeat.
“While virtual visits have been an important addition to our outpatient prenatal care practice, telemedicine isn’t a viable option for patients who don’t have access to reliable phone and internet access,” acknowledges Dr. Diouf. “If patients don’t have the means to conduct a virtual visit, we make sure that they can safely visit the hospital.”
Safe Prenatal Care During COVID-19
As part of the Brigham’s Safe Care Commitment to provide the safest possible environment for pregnant patients, all patients who visit the clinic encounter a variety of new safety protocols. These include increased frequency and intensity of cleaning and measures to minimize wait time and the number of patients in the clinics.
This spring, the Brigham also implemented a universal masking policy for staff and patients. This masking policy was proven to dramatically lower transmission rates in a recent study led by the Brigham. Moreover, in an analysis of data collected during the spring of 2020, a team of investigators from the Brigham found that in-person health care visits among pregnant patients didn’t increase the risk of getting COVID-19.
Fetal Surveillance for COVID-Positive Patients
To further protect pregnant patients during the pandemic, the Department of Obstetrics and Gynecology regularly screens all pregnant patients for COVID-19 symptoms. This measure was taken because of studies that show that an infection may have adverse effects on a pregnancy, such as higher risk of blood clots or placental pathologies.
“At the beginning of the pandemic, any pregnant patient who tested positive for COVID-19, but didn’t need to be admitted to the hospital, was monitored in person at a separate clinic by a multispecialty team of designated providers, including Louise E. Wilkins-Haug, MD, PhD, division director of Maternal-Fetal Medicine and Reproductive Genetics, and Sigal Yawetz, MD, an infectious disease expert,” says Dr. Diouf. “This allowed us to continue safely monitoring COVID-positive pregnant patients without putting staff and other patients at risk of infection.”
A surveillance program was also established to ensure that clinic nurses could check in with these patients by phone every other day. If a patient reported worsening symptoms, they were directed to visit the respiratory clinic, emergency department (ED) or OB triage. “COVID-positive pregnant patients are a higher-risk population because we’re not only thinking about the mom, but also the baby,” explains Dr. Diouf. Pregnant patients who met clearance guidelines were integrated back into the regular OB clinic.
At this stage of the pandemic, where numbers of newly COVID-positive pregnant women have decreased, patients with COVID-19 can be safely cared for in a separate part of the regular OB clinic using a protocol that minimizes exposure to staff and other patients. COVID-positive patients meet weekly with OBs and other providers for non-stress tests and ultrasounds. Due to concerns that the placenta may be affected by COVID-19, clinicians monitor fetal weights, specifically in the third trimester.
Reducing Stressors and Disparities
Since stress can play a role in inducing preterm birth, many providers are concerned about how the ongoing global pandemic may cause harmful stress to pregnancies. Beyond fear of contracting the virus, possible stressors may include the loss of a family member to COVID-19 or financial hardship due to the pandemic.
To help relieve stress, social workers at the COVID-19 prenatal clinic check in with pregnant patients at the clinic. The program also strives to reduce stress around the pandemic’s impact on the course of the pregnancy. Measures like collecting blood pressure data at home can help reduce a mother’s concern about her baby’s health, despite less frequent in-person visits.
Dr. Diouf notes that pre-existing disparities in prenatal care, including access to services, have been made more apparent in the age of COVID-19. A July study led by a team of providers in the outpatient clinic, including Dr. Diouf, found that racial and ethnic disparities exist in the incidence and severity of COVID-19.
“These findings highlight the need to ensure that prenatal services are universally accessible and tailored to each patient’s unique situation,” says Dr. Diouf. “OBs should be aware of at-risk patients and check-in with them more frequently.”
Collaboration at the Brigham and Beyond
There’s still much to learn about COVID-19 and its effects on pregnancy. In the meantime, Dr. Diouf’s team continues to provide patients with evidence-based prenatal care that keeps both the mother and baby safe. For COVID-positive patients especially, the postpartum period is extremely important to monitor high-risk patients.
Dr. Diouf notes that the outpatient prenatal care program depends on the collaboration of many specialists, from the OBs to social workers. “A team approach is essential, because prenatal care starts when a patient presents to the clinic and ends after they go home with their healthy baby,” she says. “We take care of mothers every step of the way.”
The Brigham has shared detailed considerations for COVID-positive prenatal care with midwives and other healthcare providers. This information is available to providers worldwide in the Obstetrics section of the COVID Clinical Guidelines