ISUOG Consensus Statement on organization of routine and specialist obstetric ultrasound services in context of COVID‐19

Abstract

This statement is intended for doctors and staff working in routine, high-risk and specialist obstetric ultrasound services offering care to pregnant women. Ultrasound investigation is an essential part of care in these areas. Routine and specialist obstetric ultrasound scans are an important part of prenatal care that need to be maintained despite the ongoing coronavirus disease 2019 (COVID-19) pandemic with all its associated comorbidities1. This document is not a guideline for clinical management but a consensus statement from international experts, which provides proposals and options for managing patient workflows and clinical pathways in the context of COVID-19, that can be adapted to different countries and individual units based on their resources and infrastructure. Appropriate use of personal protective equipment (PPE), hygiene, and disinfection of ultrasound transducers, equipment and the ultrasound room have been addressed in separate documents2, 3. Women and their unborn babies should be provided with clinically safe and evidence-based care, and specifically the use of ultrasound diagnostics based on existing guidelines. During the COVID-19 pandemic, every attempt should be made to minimize patient visits to safeguard patients and staff, particularly when staff shortage due to self-isolation policies is impacting workflow in the ultrasound unit. All women in need of care should be triaged based on their symptoms and infection status. The first step is to identify patients who are clearly or likely infected by the virus and those who are (supposedly) not infected, keeping in mind that there is increasing evidence that a large proportion of infected people may have no symptoms1, 4. Our recommendation is that every woman is screened (via a questionnaire) for COVID-19 before she enters the ultrasound unit. Many healthcare services have created dedicated COVID-19 triage services in which symptomatic patients can be assessed and, if necessary, tested for their infection status even before physically entering the hospital. If the symptomatic patient is pregnant, she should be assessed by her assigned care provider in accordance with local guidelines. If such a triage service is not available or if the patient is not symptomatic, it is important that the woman is appropriately screened for symptoms and risk factors based on travel, occupation, contact and cluster (TOCC)2 before attending for an ultrasound scan, as described below. On their arrival at the triage station outside the ultrasound unit, women should be asked about onset of any symptoms and TOCC risk factors. A temperature check should be undertaken. If a woman presents for their scan appointment with symptoms, such as cough, high temperature or shortness of breath, and she has not been through the dedicated triage services before attending the obstetric/specialist ultrasound unit, she should be sent to the dedicated COVID-19 room for obstetric patients according to local protocols for management of SARS-CoV-2 infection, or be evaluated by a senior member of staff in a room specially equipped for the purpose. This consensus statement addresses prioritization of the use of ultrasound in obstetric care during the SARS-CoV-2 outbreak. The proposed options for managing appointments and clinical pathways will need to be customized by each individual unit, depending on local protocols and guidelines, staffing and infrastructure. The goal is to continue using ultrasound diagnostic capabilities where indicated, while reducing the use to the essential minimum and to patients with urgent indications. The obstetric scan provides critical information that impacts timely management of mothers and fetuses by identifying at-risk pregnancies, and provides timely workup and care for optimal outcomes. Particularly in a pandemic, it also serves as a powerful tool to provide reassurance to the patient and her family as to the wellbeing of the fetus. There are various guidelines nationally and internationally5-8 on the number and timing of scans. As such, the local guidelines and practices, as well as staff availability, should be kept in mind during decision-making about the frequency and timing of scans and clinical management, and when triaging patients. Ultrasound examinations should be carried out in accordance with the ISUOG guidelines for performing first- and second-trimester fetal ultrasound5, 9 or national and local guidelines6, 7, with the recommendation to consider saving sweeps of the anatomic regions instead of still images, to shorten the duration of the direct-contact scan time. Offline capturing of specific planes and obtaining biometric measurements should be considered. The sonologist/sonographer can adopt any technique they wish to complete the examination. An experienced sonographer/sonologist should perform the scan and no trainee should be involved. In the context of the COVID-19 pandemic, depending on local disease prevalence and staff shortage, and based on the recommendation for social distancing, high-risk patients should be prioritized. In addition, prioritization by type of scan should be considered, with the second-trimester anatomical scan taking precedence over the first-trimester scan and growth scans performed based on coexisting and emerging comorbidities10, 11. In low-risk patients, consider the schedule presented in Table 1, depending on whether they are asymptomatic for COVID-19 or symptomatic and/or screen-positive for TOCC risk factors at the time of the scheduled appointment. Reschedule after quarantine in 2–3 weeks† In pregnancies with maternal indications, such as pre-eclampsia, diabetes, cholestasis, positive antibody screen, cardiovascular disease, coagulopathy, other chronic disease or prior preterm delivery, close pregnancy surveillance should be planned. In pregnancies with fetal indications, such as positive aneuploidy screening, fetal growth restriction, suspected structural anomalies, genetic abnormalities, multiple gestation (particularly monochorionic twins) or abnormal placentation, follow-up is warranted. In these patients, consider the scan schedule presented in Table 2, according to whether they are asymptomatic for COVID-19 or symptomatic and/or screen-positive for TOCC at the time of the scheduled appointment. 11 + 0 to 13 + 6 weeks (also for dating) Reschedule after quarantine in 2–3 weeks† Refer to the ISUOG Interim Guidance on the 2019 novel coronavirus infection during pregnancy and puerperium2 and the ISUOG Safety Committee Position Statement on safe performance of obstetric and gynecological scans and equipment cleaning in the context of COVID-193. In women with confirmed COVID-19, every attempt should be made to reschedule their appointment if they are not hospitalized. If they are hospitalized, the wellbeing of the fetus needs to be assured, as per the ISUOG Interim Guidance on COVID-19 during pregnancy and puerperium2. The suggested scan schedule presented in Table 3 may be considered in these patients. Different centers offer a variety of specialist ultrasound services and often routine prenatal care and sonographic services are provided in the same center. In order to minimize patient visits, every attempt should be made to schedule the specialist appointment on the same day as the routine prenatal visit/scan and to utilize Telehealth where possible, such as for genetic counseling. In the context of the COVID-19 pandemic, depending on local disease prevalence and staff shortage, and based on the recommendation for social distancing, the following recommendations are provided based on evaluation of the benefit–risk ratio: This should be planned in consultation with a pediatric cardiologist or fetal medicine subspecialist in order to ensure that patients with the most acute need are prioritized, in accordance with the availability of personnel and to mitigate the risk of transmission. It should be kept in mind that this is a lengthy examination. If the unit has the capability to offer fetal echocardiography simultaneously with the obstetric scan, then attempts should be made to schedule one visit for both. If this is to be performed at a referral center, then consultation with that center is required. Once the fetal medicine subspecialist has established that there is an indication to perform an invasive procedure for genetic investigation, this should be performed in accordance with the ISUOG guidelines12, and the following considerations should be taken into account. Even though the data are limited, studies in mothers with human immunodeficiency virus, hepatitis B, hepatitis C, cytomegalovirus and herpes simplex virus have suggested a small but finite risk of vertical transmission during invasive procedures13. As such, caution is urged. No evidence of intrauterine infection was found in a study of nine pregnant women with COVID-19 in the third trimester14, while a rapid review of studies describing women affected by COVID-19 during the perinatal period reported no case of vertical transmission among 25 pregnancies15. A recent research letter reported on one neonate, born to a mother with confirmed COVID-19, that tested positive for IgG and IgM antibodies despite having a negative viral nucleic acid result16, raising the possibility of vertical transmission, but more data are needed17. No data are available on fetal and perinatal complications when infection is contracted in the first and early second trimesters, a time when invasive procedures may be performed. Given the unknown risk of viral shedding in relation to chorionic villus sampling (CVS) and the recommendation to delay evaluating patients with suspected/probable infection by 14 days, amniocentesis may be preferable instead of CVS. In units in which uterine artery (UtA) Doppler is measured at 20–24 weeks, growth scans for pregnancies at risk of fetal growth restriction can be triaged based on values of mean UtA pulsatility index (PI); those with normal Doppler findings should have one fetal growth scan at 32–36 weeks and those with UtA-PI > 95th percentile should have regular scans from 28 weeks onwards. Women should be advised to monitor their blood pressure periodically and contact their care providers in case of elevated blood pressure or decreased fetal movements after 30 weeks. Where antenatal testing is performed using a non-stress test and subsequent amniotic fluid assessment (modified biophysical profile), consider replacing this with a biophysical profile without the non-stress test, to minimize the total visit time. Antenatal clinics and appointments for non-urgent risk factors can be conducted by virtual telephone consultations. R. S. Abu-Rustum, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA R. Akolekar, Fetal Medicine Unit, Medway NHS Foundation Trust, Gillingham, UK; and Institute of Medical Sciences, Canterbury Christ Church University, Kent, UK A. Sotiriadis, Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece L. J. Salomon, Obstétrique et Plateforme LUMIERE, Hôpital Necker-Enfants Malades (AP-HP) et Université de Paris, Paris, France F. Da Silva Costa, Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia Q. Wu, Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P.R. China T. Frusca, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy C. M. Bilardo, Department of Obstetrics, Gynaecology and Fetal Medicine, AmsterdamUmc, Location VUmc, Amsterdam, The Netherlands F. Prefumo, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy L. C. Poon, Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR