Special ambulatory gynecologic considerations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice

Abstract

The coronavirus disease 2019 pandemic has altered medical practice in unprecedented ways. Although much of the emphasis in obstetrics and gynecology to date has been on the as yet uncertain effects of coronavirus disease 2019 in pregnancy and on changes to surgical management, the pandemic has broad implications for ambulatory gynecologic care. In this article, we review important ambulatory gynecologic topics such as safety and mental health, reproductive life planning, sexually transmitted infections, and routine screening for breast and cervical cancer. For each topic, we review how care may be modified during the pandemic, provide recommendations when possible on how to ensure continued access to comprehensive healthcare at this time, and discuss ways that future practice may change. Social distancing requirements may place patients at higher risk for intimate partner violence and mental health concerns, threaten continued access to contraception and abortion services, affect prepregnancy planning, interrupt routine screening for breast and cervical cancer, increase risk of sexually transmitted infection acquisition and decrease access to treatment, and exacerbate already underlying racial and minority disparities in care and health outcomes. We advocate for increased use of telemedicine services with increased screening for intimate partner violence and depression using validated questionnaires. Appointments for long-acting contraceptive insertions can be prioritized. Easier access to patient-controlled injectable contraception and pharmacist-provided hormonal contraception can be facilitated. Reproductive healthcare access can be ensured through reducing needs for ultrasonography and laboratory testing for certain eligible patients desiring abortion and conducting phone follow-up for medication abortions. Priority for in-person appointments should be given to patients with sexually transmitted infection symptoms, particularly if at risk for complications, while also offering expedited partner therapy. Although routine mammography screening and cervical cancer screening may be safely delayed, we discuss society guideline recommendations for higher-risk populations. There may be an increasing role for patient-collected human papillomavirus self-samples using new cervical cancer screening guidelines that can be expanded considering the pandemic situation. Although the pandemic has strained our healthcare system, it also affords ambulatory clinicians with opportunities to expand care to vulnerable populations in ways that were previously underutilized to improve health equity.

Violence against women during the COVID‐19 pandemic: An integrative review

“…Authors formulate recommendations and strategies for the prevention and confrontation of domestic and family violence against women. Telemedicine has been used to maintain contact with patients while reducing the risk of exposure to COVID‐19 9,15,25,27,28,40,42 . Its use can be recommended for screening and for the provision of support resources to survivors of violence, taking into account the need to ensure the women’s privacy and security.…”

Sexual activity and contraceptive use during social distancing and self-isolation in the COVID-19 pandemic

“…The World Health Organisation has issued recommendations for social distancing to limit COVID-19 transmission and support sexual and reproductive health [10]. According to the recommendations, we avoided direct personal contact with the study participants, restricting ourselves mainly to telephone counselling of women requesting contraception and abortion services [11,12].…”

An Integrated Approach to Improve Maternal Mental Health and Well-Being During the COVID-19 Crisis

“…Such violence typically increases in frequency and severity during pregnancy (20) and humanitarian crises and natural disasters (18). Recent reports indicate that physical distancing measures may limit the ability of victims of violence to distance themselves from abusers or access external support (21). The evidence suggests that ongoing IPV has a substantial effect on a woman's physical and mental health, especially during the antenatal period (22).…”

“…Pregnant women have been reluctant to visit the health facilities during the pandemic (8) due to concerns related to use of public transportation and exposure to COVID-19 during the check-up visit (10). On the other hand, health care providers have been minimizing non-essential obstetric visits, excluding birth partners during labor and birth, separating mother and baby in the immediate postnatal period and restricting breastfeeding ultimately affecting the overall quality of care (21,24). Mental health is generally accorded low priority in LMIC health systems and with the current crisis the situation will worsen further.…”