As we struggle to contain and control the spread of COVID-19, we need to heed lessons from past pandemics. In her lecture “Preparing for Emerging Pandemic Infections,” available for CME credit on AudioDigest, Dr. Denise Jamieson, Emory Healthcare chief of gynecology and obstetrics, highlights particular issues in the field.
COVID-19 and obstetrics
Obstetricians play a critical role as front-line providers. For many of our patients, we’re the only doctor they see. We may be the first to observe unusual presentations or clusters of infections that may alert us to a novel virus. We may be critical in controlling and preventing further spread since we deal with high-risk patients. And in this day of social media and headline news, we may need to rapidly address patient inquiries and concerns about infections during pregnancy.
We know that with certain infections, like influenza, pregnant women have an increased susceptibility and a more serious response. Other infections, such as Zika and rubella, may have devastating effects on the fetus. Other challenges include managing prophylaxis, understanding which vaccines aren’t safe during pregnancy and determining treatment where dosing and safety come into play.
When we’re confronted with emerging pandemic infections, we need to quickly respond with a plan that addresses the needs of pregnant women, for both patients and healthcare providers. And we must educate other specialties, such as emergency medicine and infectious disease, about the specific issues pregnant women face.
Learning from past pandemics
We can take several lessons away from previous pandemics, most notably SARS, influenza and Ebola.
Severe acute respiratory syndrome (SARS) is a viral respiratory disease caused by a novel coronavirus. SARS was an example of how a single case could ignite an epidemic through globalization—an infected person boarded a plane. This also showed us that healthcare provider deaths were disproportionately higher than in any other group. In looking at reports from Toronto and Hong Kong, providers and hospitals learned many lessons about stopping the spread of emerging pandemic infections in obstetrics. For instance, they:
- Moved obstetric units to have separate entrances, elevators and air handling systems.
- Enforced restrictions on the unit, including allowing only one support person and no visitors and expediting discharges. Moms were also mandated to stay home for 10 days after leaving the hospital.
- Implemented strict requirements for the staff: Everyone wore masks, and obstetricians had 12-hour shifts and stayed away from their homes when off duty.
- Limited prenatal visits.
The influenza pandemic differs from seasonal flu in that it’s a novel virus that spreads easily and can be severe or life-threatening, people have limited or no immunity and no vaccine exists. In 2008, one of the first deaths from H1N1 was a pregnant woman. Hospitals became overwhelmed and needed to develop additional capabilities to handle the emerging pandemic infection. Dr. Jamieson highlighted the precautions pregnant healthcare providers took:
- They adhered strictly to universal precautions and used personal protective equipment (PPE).
- They avoided high-risk procedures.
- They still cared for infected patients (as opposed to Ebola).
Ebola was the largest emerging pandemic infection affecting three countries in West Africa. The intensity and seriousness of the infection were related to the hemorrhagic nature of symptoms. With the increased risk of exposure through bodily fluids (blood specifically), management and mode of delivery needed to consider the risks to healthcare providers. Issues that arose included:
- Unlike the influenza pandemic, pregnant healthcare providers were excluded from caring for Ebola patients.
- The screening of patients had to include a plan for those who had significant exposure and a plan for those who exhibited symptoms. All pregnant Ebola patients needed hospitalization for monitoring.
- The management of patients had to address the increased risk of miscarriage, intrapartum hemorrhage and perinatal death, as well as how much to intervene.
- During deliveries, providers needed to take into account that neonatal survival was low. They needed to determine whether it was reasonable to put the patient and providers at more risk by performing a cesarean section.
Preparing for future pandemic infections in obstetrics
Hospitals need to plan how they’ll manage pandemics in obstetrical units. Dr. Jamieson ends her lecture with these salient suggestions:
- Develop a communication plan that includes pregnant patients and providers and that separately counts those who are pregnant when tracking diseases.
- Keep a stock of PPE supplies for an outbreak.
- Run simulation exercises where the discussion includes pregnant patients.
- Consider medical countermeasures such as vaccines, antimicrobials and immunoglobulin. Determine how they would be distributed and whether they’re safe during pregnancy.
- Determine who would be fit to work and whether pregnancy affects whether someone is fit to work.
- Educate nonobstetric colleagues about pregnancy issues since pregnancy may place the patient at higher risk. Many nonobstetric physicians may be reluctant to take care of pregnant women, afraid treatment will harm the fetus. This could lead to undertreatment.
As we’re all currently working to best care for our patients during the COVID-19 pandemic and also stay up to date with new developments, looking back at previous pandemics may teach us valuable lessons.