COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology

• Q: How should gynecologic patient care be prioritized? REVISED

  Last updated July 24, 2020 at 5:29 p.m. EST.

  Plans for modifying care are best made at the local level with consideration of patient populations and available resources. Determining how best to care for patients given the COVID-19 pandemic depends on the patient’s signs and symptoms, the patient’s comorbidities and underlying medical condition, the acuity of the presentation (eg, acute versus chronic condition), available health resources, and other factors. 

  Modifying the approach to care only is appropriate when the risk of exposure to COVID-19 is elevated and health care resources for outpatient care are reduced; normal care approaches and schedules should resume when this risk subsides. 
  
  Examples of how a practice or institution may consider distinguishing urgent patient issues from those that can be addressed by telehealth or deferred until after the COVID-19 outbreak are listed below (This list is not meant to be exhaustive). Categorization or triaging of medical services should be based on the needs and resources of the individual practice, hospital, or health system and should be individualized based on patient considerations. 

  In-person appointment: situations in which delay would be harmful to patient health and safety; presence of fever or concern for gynecologic infection not related to COVID-19; suspected ectopic pregnancy; severe postoperative concerns that cannot be triaged by phone; profuse abnormal vaginal bleeding with symptoms of anemia
  
  By telehealth (virtual visit or phone appointment): contraceptive counseling and prescribing; asymptomatic ovarian cyst; management of menopausal symptoms; routine gynecologic or postoperative follow-up; routine medication abortion care; mental or behavioral health screening
  
  May potentially be deferred until after the COVID-19 outbreak: preventive visits; routine screenings for average-risk patients

  For discussion on caring for patients when PPE is limited, see COVID-19 FAQs for Obstetrician-Gynecologists, Ethics, specifically “What are the ethical considerations associated with caring for patients during the COVID-19 pandemic, including in the absence of adequate PPE?”

  Additional Resources on COVID-19 From Other Organizations

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists): 

  • Interim Guidance for Timing of Diagnostic and Treatment Procedures for Patients with Abnormal Cervical Screening Tests (ASCCP)
  • COVID-19 Updates and Resources (American Society for Reproductive Medicine)
  • Surgical Considerations for Gynecologic Oncologists During the COVID-19 Pandemic (Society of Gynecologic Oncology)  
  • Interim Guidance for COVID-19 and Persons with HIV (National Institutes of Health) 
  • COVID-19 and Human Reproduction Joint Statement (American Society for Reproductive Medicine, European Society of Human Reproduction and Embryology, and International Federation of Fertility Societies)

   
• Q: Should I screen patients before they come in for in-person appointments?

  Last updated March 30, 2020 at 9:55 a.m. EST.

  A remote approach can be considered for the routine screening of patients (and their companions, if permitted by local regulation) for potential exposure to or symptoms of COVID-19 (eg, cough, sore throat, fever) before their in-person appointment to prevent persons with COVID-19 symptoms from entering the facility. This can be done through phone calls before in-person appointments asking about recent travel, potential exposure, and symptoms. Patients should be proactively instructed to call on or before the day they are scheduled to be seen to discuss the need to reschedule their appointment if they develop symptoms of a respiratory infection (eg, cough, sore throat, fever) or if they think they have been exposed to COVID-19. Additionally, health care clinicians should confirm whether a person currently is undergoing testing for COVID-19.

  If, after screening, the patient reports symptoms of or exposure to a person with COVID-19 infection, the patient should be instructed not to come to the health care facility for the appointment and health care clinicians should contact the local or state health department to report the patient as a possible person under investigation. However, if the patient is experiencing urgent symptoms, local policies should be in place to accommodate the in-person appointment (eg, see the patient as the last appointment of the day so the room can be disinfected afterward; see the patient in an area separate from other patient examination rooms).  
  
  Because of the risk of exposure to COVID-19 by health care personnel and patients, it may be necessary to modify visitor policies. Limitations to the number of persons accompanying the patient, guests, and visitors should be based on guidance from local and state health departments and institutional or practice policies, community spread, state recommendations, and patient need.  

  Additional Resources on COVID-19 From Other Organizations

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):

  • Steps to help prevent the spread of COVID-19 if you are sick (CDC)

   
• Q: What are some considerations regarding the use of telehealth?

  Last updated March 30, 2020 at 9:55 a.m. EST.

  ACOG encourages practices and facilities that do not yet have the infrastructure to offer telehealth to strategize how telehealth could be integrated into their services as appropriate. Importantly, the ability to access telemedicine may vary by patient resources and some assessment of the patient’s condition and the patient’s available resources—although often challenging in times of crisis—is necessary to ensure equitable care. Some patients may not be able to access technology appropriate for telehealth services; practices and facilities are encouraged to explore ways to ensure those patients still have access to care. 

  As part of the COVID-19 emergency response, several new federal telehealth allowances have been made. These may be subject to ongoing changes; please see ACOG’s Managing Patients Remotely: Billing for Digital and Telehealth Services for the latest information on federal policy changes and coding advice.
  
  The Department of Health and Human Services Office for Civil Rights has announced that it will exercise enforcement discretion and waive penalties for HIPAA violations against health care professionals who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. See HHS.gov for more information on the Department of Health and Human Services response to COVID-19 and HIPAA.
  
  For obstetrician–gynecologists, maintaining confidentiality when meeting with a patient by phone or virtual visit is essential. Confidentiality is a vital component of the patient-physician relationship; it may be especially important for adolescent patients or adult patients at high risk of intimate partner violence.  
  
  The Drug Enforcement Administration has released guidance allowing health care professionals registered by the administration to issue prescriptions for controlled substances without an in-person medical evaluation for the duration of the public health emergency.

  ACOG Resources

  • Committee Opinion No. 803, Confidentiality in Adolescent Health Care
  • Committee Opinion No. 518, Intimate Partner Violence
  • Patient Education: Domestic Violence

   
• Q: What surgeries should be postponed?

  Last updated March 30, 2020 at 9:54 a.m. EST.

  In consideration of increased risk of health care staff exposure to COVID-19, limitations of personal protective equipment and other essential resources, and postoperative patient risk, the Surgeon General has encouraged that elective surgeries be postponed. Surgical procedures performed by obstetrician–gynecologists are generally medically indicated procedures necessary for the furtherance of patient health and safety. In areas where COVID-19 is particularly prevalent or where there is particular stress on the health care system, it may be necessary to modify surgical scheduling, including for procedures that are medically indicated, when a patient’s health and safety would not be harmed by such delay. Obstetric and gynecologic procedures for which a delay will negatively affect patient health and safety should not be delayed. Criteria for delaying gynecologic procedures should be based on disease severity rather than a specific surgical procedure.

  For more information, see the Joint Statement on Elective Surgeries (American College of Obstetricians and Gynecologists, American Association of Gynecologic Laparoscopists, American Society for Reproductive Medicine, the American Urogynecologic Society, the Society of Family Planning, the Society of Gynecologic Surgeons, the Society for Maternal-Fetal Medicine, and  the Society of Gynecologic Oncology). 

• Q: Are abortion services considered elective surgery?

  Last updated March 30, 2020 at 9:54 a.m. EST.

  Abortion is an essential component of comprehensive health care. It is a time-sensitive service for which a delay may increase the risks or potentially make it completely inaccessible. The consequences of being unable to obtain an abortion profoundly affects a person’s life, health, and well-being. 

  For more information, see the Joint Statement on Abortion Access During the COVID-19 Outbreak (American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, American Association of Gynecologic Laparoscopists, the American Gynecological & Obstetrical Society, the American Society for Reproductive Medicine, the Society for Academic Specialists in General Obstetrics and Gynecology, the Society of Family Planning, and the Society for Maternal-Fetal Medicine).  

   
• Q: How should provision of contraception be optimized?

  Last updated June 2, 2020 at 12:44 p.m. EST.

  Contraception is an essential component of comprehensive health care. The ability to obtain or continue contraception improves reproductive autonomy, reduces unintended pregnancies, and profoundly affects a person’s life, health, and well-being, particularly in times of stress and financial hardship.

  As hospital systems, clinics, and communities prepare to meet unprecedented demands for the care of people with COVID-19, provision of contraceptive services requires adaptations, including a “low-touch” approach to care where possible. The following strategies should be considered:

  Telehealth: Telehealth can be used to screen new patients requesting contraceptives that can be self-administered; patients may be safely screened and offered prescriptions if they do not have contraindications. Manage adverse effects related to contraceptives by telehealth, when possible.

  Prescription Refills: Refills for existing prescriptions can be made through telehealth. Prescribe enough refills to minimize trips to the pharmacy—ideally for a full year. Encourage patients to fill prescription contraceptives by mail or at drive-through pharmacies, when available.

  Emergency Contraception: Counsel patients on the use of emergency contraception, including both over-the-counter and prescription options. Provide advance prescriptions for emergency contraception, particularly for ulipristal acetate.

  Long-acting Reversible Contraceptive Methods and Permanent Contraception: Continue to offer insertion of long-acting reversible contraception (LARC), such as intrauterine devices (IUDs) and contraceptive implants, and permanent contraception where possible. If provision of LARC methods or permanent contraception is unavailable during this pandemic, offer contraceptives that can be self-administered as a bridge to delayed insertion. 

  Postpone routine LARC removals, if possible, and counsel LARC users on the effectiveness of extended use beyond the labeled duration. For information on the extended efficacy of long-acting reversible contraceptive methods past the duration of use approved by the U.S. Food and Drug Administration (FDA), see Table 1 in ACOG Committee Opinion No. 735, Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. In 2019, the FDA approved the use of Liletta (52 mg levonorgestrel-releasing IUD) for 6 years. Provide requested removals when possible.

  ACOG Resources

  • Committee Opinion No. 615, Access to Contraception 
  • Committee Opinion No. 707, Access to Emergency Contraception

  Postpartum: Prioritize access to immediate postpartum contraception, particularly because access to postpartum visits may become limited.

  Additional Resources on COVID-19 From Other Organizations

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists): 

  • Bedsider offers a clinic locator by zip code, and a list of online sources for contraception and assistance for those who may have trouble affording contraception.  
  • Interim Clinical Recommendations: Contraceptive Provision When Healthcare Access is Restricted Due to Pandemic Response, May 28, 2020 (Society of Family Planning)
• Q: How can abortion care be optimized? REVISED

  Last updated July 20, 2020 at 2:12 p.m. EST.

  Abortion is an essential component of comprehensive health care. Abortion access should not be compromised during the COVID-19 response. 

  ACOG supports several strategies to facilitate care while decreasing potential exposure to COVID-19 for both health care personnel and patients that have proved safe and effective. However, state and local laws or regulations may limit practitioners’ ability to adopt these strategies. 

  Strategies include:

  • Offer patients video or telephone counseling or consultative visits to review options for care. Clinicians also should be aware that some patients disproportionately face technological barriers (eg, reliable wireless connections, devices, confidential spaces for telehealth visits) and may continue to require in-person visits for abortion care. See COVID-19 FAQs for Obstetrician-Gynecologists, Telehealth for additional information and resources. If the practice does not provide abortion care, offer a timely referral to a nearby facility that does provide the service.
  • Assess gestational age remotely for patients with regular periods, a known last menstrual period, and no risk factors for ectopic pregnancy. An ultrasound assessment is not required.
  • Prior to abortion procedures, the preoperative visit and consent for uncomplicated patients can be completed by video or telephone. Routine in-person or video or telephone visits are not necessary after an uncomplicated abortion procedure. 
  • Other medically unnecessary restrictions should not be used to deny access to time-sensitive procedures, including abortion care. In areas where there are shortages of testing for COVID-19, lack of testing should not be used to delay or deny time-sensitive procedures, including abortion. 

  For medication abortion, clinicians can perform an assessment, counseling, and consent by video or telephone. During the COVID pandemic, clinicians may be able to provide mifepristone by mailing the medication directly to patients.* ACOG strongly encourages clinicians to consult with a lawyer before making any changes to their clinical practice. 

  Patients can safely self-administer both medications (mifepristone and misoprostol) at home. Follow-up after an uncomplicated medication abortion can be provided effectively by video or telephone to review signs of successful pregnancy expulsion; the patient can take a urine pregnancy test at home 4 weeks after the abortion. An in-person visit is not required after an uncomplicated medication abortion. 

  In an effort to improve access and recognizing the likely low risk of sensitization, Rh testing and RhD immunoglobulin administration should not be a barrier to the provision of medication abortion. 
  
  *On July 13, in response to a challenge filed by ACOG, the Council of University Chairs of Obstetrics and Gynecology, the New York State Academy of Family Physicians, and SisterSong Women of Color Reproductive Justice Collective, a federal court blocked the U.S. Food and Drug Administration’s enforcement of a restriction that requires the in-person dispensing of mifepristone. This burdensome requirement for mifepristone has had a disproportionate effect on communities hit hardest by the pandemic, including communities of color that already face existing inequities and structural barriers to care. The injunction issued by the court does not apply to patients experiencing miscarriage and the clinicians treating them. Whether a clinician now has the authority to mail mifepristone is a fact-specific, state-specific legal question. ACOG strongly encourages clinicians seeking this relief to consult with a lawyer before making any changes to their clinical practice. See ACOG’s Court’s Order Lifting Burdensome FDA Restriction: What You Need to Know for more information about this ruling.
  
  ACOG Resources

  • Joint Statement on Abortion Access During the COVID-19 Outbreak (American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, American Association of Gynecologic Laparoscopists, the American Gynecological & Obstetrical Society, the American Society for Reproductive Medicine, the Society for Academic Specialists in General Obstetrics and Gynecology, the Society of Family Planning, and the Society for Maternal-Fetal Medicine) 
  • Committee Opinion No. 613, Increasing Access to Abortion
  • Court’s Order Lifting Burdensome FDA Restriction: What You Need to Know (July 15, 2020)
  • COVID-19 FAQs for Obstetrician-Gynecologists, Telehealth

  Additional Resources on COVID-19 From Other Organizations
  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists): 

  • Planned Parenthood Abortion Care Finder: information about clinicians who provide abortion care 
  • National Abortion Federation Hotline: information about clinicians who provide abortion care and funding support
    • 877-257-0012 for referrals to clinicians who provide abortion care
    • 800-772-9100 for information, including about funding support
  • National Abortion Federation: COVID-19 Resources
  • National Network of Abortion Funds: information about funding support
   
• Q: What are special considerations for intimate partner violence and domestic violence screening and prevention services?

  Last updated April 30, 2020 at 2:00 p.m. EST.

  It is important to be aware that the risk of intimate partner violence may be increased in the context of social distancing, recommendations to shelter in place, financial hardships including loss of wages or employment based on inability to work, and potential isolation and quarantine. ACOG recommends screening all patients for intimate partner violence at periodic intervals in a private and safe setting with the patient alone and not in the presence of a partner, friends, family, or caregiver. During this pandemic, screening may need to be provided by telehealth. Screening for intimate partner violence via telehealth may not allow individuals the privacy or safety needed to disclose abuse. In addition to possibly screening during telehealth appointments, physicians should consider screening during continued in-person appointments in a private and safe setting with the patient alone and not in the presence of a partner, friends, family, or caregiver.

  Obstetrician–gynecologists should proactively identify local resources and understand how those services have been adapted to provide support in the current situation. Resources such as local hotline contacts, referral information, and safety procedures can be communicated by a telehealth visit. 

  If a patient needs help, they can call the 24-hour, toll-free National Domestic Violence Hotline: 800-799-SAFE (7233) and 800-787-3224 (TTY). Or they can text LOVEIS to 22522 or use the live chat option at www.thehotline.org.  

  ACOG Resources

  • Committee Opinion No. 518, Intimate Partner Violence

  Additional Resources on COVID-19 From Other Organizations

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):

  • Information on COVID-19 for Survivors, Communities, and DV/SA Programs (Futures Without Violence)  

   
• Q: What are additional components to postoperative care that should be considered?

  Last updated March 30, 2020 at 9:53 a.m. EST.

  It may be necessary to provide postoperative services or enhanced resources by telehealth where possible. If telehealth visits are anticipated, patients should have access to necessary equipment (eg, thermometer, blood pressure cuffs) as appropriate. Some examples of approaches to postoperative care by telehealth include asking the patient to take pictures of the postoperative wound and post to the electronic health record; physicians also can view wounds by video during virtual visits.

  In the absence of a planned in-person follow-up visit, considerations should include providing patients with an adequate amount of necessary wound care supplies, medications, or other materials for an extended period. 
  
  Potential changes to the patient’s postoperative care team and support system should be discussed. Most patients likely will have had changes to expected care support resources at home (eg, family who can no longer travel, childcare providers who are no longer available). To the extent possible, patients should be connected to community support resources.

   
• Q: Are there any special considerations regarding use of low-dose aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDS) in a patient with suspected or confirmed COVID-19?

  Last updated March 30, 2020 at 9:53 a.m. EST.

  ACOG is aware of news reports suggesting that the use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, could worsen COVID-19 infection. ACOG also is aware of the Lancet article hypothesizing that NSAIDs (ibuprofen in particular) could aggravate COVID-19 symptoms.

  Currently, ACOG is not aware of scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms. As such, and because of the importance of low-dose aspirin in the prevention of atherosclerotic cardiovascular disease in appropriate individuals, low-dose aspirin should continue to be offered as medically indicated. Similarly, other NSAIDs can continue to be offered as medically indicated.
  
  ACOG continues to monitor the situation, and the FDA continues to investigate the issue.

   
• Q: Should individuals delay attempts to become pregnant during the COVID-19 pandemic? REVISED

  Last updated September 28, 2020 at 1:37 p.m. EST.

  There is no absolute answer to this question, as individuals should make their own decisions based on their unique needs, desires, and values. Issues to consider include potential risks to pregnant individuals and their fetuses due to COVID-19, resource limitations, the social and financial effects of COVID-19 on an individual, and other factors.

  Available data suggest that pregnant women with COVID-19 may be at increased risk for more severe illness compared with nonpregnant peers (Ellington MMWR 2020, Collins 2020, Delahoy MMWR 2020, Panagiotakopoulos MMWR 2020). Specifically, these data indicate an elevated risk of ICU admissions and mechanical ventilation. No increase in the rate of mortality has been noted. Pregnant patients with comorbidities such as obesity and gestational diabetes may be at an even higher risk for severe illness consistent with the general population with similar comorbidities (Ellington MMWR 2020, Panagiotakopoulos MMWR 2020, Knight 2020). Importantly, analyses so far are limited by a large amount of missing data and the fact that many reports do not include an appropriate nonpregnant comparative control group. Similar to the general population, Black and Hispanic individuals who are pregnant appear to have disproportionate SARS CoV-2 infection rates (Ellington MMWR 2020, Moore MMWR 2020). Although these data from the CDC suggest an increase in risk of severe outcomes in pregnant women with SARS-CoV-2 infection, the absolute risk is still substantially lower than that of pandemic H1N1 influenza infection during pregnancy. During the H1N1 influenza pandemic, pregnant women made up 5% of deaths, despite only making up 1% of the population and pregnancy risk of ICU admission was reported as high as a 7-fold increase (Rasmussen 2012; Mosby 2011). ACOG recognizes the critical need for further analysis and peer review literature on SARS-CoV-2 infection during pregnancy. 

  Clinicians should counsel pregnant women and those contemplating pregnancy about the potential risk for severe illness from COVID-19. Additionally, although there are cases of reported vertical transmission of SARS-CoV-2, the data remain very limited and thus far indicate that vertical transmission is possible but uncommon. ACOG continues to monitor the literature regarding the risk of vertical transmission of COVID-19 and will continue to update our guidance as additional information becomes available.

  Patients should be aware of potential limitations on resources during the COVID-19 pandemic, including shortages of personal protective equipment (PPE), the effect of directing medical resources toward COVID-19-related efforts, and potentially reduced access to nonurgent prenatal care during this pandemic. Even with these concerns, obstetrician–gynecologists and the entire maternity care team should be committed to ensuring that patients who are pregnant or considering becoming pregnant receive the patient-centered, safe care they need. Spacing out or reducing prenatal appointments or provision of some care through telehealth when appropriate or feasible may mitigate some of the strain on resources and reduce the risk of inadvertent exposure to COVID-19.

  Should a patient decide to pursue pregnancy, prepregancy counseling can be initiated through in-person visits, or through telehealth where available. ACOG is actively monitoring the literature and will update its recommendations as new evidence and information emerge regarding COVID-19 and pregnancy.

  ACOG Resources

  • Committee Opinion No. 762, Prepregnancy Counseling (joint with the American Society for Reproductive Medicine)
  • Practice Advisory: Novel Coronavirus 2019 (COVID-19)

  Additional Resources on COVID-19 From Other Organizations (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):

  • Ellington S, Strid P, Tong VT, et al. Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020. MMWR Morb Mortal Wkly Rep 2020;69:769–775. (CDC)
  • Pregnancy and Breastfeeding (CDC)
  • A Message for Patients from The Society for Assisted Reproductive Technology (The Society for Assisted Reproductive Technology)
• Q: What issues should be considered in resuming the provision of comprehensive women’s health care? REVISED

  Last updated May 15, 2020 at 3:39 p.m. EST.

  Practices, hospitals, and health care systems are beginning to identify and consider how to safely resume care for non-COVID-19 related issues, such as preventive services, primary care, and nonurgent surgeries. The American College of Obstetricians and Gynecologists (ACOG) recognizes the importance of using a data-driven approach to make decisions regarding re-opening specific areas and services. There are several aspects to consider, including timing and scaling up of health care services, logistics in outpatient and inpatient facilities, COVID-19 testing and surveillance, current community prevalence, use of personal protective equipment (PPE), the effect of COVID-19 on the health care workforce, and others. Strategies to resume care should be developed based on scientific data and public health principles and should be individualized based on local and regional needs and resources. For additional information on these aspects, see ACOG’s Position Statement Resumption of Comprehensive Women’s Health Care Policies and Processes. It is important to recognize that strategies to resume care will need to be developed on an individualized basis at the local, state, and regional levels as national, regional, and local regulations and circumstances will influence the pace of, and approach to, resuming aspects of routine women’s health care.

  The U.S. Centers for Medicare & Medicaid Services (CMS) has released recommendations regarding timing of resumption of elective surgeries as well as nonsurgical care. CMS and the White House recommend that hospitals should not resume surgical scheduling until the state or local regions meet “Gating Criteria,” which include a downward trend in the rate of COVID-19 positive tests and patients with symptoms for at least 14 days, that hospitals must be able to treat all patients without resorting to crisis care, and must have robust testing in place for at-risk health care workers.
  
  CMS strongly encourages maximizing use of all telehealth modalities. The COVID-19 pandemic has resulted in a number of policy changes designed to enhance implementation of telehealth. Consideration may be given to the incorporation of a phased approach to increasing nonurgent visits, with an emphasis on virtual visits early on and gradually increasing in-person visits. Planning for virtual visits must account for the types of visits that could be conducted virtually, recognizing that aspects of care such as physical examination, radiology, or laboratory testing require an in-person visit. Some systems may consider maintaining telehealth in the provision of care on a more permanent basis, especially if services were safe, effective, and well-received by the patient community.
  
  Approaches to resuming gynecologic and routine preventive care will need to be adapted and individualized for specific practices and communities. Although a single universal approach is unrealistic, principles to develop approaches may be considered as processes are developed and adapted for a particular practice, clinic, or hospital. In the early stages of resuming routine gynecologic care, many policies and processes used during the pandemic will be maintained (eg, reliance on telehealth, physical distancing, and policies on PPE and visitor limitations). A phased and measured approach to ease restrictions over time may begin after there has been a sustained decline in prevalence and community spread. 
  
  Key considerations to easing restrictions include the following:

  • Staffing and scheduling: There should be adequate availability of supplies and personnel for surgical and nonsurgical care. For surgical procedures, an adequate workforce is needed to support all members of the surgical team. 
  • Personal protective equipment (PPE): Policies regarding optimizing PPE availability and use, masking, and hand hygiene for clinicians, staff, and patients are also necessary. Policies may include masks for patients and PPE for clinicians in outpatient and inpatient settings, including surgery. Several systems are using masking for both patients and staff in outpatient settings. The types of PPE used in a surgical setting may be determined based on preoperative testing.
  • Outpatient visits: Facilities are using a variety of approaches, including the following:
    • Universal mask policy for clinicians, patients, and visitors. Patients are encouraged to use facial coverings to preserve mask supplies for medical use.
    • Limiting the number of visitors and attendants.
    • Physical distancing in waiting rooms and clinic spaces (for example, by changing the spacing of furniture in the waiting area and marking floors and elevators).
    • Consideration of having patients wait in their cars and being notified when to enter the clinic space.
    • Hand hygiene stations for patients to use before entering the facility or waiting room.
    • Maximizing use of all telehealth modalities.
    • Preserving in-person visits for patients who require physical evaluation or interventions (such as ultrasonography, blood draws, and immunizations).
    • Consolidating visits so that patients do not have to move to different facilities for laboratory tests or ultrasonography or return on a different day.
    • Prioritizing in-person visits for those with greatest medial need, followed by elective visits.
    • Employing an extended hours strategy to space visits and to maintain physical spacing in the care and waiting areas.

  The CMS guidance addresses several additional considerations for outpatient care, including establishing separate “Non-COVID Care” and “COVID-19 Care” zones, use of PPE, visitor policies, and sanitation protocols.
  
  Some health care systems are providing guidance on the types of visits that could be conducted as virtual visits. One system’s list of candidates for virtual visits includes the following:

  • medication and contraception follow-up visits
  • consultations for prepregnancy care
  • follow-up for improvement in symptoms of vaginitis
  • postpartum depression follow-up
  • postoperative care
  • hormone therapy follow-up
  • overactive bladder follow-up
  • visits in episodic care that do not require a physical examination 

  This is not an exhaustive list but may serve as an example or starting point for virtual visits. For additional guidance, see the Women’s Preventive Services Initiative’s (WPSI) FAQ on the provision of preventive services during the pandemic and the potential use of telehealth for the provision of preventive services.

  • Screening: Screening patients for in-person visits may include similar strategies already in place in early stages, including pre-appointment phone screening symptom and temperature checks at the building entrance, and possible masking for both patients and clinicians. CMS suggests establishing “Non-COVID Care” zones that would screen all patients for COVID-19 symptoms. 
  • Surgery: Guidance from the American College of Surgeons and a joint document from the American College of Surgeons, the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, and the American Hospital Association are available.

  Several factors may be involved in scaling up surgical scheduling, including review of the case backlog, surgical indications such as suspicion for malignancy, or identifying cases that were previously scheduled and then canceled or postponed due to COVID-19. A scoring system (MeNTS criteria) that was devised to manage resource scarcity and provider risk during the pandemic may aid in the prioritization of surgical patients. Another consideration in early stages of scaling up surgery may involve starting with ambulatory procedures to avoid increasing the number of inpatients and their potential exposure while hospitalized. Importantly, while individual specialties or services may develop a prioritization system for their patients, prioritization strategies that affect other parts of the health care system, such as nursing, surgery, anesthesiology, or interventional radiology, should be communicated to the applicable departments in the facility in order to coordinate care. Extending operating hours also is being considered, as staffing and resources can support, to expand surgical services.
  
  Depending on capacity and supply, some hospitals have implemented universal preoperative testing for all patients scheduled for surgery; periodic testing of clinicians also is being considered.
  
  Another consideration related to surgery is implementing Enhanced Recovery After Surgery (ERAS) protocols. The use of ERAS protocols can improve postoperative recovery, resulting in shorter hospital stays and lower rates of complications and readmissions; this, in turn, may result in the preservation of health care resources. For those facilities not currently using ERAS protocols, resumption of surgical care provides an opportunity to implement ERAS to optimize surgical and hospital resources. 
  
  When prioritizing surgical cases, it is important to incorporate the patient’s values and preferences about timing of the procedures as part of a shared decision-making process. As a component of preoperative counseling, it is important to not only counsel the patient about the risks and benefits of the procedure, but to counsel the patient about the policies and processes the facility has in place to maintain the patient’s safety related to COVID-19. 
  
  ACOG Resources

  • Resumption of Comprehensive Women’s Health Care Policies and Processes
  • Committee Opinion No. 750, Perioperative Pathways: Enhanced Recovery After Surgery
  • ACOG District II Webinar: Elective Gynecologic Procedures in the Time of COVID-19 (May 5, 2020)

  Additional Resources on COVID-19 From Other Organizations
  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists)

  • Local Resumption of Elective Surgery Guidance (American College of Surgeons) 
  • Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic (American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, and American Hospital Association)
  • Society of Gynecologic Surgeons. Joint Statement on Re-Introduction of Hospital and Office-Based Procedures in the COVID-19 Climate for the Practicing Gynecologist.
  • American College of Surgeons Post-COVID-19 Readiness Checklist for Resuming Surgery (American College of Surgeons)

   
• Q: What is known about the association of COVID-19 with hypercoagulation and how does it affect counseling for use of estrogen-containing medications?

  Last updated May 12, 2020 at 5:15 p.m. EST.

  There are reports of high rates of venous thromboembolism (VTE) in patients with severe COVID-19 disease (eg, patients hospitalized in an intensive care unit). More data are needed on who is likely to develop this complication and how it can be managed in patients with COVID-19. Other risk factors also may be present in patients with COVID-19 who develop VTE, and it is not currently known if COVID-19 infection is an independent risk factor. Based on current data, obstetrician–gynecologists should continue to counsel patients and prescribe estrogen-containing medications, including hormone therapy and hormonal contraception, as indicated––based on the individual patient’s desires, risks factors, and needs.

  Although the risk of VTE is increased among people using estrogen-containing contraceptives compared with progestin-only hormonal contraceptives, and non-hormonal contraceptives, this risk is still very low and is much lower than the risk of VTE during pregnancy and the immediate postpartum period. When prescribing any contraceptive method, clinicians should consider an individual’s risk factors for VTE and refer to the U.S. Medical Eligibility Criteria for Contraceptive Use issued by the Centers for Disease Control and Prevention. 
  
  For postmenopausal estrogen therapy and hormone therapy, as part of the shared decision-making process, the women’s health professional should discuss the risks and benefits when prescribing combination estrogen plus progestin hormone therapy or estrogen therapy. In healthy individuals without  risk factors, the probability of VTE is generally low. Risk increases with age and the presence of co-morbidities, including cardiovascular disease, obesity, fracture, renal disease, and both congenital and acquired thrombophilic disorders. Careful assessment of personal and family history of patients before prescribing hormone therapy or estrogen therapy is critical.
  
  ACOG Resources

  • Practice Bulletin No. 216, Use of Hormonal Contraception in Women With Coexisting Medical Conditions
  • Practice Bulletin No. 84, Prevention of Deep Vein Thrombosis and Pulmonary Embolism
  • Committee Opinion No. 540, Risk of Venous Thromboembolism Among Users of Drospirenone-Containing Oral Contraceptive Pills
  • Committee Opinion No. 556, Postmenopausal Estrogen Therapy: Route of Administration and Risk of Venous Thromboembolism

  Additional Resources on COVID-19 From Other Organizations
  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):

  • U.S. Medical Eligibility Criteria for Contraceptive Use (Centers for Disease Control and Prevention)
  • COVID-19 and Coagulopathy: Frequently Asked Questions (American Society of Hematology)
  • COVID-19 resources on coagulation and anticoagulation (International Society on Thrombosis and Haemostasis) 

   
• Q: If a patient reports having a positive antibody test, does that individual need additional testing before having a gynecologic procedure? REVISED

  Last updated July 14, 2020 at 9:12 a.m. EST.

  Depending on capacity and supply, some hospitals have implemented universal preoperative testing for all patients scheduled for surgery. If a health care institution has established universal testing, it is important to note that serologic (antibody) testing does not replace diagnostic testing for COVID-19 infection. Antibody tests are nondiagnostic for acute COVID-19 infection, and it is unknown whether the presence of antibodies confers immunity (WHO). COVID infection is diagnosed by polymerase chain reaction (PCR) testing of a nasopharyngeal sample. Antibody testing should not be used for presurgical screening or other clinical decision making.

  Health care professionals should be aware of the limitations of antibody tests; they should not be used as the sole basis to diagnose COVID-19, to determine staffing decisions or decisions regarding the need for personal protective equipment (PPE), or to determine if a person has immunity to COVID-19 (AMA, AAFP, IDSA). Instead, these tests should be used to ascertain information about whether a person may have previously been exposed. On June 19, 2020, the U.S. Food and Drug Administration (FDA) released guidance recommending that  clinical laboratories and health care professionals stop using COVID-19 antibody tests that are listed on FDA’s “removed” test list. Additionally, for those patients who have been evaluated with an antibody test on FDA’s “removed” test list, FDA recommends considering the patient’s clinical presentation, medical history, and whether prior test results generated using these tests may have been incorrect when deciding whether the patient should be retested using an FDA-authorized test. 
  
  A recent Cochrane review on the diagnostic accuracy of antibody tests concluded that the timing of testing is important. Antibody testing appears to be most accurate when used 15 or more days after the onset of symptoms. However, there are currently scarce data on the efficacy of antibody tests beyond 35 days after symptom onset. 

  As recommended by the Centers for Disease Control and Prevention, regardless of a positive or negative antibody test, individuals should take preventive measures to protect themselves and others.
  
  Additional Resources on COVID-19 From Other Organizations

  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists):

  • Interim Guidelines for COVID-19 Antibody Testing in Clinical and Public Health Settings (CDC)
  • FAQs on Testing for SARS-CoV-2 (FDA)
  • “Removed” Test  List (see “What Tests Should No Longer Be Distributed for COVID-19?”) (FDA)

   
• Q: How should ob-gyns approach sexually transmitted infection testing and cervical cancer screening when testing capacity and supplies are limited? NEW

  During the COVID-19 pandemic, the demand for COVID-19 testing has resulted in regional limitations on laboratory capacity to run preventive care tests, including tests for sexually transmitted infections (STIs) (gonorrhea and chlamydia polymerase chain reaction) and human papillomavirus (HPV) molecular testing for cervical cancer screening. Strategies to care for patients when testing capacity and supplies may be limited should be developed based on scientific data and public health principles and should be individualized based on local and regional needs and resources.

  As stated by the Centers for Disease Control and Prevention (CDC), when faced with limitations in resources, health care professionals should prioritize services that, if deferred, are most likely to result in patient harm. ACOG recommends STI screening be done in accordance with the CDC’s 2015 Sexually Transmitted Diseases Treatment Guidelines; cervical cancer screening recommendations are detailed in ACOG’s Practice Bulletin No. 168, Cervical Cancer Screening and Prevention. Screening for gonorrhea and chlamydia of asymptomatic, sexually active adolescents and women aged 24 years and younger remains an important public health priority. ACOG encourages health care professionals to work with their labs to identify alternative methods for STI screening during the pandemic. Additionally, prioritization of screening for patients at the highest risk for STIs should be considered to make best use of limited resources.  

  The CDC has developed the following considerations to guide practice.

  CDC Recommendations for prioritization of STI diagnostic testing by population at times of diagnostic test kit shortage (September 3, 2020 Dear Colleague Letter)

  	Asymptomatic individuals	Men with symptomatic urethritis  syndrome	Women with cervicitis  syndrome	Women with vaginitis syndrome	Proctitis  syndrome	Complicated STD syndromes (PID)	Contacts to GC and/or CT
  Tier 1: Recommendations based on the 2015 CDC STD Treatment Guidelines and no CT/GC NAAT	Screen women <25 years of age and women ≥25 years of age who are at risk at least annually for CT and GC  Screen pregnant women <25 years of age and pregnant women ≥25 years of age at risk for CT and GC at first prenatal visit.  Screening should be repeated at third trimester for women <25 years of age and/or at high risk  Screen MSM by site of exposure for CT and GC at least annually and more often (every 3–6 months) in individuals with persistent risk, including MSM on HIV PrEP	Test for CT and GC	Test for CT, GC, TV and BV	Test for TV, BV and Candida	Test for CT, GC, syphilis and herpes simplex virus	Test for CT and GC	Test for CT and GC
  Tier 2: Approaches to consider when STI diagnostic test kits are limited	Prioritize women <25 years of age; pregnant women <25 years of age; women ≥25 years at risk*† ; pregnant women ≥25 years of age at risk*†  and MSM. Vaginal testing (women), rectal and pharyngeal‡  testing (MSM) for CT and GC	Gram or methylene blue stain to direct therapy; urinalysis or urine leukocyte esterase testing can be considered to confirm urethritis but will not distinguish between GC and CT. Reserve urine-based testing for persistent urethritis	Vaginal or endocervical testing for CT and GC; wet prep for BV and TV testing§	Perform wet mount for TV, BV, and Candida	Rectal testing for CT and GC	Vaginal or endocervical testing for CT and GC	Treat for appropriate organism
  Tier 3:  Approaches to take when STI diagnostic tests kits are severely limited or not available	No screening	See guidance in CDC’s Dear Colleague Letters regarding syndromic management††

   

  Abbreviations: BV, bacterial vaginosis; CT, chlamydia; GC, gonorrhea; HIV, human immunodeficiency virus; MSW, men who have sex only with women; MSM, men who have sex with men;  NAAT, nucleic acid amplification test; PID, pelvic inflammatory disease; PrEP, pre-exposure prophylaxis; TV, Trichomonas vaginalis. 
  
  *eg, those who have a new sex partner, more than one sex partner, a sex partner with concurrent partners or a sex partner who has an STI.
  † Prioritize women (including pregnant women) <25 years of age if test kits are limited 
  ‡ Prioritize rectal over pharyngeal testing in MSM if test kits are limited 
  § If CT/GC NAAT sent and TV can be performed using the same test kit, TV NAAT could be considered
  †† See https://www.cdc.gov/std/prevention/disruptionGuidance.htm 
  
  When limitations exist for HPV testing for cervical cancer, health care professionals may consider alternatives such as Pap testing alone. 

  As noted in ACOG’s FAQ, How should gynecologic patient care be prioritized?, modifying the approach to care may be appropriate only when the risk of exposure to COVID-19 is elevated and health care resources for outpatient care are reduced; normal care approaches and schedules should resume when this risk subsides.
  
  Additional Resources on COVID-19 From Other Organizations
  (These links are for resource purposes only and should not be considered developed or endorsed by the American College of Obstetricians and Gynecologists) 

  • Dear Colleagues Letter, September 3, 2020 (CDC)  
  • ACLA Update on COVID-19 Testing Capacity (American Clinical Laboratory Association) 
  • Guidance and Resources During Disruption of STD Clinical Services (CDC) 
  • Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic (CDC)
  • COVID-19 Initial Lessons Learned: Recommendations to Prepare for a Fall Surge of COVID-19 Cases (Infectious Diseases Society of America, HIV Medicine Association, & The Society for Healthcare Epidemiology of America) 
  • Testing Supply Substitution Strategies (FDA)

   

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