Outpatient Tracking and Telehealth for Pregnant Women with Symptomatic COVID-19

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Early reports on pregnant women with COVID-19 focused on those who had to be hospitalized. Now, researchers at the Massachusetts General Hospital Department of Obstetrics and Gynecology have developed a protocol for intensive monitoring of pregnant patients with COVID-19 who do not meet the criteria for hospitalization.

Results from a retrospective cohort study of the protocol by Marti Soffer, MD, MPH, maternal-fetal medicine fellow, Ilona Goldfarb, MD, MPH, maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at Mass General, and colleagues, found that most pregnant patients with symptomatic COVID-19 can be managed as outpatients with intensive monitoring for symptom progression.

Study Cohort

Between March 6 and May 22, 2020, 232 pregnant patients in the care of the Mass General prenatal practice experienced COVID-19 symptoms. 180 women were tested, and 67 women were positive for SARS-CoV-2.

Outpatient Tracking and Telehealth

Protocol-driven, intensive outpatient management of pregnant patients with COVID-19 relied heavily on two factors:

• Frequent contact: An obstetrician or registered obstetrical nurse telephoned each of the 67 patients three times weekly to assess COVID-19 symptoms and their severity, arrange repeat testing to clear infection status, provide anticipatory guidance about pregnancy during the quarantine period, perform telemedicine prenatal care and schedule in-person appointments when safe
  • 35% of patients had routine, in-person, prenatal care visits safely postponed
    
    
• Dedicated clinic: If in-person obstetric care could not be delayed until viral clearance was established, patients were referred to the Routine Ambulatory Care Center for COVID-19 patients (RACC), a Mass General-developed, multidisciplinary clinic
  • 25% of patients required visits to this dedicated ambulatory care center for COVID-19 patients for prenatal care that could not be postponed

Acute Care

• 19 patients (28%) required presentation to an acute care setting because of worsening symptoms; the others experienced mild symptoms and underwent continued outpatient management for both their COVID-19 symptoms and their routine prenatal care
• On average, the progression of disease severity occurred on day 6 after symptom onset
• Nine patients (13%) were admitted to the hospital, of whom three women required ICU admission, and two required ventilatory support
• 95% of patients who required acute care had a prior telephone encounter with the obstetrics team that appropriately triaged them for further in-person evaluation
• Initial symptoms of fever, cough, shortness of breath, chest pain and nausea/vomiting were associated with higher rates of disease progression and hospitalization

Guidance for Patient Care

By knowing the time courses of COVID-19 progression, obstetrical provider teams can better anticipate the care needs of pregnant patients with symptomatic COVID-19. Teams should plan closer contact with patients when the risk of disease progression is highest. The CDC currently holds that SARS-CoV-2 is cleared within 10 - 14 days after symptom onset.

For most pregnant patients with COVID-19, it should be reasonable to defer routine in-person prenatal care visits until the viral status is cleared. However, when patients require time-sensitive, in-person prenatal care, ambulatory settings can benefit from a dedicated clinical site for patients with COVID-19 to safely provide prenatal and COVID-related care in the outpatient setting.

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Refer a patient to the Department of Obstetrics and Gynecology