With the increasing uncertainty surrounding the coronavirus (COVID-19) pandemic, and need for social distancing, a lot of our clients are inquiring about prenatal care modifications. Prenatal care and its components are a crucial factor in optimizing pregnancy outcomes, but some components can be modified without detrimental impact on the overall care of the pregnancy. Below are some important elements of each trimester, which will provide you with the framework to start discussions with your pregnancy provider. As always, these modifying these elements are not applicable to everyone, and the decision to modify your care should be 1) based on discussion with your provider who knows your history, risk factors, and clinical status, and 2) dependent on available resources to you and your provider.
Lastly, most providers should have some element of telemedicine in their practice to provide virtual care and decrease the need for in-person visits until the social distancing period is over. In the event your provider does not, feel free to put them in touch with us (support@teleperinatal.com) as we can help them with using our platform or finding them alternate cost-effective solutions.
First Trimester (up to 14 weeks)
- Initial intake (history and physical): obtaining your detailed history (including existing medical conditions, prior surgeries, prior pregnancies, social history) can be easily performed via telemedicine or a phone call, and should not necessitate an in-person visit. As long as you're doing well, the physical exam may be delayed until this critical period of social distancing ends.
- Labs (new OB panel): your provider will determine, which labs are absolutely necessary, and order them but again many of them can wait until later in the first trimester unless there is concern for an ectopic pregnancy or miscarriage.
- Confirmation ultrasound: this is the early ultrasound performed by your provider to confirm 1) your due date, and 2) that a viable pregnancy is inside the uterus (not ectopic or miscarriage). Depending on practice resources/policies and your clinical status, your provider may elect to delay this during the peak of social distancing period.
- Genetic screening: your provider can review your risk for common genetic problems (aneuploidies including Trisomy 21/Down syndrome) via telemedicine. The various options include no testing, cell-free fetal DNA screening (aka NIPT, cffDNA, gender test), nuchal translucency (aka NT screen), and chorionic villus sampling (CVS). Again, depending on the resources at the practice and your preference regarding the tests, your provider can modify or delay these tests.
- Prenatal visits: you generally will see your provider once or twice in the first trimester, with the visits involving the components above. As you can imagine, many of the components above can be handled via telemedicine, and the "hands-on" components bundles into one visit possibly.
Second Trimester (14-28 weeks)
- Labs: the second trimester labs in general include screening for spina bifida (serum AFP), and the diabetic screening. Given that significant spina bifida can often be reliably ruled out by examining the back of the brain (cerebellum, posterior fossa), your provider may elect to bypass your exposure during a blood-draw and bypass this test. The diabetic screen is generally performed between 24-28 weeks by drinking a sugary drink and measuring your body's ability to process the sugar after a certain amount of time (1, 2, or 3-hours). Depending on how far along you are pregnant, your provider may choose to delay the test by 2-3 weeks so that we can pass the period of peak social distancing. Other alternatives include checking your blood sugar at home when you first wake up in the morning, which works if you have a machine (glucometer) at home (from a previous pregnancy, or a family member).
- Ultrasound: the second trimester includes the landmark anatomic survey, where the baby is looked at closely for presence of abnormalities between 18-22 weeks. Delaying this exam is a topic of great debate among health care providers. The decision to delay this is very personal, and there is truly no right or wrong answer. With that said, if you or your provider elect to proceed with this, we recommend limiting the exam to the bare necessities to evaluate the baby, and delaying the full detailed exam by several weeks when social distancing needs are decreased. We have outlined some of our suggestions for performing this exam in a manner that protects you and the healthcare professional, and it can be found here.
- Prenatal visits: this period of the pregnancy involves monthly visits to review labs, ultrasound, and check on the pregnancy, and almost every visit (with the exception of the hands-on components above) may be performed via telemedicine.
Third Trimester (28 weeks to delivery)
- Labs: this is the home stretch of the pregnancy, and the mile-stone labs include checking for group beta streptococcus (GBS) at 36 weeks with some other labs as mandated by local regulations (i.e. syphilis, HIV). The GBS swab can be performed by you (resources on self-collection, or in some instances (history of GBS on urine culture) testing may not be required.
- Ultrasound: in low-risk pregnancies, an ultrasound exam is generally not required in this period unless there is concern about the growth of the baby. In high-risk pregnancies, the baby's growth is evaluated every 4-6 weeks, and in some instances weekly evaluations of the baby's well-being are performed after 32 weeks. While we have outlined some suggestions for limiting the duration of these exams, the decision to modify these exams is highly dependent on your clinical diagnosis/status, and too broad for discussion in this post.
- Prenatal visits: The 3rd trimester consists of visits every 2-weeks until 36 weeks, and then weekly until delivery. These visits include checking your blood pressure, urine for protein, and fetal heart rate. With a home blood pressure cuff, test strips for protein, a tape measure, and kick counts, several of these visits may be replaced with telemedicine.
Postpartum (after delivery, also known as the 4th trimester)
- Labs: the only significant routine laboratory evaluation after delivery is the 2-hour diabetic test in mothers with gestational diabetes. This test can be reliably delayed for several weeks, or replaced with home glucose monitoring. Other labs may be modified depending on clinical indication(s) and necessity.
- Visits: the postpartum visits include risk-assessment for postpartum depression, progress with breastfeeding, contraceptive counseling, and general check-up. Considering many of the items above can be handled via discussion (not hands-on), and to limit you and your baby's exposure during social distancing, these visits may be performed via telemedicine.
Other considerations
We are after all a maternal-fetal medicine (high-risk pregnancy) site, and can't forget about mothers with high-risk diagnoses such as diabetes, hypertension, asthma, lupus, heart disease, or pulmonary problems. Given that an underlying health condition is a big risk factor for complications from COVID-19, limiting visits to the office for these mothers is paramount. If you fall into this category, ask your provider if you can do you glycemic check visits (blood sugar diary review), blood pressure checks, or other frequent check-ups via telemedicine to limit the exposure risk. Also, be sure to read our post about minimizing your ultrasound visits as you likely will be asked to come in for weekly assessments after 32 weeks.
We appreciate you reading the above. Again, we must stress that one-size does not fit all. We put this together to give you a starting point for discussions with your provider. Please please please be sure to rely on your provider's recommendations as they know your full history and status, and can provide you with the necessary information to make an informed decision.
