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 Table of Contents 
COMMENTARY
Year : 2020  |  Volume : 9  |  Issue : 12  |  Page : 5858-5861  

'How COVID 19 imposed a new normal outlook in reproductive health care of patients, research, teaching and assessment'- Perspective of a Gynecologist


Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission20-Jul-2020
Date of Decision27-Sep-2020
Date of Acceptance08-Oct-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Charu Sharma
Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1490_20

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  Abstract 


With the frequently changing guidelines on Pregnancy care, management of obstetric patients remains a major challenge during COVID-19 Pandemic. The department of Obstetrics and Gynecology had a huge responsibility to provide respectable maternity care to all women irrespective of their virologic status and at the same time protect the frontline warriors dealing with patient care during the COVID-19 pandemic. We would like to share our perspective regarding the challenges faced and the solutions sought for, in both patient care and teaching and research.

Keywords: COVID 19 pregnant, medical education, reproductive health, SARS-CoV-2, telemedicine


How to cite this article:
Sharma C, Singh P, Shekhar S, Jhirwal M, Ghuman NK, Gothwal M, Yadav G, Kathuria P. 'How COVID 19 imposed a new normal outlook in reproductive health care of patients, research, teaching and assessment'- Perspective of a Gynecologist. J Family Med Prim Care 2020;9:5858-61

How to cite this URL:
Sharma C, Singh P, Shekhar S, Jhirwal M, Ghuman NK, Gothwal M, Yadav G, Kathuria P. 'How COVID 19 imposed a new normal outlook in reproductive health care of patients, research, teaching and assessment'- Perspective of a Gynecologist. J Family Med Prim Care [serial online] 2020 [cited 2021 May 11];9:5858-61. Available from: https://www.jfmpc.com/text.asp?2020/9/12/5858/305596




  Introduction Top


The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) started from Wuhan in China during the last days of 2019. Globally, the disease traversed the journey from epidemic to pandemic as declared by the World Health Organization (WHO) in March 2020.[1] The high infectivity and the fact that it was novel forced the hands of authorities first to close down all schools and colleges, then shut the outpatient department down and to reschedule all elective procedures and surgeries. The Government then ordered lockdown. Being under lockdown in the middle of a global pandemic is in itself stressful and to that is the added burden of pregnancy. With sudden emergence of this novel corona virus and lack of valid information on its effect on pregnancy, pregnant women tend to be anxious and curious.

All India Institute of Medical Sciences Jodhpur is an Institute of National Importance (INI), catering all high risk and complicated cases of Western India. For the department of Obstetrics and Gynecology (OBG), this threw questions galore. How will the labor room run? How will the Gynecology cases be planned? How will the national programs run? How to maintain teaching and training? And above all how to maintain the still running emergency with optimum safety of all concerned. All residents and the faculty underwent training on use of personal protective equipment (PPE), intubation and ventilator training with a briefing on Standard operating protocols (SOP) for managing COVID positive patients. This brought all the task force to an even keel, just in case the disease became unmanageable. But there were certain department specific questions which needed to be addressed.


  Patient Care Top


Emergency obstetric services

Our institute takes booked, high risk and referred cases for antenatal care (ANC) and delivery. The inflow of referrals suddenly increased and in fact, the unbooked cases also kept flooding the emergency where they were sieved first according to the questionnaire as mandated by the Indian council of Medical research (ICMR) and Ministry of health and family welfare (MOHFW).[2],[3] Thereafter, these cases were received by the OBG department and managed as per protocol [Figure 1](a), [Figure 1](b), [Figure 1](c). This protocol was arrived at by observing similar national and international guidelines,[2],[3],[4],[5] and was oriented as per the departmental requirements. The department took an initiative and posted a senior resident in the triage area to sieve those cases who really required urgent care and admission. The challenge was not only to address the unprecedented collateral damage imposed by this pandemic on the mental health of pregnant women but also our residents. The fear of isolation, quarantine, morbidity and death was another obstacle in continuing the workflow. So, all possible psychological and emotional support was given to the residents, nursing staff and faculty dealing with obstetric care of patients by the institute and the department.
Figure 1: 1(a)- Work Flow for COVID 19 Pregnant patients (TRIAGING). 1(b)- Work Flow of COVID 19 Suspect Pregnant Patients. 1(c)- Work Flow of COVID 19 Positive Symptomatic patients

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Outpatient department

Gradually the institute realized the need to offer elementary consultations to the patients. Social distancing is said to be the key to curb the spread of COVID-19. Hence, taking care of all medicolegal, ethical and regulatory issues, the telemedicine consultation started where the registered patients could talk telephonically to their consultants and seek remediation of minor problems.[6],[7] Reproductive health and antenatal care was our priority. Women were encouraged to limit their hospital visits but at the same time were ensured to at least get reviewed physically at 12, 20, 28, 36 weeks and at 39–40 weeks to formulate a plan of delivery. Testing policies were being updated as and when required ensuring adequate safety of the health care staff as well as the patients. Infrastructure was redesigned for better working [Figure 2].
Figure 2: Showing the transparent screen/curtain with window in the examining field

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Effect on genetic counselling and prenatal diagnosis

The initial lockdown had a significant effect on the pregnant women who required genetic counselling or missed prenatal testing due to their inability to come to the hospital because of either administrative restriction or fear of acquiring the corona virus. Considering these special cases, the department took an initiative to restart the Prenatal diagnostic procedures like amniocentesis and chorionic villous sampling on priority. Sharing our experience through this tough journey, we encountered a 42-year-old pregnant woman who could not undergo any aneuploidy screening test due to lockdown and at 25 weeks was referred to us for amniocentesis for prognostication since the ultrasound was suggestive of features of Downs syndrome (Trisomy 21). The report came out to be positive for Trisomy 21. Legality on medical termination of pregnancy act bound our hands and the woman had to carry this baby.

Gynecologic surgeries

Surgery protocols were being formulated with frequent remodeling; therefore, the institute gave credence to pro un non-hovered and did not move ahead with routine surgeries lest it may harm both the patient and the care provider. However, with realization that this virus is going to stay with us and at the same time measuring the gravity of situation, gradually, we started with malignancy cases and few others which could not be deferred for long.


  Medical Education Top


Teaching and training

With the emergence of a highly contagious pandemic, there was an obvious fear that students may unknowingly contract the disease and transmit the virus. Hence, they were sent home as a first preventive step but at the same time, ways had to be discovered to continue medical and clinical education. Our institute took undergraduate teaching as a priority very early, because of which teaching of the undergraduates did not suffer even for a single day.[8] The Google MeetTM based platform enabled an interactive experience in this area. Subsequently, post graduate teaching and training also began to be delivered via the same mode. The students are now subsequently being called back in a stratified manner. Interestingly, the institute also started the online Faculty clinical grand rounds and inter and intra institutional panel discussions with the experts on important clinical scenarios pertaining to COVID-19, supported by You TubeTM and live FacebookTM streaming. This gave an opportunity and new realms of learning from the comfort of the home.

Online post graduate degree exam

“Necessity is the mother of invention”

This pandemic although shattered our lives to a great extent but simultaneously taught many new things also. The first ever online post graduate exit exam was conducted very smoothly through Google meetTM platform beyond our imagination in the month of June 2020.

Research

The Pandemic raised a Pandora's box of questions on what is the feto-maternal effect of COVID 19 infection, what can be tried to alleviate symptoms, if the infection occurs, what are the changes in placenta and which drugs are safe in pregnancy? Various projects have been initiated to find answers to these questions. But, definitely, less flow of routine patients has posed a challenge for all research including the post graduate thesis.

What is the way forward?

In a vast country like ours, the pandemic threw many challenges and in those were the opportunities to rise to the occasion. It did help in a general way by teaching one and all, the hand hygiene, mask and sneezing etiquettes, potentially decreasing the transmission. But, for our surgical specialty, it taught how to improve outcomes by decreasing frequency of consultation without compromising information sharing. It also enforced a rethinking on prescribing minimum medications. Delay in surgery would unfortunately impact prognosis and that remains the highest cost paid in terms of morbidity as well as mortality. Slowly life is limping back to normal. There are occasional lapses leading to infections in care providers but these have been kept in check by strict protocols as mentioned above.

Acknowledgement

We acknowledge the Director and CEO of the institute, Dr. Sanjeev Misra for his constant support and encouragement and also all our residents, interns, students and nursing staff for their co-operation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
2.
Guidance for Management of Pregnant Women in COVID-19 Pandemic, Indian Council of medical research (ICMR). 2020. Available from: https://www.icmr.gov.in/pdf/covid/techdoc/Guidance_for_Management_of_Pregnant_Women_in_COVID19_Pandemic_12042020.pdf.  Back to cited text no. 2
    
3.
Government of India, Ministry of Health & Family Welfare, Directorate General of Health Services (EMR Division). Revised Guidelines on Clinical Management of COVID-19. Version 5 [Online] July 3, 2020. [Last accessed on 2020 Aug 01].  Back to cited text no. 3
    
4.
Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) infection in Pregnancy. Information for healthcare professionals. London: RCOG; 2020:version 11. [Last accessed on 2020 Aug 02].  Back to cited text no. 4
    
5.
The Federation of Obstetric and Gynaecological Societies of India. Good Clinical Practice recommendation on Pregnancy with COVID-19 Infection; Version 2; [Online] April 28, 2020. [Last accessed on 2020 Aug 01].  Back to cited text no. 5
    
6.
7.
Mittal A, Singh AP, Sureka B, Singh K, Pareek P, Misra S. Telemedicine during COVID-19 crisis in resource poor districts near Indo-Pak border of Western Rajasthan. J Family Med Prim Care 2020;9:3789-90.  Back to cited text no. 7
  [Full text]  
8.
Singh K, Srivastav S, Bhardwaj A, Dixit A, Misra S. Medical education during the COVID-19 pandemic: A single institution experience. Indian Pediatr 2020;57:678-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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