By Shaila Gunn & Renée Reimer
While the current pandemic has British Columbia hospital beds cleared to make room for COVID-19 patients, the same cannot be said about the maternity wards, which continue to operate at maximum capacity. Though elective surgeries have been cancelled and people are avoiding hospitals whenever possible, pregnant people do not have this choice. As Dr. Chelsea Elwood, an obstetrician and infectious disease specialist at BC Women’s Hospital, says, “one thing is inevitable – pregnant people are going to continue to be pregnant and have babies.”
As many people face the boredom of stay-at-home orders and a reduced workload, Dr. Elwood instead has found her workload booming with continued high-volume patient care and growing research investigating the unknown effects of COVID-19 on pregnancy. As an obstetrician gynecologist with infectious disease (ID) training, she is currently a practicing clinician, co-chair of the Society of Obstetricians and Gynecologists of Canada (SOGC) ID committee, the representative for maternity for the provincial clinical guidelines, and a core investigator of the Reproductive Infectious Disease Program. She continues to practice clinical medicine while working to establish local, provincial, and national guidelines for ID management, including COVID-19. I had the chance to interview her to learn how her clinical practice has changed and what is currently being done to investigate the effects of COVID-19 on pregnancy.
Although her clinical practice looks different, her in-person clinical workload remains higher than many clinicians who are primarily using telehealth. In the office, social distancing and infection control measures are enforced and telehealth is utilized when possible; however, telehealth is not always an option in this patient population. Gynecology patients still seek emergency services for bleeding and masses, deliveries continue, and while elective gynecologic surgeries are cancelled, cancer surgeries are ongoing at a reduced capacity.
Dr. Elwood has not personally managed any COVID-19 patients as very few pregnant people in BC have tested COVID-19 positive and there have been no deliveries among positive patients. However, she does manage the care of concerned parents-to-be. The most common concern she hears is the potential for vertical transmission of COVID-19 to the baby, for which there is no clear evidence currently. Patients also worry about pregnancy planning; Dr. Elwood advises to not place pregnancies on hold because of COVID-19 if it is the right time for their family. Fortunately, concerns about giving birth without a partner present are alleviated: in BC, unless they are sick, partners can be present for the birth of their child. However, these policies do differ from province-to-province.
And if Dr. Elwood is not busy enough managing patients, she is also working tirelessly to learn about the effects of COVID-19 on pregnant patients and their newborns in order to establish policies and clinical care guidelines should a second wave of COVID-19 strike. The Reproductive Infectious Disease Program team includes core investigators Dr. Deborah Money, Dr. Julie Van Schalkwyk, and Dr. Chelsea Elwood along with numerous other staff, medical students, and residents. They are leading the Canadian pan-provincial response titled “CANCOVID-Preg: A National Surveillance Program of COVID-19 in Pregnancy.” Fortunately, this is not their first time engaging in this work, as the same types of guidelines are established for all infectious diseases including HIV/AIDS, H1N1, and SARS. In addition to daily literature reviews to stay up-to-date with findings on COVID in pregnancy, the team is overseeing a Canada-wide database with the goal of collecting, analyzing, and disseminating relevant information on the effects of COVID-19 on pregnant patients in Canada.
This critical research does not come without challenges: Canada is a large country with many hospitals and health authorities, all of which run differently with respect to both clinical and research protocols. Each health authority must individually approve the ethics for data collection and the eventual clinical guidelines, processes which take a significant amount of time, communication, and coordination. Additionally, reviewing the current international literature has its own challenges: double case reporting and the tendency to report only negative outcomes has inflated not only the COVID-19 rates in the literature, but also bad outcomes in this population. Furthermore, rapid peer review due to time constraints and pressures to disseminate information has resulted in lower-quality publications that are often difficult to interpret. This rapid dissemination of data without proper peer-review and scientific scrutiny creates fear mongering in the media and among the public. For example, pre-term birthrates in the literature initially appeared high at around 30%, but with further data reporting and analysis and additional systematic protocols in place, these rates may decline. In addition, due to different management protocols and lack of standardized reporting across countries, synthesizing accurate conclusions with respect to the appropriate care of these patients is proving to be difficult. Finally, maintaining anonymity for patients becomes challenging in provincial case reporting when they are one of a very small sample of cases in a database.
In addition to a full capacity clinical workload, Dr. Elwood and her colleagues continue to lead the Canadian COVID-19 response for pregnancy and dedicate countless hours to research and policymaking. This research will result in crucial, time-sensitive data to optimize the outcomes of pregnancy and guide the national response in the event of a second wave of COVID-19. It will also allow us to better understand the impact and epidemiology of COVID-19 on pregnancy.
Twitter: @CANCOVIDPreg: https://twitter.com/CANCOVIDPreg
SOGC Opinion of COVID-19 in Pregnancy: https://www.sogc.org/en/content/featured-news/Updated-SOGC-Committee-Opinion__COVID-19-in-Pregnancy.aspx