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\begin{document}

\title{Limitations of Telemedicine- a Gynecologist's Perspective}



\author[1]{Sarah Werner}%
\author[2]{Adi Katz}%
\affil[1]{Lenox Hill Hospital Health Sciences Library}%
\affil[2]{Lenox Hill Hospital}%


\vspace{-1em}



  
  \date{June 13, 2024}


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\begin{abstract}
A Gynecologist's perspective on the limitations of telemedicine in the
setting of early pregnancy diagnosis during the COVID-19 Pandemic.%
\end{abstract}%



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\par\null

To~The~Editor: As the COVID-19 pandemic
continues~on~into~its~6\textsuperscript{th}~month~since the virus was
first reported in the United States,\textsuperscript{1}~telemedicine has
become the forefront of many outpatient visits in New York City as
providers across all subtypes aim to decrease exposure risk and comply
with social distancing. The obstetrical population has been faced with
unique challenges,~including~multiple interactions with their providers
from early in their~first trimester, when~a sonogram~is performed~to
confirm intrauterine pregnancy,~all the way until delivery 40 some weeks
later. That initial antenatal visit, after~a~positive~home~pregnancy
test,~is crucial to ensure the~diagnosis of~an~intrauterine
pregnancy.~Traditionally, this initial visit~occurs two to six weeks
after a positive home pregnancy test, therefore effectually~placing~the
gestation~anywhere~from~six to ten weeks in age at the time of the first
antenatal visit.\textsuperscript{2}

The alternative to an intrauterine pregnancy is a pregnancy of unknown
location, which is a temporary diagnosis and implies either a viable
intrauterine pregnancy, a non-viable intrauterine pregnancy, or an
ectopic pregnancy.~ Ectopic pregnancies traditionally~occur~due to
incorrect implantation of an early gestation, most commonly in the
fallopian tube.\textsuperscript{2}~The annual rate of ectopic
pregnancies is about 1\% and 2\% of that of live births in the United
States, though it~may be~as high as 4\% in pregnancies involving
assisted reproductive technology.\textsuperscript{2}~These rates can be
even higher in women who have history of PID, previous history of
ectopic pregnancy, hydrosalpinx or tubal
sterilization.\textsuperscript{4}~A ruptured ectopic pregnancy is one of
the most common gynecological emergencies and accounts for 10\% of all
pregnancy-~related deaths. Death from~a~ruptured ectopic pregnancy is
between 0.1-0.3\% in developed countries\textsuperscript{2}. Despite
medical advancement and developments in diagnosis and management,
ruptured ectopic pregnancy continues to be a significant cause of
pregnancy-related~morbidity~and mortality. Management of ectopic
pregnancies~includes~IM administration of~Methotrexate~with serial
monitoring of pregnancy hormone (B-hcg)~or surgical management in the
form of laparoscopic salpingectomy.\textsuperscript{3}

At~our university-affiliated community-based hospital in the Upper East
Side of New York City we treat~on average~approximately 50~ectopic
pregnancies a year~with~either medically~or surgically.~During
the~2019-2020~interval, prior to the start of the~COVID-19~Pandemic, we
saw and treated 51~ectopic pregnancies presenting to our emergency room,
corresponding to~an average~of~4.2 ectopic pregnancies a month.~Of
these,76\%~(39) were~treated with~Methotrexate and monitored with serial
b-hcg~while 23.5\% (12) were managed surgically after either presenting
with signs and symptoms of ectopic rupture (hypotension, drop in
hematocrit, acute abdomen) or failed medical management. Between March
15\textsuperscript{th}~to May 17\textsuperscript{th}~,~2020,~during the
height of the~COVID-19~Pandemic in New York City, a total of 12 ectopic
pregnancies were evaluated and treated in our emergency room. More
importantly,~83\% (10) of these women~were hemodynamically unstable at
presentation~and~required~urgent surgical management. Only~16\%
(2)~patients had previously known their diagnosis and failed medical
management with methotrexate. One of~them~was stable at~the~time
of~the~salpingectomy and~one of who~came in unstable with a ruptured
ectopic.

In just two months, we have nearly reached our annual ruptured ectopic
pregnancy rate from the previous year. This report describes a dramatic
increase in the diagnosis and management of ectopic pregnancies
encountered within just two months at our institution, with a markedly
increased number of ruptured and unstable patients at time
of~the~initial diagnosis. When compared to previous years,~it is
critical to note~this increase,~as the~women who~presented~with ruptured
ectopic pregnancies were completely unaware of their diagnosis,~and~only
knew~that~they had a positive pregnancy test at home.

The correlation between limited outpatient visits and a
difficulty~in~making appointments to see providers with this increase in
undiagnosed ectopic pregnancies cannot be ignored. As obstetrician
gynecologists, our aim is to highlight a potential pitfall of
telemedicine in the time of~COVID-19 in order to~capitalize on these
lessons to~reduce patient morbidity and mortality. While there
are~other~potential~reasons,~we can~only~speculate~as to~why these women
did not establish initial prenatal care. Such factors
may~include~a~patient's~own~concerns about going to a doctor's office
during a pandemic. These~data~provides~both~an important reminder and~a
key~opportunity for all OB/GYN providers to strongly consider seeing and
evaluating these patients in the office in an effort to diagnose the
location of a patient's new pregnancy during these trying times.

References:

1) Holshue ML, DeBolt C, Lindquist S, et al. First Case of 2019 Novel
Coronavirus in the United States. N~Engl~J Med~2020;382:929-36.

2) Williams Obstetrics, 25e Ch 9 F. Gary Cunningham, Kenneth J.~Leveno,
Steven L. Bloom, Jodi S.~Dashe, Barbara L. Hoffman, Brian M. Casey,
Catherine Y. Spong

3)~ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy, Obstetrics
\& Gynecology: February 2018 - Volume 131 - Issue 2 - p e65-e77~doi:
10.1097/AOG.0000000000002464

4)~Ectopic pregnancy--United States, 1990-1992. Centers for Disease
Control and Prevention (CDC). MMWR~Morb~Mortal~Wkly~Rep.~1995;44:46--8.
(Level II-2)

5) Clayton HB,~Schieve~LA, Peterson HB, Jamieson DJ, Reynolds MA, Wright
VC. Ectopic pregnancy risk with assisted reproductive technology
procedures.~Obstet~Gynecol~2006;107:595--604. (Level II-3)

6)~Ankum~WM, Mol BW, Van der Veen F,~Bossuyt~PM. Risk factors for
ectopic pregnancy: a meta-analysis.~Fertil~Steril~1996;65:1093--9.
(Meta-Analysis)

7)~Creanga~AA, Syverson C, Seed K, Callaghan WM. Pregnancy-related
mortality in the United States,
2011-2013.~Obstet~Gynecol~2017;130:366--73. (Level II-2)

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