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Official Podcast TranscriptTitle: COIVD-19, Birth Control, and HypercoagulabilitySpeaker: Dr. Nisha VermaDuration: 00:19:55Katherine Atcheson (00:04):Hello and welcome to the Family Planning Files, a podcast from the National Clinical Training Center for Family Planning. The National Clinical Training Center for Family Planning is one of the training centers funded through the Office of Population Affairs to provide programming to enhance the knowledge of family planning staff. I'm your host, Katherine Atcheson. Katherine Atcheson (00:24):In response to the emergence of the novel coronavirus now known as SARS-CoV-2, and that causes COVID-19 infections, the National Clinical Training Center for Family Planning has been producing an ongoing series of podcast episodes related to issues around the provision of family planning services while COVID-19 is still present throughout the United States and US territories. In this episode we'll be discussing providing preconception and interconception care and counseling to patients during the SARS-CoV-2 pandemic. Katherine Atcheson (00:55):Our guest today is Dr. Nisha Verma. Dr. Verma is a family planning fellow and OB/GYN at Emory University. She received her medical degree from the University of North Carolina at Chapel Hill and did her residency at Beth Israel Deaconess Medical Center in Boston, Massachusetts. Welcome Dr. Verma. We're so excited to have you today!Dr. Nisha Verma (01:15):Thank you for having me today. I'm excited to be here with you all.Katherine Atcheson (01:19):So, to start with, a bit broadly, why is providing preconception and interconception care and counseling important in general, especially since Title X and family planning care in general often seems to focus more on preventing pregnancy than achieving it?Dr. Nisha Verma (01:35):Yeah, I think that's a really great question and a great place to start. I know we often think about family planning care as care that helps people prevent unwanted pregnancy, but I think it's actually much more about supporting every person's reproductive autonomy. And I think we need to remember that reproductive autonomy involves supporting our patients power to control their contraceptive use and their decisions around pregnancy and having a child. All of those are components of planning a family and need to be part of the counseling that we provide to our patients. And so, I think with that in mind, it's important whenever we're seeing patients for family planning care that we assess if they desire pregnancy and when they desire pregnancy, because that knowledge will guide our counseling and our ability to provide the appropriate preconception, interconception and contraception care.Dr. Nisha Verma (02:28):So even when I'm counseling patients about birth control and making sure I understand their values and their preferences around pregnancy planning, and allowing those values and preferences which are not static and can change over time to guide my counseling, as one example, if a patient is interested in getting pregnant in five or six months, Depo may not be the best method for them because it can impact their ability to get pregnant for longer than that time period. So I think a lot of this goes back to the idea of shared decision making, and really having a comprehensive understanding of a patient's pregnancy desires so that we can provide them with the best most appropriate counseling for all of their needs.Katherine Atcheson (03:12):What are some standard components of preconception or interconception care and counseling in a clinic?Dr. Nisha Verma (03:18):So preconception and interconception counseling and care really aims to optimize pre-pregnancy health and reduce the risk of negative outcomes for the patient and for the pregnancy. So one of the major components of this care is assessing any chronic medical conditions the patient might have, things like diabetes, hypertension, psychiatric illnesses, thyroid disease, all of which could have really significant implications for the pregnancy. And people should be connected with the appropriate healthcare providers if they aren't seeing those providers already. So things like a primary care doctor, an endocrinologist, a cardiologist, depending on their needs to allow these conditions to be optimized prior to pregnancy. It's also important to go through the patient's medications, figure out what medications are and aren't safe for pregnancy, and to work with the patient and the patient's other healthcare providers to adjust their medications if that is also needed prior to pregnancy.Dr. Nisha Verma (04:18):We also, at these visits want to make sure that people that are planning pregnancy are taking their prenatal vitamin daily, getting their folic acid supplementation which helps reduce the risk of things like neural tube defects which could have really severe consequences for the pregnancy. Also, as part of our preconception care, we offer patients genetic screening for conditions like cystic fibrosis, like sickle cell, and counsel them about being up to date on all of their vaccinations. There are infections like the seasonal flu that can often be particularly dangerous for pregnant patients. And so, even though we want everyone to get the flu vaccine, we counsel those that may be pregnant during influenza season that it's especially important for them to get vaccinated. And we also screen for things like sexually transmitted infections, talk about alcohol, tobacco, other drug use, talk about things like healthy eating habits and exercise to try to get people to as ideal of a BMI for them as possible before the pregnancy.Dr. Nisha Verma (05:23):Another big part of our preconception and interconception care is screening for and counseling about intimate partner violence. And it's also important to continue doing that throughout the pregnancy and postpartum because we know that the rates of intimate partner violence often go up during pregnancy. And then for people who have had a recent delivery, we want to make sure we're talking to them about the ideal inter pregnancy intervals. So we often recommend avoiding an interval shorter than six months, and if possible, ideally waiting 18 months before having another pregnancy. So having that inter pregnancy interval.Dr. Nisha Verma (06:04):So, I know that's a lot of different things, a lot of things to remember when we're thinking about what we want to be talking to patients about in their preconception or interconception visits. There are a lot of amazing guides and resources that can help providers who want to do this counseling and provide this care to make sure that they're hitting all of the major points. The American College of OB GYN has really good outlines and resources, up to date has really good resources and outlines that can be helpful. They know it's a lot of things to remember when we're thinking about providing this care.Katherine Atcheson (06:38):Well, that's a really good broad overview of what the standard would be, but obviously, as you know this year has been anything but standard with COVID-19 basically surrounding us. And to get more specific in terms of preconception and interconception care, what do we know about the effects of COVID-19 on conception, on pregnancy and pregnancy outcomes?Dr. Nisha Verma (07:01):Yeah, that's a great question. And I want to start by just saying that this has been a rapidly evolving area and we are constantly getting more information as research is being done. So there's still a lot that we don't know. So, I'll talk about some of the things that we do know and some of the information that we do have about COVID-19 and pregnancy, but I just want our audience to keep in mind that a lot of this is just constantly evolving. So when we think about the effects of COVID-19 in pregnancy, we can think about the effects on the pregnant person and on the fetus or baby. In terms of pregnant people, more recent research does suggest that pregnant women have a higher risk of more severe illness from COVID-19 than non-pregnant people.Dr. Nisha Verma (07:48):These studies suggest that pregnant women who have COVID-19 and show symptoms are more likely than non-pregnant women with COVID-19 and symptoms to need care in the ICU, to need ventilator support and to even die from the illness. However, we do feel that this overall increased risk in pregnant women is small. Also, just like we worry about COVID-19 infections more in non-pregnant patients with comorbid conditions, pregnant patients with comorbid conditions like obesity or gestational diabetes are likely at higher risk of developing severe illness with COVID-19. I also think it's really important to mention here that pregnant black and Hispanic patients like non-pregnant black and Hispanic patients have a higher rate of illness and death from COVID-19, which relates to the huge number of inequities that still exist in our society and our healthcare system.Dr. Nisha Verma (08:45):And then in terms of the effects of COVID-19 on the actual pregnancy, the research we currently have suggests that it is very rare for COVID-19 to pass from the mother to the fetus in utero. Some studies have suggested that there may be an increased risk of preterm birth and stillbirth for pregnant people with COVID-19, other studies have found that that isn't true. So at this point we really just aren't sure, and are continuously getting new information and new data about the effects of COVID-19 on the pregnancy and on the fetus.Katherine Atcheson (09:21):So, as we know, pregnancy isn't just a biological process for people, it involves their families, it involves their friends, their community. What are some other effects COVID-19 might have on a pregnant patient and their families or pregnancy plans that patients and their families should be aware of? For instance, policies about partners coming to prenatal care, or if a doula is allowed during labor and delivery, things like that?Dr. Nisha Verma (09:46):You're totally right that pregnancy looks different now during this pandemic than it did prior to this pandemic. And so, there's a lot of information that's really important for patients and their families to know about as they're thinking about planning their pregnancy. Many clinics and hospitals have policies right now limiting the number of visitors like you mentioned, both for prenatal care appointments and for the actual intrapartum labor and delivery care. Because these policies vary from institution to institution, I do recommend checking with the particular clinic or hospital that you're working with and that the patient is getting care through to see what those policies at that place are specifically. Here in the locations that I provide care, we are not allowing partners or families to come to prenatal care appointments or ultrasound appointments, but we are allowing one visitor in the room with the patient during their intrapartum labor and delivery care.Dr. Nisha Verma (10:46):It's also important for patients to check and see if a doula is counted as a visitor or not if they're planning on having a doula during their labor and delivery stay. Because if there is a one visitor policy, they may have to choose between having a loved one and a doula if the doula is considered a visitor. I do also offer to my patients that they can call in a family member or partner on FaceTime during their clinic visits if that is something that they want. And that can also sometimes help them to feel like they have that support and involvement of their loved ones even when loved ones can't be in the room physically with them. Many places are also doing more tele-health visits to try to minimize COVID-19 exposure. So that is also something that patients should be aware of when thinking about their prenatal care, that they may have some appointments that are tele-health and some appointments that are actually in person.Dr. Nisha Verma (11:42):A lot of hospitals are also testing all patients that come in for delivery for COVID-19 and taking extra precautions for positive patients. One question that patients often ask me about is, what will happen after birth if they test positive for COVID-19. So, current reports suggest that the risk of a baby getting COVID-19 from a positive mom after delivery does not change based on whether the baby stays in the mother's room or in a separate room. And we know that there are many other benefits to rooming in related to bonding and breastfeeding. Our current data also suggest that it is safe to feed breast milk to babies of COVID positive moms, but recommend taking precautions such as mom wearing a face mask when breastfeeding and practicing really good hand hygiene. COVID positive moms can also pump and then have a support person who is COVID negative feed the baby the pumped milk if that is possible for them, for that family to reduce the risk of transmission.Dr. Nisha Verma (12:44):And I also just want to note that for babies with other medical conditions or babies in the NICU, moms may have to take even additional precautions to really minimize the risk of transmission. But I think a lot of this discussion of preventing transmission from mom to baby in COVID positive moms goes back to the idea of shared decision making and really talking with the patient and the family about the options and figuring out what works best for them. But those are some of the things that have come up for me when I've been talking to patients about planning their pregnancies during this time, and thinking about how pregnancy and labor and delivery and postpartum care could be different during the pandemic.Katherine Atcheson (13:26):To backtrack a little, we talked about pre-existing and chronic conditions and addressing those during preconception and interconception care and counseling. In general, how might COVID fit in with how those conditions affect pregnancy, how pregnancy affects those conditions, and how can a clinician speak to their clients about that?Dr. Nisha Verma (13:47):Yeah. I think like we mentioned previously, a big part of preconception counseling is really optimizing a person's pre-existing chronic conditions prior to pregnancy to try to make sure the patient and their pregnancy are as healthy as possible. Right now I think we absolutely need to be talking about COVID-19 as part of that counseling. We mentioned that pregnant patients like non-pregnant patients with comorbid conditions can get much sicker with COVID-19, which makes it all the more important to get those conditions under as good control as possible prior to pregnancy. I think we also need to be talking to patients with and without comorbid conditions about steps that they can take to minimize their risk of getting COVID during their preconception counseling.Dr. Nisha Verma (14:33):So talking to them about those things that we all hear all the time, limiting contact with other people as much as possible, staying six feet away from others as much as possible, wearing a face mask, practicing hand hygiene. People are hearing that all over the place, but I think it's important as healthcare providers that we really emphasize to patients how important those things are especially during pregnancy to keep them and the pregnancy safe. And I also know there's been a lot of talk about the vaccine recently, and we're getting more information daily about the vaccine's availability, about its distribution. Right now it seems pregnant women may be excluded from being able to get the vaccine. So I would recommend that anyone who is planning pregnancy try to get the vaccine before becoming pregnant if that's possible for them, as that can also help keep people with and without comorbid conditions safe during the pregnancy during the COVID-19 pandemic.Katherine Atcheson (15:33):Again, there is tons of new information coming out every day, every week, things sometimes seem like they're changing very quickly. So, where can clinicians go to find the latest most reliable information on pregnancy and preconception care in regards to COVID-19 as it emerges?Dr. Nisha Verma (15:50):We definitely talked about how this is such a rapidly evolving area and new information is constantly coming out, and so we do really need to work to keep up to date. The American College of OB GYN, or ACOG, has really excellent resources that they update regularly on COVID-19 and on pregnancy, both for healthcare providers and for patients that I find really useful. And the Society of Maternal-Fetal Medicine and the CDC also have really useful resources that are regularly updated about pregnancy and COVID-19 and things that are coming out every day. So I think that those are really good resources for healthcare providers to use to keep up to date with new information as it emerges.Katherine Atcheson (16:36):Well, this has been a lot of really great information but our time is almost up today. But before we go, what would you say are your top takeaway messages for clinicians working in family planning, working in Title X, going forward when they provide preconception and interconception care and counseling while COVID-19 is still present?Dr. Nisha Verma (16:56):I think it's important to remember that our job is not to tell patients whether they should or shouldn't get pregnant, but more to present them with all of the information and allow them to make the best decision for their lives based on their values and preferences. So my approach during this time is to really present patients with a lot of this information that we've discussed today. Talk to them about what the research says, what to expect with a pregnancy right now, how to minimize the risks of COVID-19, and really allow them to make their own decisions about the risks and benefits of pregnancy during this pandemic based on all of that information.Dr. Nisha Verma (17:34):We all know this pandemic has been going on for a very long time, and for many people it just isn't reasonable to delay pregnancy for months, for a year. And so, I think that right now it's really about just presenting them with this information as part of preconception and interconception care and allowing them to make their decisions based on that information. So, I think for me that's really the big take away from how we should approach pregnancy and this counseling during these times.Katherine Atcheson (18:07):Well, thank you so much for joining us today, Dr. Verma, and for sharing your time and expertise. For more content including previous episodes about COVID-19, search for the Family Planning Files podcast or subscribe to our show on iTunes, Google podcasts, Spotify, Stitcher, or wherever you listen to podcasts. For a transcript of this podcast as well as other online learning activities and continuing education opportunities, please visit our website at . You can also follow the National Clinical Training Center for Family Planning social media on Twitter @NCTCFP, and sign up for our monthly newsletter, Clinical Connections, on our website.Katherine Atcheson (18:50):This training is supported by DHHS grant number five FPTPA 006029-03-00. The contents of this podcast solely represent the views of the speakers and do not necessarily reflect the official positions of the Department of Health and Human Services or DHHS, Office of the Assistant Secretary of Health, or OASH, or the Office of Population Affairs, or OPA. No official support or endorsement of DHHS, OASH and or OPA for the opinions described in this podcast is intended or should be inferred. Katherine Atcheson (19:28):Theme music written by Dan Jones and performed by Dan Jones and The Squids. Other production support provided by the Collaborative to Advance Health Services at the University of Missouri-Kansas City, School of Nursing and Health Studies. And thank you, to our listeners, for tuning in today. We hope that you'll join us next time for another episode of the Family Planning Files. ................
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