The COVID-19 global pandemic has enormously impacted healthcare systems and health resources. Rapid transmission of disease has significantly raised concerns in the global community. This illness has tested healthcare systems in well‐developed countries as well as those with weaker healthcare systems. As the COVID‐19 pandemic continues to spread rapidly in many countries, physicians and health care systems need to plan and prepare themselves proactively to provide timely and efficient health care access to their patients along with psychological support and counseling. At this time, COVID-19 related effects on pregnant women and infants are not completely yet known. Experts are learning every day about novel coronavirus that causes COVID-19 and its possible impact on pregnant and breastfeeding women. Recommendations and practice guidelines once issued are continuously updated by several national health authorities regarding patient’s care with COVID-19, as more information about its epidemiology, pathophysiology, and clinical outcome in infected pregnant patients is being gathered.

Various organizations and health authorities, for example, World Health Organization (WHO), U.S Centres of Disease Control and Prevention (CDC), and American College of Obstetricians and Gynecologists (ACOG), are developing and publishing the interim guidance and practice advisory regarding antenatal and intrapartum care, and protection of healthcare professionals during contact with infected women in their care. These expert opinions are intended to supplement healthcare professionals with the information on how to optimize obstetric care in the context of COVID-19, as COVID-19 pandemic evolves^[1].

Telemedicine and virtual care have quickly become important tools in the care of patients as the COVID-19 pandemic quickly evolves. Technology-enhanced healthcare delivery opportunities enhance the access to the current standard of care. Various health systems inside the united states are offering telehealth options to the public for COVID-19 screening such as virtual screenings through video visits, telephone screening, telemedicine drive-thru option for testing COVID-19^[2].

To prepare healthcare providers, and healthcare systems during the global COVID-19 pandemic, U.S CDC has recommended take advantage of existing telehealth tools that can be applied to direct patients to the right healthcare level for the required management[3]. Because of surging global demand for personal protective equipment (PPE), WHO recommends strategies to optimize the availability of PPE. One such strategy involves using telemedicine for evaluating suspected COVID-19 cases, as an intervention to keepthe need of PPE to a minimum in healthcare settings while preventing exposure of healthcare workers and other individuals toCOVID-19^[4]. To ensure adequate safety and protection of healthcare professionals, nurses, and paramedics, it is important to prioritize the provision of proper training of healthcare personnel to undertake infection prevention strategies, besides improving the healthcare governance.

Health agencies in the United States have urged hospitals to expand their use of telemedicine during ongoing COVID-19 pandemic. Dedicated Telehealth services can help to reduce the spread of COVID-19 by keeping patients out of crowded waiting rooms. It can be used to raise awareness among the patients related to COVID-19 transmission in high-risk groups of people within the community. American Academy of Family Physicians (AAFP) provides information for healthcare professionals about using telehealth in taking care of their patients during the COVID-19 pandemic^[5].

Telehealth can be a crucial tool for reaching patients. Obstetricians-gynecologists and other physicians need to become familiar with and adept in a new technology of “Telehealth.” ACOG has provided structured guidance with the help of ACOG’s Presidential Task Force in collaboration with its task force members^[6]. This provides healthcare professionals a structured guidance to help them implement various telehealth practice strategies. During these unique times of COVID-19 pandemic, patients requiring fertility treatment may become stressed in such difficult circumstances. Telehealth appointments can be offered by telehealth virtual care providers for patient consultations, treatment planning, preconception counseling, and mental health counseling. Besides, certified community behavioral health clinics are encouraged to use telemedicine to enhance access to care while overcoming any impending workforce shortages^[7]. This is to ensure the safety of people, including office and paramedic staff, physicians, and patients.

Given ongoing COVID-19 pandemic, the American Academy of Pediatrics (AAP) encourages clinicians to use telemedicine and other non-direct care, when appropriate and review infection-control measures, including asking patients with symptoms to call ahead so they can be evaluated in isolation from other patients^[8]. It also encourages pediatricians to utilize “drive-through” dedicated COVID-19 testing sites, when available^[9].

Clinical recommendations for COVID‐19 management in pregnancy and breastfeeding should be based on data finding from the current pandemic rather than concluding previous coronaviruses related outbreaks such as SARS and MERS because of the epidemiological factors, disease progression, and management related outcomes may differ from one another. Establishing practice guidelines using more data is becoming readily available, as the current pandemic evolves and more information is gathered^[10]. This review summarizes the impact of COVID-19 on pregnant women and breastfeeding mothers and women with infertility. Telehealth complements standard practice. It also outlines the telehealth application and its integration in health care services related to Obstetrics and Gynecology, amid COVID-19 pandemic. This literature review allows its reader to become aware of digital technologies, to enhance access to care in current challenging times of ongoing pandemic.

Discussion

Impact of COVID-19 on Pregnancy

Pregnant women are more susceptible to viral respiratory infections due to immunologic and physiologic changes in pregnancy. Therefore, COVID‐19 may have serious implications for pregnant women^[11]. Pregnant women have been reported to have a higher risk of severe illness,and so is the associated morbidityor mortality with other coronavirus infections such as SARS-CoV, MERS-CoV, and influenza when compared with the general population^[12].

There is limited information about the susceptibility of pregnant women to COVID-19 infection and severity of disease in pregnant women^[13]. Current data is limited and mostly available from published scientific reports and small case series. However, the ongoing pandemic has the potential to adversely impact pregnant women and their newborns^[14]. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists consider women with pregnancy to be a vulnerable or at-risk group to become infected with COVID-19^[15].

Severe symptoms in pregnant women have been reported particularly those with comorbidities such as asthma or diabetes^[12]. Practice advisory “Novel Coronavirus 2019 (COVID-19)” (March 13, 2020) of ACOG mentions,using limited data, theadverseoutcomes such as preterm birthin infantsborn to women with COVID-19 during pregnancy. However, it is unclear whether there was any association of such outcomes with maternal infection. Although, peer-reviewed literature of limited case series did not findanypositive COVID-19 infants, transplacental transmission of COVID-19 couldn’t be confirmed yet through currently available literature.

Pregnant patients with confirmed COVID-19 or those who are suspected for COVID-19 or women considered as “persons under investigation” (PUIs), all such individuals are advised to inform the obstetric unit before arrival to their hospitals, so that appropriate infection control measures are in place^[16]. Newborns ofconfirmed COVID-19 mothers should be contemplated asinfants with ‘suspected’ COVID-19. Such infants are taken to isolation units toseparate themfrom other healthy infants^[16]. The decision to separate a mother, with confirmed or suspected COVID-19 status, from her infant is based on shared-decision-making that involves a mother and her healthcare team. Many factors that may influence such decisions include the clinical condition of the mother and newborn, COVID-19 test results of mother and newborn, mother’s choice for breastfeeding, healthcare facility to allow isolation, and other factors^[16].

An updated inpatient obstetric healthcare guidance can be accessed at the United States CDC’s website^[16]. Also, ACOG and Society for Maternal-Fetal Medicine (SMFM) have issued guidance about prenatal care during the COVID-19 pandemic, including general guidelines for testing and prevention of COVID-19, suggestions for modifying traditional protocols for prenatal and postnatal visits and hospital discharge, and algorithms for assessment and management. Such information is available at their respective websites.

Impact of COVID-19 on Breastfeeding

At this time, experts do not know for sure about COVID-19 transmission through breast milk^[13]. Women should decide about breastfeeding with the help of shared decision-making with her clinical team. If temporary separation is undertaken, mothers who intend to breastfeed should be encouraged to express their breast milk with a dedicated breast pump. It is advised that healthy care givers should give the expressed breast milk to the newborn, as U.S CDC mentions. After each pumping session, it is important to thoroughly wash and appropriately disinfect all parts of the entire pump that has touched breast milk, as per the manufacturer’s instructions. Women choosing direct breastfeeding should be advised to wear facemasks and take care of strict hand hygiene before each feeding^[13]. Women must take appropriate infection control precautions (including hand hygiene, use of a face mask, disinfection of shared surfaces) to prevent transmission while breastfeeding. There is limited evidence of antibodies transmission from mother to infant through breastmilk, and the potential benefits are not currently clear^[17]. The U.S CDC has issued guidance about breastfeeding-related information to guide mothers and healthcare professionals.

Global efforts for Women’s Health

Data on the clinical outcomes and optimal management of infected pregnant women and their babies remains limited^[14]. The United States CDC, Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Society of Obstetricians and Gynecologists of Canada (SOGC), Society of Maternal-Fetal Medicine (SMFM), American Society of Reproductive Medicine (ASRM) and American College of Obstetricians and Gynecologists (ACOG), all have provided their guidance regarding COVID-19 in pregnancy based on the evidence to date^{[12,15,17-19]}. ACOG and SMFM have developed an algorithm for practitioners to assist them in the assessment and clinical management of pregnant women who are suspected ofor have confirmed COVID-19. RoyalCollege of Obstetricians and Gynecologists (RCOG) has also published its guideline “Coronavirus (COVID-19) infection in pregnancy”, which is useful information for healthcare professionals, as this guidance is regularlyupdated as new evidence emerges. It must be noted, information about COVID-19 is evolving rapidly, and interim guidance by multiple organizations is constantly being updated and expanded. Geneva Foundation for Medical Education and Research has compiled hyperlinks on its webpage to access various guidelines in Obstetrics and Gynaecology from various organizations around the world^[10].

Impact of COVID-19 on Infertility Treatment

Infertility treatment can be stressful and COVID-19 pandemic related conditions can further increase that stress. SART recommends that referral to a trained mental health provider can be helpful for patients with stress in such difficult situations. Many of these providers may offer telehealth consultation options particularly if an individual’s insurance carrier permits to use such services^[20]. COVID-19 has influenced the patients who were planning to take treatment for infertility. The Pandemic took its toll on such patients, emotionally and financially^[21].

ASRM Coronavirus/COVID-19 Task Forceas of March 17, 2020, has provided guidance “Patient Management and Clinical Recommendations during the Coronavirus (COVID-19) Pandemic”^[22]. ASRM recommends suspendingnew treatment cycle and certain procedures for addressing infertility, and elective surgeries and non-urgent diagnostic procedures. Also, it strongly considers canceling fresh/frozen embryo transfers. ASRM continues to take care of patients who are currently “in-cycle” or who require urgent stimulation and cryopreservation. The guidance specifically recommends keeping the physical interactions to a minimum while encouraging the use of telehealth.

According to ASRM’s updated guidance published on April 13, 2020, it is mentioned; “while it is not yet prudent to resume non-emergency infertility procedures, the Task Force recognizes it is also time to begin to consider strategies and best practices for resuming time-sensitive fertility treatments in the face of COVID-19 in the population.” This guidance is revisited periodically as the pandemic evolves, intending to resume usual patient care as soon and as safely as possible.

Information Sources on COVID-19

Research on the COVID-19 pandemic has been evolving, it is recommended for healthcare professionals to keep themselves abreast of updated guidelines in Obstetrics and Gynecology.

Following are some useful Hyperlinks to COVID-19 related to health information and guidance in Obstetrics and Gynecology^[10]:

• World Health Organization https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-pregnancy-childbirth-and-breastfeeding.

• The United States CDC https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html.

• American College of Obstetricians and Gynecologists (ACOG) https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019.

• American Society of Reproductive Medicine (ASRM) https://www.asrm.org/Patient-Mgmt-COVID-19.

• Academy of Breastfeeding Medicine https://www.bfmed.org/abm-statement-coronavirus.

• Society of Maternal-Fetal Medicine (SMFM) https://s3.amazonaws.com/cdn.smfm.org/media/2262/COVID19_PDF.pdf.

• Society for Assisted Reproductive Technology (SART) https://www.sart.org/patients/covid-19-alert-for-patients/.

• RoyalCollege of Obstetricians and Gynecologists (RCOG) https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy.

• Human Fertilisation and Embryology Authority https://www.hfea.gov.uk/treatments/covid-19-and-fertility-treatment/coronavirus-covid-19-guidance-for-professionals/.

• Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) https://ranzcog.edu.au/news/pregnancy-during-the-covid-19-pandemic-crisis.

• Society of Obstetricians and Gynecologists of Canada (SOGC) https://sogc.org/en/content/featured-news/Updated-SOGC-Committee-Opinion__COVID-19-in-Pregnancy.aspx.

• International Federation of Gynecology and Obstetrics https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1002/ijgo.13156?af=R.

Telehealth versus Telemedicine

Telehealth can be defined in several ways. It can be defined as,“the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration”^[23]. The American Telemedicine Association (ATA) has defined telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status” ^[24]. Telehealth related technologies work by using modalities such as the internet, video conferencing, digital image technologies, and telecommunications, and health information.

Telehealth can be differentiated from telemedicine^[23]. Telehealth entails providing clinical and non-clinical healthcare services remotely such as training sessions, medical education activities, and meetings for administrative purposes. Whereas, telemedicine specifically utilizes telecommunications technology to provide remote clinical services to patients. That is to say, telehealth is a term with a broader perspective, and telemedicine is one of its many features^[24].

Concept of Telehealth in Obstetrics and Gynaecology

Telehealth clinical services are provided through telecommunications, information, and virtual technologyremotely. Fundamentals of “eHealth,” include telehealth that works by integrating information and communication technologies (ICTs). Digital technologies can be used to deliver health care services and health promotion and education, by linking peopleatthe same time in different locations. Telehealth includes a variety of applications and services such as telemedicine, and modalities to facilitate patient assessment and surveillance, along with awareness programs for disease prevention and control. Such services can be achieved using telecommunications technologies such as real-time synchronous secure audio and video services, store-and-forward secure “asynchronous telemedicine services and health information for remote patient monitoring, and mobile Health^[6,7].

As global developments and research increase to explore various aspects and impacts of COVID-19 pandemic, so does the growing concern on how the COVID-19 will impact those of us who are in the midst of fertility treatments. The American Society of Reproductive Medicine (ASRM), Society for Assisted Reproductive Technology (SART), and RESOLVE: The National Infertility Association in the U.S continue to provide education and public awareness in the community throughout the time of crisis^[18,20.25]. The ASRM COVID-19 Task Force has provided updated guidance for physicians as regards fertility care during the COVID-19 pandemic. SART and ASRM provide information as frequently asked questions (FAQ) and recommendations for patients requiring fertility medical treatments^[20], and they revise those responses depending on the new information that becomes available. RESOLVE: The National Infertility Association in the United Statesoffersan online support community including webinars and virtual meetings^[25]. ACOG has recommended Obstetricians-Gynaecologists and other physicians to adept at new technology of “Telehealth” and has developed Committee Opinion “implementing Telehealth in Practice.” This provides structured guidance for implementing telehealth in practice and technical information such as licensing requirements, coding, and billing information.

Health care delivery services, supplemented by technology advancements, are meant to enhance the current standard of practice^[6]. Examples of implementing telehealth to improve access to care in patients with infertility include patient consultation by virtual means,ultrasound recording assessment by gynecologists and fertility specialist remotely^[6]. Popular health apps in Obstetrics and Gynaecology are fertility tracking and pregnancy apps. A large numberof user-friendly medical applications,such as fertility tracking apps, ovulation, and menstrual period trackers, bladder diary tracking apps, and Wi-Fi smart blood pressure monitoring are designed formobile devices^[26].

Requirements for providing telehealth services include networking, internet connectivity, and related equipment requirements, site resource assessment, integration of electronic medical records, technical and non-technical safeguards to protect the privacy and security of health information as well as physical and administrative safeguards^[6]. General considerations for telehealth and related policies require telehealth physicians and obstetricians-gynecologists to be knowledgeable about their respective country’s laws and regulation such as Licensure requirements applicable for practicing telehealth; credentialing, reimbursement, and other relevant issues, compliance to healthcare-related insurance policy and related laws and regulations, network encryption, andsecurity requirements; awareness about credentialing and privileging; telehealth policy including billing for digital and telehealth services; and malpractice insurance and telehealth coverage policy^[6]. Telehealth physicians should be aware of information such ascoding and billing, wherever applicable^[27].

Many organizations, such as ATA in the United States that include more than 400 other organizations, are focused on transforming health care through efficient delivery acceleratedby telehealth and virtual care since 1993. These organizations provide practice guidelines and education resources to helpintegrate the virtual care into emerging delivery models^[28]. American Health Information Management Association (AHIMA) is another organization that has prepared “telemedicine toolkit”^[5]. This toolkit is designed to provide guidance and reference for organizations to implement or expand their telehealth programs. Telehealth services can reduce demands on crowded healthcare facilities and make health systems more efficient and resilient^[29]. It also refers to the evolving practice of telemedicine and provides necessary steps and requirements in implementing a program. It is emphasized, evidence-based telehealth practice should beincorporated current standards of practice, clinical practice guidelines and recommendations, and professional policies related to practice.

Conclusion

Telehealth involves the delivery of technology-enhanced health care services. Well-designed telehealth schemes can help in achieving cost-savings to the healthcare system and improve access to health care with improved patient outcomes particularly in vulnerable groups and chronic disease management. Challenges of providing telehealth services include limited access to technology in regions lacking ICTs services– unless the government, health care systems, and others take the extra step to help give them the required access. Telemedicine provides enhanced access to care. However, it cannot replace the current standard of care even in behavioral health care where it cannot serve to replace face-to-face visits in many cases. Also, there are challenges to the telehealth related protection of personal health information.Before telehealth program implementation, it is important to ensure the provider’s ability to bear the implementation-related cost as well as maintenance cost to continue the program. Telehealthcare providers with limited resources to acquire and run the technology-based telehealth programs may fail to obtain the optimal results.

While the COVID-19 pandemic is enormously testing the healthcare systems around the world, it is the time when more healthcare providers should be encouraged to adopt virtual care strategies in their practices. Healthcare professionals need to consult literature and access other resources to learn how to best integrate telehealth into their clinical toolbox, even amid an outbreak. Global telehealth solution providers are quickly ramping up to expand their offerings to meet the growing demand for these technologies, and policymakers are working to ensure that legislation keeps pace with such advances.

Many efforts are still required to enable healthcare professionals who are striving to provide access to high-quality healthcare in the most effective manner for both urban and rural populations. Such clinical services can be provided remotely via telehealth services. However, health information professionals need to ensure fulfilling the required documentation and regulatory requirements. Until this COVID-19 pandemic is over, the impact of telehealth technologies can play a significant role in patient management at present, even afterward. Health care facilities, governments, insurance companies, and many others should make new technologies available to help the people in the post-pandemic period.

Declaration of Interest: None

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