Nephrolithiasis for the OB/GYN

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Background

  • Kidney stones are super common - affecting up to 10% of US adults.

    • There is a described “kidney stone belt” in the US where they are even more prevalent - mostly the South and Southeast of the US.

  • Presentation is frequently classic, but to review:

    • Unilateral flank pain, colicky in nature, waxing-waning with episodes every 20-60 minutes

    • Can radiate to groin

    • Urinary urgency, hematuria, or dysuria also present

    • Nausea, vomiting, and generalized abdominal pain may also be present 

      • Pain also will relieve itself once the stone passes - many patients familiar with the symptoms will recognize this.

  • Risk factors for stones include:

    • Hypertension

    • Gout

    • Obesity

    • Diabetes

    • Certain dietary characteristics:

      • Excessive protein, carbohydrate, and sodium intake

      • Poor fiber intake

      • High oxalate or consumption of carbonated drinks with phosphoric acid (mostly present in higher quantities in colas)

    • Recurrent UTIs with urease-producing organisms 

      • Most classically, Proteus mirabilis 

    • Certain medications and supplements: 

      • Topiramate, Furosemide, Acetazolamide

      • Vitamin C, Vitamin D

  • Kidney stones are made of different stone materials:

    • The most common is calcium oxalate, followed by calcium phosphate (>80%).

    • Other types are uric acid, struvite, and cystine stones.

Diagnosis and Evaluation of Nephrolithiasis

  • Labs

    • Patients with suspected stone should receive a BMP to assess kidney function

    • Should also have a UA to assess for hematuria and potential infection

      • Concomitant UTI may complicate stone management

  • Imaging

    • Preferred: CT abdomen/pelvis without contrast

      • This allows for good imaging of the kidneys and bladder

      • CT characteristics of stones can also help predict stone composition and guide therapy.

    • Pregnancy: ultrasound of kidneys and bladder

      • This avoids radiation while still providing good imaging to evaluate for presence of stones, and if severe obstruction is present.

      • Bladder follow through is important to evaluate for presence of “ureteral jets,” or visible efflux on ultrasound of urine entering the bladder from the ureters.

    • US is not a great modality - sensitivity of ultrasound for stone detection is only about 50-75%, whereas for CT it is 90%+. 

      • However, complication rates from missed diagnoses are similar between CT and ultrasound (less than 1%), and thus it’s prudent in the pregnant patient to use ultrasound if stones are the primary suspicion.

Basics of Management

  • Most patients can fortunately be managed expectantly with pain medication and hydration until the stone passes through. 

    • Hospitalization may be required if patients can’t take PO, or have uncontrolled pain or fever.

    • Patients should strain their urine for several days and bring any collected stones/gravel to clinic.

      • This will allow for stone analysis and to direct preventive therapy.

  • NSAIDs are preferred for pain management over opioids.

    • In pregnant patients, it can be considered to give a single dose of ketorolac if not near delivery timing to provide some short-term relief; however, they are one class of patient where opioids may be used instead.

  • Stone size is the best predictor of passage:

    • < 5 mm stones almost always pass spontaneously. 

    • Stones > 10mm are unlikely to pass spontaneously, as are stones that are in the proximal ureter.

  • Medical expulsive therapy can be considered with alpha blockers for stones between 5-10mm:

    • Tamsulosin 0.4mg daily for up to four weeks can help facilitate stone passage.

      • These generally have minimal side effects.

      • Most effective for more distal stones.

      • There is not much safety data for pregnancy, so typically are not used in pregnant patients.

    • Nifedipine and other calcium channel blockers can also be considered, but with lower success rates compared to alpha blockers.

Urology Referral / Complex Management

  • Surgical indications include persistent pain, infection, and urinary tract obstruction.

    • Urgent decompression is required in patients with:

      • Suspected/confirmed UTI

      • Bilateral obstruction and AKI

      • Unilateral obstruction and AKI in patients with solitary kidney

    • Elective decompression can be considered in patients with:

      • Stones > 10mm

      • Stones under 10mm that have not passed after 4-6 weeks of observation

      • Pregnant patients with stones after failing observation period

      • Persistent kidney obstruction

      • Recurrent UTI

  • Surgical approaches can be with shockwave lithotripsy, ureteroscopy with stenting, or percutaneous nephrolithotomy.

    • Stenting and shockwave therapy are generally preferred, and urologists will choose based on stone location and characteristics.

    • Shockwave therapy cannot be performed with an indication for urgent decompression, nor in the pregnant patient.

      • Ureteroscopy with stenting is the preferred method in pregnancy.

      • Stent exchange or nephrostomy tube change has to be performed much more frequently in pregnancy (every 4-6 weeks) due to higher GFR and thus higher risk of stent/tube obstruction and/or infection. 

Prevention of Recurrent Stones

  • Fluid intake is very important:

    • Drink enough to produce at least 2L of urine a day. Spread fluid throughout the day. Studies have shown even small amounts of urine volume increase reduces recurrence!

    • Water is the best choice, but avoid sweetened soda at the very least due to phosphoric acid content.

  • Limit sodium intake to under 2300mg / day

    • This is due to calcium reabsorption becoming more favorable in the proximal tubule down the same sodium concentration gradient.

    • By reducing dietary sodium, you enhance reabsorption of sodium (and consequently calcium).

  • Fruits and vegetables rich in potassium help excrete citrate better, limiting stone formation.

  • Weight loss in obese patients may also help prevent stone recurrence, though data is limited.

  • In patients with the most common type of stone (calcium oxalate):

    • A calcium-rich diet may be helpful, while trying to obtain as much from dietary sources as possible.

      • Restricting calcium intake is not advised unless it is excessive at baseline.

    • Reduce animal protein intake

      • High sulfur content in animal proteins generates more acid, which then through a variety of complicated renal mechanisms may increase calcium excretion and stone formation.

    • Limit intake of oxalate, fructose, and sucrose.

      • These all increase calcium excretion and/or oxalate excretion.

Premenstrual Dysphoric Disorder (PMDD)

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Great Pearls of Exxcellence article about this from Society for Academic Specialists in General Ob/Gyn (SASGOG).If you haven’t heard of the Pearls of Exxcellence, go and check it out! Great review for CREOGs and boards.

Background

  • What is PMDD? 

    • You have probably heard of premenstrual syndrome (PMS) 

      • PMS: wide variety of signs and symptoms that occur in a predictable pattern usually before or during menses 

        • Symptoms/signs: mood swings, tender breasts, food cravings, fatigue, irritability, depression 

        • Can affect up to 3 out of 4 menstruating people 

        • Estimated that 15-20% of patients who have PMS will have PMS that significantly impairs functioning 

    • PMDD is a more severe form of premenstrual syndrome, according to the DSM-V 

      • Usually appears the week before menstruation and end within a few days of menses starting 

      • Will involve at least one severe affective symptom such as depression, hopelessness, anxiety, affective lability, or persistent anger that resolves around time of menses onset 

      • But not just mood, it can involve multiple systems (don’t have to list all of them, just some) 

        • Psychological symptoms 

          • Irritability, nervousness, feeling of lack of control, anger, insomnia, difficulty concentrating, severe fatigue, depression, anxiety, confusion, forgetfulness, paranoia, emotional sensitivity

        • Respiratory problems 

          • Allergies, infections 

        • Eye problems 

          • Vision changes 

        • GI symptoms 

          • Abdominal cramping, bloating, constipation, nausea/vomiting, pelvic heaviness or pressure, backache 

        • Skin symptoms 

          • Acne, itching, aggravation of other skin disorders (ie. coldsores) 

        • Neurologic/vascular symptoms 

          • Headache, dizziness, fainting, numbness, tingling, heart palpitations, muscle spasms 

        • Other 

          • Painful menstruation, diminished sex drive, appetite changes, food cravings, hot flashes, weight gain/swelling, breast tenderness/pain 

      • Approximately 3-8% of patients who menstruate will have PMDD 

  • Differential diagnosis 

    • Diagnosis of PMDD 

      • As discussed above, can be any of those symptoms + one severe affective symptom 

      • Be coordinated with timing of menses (onset prior to menses and resolves within a few days of menses) 

      • Demonstrates a history of two consecutive menstrual cycles in exclusion of other medical conditions 

    • Should rule out primary mood or anxiety disorders, thyroid function, substance abuse, and menopausal transition

      • This means that we need to take an extensive history and do a physical exam to rule out these other possibilities 

      • Other tests that you may want to order depend on patient symptoms 

        • Ie. excessive fatigue/insomnia/temperature dysregulation, weight gain, etc: rule out thyroid disorders 

        • If concerns for premenopausal transition, can order FSH/estrogen

        • If concerns for heavy bleeding, irregular bleeding, depending on situation may need to do endometrial biopsy, etc

        • We won’t go into everything here, as we have other episodes that discuss how to manage AUB 

        • If you think the patient has a mood disorder that is not due to menstrual cycle, can be a reason to start treatment, refer to psychiatry/psychology 

What are some conservative ways to manage PMDD? 

  • A word on management 

    • As with many chronic conditions in medicine, the goal of treatment is to improve patient function and symptoms, with the understanding that we may not be able to make symptoms go away 100% 

    • Often, it may not be a single management method that helps but a combination 

  • Lifestyle modifications 

    • Diet 

      • Some evidence that diet can affect severity of PMS and PMDD - doesn’t mean that eating certain foods will cause PMDD, but there is a possibility that certain dietary modifications can reduce severity 

      • Reduction of sugar, salt, red meat, caffeine, and alcohol may reduce PMDD symptoms 

      • Some evidence that calcium and vitamin B6 supplementation can benefit 

    • Exercise 

      • Aerobic exercise can improve PMDD symptoms 

      • One study showed that women that did 60 minute aerobic exercise 3x/week for 8 weeks felt much improved physically, mentally, and emotionally 

      • A systematic review and meta-analysis shows that there is likely some improvement in symptoms, but some uncertainty remains: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465566/

    • Adjunct/alternative treatments 

      • Some studies, but no enough evidence at this time to recommend routinely the following: 

        • Massage, biofeedback, yoga, chiropractic manipulation, evening primrose oil and Chinese herbal medicines 

        • If patients find these work for them, they can continue 

      • Things that have some limited evidence that they may work: bright light therapy, stress reduction, and adequate sleep 

      • Low quality evidence suggests that acupuncture may reduce symptoms of PMDD 

  • Cognitive behavioral therapy

    • Can be effective 

    • Group psychoeducation and relaxation therapy may benefit patients with significant stress or anxiety component 

  • Pharmacologic Therapy/Medication 

    • Psychoactive therapy 

      • Selective serotonin reuptake inhibitors (SSRIs) have been shown to be very effective and are first line treatment for PMDD 

      • Results in response in 60-70% of patients 

      • You can try both continuous or just luteal phase SSRIs 

      • No single agent has been shown to be better than the other 

      • First line therapy include sertraline, paroxetine, citalopram, escitalopram, and fluoxetine 

      • Second line: venlafaxine, alprazolam 

    • Hormonal therapies 

      • Combined oral contraceptives have shown mixed effects in RCTs 

        • Both cyclic and extended regimens inhibit ovulation and may reduce physical symptoms 

      • For patients who desire contraception, COC is reasonable first line therapy with addition of SSRI if needed 

      • Drospirenone-containing COC formulations are specifically FDA approved for treating PMDD, with 48-60% of patients reporting significant improvement 

    • NSAIDs 

      • May be useful to manage physical symptoms 

More advanced therapies 

  • GnRH agonists 

    • Example: leuprolide 

    • Has been shown to be effective for ovulation suppression and physical symptoms of PMDD 

    • Long term use should be approached with caution, and only after informed consent 

    • Reasoning: side effects (ie. hot flashes), and irreversible bone loss 

  • Surgery 

    • If patient has disabling symptoms refractory to other medical therapies, oophorectomy can be considered 

    • A 3-6 month trial of GnRH agonist demonstrating efficacy is a prerequisite to surgical treatment 

    • Must discuss risks and benefits, given oophorectomy in younger women can be associated with multiple morbidities such as cardiovascular events and osteoporosis

Updates on Gestational Diabetes Screening

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We last talked on the podcast about gestational diabetes with Dr. Coustan very shortly after we began in December 2018. Those podcasts are so good, and feature the man himself who is co-credited with the “Carpenter-Coustan” criteria we all know…

But if you’ve been watching journals recently, you probably have seen a lot of interesting papers with respect to GDM screening. So today’s episode will be a bit of an update on part one of those past GDM podcasts! Treatment fortunately hasn’t changed much so we won’t update that part today.

By the way – ACOG PB 190 on Gestational Diabetes Mellitus is still an excellent read!

Physiology of Insulin Resistance in Pregnancy 

  • Progesterone effects on insulin resistance

    • Normally, insulin binds to insulin receptor → phosphorylation of beta-subunit of receptor and leads to phosphorylation of the insulin receptor substrate I (IRS-I) 

    • Progesterone reduces expression of IRS-1  

  • Human placental lactogen effects on insulin resistance

    • Both insulin-like and anti-insulin effects 

    • Generally decreases maternal insulin sensitivity

    • Decreases maternal glucose utilization

    • Increases lipolysis and free fatty acids

      • This allows for free fatty acids to become available for mother’s metabolism (do not cross placenta) so fetus gets glucose preferentially

  • On the fetal side, exposure to hyperglycemia:

    • Leads to increase in its own endogenous insulin production and production of insulin-like growth factor 1

      • These lead to increased growth, fat deposition, and risk for macrosomia.

Prevalence and classifications of diabetes 

  • Prevalence - hard to know b/c not everyone is tested

    • 2009: 7% of pregnancies were in people with diabetes.

      • 86% of these cases were GDM  

  • Classification: The White Classifications

    • Depending on where you are, you may still see these in use; they are also helpful in classifying pre-gestational diabetes.

    • Named for Dr. Priscilla White, who developed the schema in the 1950s and 1960s

      • Class A1: diet-controlled GDM

      • Class A2: medication-controlled GDM

      • Class B: onset at age 20 or older or with duration of less than 10 years

      • Class C: onset at age 10-19 or duration of 10–19 years

      • Class D: onset before age 10 or duration greater than 20 years

      • Class E: overt diabetes mellitus with calcified pelvic vessels

      • Class F: diabetic nephropathy 

      • Class H: ischemic heart disease

      • Class R: proliferative retinopathy

      • Class RF: retinopathy and nephropathy

      • Class T: prior kidney transplant

Complications of GDM - ie. Why do we care? 

  • Maternal complications

    • High risk of developing preeclampsia, undergoing C/S

    • Increased risk of developing type 2 diabetes later in life (up to 70% of patients with GDM develop T2DM within 22-28 years after pregnancy) 

  • Fetal complications

    • Increased risk of macrosomia, neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia and birth trauma 

    • Increased risk of stillbirth 

    • Fetal exposure to maternal diabetes may contribute to adult-onset obesity and diabetes in offspring 

Screening for GDM - The Basics 

  • Used to be medical history and past obstetric outcomes and family history → fails to get 50% of patients with GDM 

  • All pregnancies should be screened between 24-28 weeks of gestation, with one of two strategies:

    • Two Step:

      • 1973: O’Sullivan et al - described a 1 hr GTT with 50g of glucose  

        • Carpenter-Coustan criteria: positive if >/= 130 mg/dL, though some institutions use 140 mg/dL

      • If screened positive, should get a follow up test with 3hr GTT (100g)

        • Diagnose if 2 abnormal values 

          • However, even 1 elevated → increased risk of adverse perinatal outcomes compared to those without GDM or elevated values

      • Carpenter-Coustan: Fasting: 95, 1 hr: 180, 2 hr: 155, 3 hr: 140  

      • Alternative criteria (not in wide use): National Diabetes Data Group: 105, 190, 165, 145 

    • One-Step alternative screening: International Association for the Study of Diabetes in Pregnancy Group (IASDPG) method:

      • 75g 2hr test - just one test!

      • Fasting: 92 mg/dL, 1hr: 180 mg/dL , 2hr: 153 mg/dL 

      • If > 1 elevated = GDM

  • “Early GDM screening” to look for early gestational diabetes  should be considered in some patients with risk factors.

    • The best test to use for early screening is up for debate, however:

      • Some might consider A1c, but because of new red cell generation / faster turnover in pregnancy, may artificially lower the A1c

      • Some consider using an OGTT, but then it might be hard to convince patients to do it again if they screen negative.

      • Some might consider a trial of “glucose profiling” with a glucometer but not any rigorous testing done about this.

ACOG PB 190


Updates in the World of GDM Screening:

  • What’s better: two-step Carpenter-Coustan style, or one-step IASDPG style?

    • In the last year, two randomized trials (NEJM, AJOG) and a systematic review/meta analysis (Green) have been published to help answer this question. 

    • Because findings are similar, summarized from the meta-analysis:

      • Patients with one-step screening are more likely to be diagnosed with GDM (16.3% vs 8.3% in the meta-analysis)

      • Patient with one-step screening are more likely to be started on medications (7.1% vs 3.8%)

      • Patients undergoing one-step screening were more likely to have NICU admission (5.1% vs 4.5%)

      • Patients undergoing one-step screening were more likely to have babies experience hypoglycemia (9.3% vs 7.6%)

      • Rates of LGA  babies are similar between strategies (8.8% one step, 9.2% two step)

      • Rate of primary cesarean delivery was similar between groups (24.0% one step vs 24.7% two-step).

    • What can we conclude from this?

      • One-step testing seems to lead to increased resource utilization (more diagnoses, more folks on treatment, more NICU admissions)

      • One-step testing does not appear to differ from two-step testing for some maternal short-term outcomes (LGA, cesarean delivery rate) or fetal outcomes (did not cover above but shoulder dystocia, RDS, stillbirth, neonatal death were all similar between groups)

      • We don’t have any significant evidence about long-term outcomes for mother or fetus (i.e., later-in-life diabetes diagnoses, obesity rates in offspring, etc.)

        • An editorial about the meta-analysis makes the case that one-step testing might still be cost-effective if the increased resource utilization means fewer downstream consequences… remains to be seen and tough to study!

  • Early GDM screening: do we have anything new?

    • Since our last podcast, there have been two US-based RCTs about this (Roeder, Harper)

      • In the Roeder paper, patients with an A1c of > 5.7% or fasting glucose of > 92 were randomized to hyperglycemia therapy and nutritional counseling at the time of enrollment (early pregnancy) vs usual timing (3rd trimester)

        • The study was ended early due to poor enrollment, but:

          • Treatment in early pregnancy didn’t improve maternal or neonatal outcomes, including fat mass, weight percentile, macrosomia, or maternal weight gain.

          • Treatment also didn’t significantly reduce the diagnosis rate of GDM at a usual-timing screening test (14.2% early treatment vs 25.8% usual treatment, p=0.17)

      • In the Harper paper, obese patients (BMI > 30) were randomized to a traditional two-step test in early pregnancy (14-20 weeks) versus traditional timing.

        • Those who screened negative early were also re-tested at traditional timing.

        • Early screening did not reduce a composite perinatal outcome, nor did it seem to affect other important secondary outcomes.

      • What can we take away from these papers?

        • We still have a ways to go on proving the value of the “early GDM screen,” particularly of doing multiple glucose challenge tests.

  • Guidance before the 1st step of the two-step approach:

    • One common patient question is whether fasting or eating anything in particular might make one more likely to “screen in” on the 50g, 1h OGTT.

      • In the January 2023 Green Journal, a group at Stanford randomized patients to a 6-hour fast prior to the 1hr test, versus eating within 2hr of the OGTT.

      • The “fed” group actually had a lower rate of screening positive (13%) versus the “fasting” group (31%).

        • Ultimately, the incidence of GDM was also higher in this “fasting” group (12.4% vs 5.1%). 

      • The group theorizes this is due to a phenomenon previously called “starvation diabetes,” in which fasting leads to an increase in glucagon and decrease in insulin, thus making one transiently glucose intolerant; and then later, insulin kicks back in and returns you to a normal metabolic state. 

      • This study only had about 100 individuals per arm of the trial, so hard to draw conclusions about neonatal/obstetrical outcomes, but none different in what they were able to assess.

    • What can we take away?

      • Hard to know totally, but probably don’t encourage fasting prior to the 1hr OGTT!

Colorectal Cancer Screening

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Given that OB/GYNs have one foot in the world of primary care and another foot in the world of specialty care, we thought we’d review these recently updated USPSTF guidelines (5.2021) which have been endorsed by ACOG.

Why do we care?

  • Colorectal cancer (CRC) is the third leading cause of cancer death in the USA for men and women

    • Almost 53,000 deaths from CRC in the US in 2021

  • Most frequently diagnosed among folks aged 65-74, but

    • 10% of cases occur in persons under age 50.

    • 15% increase of incidence in persons aged 40-49 between 200-2016.

  • 26% of eligible adults have never been screened, and 31% are not up to date with screening as of 2018!

What population are we talking about, and who is at most risk?

  • The USPSTF recommendations are limited to “average risk” population, so:

    • Not talking about those with:

      • Genetic syndromes (i.e., Lynch, familial adenomatous polyposis)

      • Inflammatory bowel diseases

      • Personal history of CRC or adenomatous polyps

  • Age is one of the most important risk factors.

    • CRC screening particularly in average risk adults aged 50-75 has significant benefit, and in adults over age 45 also likely has at least moderate net benefit.

      • After age 75, the benefit of CRC screening is lessened, but may still be there for folks who have never been screened.

    • All adults aged 45 or older should be offered screening!

  • Rates of CRC are higher in Black adults, as well as Native adults.

    • This likely reflects complex issues in health disparities and access to screening (which was previously procedural and only colonoscopy or flex-sig based).

      • The USPSTF mentions that this health disparity is not rooted in genetic difference – we appreciate that recognition that race does not equal genetics, and some evidence to back it up.

  • Additional risk factors include:

    • Family history of CRC (even in absence of genetic syndromes)

    • Obesity

    • Diabetes

    • Smoking

    • “Unhealthy” alcohol use

What tests are available for screening, and how do they work?

  • Stool-based tests include high sensitivity guaiac fecal occult blood test (gFOBT), fecal immunichemical tests (FIT), and stool DNA tests. 

    • gFOBT and FIT detect blood in the stool. gFOBT is chemical while FIT uses antibodies.

    • There is one stool DNA test on the market that also includes a FIT component.

    • If one of these tests are employed for screening, it is recommended that:

      • gFOBT or FIT annually

      • sDNA-FIT every 1-3 years

        • FIT and sDNA-FIT annually provides greater benefit than every 3 year schedule, but sDNA annually leads to more colonoscopies; thus, the range is provided to help balance.

        • gFOBT likely has lower sensitivity to detect CRC and advanced adenomas.

          • Positive results on any test should be followed up with colonoscopy.

    • Stool-based tests are quick and non-invasive and don’t require a bowel prep, so likely make screening more available for patients.

      • gFOBT does require some dietary and medication restriction, but FIT and sDNA-FIT do not.

      • gFOBT requires 3 separate bowel movement samples; FIT and sDNA-FIT can be performed from one sample.

        • sDNA-FIT requires collection of an entire bowel movement, though!

    • The benefits of stool-based testing accrue with frequent, repeated testing – so to get max benefit, the annual frequency is definitely recommended!

  • Direct visualization tests look inside the colon and rectum - options are colonoscopy, CT colonography, and flexible sigmoidoscopy. 

    • Flexible sigmoidoscopy uses a scope to visualize the rectum, sigmoid, and descending colon.

    • CT colonography uses x-ray images to visualize the colon.

    • Colonoscopy uses a scope to visualize the entirety of the colon.

      • Flex sig and CT colonography require colonoscopy as a reflex test if an abnormality is found.

    • If one of these tests are employed, recommended screening intervals are:

      • Flexible sigmoidoscopy:

        • Every 5 years alone, or 

        • Every 10 years in combination with annual FIT

      • CT colonography every 5 years

      • Colonoscopy screening every 10 years

        • Colonoscopy and CT colonography provide greater estimated life-years gained versus flexible sigmoidoscopy every 5 years.

    • These are the gold standard in screening, but must be performed in a clinical setting, require bowel preparation, and may require sedation or anesthesia.

Which test should I order?

  • As of the time of the USPSTF recommendation, there were no high-quality trials comparing effectiveness of different strategies to reduce CRC mortality

  • There are also relatively few studies in younger populations (i.e., younger than age 50). 

  • So it’s up to you and your patient’s values/context to decide what will get screening done reliably to reduce their risk!

Telehealth for the Ob/Gyn

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Reading for this podcast:
Committee Opinion 798: Implementing Telehealth in Practice 

What is Telehealth? 

  • Definition

    • Collection of means or methods for enhancing the health care, public health, and health education delivery and support using telecommunications technologies

    • Term of “telehealth” is often used to refer to traditional clinical diagnosis and monitoring that are delivered by technology (ie. doing a visit on Zoom) 

    • Connected health and digital health are also terms that broadly describe similar technology applications in health care 

    • But remember that telehealth can refer to a broad list of healthcare topics, such as diagnosis and management, education (ie. podcasts!), and other related fields of health care 

      • Can include remote monitoring, mobile health care (ie. text messages, apps) 

      • These services can be real time (synchronous) or “store-and-forward” (ie. asynchronous) 

The Data Behind TH 

  • A lot of this data is recent due to the COVID-19 pandemic 

    • This has especially been true in OB care given the need for multiple prenatal visits in a short period of time 

  • One great study that came out in February 2020 (right before COVID!) in the green: 

    • Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes, by Dr. Denicola et al 

    • The looked at 47 total studies, which included 31,967 patients 

    • Telehealth improved obstetric outcomes via: 

      • Increased smoking cessation and increased breastfeeding 

      • Also decreased need for high-risk obstetric monitoring office visits, but did not lead to worse maternal and fetal outcomes 

      • Also effective for continuation of oral and injectable contraception 

      • TH provision of medication abortion services had similar outcomes compared with in-person care and improved access to early abortions 

Providing Equitable Telehealth Care 

  • Just like in any time of health care, there will always be barriers to equity 

  • Healthcare practitioner factors 

    • Includes attitudes and perceptions, inherent biases and assumptions 

    • Studies have shown that when looking at patient portal use, Latino, Black and individuals with low income were less likely to be offered patient portal access and had significantly lower uptake 

  • Health system factors 

    • Safety net health systems and community health centers often lag behind in offering telemedicine 

    • Possibly due to lack of supportive infrastructure 

  • Patient factors 

    • Absence of technology or reliable internet coverage

    • Low health and digital literacy 

    • Non-English speakers can also have a barrier to telemed use 

    • Disproportionately affect those in rural areas, those identify as BIPOC, and those living on low incomes 

  • Payor and Policy Factors 

    • State Medicaid programs continue to restrict coverage of telemedicine and other remote management services 

    • Before COVID-19, only 19 state Medicaid programs explicitly recognized patient’s home as an eligible originating site for telemedicine 

    • States also require practitioners to be licensed within the state where the patient was receiving their care, so this limits patients from accessing telehealth services from out of state practitioners 

    • Also there is limited coverage for audio-only services 

  • Recommendations to mitigate these barriers 

    • Individual practitioners to acknowledge and mitigate implicit biases 

    • Systems should ensure that telehealth platforms are secure and widely usable 

    • Provide technological and clinical infrastructure including patient-centered education tools 

    • Allow for telephone visits when video visits are not feasible or desired

    • Conduct rigorous quality assurance efforts  

    • Payers should make telemedicine a standard coverage benefit and cover at-home monitoring equipment 

    • Payers can also provide mobile devices with data plan or Wi-Fi 

    • Require reimbursement of audio-only visit 

    • Ensure payment parity across sites and types of visits 

    • Expand ability to practice telemedicine across state lines and remove existing barriers to multi-state licensure