Table 2 Considerations at in-person antenatal visits for high-risk pregnancies during the pandemic

Genetics

• Continue to offer; genetic testing and diagnostic procedures are considered essential, but not emergent [65,66,67]. Consider deferring non-pregnant consults, unless a timely appointment is necessary, such as in the case of advanced maternal age.

• [Defer by 2 weeks if possible in those who are COVID-19 positive or suspected [65, 67, 68]].

• [Amniocentesis, with a lower risk of vertical transmission from intra-amniotic bleeding and disruption of the feto-maternal barrier, has a theoretical advantage of over chorionic villi sampling (CVS) [65,66,67].]

• To minimize in-person contact, consider creation and dissemination of PowerPoint presentations on genetic conditions, screening and diagnostic procedures, pregnancy termination options and contraceptive services in multiple languages.

Fetal disorders

• Given the reliance on ultrasound, virtual care is not feasible in fetal medicine clinics. Consider organizational changes to reduce in-person contact including history-taking by senior personnel via virtual platforms prior to the in-person appointment, ultrasound scans by experienced staff during the in-person visit and virtual counselling following the appointment.

Fetal Therapy

• Fetal therapies should not be considered elective, and life-preserving procedures should continue, with appropriate modifications, within the context of local resources [65, 66]. At our hospital, which is home to the Ontario Fetal Centre, the largest and most advanced fetal therapy centre in Canada [69], life-saving procedures including fetal blood transfusion, fetoscopic placental laser ablation and amnioreduction for twin-to-twin transfusion syndrome, and shunting procedures continued to be available. The resource-intensive fetal myelomeningocele closure program which was initially halted, soon resumed given the low disease prevalence in Toronto.

• [Procedures should be deferred if safely possible in those with confirmed or suspected COVID-19]

Pregnancy termination

• Abortion care is considered an essential service, due to its time-sensitive nature and implications to a person’s life, health, and well-being [70].

Preterm birth

• Suggested modifications to the management of those at risk for preterm birth include initiation of cervical length screening for high-risk pregnancies at 16 weeks, with discharge from clinic if stable cervical length at 18 and 20 weeks [51], delaying ultrasound scans in COVID-19 positive or suspected and starting progesterone instead [51], and trans-abdominal vs. transvaginal measurement of cervical length [55]. Since these recommendations are based on limited evidence, in our clinic, we continued two-weekly transvaginal cervical length measurement, between 18 and 28 weeks, as was the case prior to the pandemic. Both elective and rescue cerclage continued to be offered, given their time-sensitive nature.

Medical Disorders

• Consider reducing frequency of inpatient visits, through provision of equipment to monitor blood pressure, blood sugar and fetal movements, as required.