Category Archives: Coronavirus

Coronavirus update

Updated: March 21, 2021:  INCLUDES COVID-19 VACCINE UPDATE

Dear Patient,

Thank you  for your cooperation in keeping everyone in your life safe!  We have been  normalizing our office through a slow and measured process.  Here is some updated information as you consider taking care of your physical and medical health:


Here are some things to keep in mind as you come to our office for care:

  • We are working with a reduced administrative staff!  Please be patient if there are minor delays on phones, call backs, etc.  We are working as hard as we can!
  • If you are currently sick or have been exposed to a COVID-19 person within the last 14 days, or have any COVID-19 symptoms, please do not come to our office.
  • Please come by yourself. Although we love having children and partners in the office, now is not that time!  We want to keep everyone safe. If you are coming in for an OB appointment, feel free to FaceTime with your partner during your visit.
  • MASKS OR OTHER FACIAL COVERING (BANDANA OR SCARF) ARE MANDATORY.  Gloves are not recommended any more.
  • We will limit the exposure time for your appointment, so visits will necessarily be brief.  If you feel we are rushing you out, keep in mind you will have the option for follow-up phone calls as necessary.
  • Our entire staff has been immunized against COVID-19.  We will be wearing masks in the exam room as well. We hand sanitize regularly and wear gloves when needed
  • Each room is thoroughly cleaned after each patient departs with a bleach solution.
  • Please social distance. If our waiting room fills up, please wait in the hallway or downstairs and we will be happy to call your cell phone to let you know we are ready for you. Make sure we have your correct phone number!  If you are waiting outside of our waiting room,  and we call you, please be ready to answer your phone and come up promptly.

Gynecologic Patients:

  • We are open for Express Check Annual examinations, details on the tab to the left of this page.  These are quick exams, geared to get you in and out of the office quickly- perfect for COVID-19 life.  The Express Check Annual Exam encompasses a brief history, thorough breast and pelvic examination, a refill of gynecologic related medications, and referrals for any screening tests (mammograms / indicated pelvic ultrasounds) for which you may be due.  These appointments will likely be in the afternoon to keep pregnant moms separate,  thereby decreasing risks for vulnerable patients.  If you have other gynecologic concerns, please set up a different appointment!
  • We are open for appointments for routine gynecologic issues and surgical consultations.  

Obstetrical Paients:

  • We are open for all obstetric appointments, scheduled mostly in the morning to keep you safe
  • Please come alone.  You may FaceTime your partner during the visit.


COVID-19 Vaccine during pregnancy and breastfeeding- UPDATE

We have encountered an avalanche of patients inquiring about the safety of COVID19 vaccines in pregnancy. We hope to provide assistance in answering this question and those that follow. Attached are the SMFM/ACOG (Society of Maternal Fetal Medicine / American Congress of Obstetrics & Gynecology)  statements regarding vaccination.

Quick summary in bold, Links to the Society Statements Below: 

Almost anyone including pregnant/lactating women can receive the COVID vaccine, all will likely be fine, but they need to know we have no data regarding safety/side effects. The Pfizer and Moderna vaccines facilitate the same immune protection that older vaccines, do but with a faster start. FDA, ACOG, and SMFM all endorse vaccinating pregnant women with disclosure of lack of data.  As soon as more info emerges, we will update everyone.

COVID Vaccination?

Presently, Pfizer’s mRNA-based vaccine has received FDA approval. The distillation of the message from ACOG and SMFM (as of 12/16/2020) is as follows:

1.       The Pfizer vaccine should be made available to all pregnant and lactating women, and not withheld.

2.       Patients should know that the safety of this vaccine in pregnancy/lactation is unknown given lack of inclusion of these patients in trials. 

3.       Time will bring more data.

The CDC has made it clear that priority for the vaccine is for health care personnel, the majority of which are women, and current/recent pregnancy should not thwart vaccination.

A quick vaccine review:

There are several types of vaccines, and the new vaccines from Pfizer and Moderna (like similar ones in development) are a new form of technology. All vaccines aim to introduce pathogenic antigens to the immune system in order to generate antibodies that activate host defenses in response to viral exposure. Traditional vaccines achieve this antigen exposure either through administration of:

a.   live attenuated viruses (stronger immune response, ie MMR, varicella, rotavirus), or

b. inactivated viruses (weaker immune response, boosters needed, ie Hep A, influenza, polio, rabies)

c.  subunit/recombinant/polysaccharide/conjugate vaccines (stronger immune response to specific protein parts, not as useful to rapidly mutating viruses, needs booster, ie Hib, hep B, Pertussis, shingles)

d.  toxoid (similar to recombinant, needs booster, ie TD)

When cells are infected with coronavirus, the virus uses the host cell’s own organelle to produce mRNA that instruct host cells to produce many proteins including a unique “spike” protein. The host defense machinery recognizes these proteins, shreds them, and displays the pieces of the viral proteins their cell surfaces via major histocompatibility complex (MHC) molecules for immune cells to learn and build immunity against. The next generation mRNA vaccines simulate infection by giving short-lived instructions for host cells to produce these spike proteins in cells without any other viral proteins, thus allowing the immune system to learn about and prepare immune response to future viral exposure. Instead of a dilute mixture of attenuated/dead virus/protein/toxoid, the antigens are synthesized by the cells themselves, building a very large transient burst of high antigen levels for the immune system to learn from. This is thought to provide a stronger immune response faster.

The mRNA is delivered into the cytoplasm of host cells via lipid nanoparticles (droplet endocytosis), and are then translated by the host ribosomes into these spike proteins. These spike proteins are then recognized and bound by host defense machinery, then delivered to the cell surface on MHC-I molecules for antigen presentation and immune response. Pfizer uses a positively charged mini lipid droplet (100 micrometers, the size of coronavirus itself) that binds the negatively charged mRNA within. The nanoparticle melts into the cell membrane via endocytosis, facilitating transport of mRNA into the cytoplasm. This essentially “cuts out the middle man,” bypassing a virus transcribing DNA into mRNA that is then translated, and skips th toxoid/antigen-based immunity that is slow to mount and fast to lapse. One downside to this technology is that RNA is inherently unstable and needs to be kept at extreme cold (-80C) for preservation.

Older vaccination techniques that employ replication of the entire virus or processing of dilute protein in serum for immune responses are time consuming, weaker, and may produce more side effects, whereas mRNA-driven protein production in theory and emerging practice produces a stronger immune response with less side effects. 

There is no risk for permanent viral incorporation into host cell DNA as the mechanisms for reverse transcription are absent. No mutagenesis potential is anticipated. Testing for prior infection is also not recommended prior to administration. 


Side effects?

Low grade fever, malaise, myalgia, nausea, vomiting may be experienced upon taking the vaccine. No need for fetal monitoring unless severe illness arise.


Our honest opinion?

We would recommend offering the vaccine with disclosure that it’s likely safe, it’s ultimately doing the same thing traditional vaccines do (just faster), but there is no human pregnancy data yet. The FDA, ACOG, and SMFM all endorse this posture. 


Ultrafast update on consequences of COVID in pregnancy

There is a <1% risk of vertical transmission of COVID in pregnancy, but pregnant women are 3x more likely to be admitted to an ICU and require mechanical ventilation (2.9/1000 pregnant infections) and 2.4% more likely to require ECMO (0.7%/1000 pregnant infections), and 1.2x death (1.5/1000 pregnant infections). Emerging reports of COVID infection in pregnancy have demonstrated visible placental damage (ie, microthrombi) on pathologic examination. 

Antenatal surveillance for COVID?

Reports from the UK showed that stillbirth and poor OB outcomes increased during the COVID era tripled, even in absence of known COVID infection. As risks are higher and causes unknown, we recommend that if COVID infection arises at any point in pregnancy, obtain serial growth, NST twice weekly at 32 weeks, and delivery by 39 weeks. SMFM states that delivery plans should be individualized for patients with COVID infection at term. Cesarean is not recommended to reduce risk of transmission to neonates and staff. 


Fetal/neonatal risks?

ACOG, SMFM, and the FDA recommend offering the vaccine to pregnant and lactating patients with the anticipation of very low risks of fetopathy or neonatal complications. There is no data, but risks are anticipated to be low.


Lovenox, COVID, and pregnancy oh my?

Emerging data has  shown that severe COVID infection produces hypercoagulative state and life threatening thrombosis. This has lead many centers starting anticoagulation on patients admitted with COVID. Given lack of data, we are presently recommending treating these situations like thrombophilia/history of DVT, and that if a patient is started on lovenox in the hospital for COVID infection or admitted to the ICU for COVID, continue prophylactic lovenox until 6 weeks postpartum.

Thanks for this vaccine excerpt from our colleagues at Diablo Valley Perinatology!


As a pregnant patient, should I consider the hospital a safe place to deliver my baby?

As some hospitals have experienced an increase in COVID-19 patient admissions, some patients are frantically wondering if the hospital will be a safe place to be.  The following are things to consider as you contemplate your choice of location for your birth:

  • To date (since March), we have seen a mostly recent uptick in nearly asymptomatic COVID-19 women laboring and delivering at John Muir Medical Center.  Numbers thus far are in the handful range, but I expect that number to increase due to holidays.
  • John Muir is prepared. It is a resource rich hospital and has been preparing for COVID-19 by learning from those facilities already hit hard by the virus.
  • Labor & Delivery has it’s own entrance, separate from the main hospital and emergency room. The secured location of the L&D unit within the hospital lends itself to isolation from other COVID-19 patients.  In other words, only those people involved with pregnant and postpartum women will be present in that particular part of the hospital.  Patients and their partners will walk in to the L&D entrance, walk 6 feet, take an elevator to the third floor, walk another 6 feet, and then enter the secured L&D area.  
  • John Muir swabs all patients for COVID-19 upon arriving on Labor & Delivery if not already done prior to the day of induction, cesarean section or labor. These policies are geared to keeping you and your growing family safe.  Additional screening includes temperature evaluations and a 4-question risk assessment screening tool.
  • John Muir’s current visitation policy will continue to allow pregnant and postpartum women to have their healthy partner by their side during their stay in the hospital. They will now allow other visitors to enter at this time.
  • Women and their partners will be asked to wear masks in their L&D and postpartum room when staff members enter.
  • John Muir has the resources to care for women, pregnant and postpartum if they are diagnosed and become symptomatic with the virus. I’m sure many of you have read the article of two completely asymptomatic women in New York who became incredibly symptomatic shortly after their delivery and required immediate ICU care.  As a result, both new moms did well.  At John Muir, we have the ability to provide rapid diagnostic testing and just that level of ICU care, just in case.

So what should I do in preparation for my hospital delivery?

  • Know that we will provide frequent updates on our website should there be any significant changes in policies or procedures.
  • Stop working at 36 weeks, unless you can work from home, to allow for 2 weeks of family isolation prior to your expected delivery. We are encouraging everyone to do this so that collectively we are keeping the unit safe.  Pregnant women are as fastidious in maintaining social distancing and self / family isolation as most 80 year olds currently are, so they may very well be the safest population in our area.
  • Pack enough belongings so that, once tucked in at the hospital, your partner won’t have to leave your side until you are all discharged together. Although not enforceable, coming and going naturally increases risk.
  • Prepare your home ahead of time, knowing you and your family may be holed up for a while when you come home. Visitors can wait!

The financial policy that you have with Stephen R Wells, MD remains in effect as well as our cancelation policy.  The financial responsibility will be yours for this visit just like it would be if it was an in-person visit in the office.  We will bill your insurance for a routine office visit and typical co-pays and deductibles will apply.

This is an unprecedented time for our community.  Let’s all remember to be kind and patient with inconveniences and disruptions as everyone is doing their best to make sure we are all safe, healthy and cared for. Please know that our office is doing everything we can to keep you and your family healthy!

Stay safe and have faith!  We will get through this!

Stephen R Wells, MD