Management of gynecology patients during the coronavirus disease 2019 pandemic: Chinese expert consensus

 [bib_ref] Clinical characteristics of coronavirus disease 2019 in China, Guan [/bib_ref] [bib_ref] Clinical course and risk factors for mortality of adult inpatients with COVID-19..., Zhou [/bib_ref] 

## Ii. infection precautions for operating room
Patients deemed to have a very low risk of COVID-19 infection can be cared for in ordinary operating rooms, and medical staff should follow primary precautions.
Surgery for a patient with suspected COVID-19 infection should be performed in a special operating room with negative air pressure, and the medical staff should follow tertiary precautions (as mentioned previously).
For any surgery in any operating room where there is concern of the patient being infected with COVID-19, the door of the operating room should be kept closed during the operation. Negative pressure with respect to the surrounding facilities should be maintained. The number of people entering and leaving and remaining in the operating room should be minimized. Equipment and supplies should be brought to the operating room door by specific external personnel and retrieved by specific personnel inside the operating room. Internal and external personnel, supplies, and equipment must not be mixed.
Operating rooms should use disposable equipment wherever possible. To prevent the surface of nondisposable and fixed objects in the operating room from being contaminated, disposable plastic films can also be used to cover the surface of diagnostic instruments and other surfaces. After the operation, these films should be treated as special contaminated medical waste. When medical devices or contaminated fabrics need to be sterilized, the operating room should notify disinfection supply centers and laundry rooms that these are COVID-19econtaminated material.
After conducting surgeries involving a patient suspected of having COVID-19, medical staff should take off the contaminated surgical gowns and then gloves and disinfect the hands when leaving the operating room.Environment and surface disinfection should follow the principle of cleaning first and then disinfecting. An infected operating room should only be used after cleaning for 30 minutes, terminal disinfection, and air disinfection.
Medical trainees (medical residents and students) who lack specific training and do not already have substantial Special Report ajog.org surgical experience should not participate in surgery on patients with suspected COVID-19. The risk of a serious error by an inexperienced trainee could put many healthcare workers at risk.

## Iii. epidemiologic screening tool
This tool was developed for use during the COVID-19 pandemic .

## Iv. classification of surgical procedure priority
During the COVID-19 pandemic, each operation can be classified into 3 types according to urgency, including emergency surgery, "time-limited" surgery, and elective surgery. The details are as follows:
Emergency surgery: life-threatening circumstances requiring immediate surgical treatment such as trauma, acute abdomen, and massive hemorrhage; diseases specific to gynecology include ectopic pregnancy, ovarian torsion, uncontrollable uterine bleeding from cancer, pelvic mass causing severe symptoms, etc. "Time-limited" surgery: this phrase is used to define those procedures needed to extend life; for example, operations on malignant tumors. Although the time of operation can be delayed, it should not be delayed for too long. Elective surgery: an elective surgery refers to an operation that is neither emergency nor "time-limited." This type of procedure is intended to improve the quality of life physically and/or psychologically; for example, excision of pelvic masses without high suspicion of malignancy, hysterectomy for benign diseases, etc.

## V. management of gynecologic patients
All the suggestions below use principles reviewed in IeIV.

## Outpatient
There should be triage for outpatients. Patients suspected of having COVID-19 should go to the fever clinic for further treatment. In principle, suspected cases, probable cases, or confirmed cases should not be allowed to seek medical advice in the outpatient gynecology clinic. Avoid having people gathering in the waiting area. One doctor or provider should treat 1 patient at a time in the consulting room, and the consulting room should be disinfected immediately after use. During the COVID-19 pandemic, we recommend online or remote consultation by telephone as much as practical, to minimize the risk of disease spread by close contact. presents the outpatient triage protocol.

## Operative patient
In emergency surgery with sufficient time available for screening, patients who are clinically stable should be asked the screening questions listed in , have their temperature assessed, and be checked for clinical symptoms to eliminate the possibility of COVID-19. If the possibility of a COVID-19 diagnosis cannot be completely ruled out, patients should go to the fever clinic for further screening . If the patient is clinically unstable or the patient's ajog.org Special Report condition is life-threatening, an emergency consultation with infection control experts may be useful. The decision may be made to treat the patient as a suspected case or even confirmed case .
For "time-limited" surgery, prehospital screening and education should be done. Inquiry using the screening questions in should be conducted before admission. Once the patient is admitted, the protocol for triage after admission should be followed. .
In principle, it is recommended to reduce elective surgery during the epidemic. If the decision is made to perform elective surgery, the inquiry (screening questions) and triage protocol should be followed as for "timelimited" surgery.
Planning coordination throughout the hospital system, including the various surgical departments, anesthesia, and nursing services, is important in managing surgical services in the setting of a health emergency. [bib_ref] Coronavirus disease 2019 pandemic: staged management of surgical services for gynecology and..., Weber Lebrun [/bib_ref] Furthermore, adequacy of the blood supply must be considered when arranging operations.Autologous blood donation, acute normovolemic hemodilution, directed donation, and other methods can be considered as alternatives to allogenic blood transfusion.

## Nonoperative inpatient
The triage protocol for a newly admitted patient is provided in . Recommendations for ward management include the following: First, review the screening questions and take the temperature of patients, visitors, and accompanying persons; any patient with an elective admission or any nonpatient suspected of infection should be refused entry into the hospital. Second, visiting rules can be modified according to local preference. It is recommended to prohibit visiting, and if visitors cannot be avoided, the number of visitors should be no more than 1. Visitors must be screened. Third, if a patient develops fever that cannot be explained by the primary disease (requires judgment by the attending doctor or professor), a consultation with infectious disease specialists is recommended. Fourth, if a patient is identified to have COVID-19, the patient should be transferred to a facility that can provide an airborne infection isolation room. At the same time, everyone who has had close contact with the patient should be isolated (This is a recommendation from our Special Report ajog.org experience in mainland China. If there is a shortage of local medical staff, the strategy can be modified according to the actual situation.). Fifth, rooms should be reserved for emergency use for patients with infections during the outbreak (for emergency operations and for emergency isolations). Sixth, provide education for patients and close contacts .

## Vi. management of gynecologic clinical trials during the epidemic
The core guideline for clinical trials during the outbreak is that the safety of subjects and researchers is the first priority.
"Elective" clinical research that is not time-sensitive should be postponed until the current severe restrictions and precautions are lifted. If the research is timesensitive, researchers should evaluate whether implementation of the clinical trial program will be significantly affected by the epidemic. If so, the research should be postponed if possible, or the research plan should be amended.
All parties in clinical trials should try to rely on the internet for communication, use information platform technology, and adopt remote collaborative work as much as possible for clinical trial management, to reduce the flow of clinical trial personnel and reduce the risk of disease transmission.

# Consensus statement
This consensus is made by experts in gynecology and obstetrics from 31 provinces and autonomous regions in China, based on their experience in diagnosis and treatment during the COVID-19 epidemic. With the implementation of these guidelines, no nosocomial infections of COVID-19 have been identified at PUMCH. These guidelines might be helpful to departments of obstetrics and gynecology internationally during these unprecedented times. The understanding of COVID-19 is still changing; therefore, parts of this consensus statement may become obsolete as knowledge about the epidemic evolves.