We would like to acknowledge the thoughtful contributions of the Expert team who participated in the consensus represent an effort to integrate infection control strategy and promote professionalism in medical 79
practice. The guidelines represent collaboration with experts from 31 provinces and autonomous 80 regions of mainland China over 2 weeks' time. With the implementation of these guidelines no 81
nosocomial infections of COVID-19 have been identified at PUMCH. We think these guidelines 82 might be helpful to departments of obstetrics and gynecology internationally during these 83 unprecedented times. In our guidelines, we describe basic infection precaution principles, an 84 epidemiologic screening tool, prioritization of surgical procedures, and operating room 85 requirements. Using these principles, we then review management of gynecologic patients during 86
the COVID-19 epidemic in the outpatient and operative and non-operative inpatient settings, as 87 rooms, and medical staff should utilize primary precautions.
Surgery for a patient with suspected COVID-19 infection should be performed in a special 159 operating room with negative air pressure, and the medical staff should utilize tertiary precautions 160 (see above).
For any surgery in any operating room where there is concern that the patient is infected with 163 COVID-19, the door of the operating room should be kept closed during the operation. Negative 164 pressure with respect to the surrounding facilities should be maintained. The number of people 165 entering and leaving and remaining in the operating room should be minimized. Equipment and 166
supplies should be brought to the operating room door by specific external personnel and retrieved 167 by specific personnel inside the operating room. Internal and external personnel, supplies and 168 equipment must not be mixed.
Operating rooms should use disposable equipment wherever possible. In order to prevent the 171 surface of non-disposable and fixed objects in the operating room from being contaminated, 172
disposable plastic films can also be used to cover the surface of diagnostic instruments and other 173
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 175 notify disinfection supply centers and laundry rooms that these are COVID-19 contaminated 176 material.
After surgeries involving a patient suspected of COVID-19 infection, medical staff should take off 179 the contaminated surgical gowns and then gloves and disinfect the hands when leaving the 180 operating room. 9 Environment and surface disinfection should follow the principle of cleaning 181 first and then disinfecting. An infected operating room should only be used after cleaning for 30 182 minutes, terminal disinfection, and air disinfection.
Medical trainees (medical residents and students) who lack specific training and do not already 185
have substantial surgical experience should not participate in surgery on patients with suspected 186
COVID-19 infection. The risk of a serious error by an inexperienced trainee could put many 187
health care workers at risk. 188 189
This tool was developed for use during the COVID-19 pandemic (Figure 1 ).
IV. Classification of surgical procedure priority 193
During the COVID-19 pandemic, each operation can be classified into three types according to 194
urgency, including emergency surgery, "time-limited" surgery and elective surgery. The details are 195 as follows: 196
Emergency surgery: life-threatening circumstances requiring immediate surgical treatment 197 such as trauma, acute abdomen, and massive hemorrhage; diseases specific to gynecology 198 include ectopic pregnancy, ovarian torsion, uncontrollable uterine bleeding from cancer, 199
pelvic mass causing severe symptoms, etc.
"Time-limited" surgery: this phrase is used to define those procedures needed to extend life; 201
for example, operations on malignant tumors. Although the time of operation can be delayed, 202
it should not be delayed for too long. 203
Elective surgery: an elective surgery refers to an operation that is neither emergency nor 204 "time-limited". This type of procedure is intended improve the quality of life physically 205 and/or psychologically; for example, excision of pelvic masses without high suspicion of 206 malignancy, hysterectomy for benign diseases, etc. 207 208 V. Management of gynecologic patients 209
All of the suggestions below are utilizing principles reviewed in I-IV. 210
1. Outpatient 211
There should be triage for outpatients. Patients suspected of COVID-19 infection should go to the 212 fever clinic for further treatment. In principle, suspected cases, probable cases or confirmed cases 213
should not be allowed to seek medical advice in the outpatient gynecology clinic. Avoid having 214
people gathering in the waiting area. One doctor or provider should treat one patient at a time in 215 the consulting room, and the consulting room should be disinfected immediately after use. During 216 the COVID-19 pandemic, we recommend online or remote consultation by telephone as much as 217
practical, in order to minimize the risk of disease spread by close contact. For outpatient triage 218 protocol see Figure 2 . 219
In emergency surgery if sufficient time for screening, patients who are clinically stable should be 222 asked the screening questions in Figure 1 , have their temperature assessed and checked for clinical 223 symptoms to eliminate COVID-19 infection. If COVID-19 cannot be completely excluded, 224
patients should go to the fever clinic for further screening (Figure 3 ). If the patient is clinically 225 unstable or the condition is life-threatening, an emergency consultation with infection control 226
experts may be useful. The decision may be made to treat the patient as a suspected case or even 227 confirmed case (Figure 4) .
For "time-limited" surgery, pre-hospital screening and education should be done. Inquiry using the 230
screening questions in Figure 1 should be done before admission. Once the patient is admitted, the 231
protocol for triage after admission should be followed. (See Figure 5 .) 232 233
In principle, it is recommended to reduce elective surgery during the epidemic. If the decision is 234 made to do elective surgery, the inquiry (screening questions) and triage protocol should be 235 followed as for "time-limited" surgery.
Planning coordination throughout the hospital system, including the various surgical departments, 238
anesthesia, and nursing services is important in managing surgical services in the setting of a 239 health emergency. 10 Furthermore, adequacy of the blood supply must be considered when 240 arranging operations. 11 Autologous blood donation, acute normovolemic hemodilution, directed 241 donation and other methods can be considered as alternatives to allogenic blood transfusion. 242 243
3. Non-operative inpatient 244
The triage protocol for a newly admitted patient can be seen in Figure 5 . Recommendations for 245 ward management include the following: 1) Review the screening questions and take the 246 temperature of patients, visitors and accompanying persons; any patient with an elective 247 admission or any non-patient suspected of infection should be refused entry into the hospital. 2) 248
Visiting rules can be modified according to local preference. It is recommended to prohibit 249 visiting, and if visitors cannot be avoided, the number of visitors should be no more than 1. 250
Visitors must be screened. 3) If a patient develops fever that cannot be explained by the primary 251 disease (requires judgment by the attending doctor or professor), a consultation with infectious 252 disease specialists is recommended. 4) If a patient is identified to have COVID-19, the patient 253
should be transferred to a facility that can provide an airborne infection isolation room. At the 254 same time, everyone who has had close contact with the patient should be isolated. (This is a 255 recommendation from our experience in mainland China. If there is a shortage of local medical 256 staff, the strategy can be modified according to the actual situation.) 5) Rooms should be reserved 257 for emergency use for infected patients during the outbreak (for emergency operations and for 258 emergency isolations). 6) Provide education for patients and close contacts. (See Figure 6 ). 259 260 VI. Management of gynecological clinical trials during the epidemic 261
The core guideline for clinical trials during the outbreak is that the safety of subjects and 262 researchers is the first priority. 263 "Elective" clinical research that is not time-sensitive should be postponed until the current severe 265 restrictions and precautions are lifted. If the research is time-sensitive, researchers should evaluate 266
whether implementation of the clinical trial program will be significantly affected by the epidemic. 267
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 270 platform technology, and adopt remote collaborative work as much as possible for clinical trial 271 management, to reduce the flow of clinical trial personnel and reduce the risk of disease 272
transmission.
Consensus statement 275
This consensus is made by experts in gynecology and obstetrics from 31 provinces and 276 autonomous regions in China, based on their experience in diagnosis and treatment during the 277 epidemic. With the implementation of these guidelines no nosocomial infections of COVID-19 278
have been identified at PUMCH. These guidelines might be helpful to departments of gynecology 279
internationally during these unprecedented times. The understanding of COVID-19 is still 280 changing, therefore, parts of this consensus statement may become obsolete as knowledge about 281 the epidemic evolves. 282