key: cord-0916311-lty908kq authors: Wang, Hongbo; Zhang, Wei; Du, Xin; Kuang, Yan; Li, Xiaomao; Ma, Xiaoxin; Xiao, Lan; Chen, Xiaojun; Zhang, Yu; Li, Donglin; Zheng, Lang; Li, Yanhui; Wang, Jianliu title: Expert Consensus on the Management Process of Gynecological Emergency under the Regular Epidemic Prevention and Control of COVID-19 date: 2021-03-19 journal: nan DOI: 10.1016/j.gocm.2021.03.004 sha: b0e9b291eae0342bdc765673ae745c115436c9c5 doc_id: 916311 cord_uid: lty908kq At present, China is in the stage of the COVID-19 epidemic where regular prevention and control measures are required to contain the spread of disease. Reports of new sporadic cases are still widespread across China and medical personnel remain at high risk of exposure to infection. This is especially the case for medical staff working within emergency departments. Most gynecological emergency cases are complex and a high proportion require emergency surgical treatment. By referring to national regulations and requirements on COVID-19 prevention and control, and by summarizing our experiences in the battle against COVID-19 within Wuhan, this consensus report provides recommendations on the triage, reception, consultation, admission and surgical management of gynecological emergency patients. We also make suggestions for the environmental layout and disinfection and the medical waste management. This consensus aims to optimize the diagnosis and treatment process of gynecological emergency patients and reduce the exposure risk of medical staff within the current context of routine COVID-19 prevention and control. Following the outbreak of the 2019 novel coronavirus disease in December 2019, [1] its causative pathogen has spread rapidly into 192 countries, causing over 100 million known infected cases and over 2. Taxonomy of Viruses renamed the pathogen of COVID-19 as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). [2] Through joint national efforts in 2020, China survived the most difficult period of the COVID-19 epidemic; however, we remain in a period where regular prevention and control of COVID-19 is required to contain the spread of this infectious disease. New sporadic cases are still being reported across many places in China. Medical personnel therefore remain at high risk of exposure to COVID-19, and this is especially the case for healthcare staff working within emergency departments (includes emergency gynecology clinics). In response to the continued risk, the National Health Commission issued the "Notice on of medical personnel. Abdominal pain and vaginal bleeding are the chief complaints amongst gynecological emergency patients. Most of these emergency cases are complex and can involve a wide variety of diseases. In the context of the ongoing COVID-19 epidemic, medical staff are at a greater risk of infection and face greater difficulties in clinical practice than in the past. This raises a number of questions surrounding the management of gynecological emergencies. Therefore, in order to improve the diagnosis and treatment of gynecological emergencies during the COVID-19 pandemic, we carefully summarize our experiences with prevention and control measures within the hospitals of Wuhan and Hubei, discussing the characteristics of emergency gynecological diseases and exposure risk of relevant healthcare personnel during clinical work. In addition, we make recommendations for standardizing emergency pre-examination, admissions, gynecological surgery strategies, environment layout and disinfection management, alongside other medical procedures for gynecological emergency patients. For patients seeking emergency medical services, the 120 command and dispatch center should identify potential risks using the early warning score. [4] The 120 command and dispatch center must quickly determine whether patients have fever, any travel history in high-risk epidemic areas, any contact history with covers, gloves and work caps. In strict accordance with the regional management requirements, properly wear and take off protective equipment, and pay attention to the respiratory tract, oral cavity, nasal mucosa and eye hygiene and protection. Transport procedure for suspected or confirmed COVID-19 patients should refer to the "Pre-hospital emergency transport scheme for COVID-19 cases [7] " and the "Transport route of emergency department for COVID-19 patients [6] . " During transport, medical personnel should strictly implement the three-level protection measures; hospitals with negative pressure isolation stretchers should make use of these during transportation to avoid the spread of the SARS-CoV-2. For patients needing emergency surgery, a designated transport channel should be established for entry to the emergency isolation operating room. Specially assigned personnel should ensure the passage is unobstructed to prevent the need for stopping on route, reducing exposure risk to other hospital staff. [8] Prior to reception on site, when imaging results and SARS-CoV-2 nucleic acid or antibody test cannot be obtained to determine COVID-19 status of the patient, careful J o u r n a l P r e -p r o o f assessment of patient history and preliminary analysis of clinical manifestation of disease should be made. [4, 9] The triage station should first assess whether the patient's vital signs are stable. For critically ill patients, emergency treatment should be performed under secondary protection. For non-critically ill patients with stable vital signs, the triage station should evaluate whether the patient is of medium-or high-risk. Care should be taken to determine whether the patient has travelled from a high-risk COVID-19 region within the last 14 days. Assessment of the patient for history of close contact with a confirmed/suspected COVID-19 case or demonstration of respiratory infection symptoms such as fever (axillary temperature≥37.3℃), cough, etc., should also be made. [10] SARS-CoV-2 nucleic acid and antibody examination should be performed in a timely fashion. In the absence of fever, respiratory symptoms or epidemiological history of potential COVID-19 exposure, medical staff can quickly receive patients for examination and treatment under first-level protection. Gynecological emergencies can involve a wide range of disease and are often accompanied by other complications. Most gynecological emergency patients present with abdominal pain and vaginal bleeding. Fever is common with pelvic infectious diseases, posing a challenge for medical personnel when distinguishing acute abdomen from COVID-19. Gynecological emergencies include ectopic pregnancy, ruptured corpus luteum, torsion of an ovarian tumor, ruptured ovarian tumor, inevitable miscarriage, abnormal uterine bleeding, intra-abdominal hemorrhage causing hemorrhagic shock, vaginal stump bleeding, severe bone marrow suppression with fever following chemotherapy, pelvic cavity malignant tumors with associated large volume pleural effusion or ascites, vulvovaginal trauma, and hematomas cause hemorrhagic shock. These may be accompanied by abdominal pain or fever. As COVID-19 patients may also present with abdominal pain and/or fever, careful differential diagnosis is required by the attending physician. [11] J o u r n a l P r e -p r o o f team. [12] Medical service should be carried out in accordance with the requirements of "Covid-19 Prevention and Control Plan (Seventh Edition) [10] " and "Covid-19 Diagnosis and treatment plan for COVID-19 (trial version 8) [9] ", alongside the workflow of the emergency department. It is recommended that gynecologists adopt appropriate levels of protection according to the patient's risk of developing COVID-19; consideration should be given to the different emergency areas visited by the patient. Primary protection should be adopted when receiving low-risk patients in pre-examination and triage. For patients in which COVID-19 has not been excluded, secondary or tertiary protection is recommended during gynecological examinations or invasive procedures such as retrovaginal fornix puncture or abdominal puncture. Hand hygiene should be practiced in accordance with the "Specification of hand hygiene for healthcare worker WS/T 313-2019 [13] "; this includes hand washing with running water before and after wearing gloves or removing isolation clothing. [14] At reception and consultation, the patient's temperature should be re-assessed. A J o u r n a l P r e -p r o o f patient history should be taken to check for symptoms related to COVID-19; in particular, history of headache, changes in smell, diarrhea, cough and expectoration should be investigated. A patient history for contact with known/suspected COVID-19 cases or recent travel within high-risk regions should also be taken. Patients should also be asked in detail about their sexual history, marital and child history, menstrual history, gynecological complications, and other relevant medical history. Fever accompanied by respiratory symptoms is the typical manifestation of COVID-19 patients, but some COVID-19 patients display nausea, diarrhea, abdominal pain and other symptoms as the first indication of infection, and may lack typical respiratory manifestations. Such patients are prone to missed diagnosis or misdiagnosis; receiving physicians should be vigilant. [12] Within the current setting of regular COVID-19 epidemic prevention and control, the green channel is of great significance to reduce the mortality rate of patients with acute and critical diseases. Where there is a gynecological emergency and fever clinics are not staffed with gynecologists or house rescue equipment, critically ill patients in moderate/high-risk groups should be transferred to an isolation emergency room or isolation wards according to the isolation prevention and control standard of The diagnosis and treatment workflow of gynecological emergency patients can be J o u r n a l P r e -p r o o f seen in Figure 1 . During the current climate of regular COVID-19 epidemic prevention and control, optimization of the clinical laboratory workflow is of great importance. When collecting, testing and transporting specimens from emergency patients, personnel should refer to the "Manual for New Coronavirus Nucleic Acid detection in Medical Institutions (Trial) [15] ". The collection and transportation of specimens from suspected COVID-19 patients must be performed by professionally trained medical staff. [16] Figure 2 . an ordinary operating room can be used in an emergency, but the location of the operating room should be as distanced as possible from other areas. When operating in a positive pressure operating room, it is necessary to turn off the air conditioning system or increase the ventilation of the operating room. For surgery in a negative pressure room, the air purification and negative pressure system should be turned on 30 minutes before surgery. Confirm that the operating room is in a state of negative pressure (the absolute value of minimum static pressure difference should be≥5Pa) . If laparoscopic surgery is required, a closed air suction device should be prepared in advance and aerosol dissemination should be tightly protected. [18] Operative approaches can vary and should be selected on a case-by-case basis. (1) Tertiary protection should be used by medical personnel. Surgical patients not undergoing general anesthesia should wear surgical face masks. (12) After surgery, the operating room and equipment should be thoroughly disinfected. Continuous surgery should be avoided. [12, 19] (4) For patients with dyspnea, appropriate oxygen therapy should be administered based on their blood oxygen saturation and condition. (5) Be alert for signs of multiple organ dysfunction; actively prevent and treat complications such as heart, brain and kidney conditions, and promptly carry out organ support treatment. [20] " and "Regulation of disinfection technique in healthcare settings [21] ". Formulate disinfection measures, dividing each area into routine disinfection areas, enhanced disinfection areas, key disinfection areas and special disinfection areas. (4) The isolation and rescue room is a special disinfection area: after the patient leaves, the air, the surface of the items and the floor should be immediately disinfected using the methods described above for the key disinfection areas. The population is generally susceptible to SARS-CoV-2. The principal source of transmission is thought to be COVID-19 patients; asymptomatic infections are J o u r n a l P r e -p r o o f recognized as a source of transmission. Known SARS-CoV-2 transmission routes include respiratory droplets, contact transmission, aerosol and digestive tract, etc. [22] Gynecologists, -being in close contact with respiratory droplets or body fluids when they receive emergency patients, performing gynecological examinations or performing operations such as posterior fornix or abdominal puncture, -have a high risk of exposure. Management procedures for exposure should be formulated according to the exposure risk. [23] [24] [25] (1) Leave the exposure site as soon as possible following respiratory exposure. (2) Report exposure to the hospital infection-control department as soon as possible. Wear qualified masks. (3) After receiving the report, the hospital infection-control department should immediately evaluate the exposure risk. If the exposure source is a COVID-19 patient or the environment at the time of exposure is an isolation ward, fever clinic, or isolation observation room, the risk of infection is high. (4) Exposed individuals should be isolated in a single room at the designated medical observation site. High-risk exposed individuals should be isolated for 14 days in a single room. If there is no abnormality, the isolation can be terminated after 14 days. (1) When exposed by direct blood or bodily fluid contamination of the skin, the individual should immediately go to the buffer room for cleaning: wipe the site with 75% ethanol or iodophor and then clean with water. (2) When goggles or protective clothing and masks are contaminated, individuals should immediately discard and replace the items within the buffer room. (3) When eyes are contaminated, individuals must immediately go to the buffer room and thoroughly wash the affected eye(s) with clean water. (4) When a needle stick or sharp injury occurs during inspection or surgery, remove gloves nearly and squeeze blood from the injured area, rinse with running water J o u r n a l P r e -p r o o f and disinfect the wound with 75% ethanol or iodophor. Gloves must be discarded and replaced. Carry out emergency measures according to the workflow of blood and bodily fluid exposure. In the current climate of regular epidemic prevention and control of COVID-19, medical staff still need to follow the requirements of the "Regulations for Medical Waste Management [26] " and the "Measures for the medical waste management in medical and health institutions [27] ". Medical waste from suspected or confirmed COVID-19 patients must be treated as infectious waste. [28] Use double-layer yellow medical disposal bags for transportation. Sharp objects must be placed in a designated plastic box and sealed. Disposal bags and sharps boxes should be sprayed with 1000mg/L chlorine disinfectant prior to collection and transfer by a trained cleaner. Waste should be transferred to a temporary storage point for medical waste along a specified route at a fixed time . Only authorized personnel should have access to the medical waste storage area. Infectious waste must be collected and disposed by a medical waste disposal vehicle within 48h; the date and quantity of medical waste should be recorded and signed for upon collection. Non-infectious waste generated by non-COVID-19 patients should be treated as general medical waste and should be stored and treated separately to infectious waste. This consensus is based on currently available literature, regulations and expert opinions. Its purpose is to optimize the timely diagnosis and treatment of gynecological emergency patients and reduce the exposure risk of medical personnel working within the COVID-19 epidemic. However, this consensus cannot be used as a legal basis for any medical disputes and litigation. This consensus captures the contemporary concerns surrounding the topic but cannot address emerging and future issues; the changing landscape of the COVID-19 pandemic will necessitate further discussion and updated consensus. J o u r n a l P r e -p r o o f Outbreak of pneumonia of unknown etiology in Wuhan, China: The mystery and the miracle Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. 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The First Affiliated Hospital Risk assessment and management of exposure of health care workers in the context of COVID-19: interim guidance Ministry of Health of People's Republic of China. Measures for the medical waste management in medical and health institutions Legends: Figure 1. Flow chart of diagnosis and treatment for emergency gynecological patients. MDT: Multidisciplinary team The authors declare that there is no conflict of interest. This work was supported by the National Natural Science Foundation of China (grant number 81701423).