2.1 Pre-hospital transportation

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 COVID-19 patients, etc., to assess emergency cases. Patients with low-risk of COVID-19 infection can undergo rapid home visits with primary protection. When receiving medium- and high-risk patients, medical staff should adopt secondary protection and transfer patients within a negative pressure ambulance.⁵ During transfer, the fever clinic should be informed in advance and should receive patients through a specific channel to the designated area.⁶ The requirements of primary and secondary protection see Table 1.

2.2 Patient transport in hospital

Transport procedure for suspected or confirmed COVID-19 patients should refer to the “Pre-hospital emergency transport scheme for COVID-19 cases⁷” 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

4.1 Characteristics of gynecological emergencies

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

Patients with a history of gynecological surgery or cancer have reduced immune function and are at increased risk of pulmonary infection. Both ventilator assistance and supine position following surgery lead to prolonged postoperative pulmonary function recovery time. At present, minimally invasive surgical approaches, such as laparoscopy and hysteroscopy, are widely used. During laparoscopic surgery, pneumoperitoneum can lead to decreased lung volume, increased airway pressure, CO₂ retention and decreased lung compliance, which is not conducive to timely postoperative lung function recovery. Gynecological emergency patients also frequently demonstrate multiple complications. Emergency surgery requires the joint participation of multiple departments - gynecology, anesthesiology, operating room, infectious disease, internal medicine, surgery department and medical affairs - when undertaking decision-making and establishing the multidisciplinary treatment (MDT) team.¹²

4.2 Preparation of gynecologist before reception

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 313–2019¹³"; this includes hand washing with running water before and after wearing gloves or removing isolation clothing.¹⁴

4.3 Reception and consultation

At reception and consultation, the patient’s temperature should be re-assessed. A 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

4.4 Establishing a "green passage"

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 COVID-19 via the green channel. The specification of patient transport in-hospital can refer to the above guidelines in section 2.2. Medical personnel in isolated emergency rooms should be equipped with secondary or tertiary protection. The department of gynecology should set up an isolation ward with rescue equipment and trained doctors. The department should prepare in advance for the transfer, preoperative examination, and postoperative monitoring of gynecological emergency patients. SARS-CoV-2 nucleic acid and antibody sampling should also be performed as soon as possible to exclude possible COVID-19. Patients testing negative for COVID-19 should be admitted into an isolation room.

4.5 Diagnosis and treatment workflow of gynecological emergency

The diagnosis and treatment workflow of gynecological emergency patients can be seen in Fig. 1.

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Fig. 1

Flow chart of diagnosis and treatment foremergency gynecological patients

MDT: Multidisciplinary team; ICU: Intensive Care Unit.

6.1 Preoperative preparation

Pre-operative reporting to the general-on-duty, medical affairs department, hospital infection-control department and other management departments should be undertaken. Appropriate surgical routes should be taken. Prior to surgery, fully communicate and discuss with the relevant personnel in the operating room and the anesthesiology departments, confirming the surgical position and anesthesia method. MDT team discussion of possible intraoperative or postoperative complications and a detailed treatment plan should be undertaken, including the following departments as appropriate: gynecology, anesthesiology, operating room, infection, internal medicine, surgery. The surgeon should be contacted in advance. Minimize the number of personnel involved in surgery. If a surgical condition is found during the operation, further surgical personnel can be invited to join in the procedure. Communicate with the blood transfusion department to ensure adequate blood supply as needed. Doctors and nurses involved in the operation should have received protective training and be familiar with the three-level protective operation measures.

For hospitals without negative pressure operating rooms, surgery can be arranged independently in the positive pressure operating room with air purification equipment; 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 ​min 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 Prepare all surgical instruments and equipment in advance, including sutures, hemostatic materials and other consumable items; avoid multiple collections and deliveries to reduce exposure risk. Test and maintain a clear line of communication between the operating room and external personnel; ensure lines of communication are ready for emergency use.

6.2 Selection of surgical routes

Operative approaches can vary and should be selected on a case-by-case basis. The majority of gynecological emergency operations are pelvic surgery or perineal surgery, including open surgery (to avoid adverse effects on lung function), laparoscopic surgery (following assessment of lung function and likely duration of the procedure), diagnostic curettage, induced abortion and vulvovaginal trauma repair surgery. Medical personnel should seek to "fight and win battles of quick decision". Cold knife surgery is recommended; ultrasonic scalpels and electrocoagulation under laparoscopy will lead to aerosol production. However, compared with open surgery, laparoscopy reduces operation time attributed to incision and suture. Use of electrosurgical instruments in open surgery is associated with risk of aerosol production. It is also important to consider the impact of tertiary protective equipment on the visual, auditory, and tactile sensory capacity of medical personnel. The surgeon needs to consider the above factors and choose open or laparoscopic surgery according to the individualized surgical site or scope.

6.3 Intraoperative precautions

• (1) Tertiary protection should be used by medical personnel. Surgical patients not undergoing general anesthesia should wear surgical face masks.

• (2) During comprehensive exploration, operation times should be minimized where possible. Medical personnel should operate gently and avoid contamination from the patient’s blood and other bodily fluids. Care should be taken to avoid needle stick injuries.

• (3) Attention should be paid to the potential risk of generated aerosols. Special care should be taken during tracheal intubation, sputum suction and other operations that may generate aerosols.

• (4) Where possible, use of surgical equipment such as electrosurgical knives and ultrasonic knives should be avoided; where the use of these instruments is required, they should be used with the minimum power. When using an electric knife, use a smoking device as much as possible, or use a sealed suction device to minimize the spread of aerosols.

• (5) Lengthy operation time should be avoided; the surgery should address the primary emergent problem. The scope of surgical intervention should be small rather than large, to minimize trauma.

• (6) In the absence of additional safety protection facilities in the pathology department, intraoperative frozen section examination should not be performed; safer alternative examination methods should be used. Further treatment after the emergency operation may be performed following the reporting of pathology results through the routine pathology pipeline.

• (7) All equipment, instruments and medicines should be used by a single person only. Anesthesia appliances that contact the patient’s respiratory tract, such as visual laryngoscope lenses, breathing masks, breathing balloons, filters, etc., should all be disposable.

• (8) Throughout the duration of the operation, personnel should not be permitted to leave the operating room. Persons wishing to enter must don protective equipment prior to entering the operating room.

• (9) Following completion of the operation, infection control and the disinfection of the operating room should be implemented in accordance with the recommendations of the operating room protection.

• (10) Surgical specimens should be packaged in double-sealed bags for transportation.

• (11) At the end of the operation, protective equipment should be removed before leaving the isolated operating room. All medical waste generated during the operation should be packaged in a double-layer medical waste bag and disposed of as infectious medical waste.

• (12) After surgery, the operating room and equipment should be thoroughly disinfected. Continuous surgery should be avoided.^12,19

6.4 Management strategies for postoperative patients

• (1) Postoperative patients should be transported to the isolation ward along a dedicated transport channel.

• (2) SARS-CoV-2 nucleic acid and antibody test results should be reported in a timely manner. If the patient is positive for COVID-19, the department of Respiratory Infection should take over treatment of the patient after surgery, with gynecology providing assistance as needed. After stabilization of the patient’s condition, COVID-19-confirmed patients should be transferred to a designated hospital for treatment. If infection with SARS-CoV-2 is excluded, the patient can be transferred to the general ward for further treatment.

• (3) Monitor the patient’s temperature after surgery. If the patient develops fever, this should be investigated for cause, including postoperative complications such as infection and pulmonary embolism.

• (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.

• (6) Suspected or confirmed COVID-19 patients are more likely to develop complications such as deep vein thrombosis and pulmonary infection due to their more complex condition and the need for prolonged postoperative bed rest. Physicians should be particularly vigilant.

• (7) Efforts should be made to prevent pulmonary embolism. Pulmonary embolism can cause clinical manifestations similar to those of COVID-19: chest tightness, shortness of breath, decreased blood oxygen saturation. Lung CTA can be used as required.

• (8) Pay attention to patients’ needs for psychological interventions and counseling. Patients receiving treatment in isolation ward are prone to panic, anxiety and other negative emotions; medical staff should actively conduct psychological counseling for these cases.

8.1 Management after exposure of respiratory tract

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.

8.2 Management after exposure to blood and body fluids

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 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.