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COVID-19: Category 1 (Australia) and Urgent (New Zealand) Gynaecological Conditions and surgical risks

25 March 2020

Update 4 April 2020

(Please note: This statement was previously titled COVID-19: Category 1 (Australia) and Urgent (New Zealand) Gynaecological Conditions. The name change and content changed occurred on March 29)
 
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges the risk posed to the community, health workers and all patients due to the COVID-19 pandemic. RANZCOG also recognises our responsibility to respond to this situation as a large organisation and also as a medical college and health leader.
 
The College respects the role of government, health departments and health administrators in coordinating a national response. The College has already raised the importance of hospitals considering a reduction, or cessation, of elective surgical procedures in preparation for a potential surge in hospital admissions. The purpose of this communiqué is to address the issue of categorisation of emergency and essential gynaecological services. As healthcare resources and personnel are limited, triaging decisions will need to be made.

The College recommends that gynaecological surgery should be restricted to urgent/non-elective and those that meet the criteria for Category 1(Australia) i.e.urgent.. As always, it is essential that all services defer to justifiable clinician assessment and discretion. In New Zealand, the guidance, from the New Zealand Ministry of Health, codes surgical procedures as routine, semi-urgent and urgent. There is also reference to deferrable and non-deferrable. In this document, we consider Category 1 in Australia to be essentially equivalent to urgent, or non-deferrable, in New Zealand.

The College recommends that the following gynaecological conditions merit Category 1 (urgent) classification. As always, it is essential that all services defer to justifiable clinician assessment and discretion:
 
  • Assessment and treatment associated with suspected or proven gynaecological cancers
  • Acute haemorrhage not responsive to medical treatment
  • Early pregnancy assessment for risk of miscarriage and ectopic pregnancy
  • Timely access to abortion services, both medical and surgical
  • Acute pelvic pain e.g. suspected ovarian torsion, cyst accident, acute pelvic abscess, Bartholin’s abscess causing severe pain
  • Acute on chronic pelvic pain following failed medical management and after multidisciplinary team assessment

NB: Gynaecological care usually requires ultrasound, other imaging and pathology services

Accurate triage is critical to preserving resources and protecting staff and patients. Consideration should be given to non-surgical options. A recommendation for surgery would ideally be made in a multidisciplinary team setting. Clinicians should engage in informed consent and shared decision making with their patients, with attention to counselling patients about the risks of surgical delay versus potential in hospital COVID-19 exposure. It is best practice to make decisions regarding surgery for COVID-19 patients in a multidisciplinary team.

There are variations in access to operating theatres between centres within the same state or territory in Australia. Allowable Category 1 or semi-urgent cases (e.g. surgery for cancer) today may change tomorrow as has been seen in the New York city where cancer cases are being deferred. 
 
If you are still performing surgery, observe these overarching principles during these extraordinary times.
 
Surgical risks
 
General
  • Simulation training in PPE competency is strongly encouraged
  • All usual surgical principles regarding sterile procedures and theatre sanitisation should still apply. This includes allowing for additional time for changeover between cases.
  • To reduce exposure, the surgical team should vacate the theatre during intubation and extubation.
  • To reduce exposure, the duration of the procedure should be kept as short as practical
  • Equipment to reduce the effects of aerolisation should be utilised
  • Personal Protective Equipment should be used in line with locally developed protocols
 
Laparoscopy or laparotomy?
  • Laparoscopy may be the appropriate surgical modality because of specific surgical advantages, shorter length of hospital stay, quicker recovery and comparable, often superior, surgical outcomes
  • Laparoscopy is an aerosol-generating procedure. Therefore consider using lower insufflation pressures, smoke evacuators intraoperatively and when releasing the pneumoperitoneum. Cease insufflation during specimen retrieval
  • Bowel surgery is associated with a higher risk of viral transmission and a laparotomy may be a better alternative.
 
RESOURCES
 
American College of Surgeons
 
RCOG/BGSE Joint Statement

Surgical Considerations for Gynecologic Oncologists During the COVID-19 Pandemic (Society of Gynecologic Oncology)



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