ISUOG Consensus Statement on rationalization of gynecological ultrasound services in context of SARS‐CoV‐2

Given the challenges of the current coronavirus (SARS-CoV-2) pandemic and to protect both patients and ultrasound providers (physicians, sonographers, allied professionals), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) has compiled the following expert-opinion-based guidance for the rationalization of ultrasound investigations for gynecological indications. This guideline focuses on patients with gynecological complaints. Recommendations for each triage category are summarized in Table 1 and justification is provided within the document. - Ovarian torsion - Ruptured hemorrhagic ovarian cyst - Pelvic inflammatory disease and/or tubo-ovarian abscess - Menorrhagia with severe anemia or hemodynamic instability - Postmenopausal bleeding - Postcoital bleeding - High risk of malignancy as per IOTA-ADNEX model (≥ 10%) Ultrasound evaluation should be postponed for duration of pandemic Patients may still be referred for ultrasound assessment, but appointments will not be given until pandemic is over; appropriate systems should be put in place to ensure appointments take place at a later date - Breakthrough bleeding while on hormonal medication - Heavy menstrual bleeding/menorrhagia without associated anemia - Infrequent menstrual bleeding (oligomenorrhea) - Intermenstrual/irregular bleeding - Perimenopausal abnormal uterine bleeding - Chronic pelvic pain - Cyclical dyschezia - Dysmenorrhea - Dyspareunia - Unilocular cyst - Endometrioma - Dermoid/mature cystic teratoma - Hemorrhagic ovarian cyst (including corpus luteal cyst) - Hydrosalpinx - Low risk of malignancy as per IOTA-ADNEX model (< 10%) - Uterine polyp(s) - Leiomyoma(s) - Adenomyosis - Endometriosis Endometriosis and adenomyosis are amongst the most common conditions leading to any of these pain complaints. In many cases, a number of symptoms are present. While these are extremely troublesome conditions, patients and healthcare providers should consider delaying ultrasound evaluation until resolution of the COVID-19 pandemic. Acute episodes of pelvic pain in the presence of persistent non-acute pelvic pain should continue to be evaluated as outlined above. Although some centers have suspended elective gynecological surgery, most centers continue to perform urgent gynecological oncology procedures. In all centers, emergency procedures (e.g. Cesarean section, ectopic pregnancy, ovarian torsion) will still need to be performed during the pandemic and postoperative complications (e.g. hemorrhage, abscess, collections, hydronephrosis) should be considered. If there is suspicion of a procedure-related complication (e.g. perforation) or the patient experiences an adverse event post-procedure, such as after placement of an intrauterine contraceptive device (IUCD) (e.g. severe pain, bleeding, infection), gynecological ultrasound should be offered immediately. Ultrasound assessment should also be offered after major oncological procedures, if required (see also ‘gynecological malignancy’ section below). Postmenopausal bleeding (SOON): Postcoital bleeding (SOON): First diagnosis: Uterine: Ovarian: Extrauterine and extraovarian: During the pandemic, there is expected to be a decrease in face-to-face consultations, which will likely mean a reduction in appointments for placement of IUCD. However, contraception is essential and patients should still be offered IUCD as an option. Should a patient choose an IUCD and undergo placement, we recommend postponing any routine evaluation of placement by gynecological ultrasound until the resolution of the pandemic. If IUCD strings cannot be seen on speculum examination, we suggest recommending to the patient back-up contraception and postponing ultrasound evaluation, as it is known that asymptomatic perforation or expulsion is very rare. Patients undergoing active follow-up based on ultrasound should be counseled about the symptoms of recurrent disease and be advised to inform the gynecological oncology team in charge of their care by telephone if they develop any such symptoms. All women in need of care should be triaged based on their symptoms and infection status. Ideally, this should be carried out over the phone by a senior healthcare practitioner prior to an appointment. However, in the event that the patient is first seen in the clinic, the healthcare professional undertaking triage should wear appropriate personal protective equipment (PPE). Triaging for common symptoms, such as cough and fever7, is critical before a patient gains access to a clinical area for an ultrasound scan or consultation. Screening for travel, occupation, contact and cluster (TOCC) risk factors should also be implemented. If the local prevalence of COVID-19 increases, a policy of managing all patients as high risk may need to be implemented at some point. We also recommend that senior healthcare practitioners acquire and consider the details of the clinical history of the women to determine whether they need to attend the hospital or clinic. Any woman with probable or confirmed COVID-19 should be asked not to attend the unit. If assessment is required, they must be seen in a designated COVID-19 area. Only screen-negative patients or patients with probable COVID-19 who need to be reviewed without delay should be asked to attend the unit. If an ultrasound scan is required, we recommend that one ultrasound machine and room is designated for patients with probable or confirmed COVID-19, if possible. It is important to clean the equipment according to safety guidelines8. If a patient with suspicion of COVID-19 is stable, they should be sent home to self-isolate for 7 days, if clinically appropriate. Ideally, any patient who is cohabiting with someone who shows possible symptoms of COVID-19 should self-isolate for 14 days; however, in the context of early-pregnancy care, this is unlikely to be practical9. Any rooms or areas in the department in which the patient was present will require deep cleaning. If the patient requires admission to the hospital, the location will depend on the reason for admission and availability of a side room until SARS-CoV-2 testing confirms their status. Any patient with a suspicion of possible SARS-CoV-2 infection must be highlighted immediately to all healthcare team members. All recommendations from local infection-control departments should be followed, including: T. Bourne, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK; Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Development and Regeneration, Leuven, Belgium M. Leonardi, Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia C. Kyriacou, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK M. Al-Memar, Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK C. Landolfo, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy D. Cibula, Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic G. Condous, Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, Sydney Medical School Nepean, University of Sydney Nepean Hospital, Penrith, Sydney, Australia U. Metzger, Centre d'Échographie de l'Odéon, Paris, France D. Fischerova, Gynaecological Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic D. Timmerman, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium; KU Leuven, Department of Development and Regeneration, Leuven, Belgium T. van den Bosch, Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium Peer review was provided by Juan-Luis Alcazar (Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Pamplona, Spain), Misty Blanchette-Porter (Larner College of Medicine at the University of Vermont Obstetrics, Gynecology, and Reproductive Sciences Division, Reproductive Medicine and Infertility Burlington, VT, USA), Christina Fotopoulou (Department of Surgery and Cancer, Imperial College London, London, UK) and Wouter Froyman (KU Leuven, Department of Development and Regeneration, Leuven, Belgium).