Surgical prioritization of obstetrics and gynecology procedures in the UK during the COVID-19 pandemic.

The COVID‐19 pandemic has strained healthcare systems across the world. One such impact has been on surgical practice in the United Kingdom’s (UK) National Health Service (NHS). From March 17, 2020, NHS hospitals were instructed by NHS England to postpone non‐urgent elective operations for 3 months. The present study offers a summary of the guidance available on the prioritization of surgical services pertaining to obstetrics and gynecology in the UK.

Obstetric care is a core, non‐elective service with little scope for prioritization. Therefore, a balance between the COVID‐19 response and continued management of obstetric risk is needed. Suggestions have included suspension of certain maternity services, allowing for consolidation of nearby units, and changes to women’s choices regarding birthplace (home, midwifery‐led, or obstetric unit).

Gynecological services, however, have experienced significant re‐prioritization since the onset of the pandemic and at present as services are being restored. The Royal College of Obstetricians and Gynaecologists (RCOG) and British Gynaecological Cancer Society (BGCS), in collaboration with other specialist societies, have provided guidelines comprising four priority levels to aid the triage of patients and help restore services. These range from Priority 1 cases (emergency surgery) to Priority 4 cases (deferred surgery beyond 3 months). Table 1 provides an overview.

The response of specialist societies in providing guidance for surgical prioritization has been excellent. , However, interpretation of these clinical priorities will undoubtedly vary across trusts due to the overlap in groupings and varying constraints in Intensive Care Units (ICU) and High Dependency Unit (HDU) facilities.

Therefore, it is important that practice is as safe for practitioners as it is for patients themselves. Ordinarily, triage decisions are made primarily in the best interests of the patient. However, current guidelines also take into account the change in availability of resources and the COVID‐19 risk. Whilst urgent procedures are prioritized, situations such as the incorrect placement of a patient within overlapping priorities or delays due to lack of ICU and HDU facilities may arise. In the event of any resultant adverse outcome, clear medico‐legal guidance for doctors is needed for protection against decisions which typically would be outside of normal practice. This could be implemented by updating consent forms based on the different risks associated with these changes.

Finally, in order to minimize discrepancies in care across trusts, it is vital that women receive individual holistic assessment with particular emphasis on safety alongside these prioritization frameworks.

AUTHOR CONTRIBUTIONS

SM, NK, AA and ARA contributed substantially to the conception of this piece. All authors performed the literature review. All authors contributed to drafting the article and provided critical revision. SM provided final approval of the version to publish. All authors agreed to be accountable for the accuracy of all aspects of the work.

CONFLICTS OF INTEREST

The authors have no conflicts of interest.

Table 1

Summary of prioritization of surgical services within obstetrics and gynecology during the COVID‐19 pandemic. ,

Priority level	Time to surgery	Gynecology	Gynecologic oncology
1a	Surgery within 24 h	Adnexal torsion Tubo‐ovarian abscess Genital trauma Intra‐abdominal bleeds Burst abdomen Ectopic pregnancy Miscarriage with heavy vaginal bleeding	Intra‐abdominal bleeds Stoma leak Peritonitis
1b	Surgery within 72 h	Pelvic abscess unresponsive to antibiotics Post‐operative wound complications Unresolved pelvic pain Bartholin’s abscess	Laparotomy for bowel obstruction Staging for cervical cancer Life threatening haemorrhage from cervical/uterine cancers
2	Surgery within 4 wk	Hysteroscopy/endometrial biopsy for suspected endometrial hyperplasia or cancer	Debulking surgery Treatment of all gynecological malignancies with view to save life or prevent progression beyond operability Treatments for vulval intraepithelial neoplasia (VIN) and high grade cervical intra epithelial neoplasia (CIN)
3	Surgery within 3 mo	Hysteroscopy for abnormal bleeding Endometrial ablation Endometriosis treatment Hysterectomies for heavy menstrual bleeding and fibroids	Low grade cancers with preliminary treatment given E.g. low‐volume cervical cancers completely excised at loop excision, or uterine cancer managed by progestogens
4	Surgery after 3 mo	Diagnostic hysteroscopy Structural abnormalities Investigation for pain and endometriosis Myomectomies Prolapse and/or incontinence	Stoma reversals