Discussion
This rapid systematic review of 12 studies compares the management of
ectopic pregnancy during the peak of covid-19 with a similar cohort
pre-Covid. Despite the initial perceived risks of viral transmission
associated with surgery and general anaesthetics (10), there was no
significant difference in the rate of surgical management between the
covid-19 and pre-Covid cohorts overall. This trend is confirmed in
studies conducted where EPU structures have not been implemented.
Werner et al reported an increased rate of undiagnosed EP during
the height of Covid-19 resulting in a higher rate of haemodynamically
unstable patients and need for surgical management (28). Similar
findings of increased surgical management, mostly secondary to higher
rate of rupture, were expressed in a meta-analysis of three studies by
Chmielewska et al (20) . However, in hospitals where EPU
structures exist, there is a clear trend towards non-surgical
management. Conservative or medical management was advised for the
appropriately selected patients (11). This finding is particularly
supported by 2 multicentred studies by Platts and Kyriacou (21,24). This
trend could be explained by the advice from national bodies recommending
the use of conservative and medical management for EP during the
pandemic (15). This guidance was motivated by safety concerns with the
aim to limit hospital foot fall and unnecessary exposure to potential
aerosol generating procedures for both patients and staff. When surgery
was required, in the UK, minimal access surgery was recommended over
open surgery with use of additional precautions (smoke extractor, full
PPE, minimal use of electrosurgery) as the lack of evidence of
coronavirus transmission did not mean infection is not possible (18, 29)
.
We highlight a significantly increased rate of ruptured ectopic
pregnancies within the Covid-19 cohort in the NEPU branch of our study.
Many studies reported a significant reduction in the number of women
presenting with gynaecological problems to emergency departments during
the covid-19 pandemic (2). It is speculated that women who had to attend
main emergency departments would delay their visit for fear of infection
by Covid-19. In these circumstances, women were found to be more
symptomatic at presentation (2, 26). Such delay in presentation offers
an explanation to the increased rate of ruptured ectopic, and
subsequently, to the higher use of blood transfusion and higher
complication rate. A case series from a tertiary referral centre in
India revealed 28 cases of rupture out of 32 diagnosis of ectopic
pregnancies during an 8-month period at the peak of Covid-19 (30). Our
meta-analysis did not reveal any increase in the rate of ectopic rupture
during Covid in healthcare system with EPU structures. Kyriacou et
al report no difference in the ectopic rupture rate during Covid
despite a slightly higher level of bHCG at diagnosis (24).
Our data analysis revealed no difference in the complication rate in the
EPU cohort. In contrast, in the NEPU cohort, the rate of complication
was significantly increased (RR 1.69) during Covid-19. Anteby et
al commented that in their study, women with a confirmed diagnosis of
EP were significantly more symptomatic on arrival (2). This may explain
the higher requirements of blood transfusion and other complications for
women in the NEPU Covid cohort.
The structured systems of EPU in the UK, where women are encouraged to
self-refer, may have prevented the delay in presentation disclosed in
studies without EPU structures. Also, A and E would be very busy during
covid peaks with even longer waiting time for non-covid related
presentations. This may be coupled with the fact that these units are
often away from the Accident and Emergency department, hence reducing
women fears of possible nosocomial contamination with coronavirus.
During the Covid peak wave, women continued to self-refer to EPU with
symptoms such as pain or bleeding in early pregnancy and be assessed
within 24 hours with a transvaginal scan. Equally, if further visits
were indicated for follow up of PUL or medical treatment with
methotrexate, they could safely attend consecutive visits in the EPU
with an appointment. We did not find evidence of a similarly structured
Early Pregnancy Unit system in any of the countries where other studies
were published: USA, Canada, Israel and Italy. The value of such units
has been assessed in the USA (31), Canada (32),(33), and Australia (34)
with good evidence of cost effectiveness. Despite EPU reported
efficiency in reducing repetitive assessments and improving follow up of
women with ectopic pregnancy, it has not yet been integrated into
healthcare systems worldwide.
We have analysed the effect of the pandemic restrictions on the
presentation, management and ensuing complications of ectopic
pregnancies based on data from 12 studies published world-wide,
involving various healthcare systems, all impacted by the Covid-19
pandemic. This was also a good opportunity to compare existing
structures of early pregnancy and emergency gynaecology services. And
importantly, we have sought to identify the safest and most efficient
method of service provision for ectopic pregnancy as wide dissemination
of the knowledge of such a service and its adoption by all health
services would ensure a robust recovery programme and will enable the
health service to resist future pandemics efficiently.
A retrospective study reported a high patient satisfaction level after
surgical care -including some gynaecological cases- during Covid 19.
Patients rated the hospital stay high and also reported very good
emotional and mental health following surgery (35). We did not identify
any published patient’s satisfaction survey related to early pregnancy
care during Covid-19 in either type of healthcare structures (EPU and/or
NEPU). Evaluating the stakeholders’ opinion and feedback in EPU versus
NEPU in times of a pandemic crisis could contribute to understanding the
difference in outcomes that we revealed in our analysis.