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.