Abstract
Lay Summary
During the COVID-19 pandemic, the public delayed seeking medical help, which may have affected the impact of having an ectopic pregnancy. An ectopic pregnancy is when pregnancy tissue grows outside its normal position in the womb, and it can be life-threatening. It can be treated by non-surgical or surgical options, and any delay in seeking help can reduce the options for treatment and increase the need for more urgent management. We wanted to assess whether there were differences in the presentation and management of ectopic pregnancies in a major teaching hospital between 2019 (pre-COVID-19) and 2021 (COVID-19 period). We found that the pandemic did not cause a delay in seeking medical help or cause worse outcomes. In fact, immediate surgical treatment and time in the hospital were less during COVID-19, perhaps because of a desire to avoid admission to hospital. One outcome of COVID-19 is reassurance that we can safely use more non-surgical treatments for ectopic pregnancies.
Research Letter
During the COVID-19 pandemic, public attitudes towards seeking medical help changed with delayed presentations across multiple specialities, often leading to worse outcomes. A small number of studies have analysed the impact of COVID-19 on presentations and outcomes of ectopic pregnancies (EP) with mixed results. Two Israeli studies reported that during the lockdown in Spring 2020, rates of ruptured EP were higher than in previous years (Barg et al. 2021, Dvash et al. 2021). Whereas a study conducted in London in 2020 found no diagnostic delays or increase in adverse outcomes (Kyriacou et al. 2021). Most studies have focused on the initial pandemic wave from March 2020, yet COVID-19 had a lasting impact on the National Health Service (NHS) into 2021.
We hypothesised that if the presentation of EP was delayed there would be an increased rupture rate with increased immediate surgical management and morbidity. We assessed whether there were differences in the presentation and management of EP in a large single UK tertiary unit in 2019 and 2021. A retrospective cohort study was carried out using electronic patient notes of women diagnosed with EP in January–December 2019 (pre-COVID-19) and January–December 2021 (COVID-19 period).
There were similar numbers of EP diagnosed in 2019 (n = 157) and 2021 (n = 159; Table 1). In both years, the median gestation for presentation was 6 weeks and there were no differences in human chorionic gonadotropin (hCG) concentrations at the time of presentation. In 2019, 61% of women (n = 96) received immediate surgical management compared to 48% (n = 77) in 2021 (P = 0.02). There was no difference in the rate of sonographic haemoperitoneum in 2021 (23%; n = 37) when compared to that in 2019 (20%; n = 31; P = 0.49) or in the rate of failed medical management (4%; n = 6 vs 6%; n = 10; P = 0.44). There were no differences in estimated blood loss at surgery or haemoglobin change, but the number of days of admission was less in 2021 than in 2019 (P = 0.005).
Diagnosis, management and morbidity associated with ectopic pregnancy. Data are presented as median (range) or as n (%).
| 2019 | 2021 | P value | |
|---|---|---|---|
| Total number EP | 157 | 159 | |
| Age | 31 (15–47) | 31 (16–44) | 0.91 |
| Immediate surgical management | 96 (61%) | 77 (48%) | 0.02* |
| Medical management | |||
| 1 MTX only | 34 (21%) | 44 (27%) | 0.23 |
| 2 MTX onl) | 7 (4%) | 10 (6%) | 0.62 |
| 1 MTX + surgery | 5 (3%) | 9 (5%) | 0.41 |
| 2 MTX + surgery | 1 (1%) | 1 (1%) | 1.00 |
| Conservative management | 14 (9%) | 18 (11%) | 0.58 |
| Sonographic haemoperitoneum | 31 (20%) | 37 (23%) | 0.49 |
| Initial beta hCG (µ/L) | 1091 (21–56,309) | 595.5 (22–43,759) | 0.061 |
| Gestational age on initial review | 6 (0–16) | 6 (1–13) | 0.68 |
| Estimated blood loss (mL) | 200 (0–3000) | 200 (0–3000) | 0.96 |
| Estimated blood loss > 500 mL | 16 (10%) | 16 (10%) | 1.00 |
| Haemoglobin levels (g/dL) | |||
| Initial | 128 (102–151) | 130 (92–149) | 0.88 |
| Post operative | 112 (75–137) | 119 (77–133) | 0.15 |
| Drop | 12 (-6–44) | 8 (-11–40) | 0.12 |
| Days of admission following surgery | 1 (0–6) | 1 (0–3) | 0.005* |
| Number > 1 day admission | 31 (32%) | 15 (17%) | 0.03* |
hCG, human chorionic gonadotrophin; MTX, methotrexate.
*Represents statistically significant result (P < 0.05). Analysis was done by Student t-test for parametric data and Mann–Whitney test for non-parametric data with Fisher’s exact test for proportional categorical data.
Although the study is limited by small numbers, there was no evidence of delayed presentation in 2021 when compared to 2019. In 2021 women were less likely to receive immediate surgical treatment. This was also seen in London between March 2020 and August 2020 using EP registry analysis (Platts et al. 2021). The reason for this is likely to be multi-causal. COVID-19 caused a reduction in theatre capacity due to reduced staffing levels and more time-consuming infection control protocol. Clinical teams may also have opted to manage more conservatively. The British Society for Gynaecological Endoscopy issued guidance recommending non-surgical methods of treatment, in safe circumstances, to reduce the risk of COVID-19 transmission (2020).
Surgical management was most common during both years, but the lower rate of immediate surgery in 2021 was not correlated with more adverse outcomes such as blood loss, rate of sonographic haemoperitoneum and time in the hospital. Instead, patients in 2021 were discharged earlier. While we did not look at the impact of COVID-19 on the overall number of follow-up visits in this cohort, Platts et al. (2021) showed that during COVID-19 in 2020, conducting fewer follow-up visits for non-surgically managed EP did not result in more adverse effects. Our small study reassures about the impact of COVID-19 on managing EP and adds to the collective data on the safety of less invasive management options for EP and highlights there may be positive effects of the COVID-19 experience in the future management of EP.
Disclosure of interest
W Colin Duncan is an Associate Editor of Reproduction and Fertility and was not involved in the review or editorial process for this paper, on which he is listed as an author. The other authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
Author contribution statement
BC, CG and AP collected and analysed data and wrote the article. LS and CD conceived the project and reviewed the data analysis and the article.
References
Barg M, Rotem R, Mor P, Rottenstreich M, Khatib F, Grisaru-Granovsky S & & Armon S 2021 Delayed presentation of ectopic pregnancy during the COVID-19 pandemic: a retrospective study of a collateral effect. International Journal of Gynaecology and Obstetrics 153 457–461. (https://doi.org/10.1002/ijgo.13647)
Dvash S, Cuckle H, Smorgick N, Vaknin Z, Padoa A & & Maymon R 2021 Increase rate of ruptured tubal ectopic pregnancy during the COVID-19 pandemic. European Journal of Obstetrics, Gynecology, and Reproductive Biology 259 95–99. (https://doi.org/10.1016/j.ejogrb.2021.01.054)
Kyriacou C, Cooper N, Robinson E, Parker N, Barcroft J, Kundu S, Letchworth P, Sur S, Gould D, Stalder C, et al.2021 Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic. Ultrasound in Obstetrics and Gynecology 58 909–915. (https://doi.org/10.1002/uog.24793)
Platts S, Ranawaka J, Oliver R, Patra-Das S, Kotabagi P, Neophytou C, Shah N, Toal M, Bassett P, Davison A, et al.2021 Impact of severe acute respiratory syndrome coronavirus 2 on ectopic pregnancy management in the United Kingdom: a multicentre observational study. BJOG 128 1625–1634. (https://doi.org/10.1111/1471-0528.16756)
RCOG & BGSE 2020 Joint RCOG/BSGE Guidance on gynaecological endoscopy during the Covid-19 pandemic. Available at: https://www.rcog.org.uk/globalassets/documents/ guidelines/2020-12-21-joint-rcog-bsge-gynaecologicalendoscopy.pd.
