To Fight or to Flee? A Systematic Review of Ectopic Pregnancy Management and Complications During the Covid-19 Pandemic.

BACKGROUND/AIM: During the COVID-19 pandemic, concerns regarding theoretical risks of surgery contributed to changes in clinical management to prevent contamination. We looked at the effect the pandemic had on the management of ectopic pregnancy. Our review compares published data on pre-COVID to COVID management of ectopic pregnancies and evaluates the differences where Early Pregnancy Unit (EPU) structures exist. MATERIALS AND METHODS: We performed a systematic review of the published evidence using a keyword strategy. The "Population Intervention Comparison and Outcome" (PICO) criteria were used to select studies. Three independent reviewers agreed on the data extracted after screening of the literature. The total population analysed included 3122 women. A meta-analysis of the included studies was completed using a random or fixed effect model depending on the heterogeneity (I2). Our outcomes were the following: type of management of ectopic pregnancy (EP), incidence of ruptured EP and rate of complications. We compared units with and without EPU infrastructure. RESULTS: We included every study which recruited women diagnosed with ectopic pregnancy and compared the type of management during and prior the COVID-19 peak. Our literature search yielded 34 papers. 12 were included using the PRISMA guidelines. We observed no difference in the type of management (surgical versus non-surgical) [OR=0.99 (0.63-1.55), p=0.96, I2=77%] in the pre-Covid vs. Covid cohorts overall but a reduction of surgical management in EPU structures. There was no difference in the ectopic rupture rate within the EPU branch [OR=0.66 (0.33-1.31), p=0.24, I2=37%]. In contrast, in non-EPU (NPEU) structures there was a clear increased risk of ruptured ectopic pregnancy [OR=2.86 (1.84-4.46), p<0.01 I2=13%] and complications [OR=1.69 (1.23-2.31), p=0.001, I2=45%]. CONCLUSION: The risk of ruptured ectopic and complications was significantly higher in the absence of EPU structures. This worldwide trend was not reflected in the UK, where EPU systems are widespread, suggesting that EPU structures contributed to prompt diagnosis and safe management. In the post-COVID era, healthcare systems have come to realise that pandemics might become the norm and thus the onus is to identify services that have worked seamlessly.

Diagnostic Challenges of an Abdominal Pregnancy in the Second Trimester.

Abdominal pregnancies are a rare form of ectopic pregnancy, which presents a significant risk of maternal morbidity and mortality. We describe an unusual case of a late diagnosis of an abdominal pregnancy in the second trimester, which due to diagnostic challenges, was not detected on 1st trimester and subsequent antenatal ultrasound scans (USS). The abdominal pregnancy was later diagnosed at the repeat anomaly scan and confirmed with a pelvic MRI. This case of abdominal pregnancy is unique when compared to other reported cases, as the fetus was initially enclosed within the amniotic sac with normal liquor volume. Both transvaginal and transabdominal scans appeared to demonstrate an intrauterine pregnancy. The diagnosis of abdominal pregnancy was only made possible following rupture of the amniotic sac, leading to anhydramnios, which resulted in the repositioning of the fetus to the upper maternal abdomen. This case represents the challenges faced by obstetricians in diagnosing, managing, and counselling a woman when faced with an abdominal pregnancy.