key: cord-0790660-zf989c8r
authors: Toma, Helen V.; Bank, Tracy Caroline; Hoffman, Matthew K.
title: Care for Women With Ectopic Pregnancies During the Coronavirus Disease 2019 (COVID-19) Pandemic
date: 2021-05-04
journal: Obstet Gynecol
DOI: 10.1097/aog.0000000000004392
sha: d4db0947c74a788cf43a65246c9ee72d0d68cd38
doc_id: 790660
cord_uid: zf989c8r

Women with ectopic pregnancies may be delaying care owing to concerns over coronavirus disease 2019 (COVID-19) exposures and presenting for medical care in more critical condition.

S ince coronavirus disease 2019 (COVID-19) was declared a global pandemic, health care systems have adapted to deal with an influx of COVID-19related illness while maintaining essential services. 1 We compared rates of ectopic pregnancy rupture at a large tertiary care center before and after COVID-19 achieved pandemic levels.

We performed a retrospective observational cohort study of women treated for ectopic pregnancy in Newark, Delaware. We obtained ChristianaCare Institutional Review Board approval (CC# 40111).

Patients cared for between March 2019 and February 2020 were in the PRECOVID group, and those seen between March 2020 and June 2020 were in the COVID group. Patients were identified and data extracted from the electronic medical record. Cases were confirmed through manual chart review. Race and ethnicity were self-reported in the electronic medical record.

The primary outcome was the rate of presentation with a ruptured ectopic pregnancy. Additional outcomes examined included rates of blood transfusion, presenting b-hCG levels, resolution using medical treatment, estimated blood loss, and hemoperitoneum at the time of surgery (Appendix 1, available online at http://links.lww.com/AOG/C287). Detailed methods are reported in Appendices 2 and 3, available online at http://links.lww.com/AOG/C287.

Our cohort included 198 women with ectopic pregnancies: 62 in the COVID group and 136 in the PRE-COVID group. Demographics for patients were similar between the two groups, except for ethnicity (Table 1) .

Most patients were treated surgically (64%). There was a statistically significant increase in ruptured ectopic pregnancies during the COVID-19 pandemic period (81% vs 60%, relative risk [RR] 1.34, 95% CI 1.06-1.7). The rate of methotrexate treatment failure was similar (19% vs 13%, RR 1.47, 95% CI 0.50-4.36). Of note, the methotrexate protocol did not differ before and during the COVID-19 pandemic period. There was a nonstatistically significant increased rate of blood transfusions in the COVID-19 pandemic period (28% vs 11%, RR 2.48, 95% CI 0.95-6.47).

Our study showed a concerning increased rate of ruptured ectopic pregnancies during the COVID-19 pandemic period. This is in line with studies study from Northern Italy and New York that reported similar findings. 2,3 If women avoid seeking medical care early in pregnancy owing to fears about COVID-19, methotrexate treatment may be more likely to fail, leading to increases in morbidity and mortality.

Limitations of our study include those inherent to an observational retrospective study, including the inability to draw causal inferences. Additionally, it is possible that women who presented with ruptured ectopic pregnancies did not originally follow-up with previously recommended instructions. Finally, this is a single institution study that may not be generalizable to other populations.

Concerns about late presentation to care during the COVID-19 pandemic have been described in numerous specialties, including surgery, cardiology, and pediatrics, raising concerns that a worrying trend is emerging. [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] Our data suggest that women may be delaying care owing to concerns about COVID-19 exposure and presenting in more critical condition. Although it is important to continue to encourage the public to practice social distancing measures, it is equally important to encourage patients to present for care if they experience worrying symptoms. Efforts to educate patients through social media campaigns, access to urgent care telemedicine, and other strategies may help overcome these challenges. Monitoring the indirect effects of COVID-19 on health outcomes not related to virus infection remains important as the pandemic continues. Unauthorized reproduction of this article is prohibited.

World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19-11

Increased rate of ruptured ectopic pregnancy in the COVID-19 pandemic: an analysis from the North of Italy

Change in ectopic pregnancy presentations during the covid-19 pandemic

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Delayed access or provision of care in Italy resulting from fear of COVID-19

The untold toll-the pandemic's effects on patients without Covid-19

Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage

Emergency surgery in COVID-19 outbreak: has anything changed? Single center experience

Acute care surgery during the COVID-19 pandemic in Spain: changes in volume, causes and complications. A multicentre retrospective cohort study

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Where have all the emergencies gone? The impact of the COVID-19 pandemic on obstetric and gynecologic procedures and consults at a New York City hospital

The impact of COVID-19 lockdown on admission to gynecological emergency departments: results from a multicenter Italian study