ORIGINAL ARTICLE | https://doi.org/10.5005/jp-journals-10006-1956 |
Impact of Both the Waves of COVID-19 Pandemic on Ectopic Pregnancy in India
1–6,9Department of Obstetrics and Gynecology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
7,8Department of Clinical Research Laboratory, Mumbai, Maharashtra, India
*These authors contributed equally.
Corresponding Author: Rahul K Gajbhiye, Department of Clinical Research Laboratory, Mumbai, Maharashtra, India, Phone: +91 22 24192036, e-mail: gajbhiyer@nirrh.res.in; Niraj N Mahajan, Department of Obstetrics and Gynecology, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India, Phone: +91 9004696920, e-mail: nirajdr@hotmail.com
How to cite this article: Pednekar R, Kore SJ, Sankalecha S, et al. Impact of Both the Waves of COVID-19 Pandemic on Ectopic Pregnancy in India. J South Asian Feder Obst Gynae 2021;13(6):403–406.
Source of support: Intramural grant of ICMR-NIRRH (No. ICMR-NIRRH/RA/1070/05-2021). Rahul K Gajbhiye is an awardee of the DBT Wellcome Trust India Alliance Clinical and Public Health Intermediate Fellowship (Grant no. IA/CPHI/18/1/503933).
Conflict of interest: None
ABSTRACT
Aim and objective: Although two-wave pattern of the coronavirus disease-2019 (COVID-19) pandemic was observed in many countries, there is limited information on the impact of both the waves on clinical presentations of ectopic pregnancy (EP) with COVID-19. Therefore, we aimed to understand the impact of the first wave and second wave of COVID-19 pandemic on women with EPs in India.
Materials and methods: We conducted a retrospective study at BYL Nair Charitable Hospital (NH), a dedicated COVID-19 tertiary care hospital in Mumbai, India. We analyzed the impact of the first wave and second wave on women with EPs and the challenges encountered for management during the pandemic in our hospital.
Results: A total of 1,660 pregnant and postpartum women with confirmed diagnosis of COVID-19 were admitted at NH during the first wave and the second wave of the COVID-19 pandemic. All cases of EP were asymptomatic for COVID-19. During the prepandemic period of 4 years, there were 220 (15.2 per 1,000 births) women with EPs, which was higher compared to seven EPs (6.3 per 1,000 births) during the COVID-19 pandemic. EP rate per 1,000 births during the second wave was found to be 9.6, which is comparatively higher than the first wave (3.8) (p = 0.24).
Conclusion: Increased frequency of EPs during the second wave of the COVID-19 pandemic could be due to the new variant of concern B.1.617. 2 (Delta). For ruptured EP, we recommend surgical management with laparotomy as a treatment option as it is useful in reducing the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to healthcare workers.
Clinical significance: The COVID-19 pandemic is likely to last longer and hence healthcare providers should ensure that pregnant women have access to medical assistance whenever needed.
Keywords: Cesarean scar pregnancy, Coronavirus disease-2019, Ectopic pregnancy, Low-income and middle-income country, Pregnancy, Severe acute respiratory syndrome coronavirus 2 infection
INTRODUCTION
Coronavirus disease-2019 (COVID-19) is a global concern and India continues to be among the top two countries having increasing numbers of COVID-19 cases.1 The second wave of the COVID-19 pandemic was more fatal than the first wave leading to increased severity of disease, intensive care unit admissions, and maternal mortality.2 Although two-wave pattern of the COVID-19 pandemic was observed in many countries, there is limited information on the impact of both the waves on differences in clinical presentations of ectopic pregnancy (EP) with COVID-19 during the first wave and second wave of the COVID-19 pandemic. EP is a life-threatening condition and the reported incidence of EP is 1–2% of all pregnancies3 accounting to 2.7% of pregnancy-related maternal deaths.4 The majority of the cases (85%) in the Western population are detected before they present with a rupture3 in contrast to low-income and middle-income countries (LMICs). Rupture of the fallopian tube leads to internal bleeding and death in women with EPs. Several risk factors have been reported, including previous history of EP, in vitro fertilization (IVF), and mechanical obstruction of the fallopian tubes.3,5 The COVID-19 pandemic has impacted early pregnancy care globally. There is limited information available on the impact of COVID-19 pandemic on women with EPs. This information is extremely important as the management of ruptured EPs is extremely challenging in low-resource settings. Therefore, to understand the impact of the first wave and second wave of COVID-19 on women with EPs, we conducted a retrospective study at BYL Nair Charitable Hospital (NH), a dedicated COVID-19 tertiary care hospital in Mumbai, India. Additionally, we describe the management of seven EPs, including one cesarean scar pregnancy (CSP) and challenges encountered in our hospital.
MATERIALS AND METHODS
A retrospective data analysis of the medical case records of women with COVID-19 and EPs admitted at NH was carried out. A total of 1,660 pregnant and postpartum women who suffered through COVID-19 were admitted at NH as per the admission policy described elsewhere,3 during the first wave (n = 1,143) (April 1, 2020–January 31, 2021) and the second wave (n = 517) (February 1, 2021–July 26, 2021) of the COVID-19 pandemic. The COVID-19 diagnosis was confirmed as per the existing National testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in India.6 Transvaginal sonography (TVS) was performed for confirmation of EP. The study was approved by the Ethics Committees of NH and ICMR-NIRRH. Since the data were collected from the medical case records of the pregnant women with COVID-19, a waiver of consent was granted by the IECs. The primary outcome was the rate of EPs diagnosed during the first and second waves of COVID-19 pandemic. Secondary outcomes included the clinical presentations, rate of ruptured EPs requiring surgical management, need for blood transfusions, and duration of hospital stay. The statistical analysis was conducted with Prism (GraphPad, San Diego, California, USA). p value of <0.05 was considered statistically significant.
RESULTS
During the 15 months of study period (April 1, 2020, to July 26, 2021), a total of 1,091 women with COVID-19 were delivered at NH during both the waves of the COVID-19 pandemic compared to 14,511 women during 4 years of prepandemic period (January 2016–March 2020) (Supplementary Table 1). The number of EPs at NH during pandemic (2020–2021) and prepandemic period (2016–2020) was 7 and 220, respectively. The EP rate was 15.2 per 1,000 births during prepandemic period compared to 6.3 per 1,000 births during the COVID-19 pandemic. The rate of EP per 1,000 births at NH during the second wave is found to be comparatively higher (12.1 per 1,000 births) than the first wave (3.8 per 1,000 births) (Table 1).
| Parameters | Total EP cases during COVID-19 pandemic; n = 7 | The first wave of COVID-19 pandemic (April 1, 2020–January 31, 2021); n = 3 | The second wave of COVID-19 pandemic (February 1, 2021–July 26, 2021); n = 4 |
|---|---|---|---|
| The total number of pregnant and postpartum women managed | 1,660 | 1,143 | 517 |
| Total number of deliveries among COVID-19 mothers | 1,091 | 771 | 320 |
| Total births among COVID-19 mothers | 1,113 | 783 | 330 |
| EP rate per 1,000 births | 7 (6.3) | 3 (3.8) | 4 (12.1)a |
| Mean age | 29.6 | 29.3 | 29.8 |
| Multigravida | 7 (100) | 3 (100) | 4 (100) |
| Weeks of gestation | 7 (7–8.5) | 8 (7–9) | 7 (7–7.5) |
| Previous cesarean section | 1 (14.3) | 1 (33.3) | 0 |
| Spontaneous conception | 7 (100) | 3 (100) | 4 (100) |
| Previous spontaneous abortion | 3 (42.9) | 1 (33.3) | 2 (0) |
| Previous EP | 1 (14.3) | 1 (33.3) | 0 |
| Anemia | 6 (85.7) | 2 (66.7) | 4 (100) |
| Asymptomatic for COVID-19 | 7 (100) | 3 (100) | 4 (100) |
| Clinical presentation of ectopic pregnancy and treatment | |||
| Cesarean scar pregnancy | 1 (14.3) | 1 (33.3) | 0 |
| Ruptured EP | 6 (85.7) | 2 (66.7) | 4 (100) |
| Blood transfusion | 6 (85.7) | 2 (66.7) | 4 (100) |
| Medical treatment | 1*(14.3) | 1 (33.3) | 0 |
| Surgical treatment | 6 (85.7) | 2 (66.7) | 4 (100) |
| Median duration of hospital stay | 7 (5–7.5) | 7 (7–13.5) | 5 (4–6.5) |
| Maternal mortality | 0 | 0 | 0 |
Of the seven EPs during COVID-19 pandemic, six were managed surgically and one was managed by medical treatment. One case of CSP was reported during the COVID-19 pandemic period compared to three CSP during prepandemic period. Six out of seven (85.7%) women presented with ruptured EP with hemoperitoneum and anemia requiring blood transfusion and emergency surgical management with laparotomy.
All cases of EP were asymptomatic for COVID-19. The median age of the women with EP in the pandemic period was 30 years and all women belonged to low socioeconomic strata. None of the women with EP had any comorbidities. All women with EP were multigravida, one had a prior history of EP, and three had a previous history of spontaneous abortions. The median duration of hospital stay of EP cases was higher during the first wave (7 days) compared to the second wave (5 days) (Table 1).
One woman with EP reported during the first wave of COVID-19 had a history of previous cesarean section. All women with EPs during both the waves of pandemic had conceived spontaneously. One woman had a history of previous EP in our study cohort. Six women with EPs had anemia. All four women with EPs required blood transfusion during the second wave (Table 2).
| Parameters | First wave of COVID-19 pandemic (April 1, 2020–January 31, 2021); n = 3 | Second wave of COVID-19 pandemic (February 1, 2021–July 26, 2021); n = 34 | |||||
|---|---|---|---|---|---|---|---|
| EP1 | EP2 | EP3 | EP4 | EP5 | EP6 | EP7 | |
| Age | 31 | 27 | 30 | 30 | 34 | 30 | 25 |
| Gravida/parity | G3P2 | G2A1 | G4P1A1EP1 | G5P2A2 | G3P2 | G3P2 | G3P1A1 |
| Weeks of gestation | 8 | 10 | 6 | 9 | 7 | 7 | 7 |
| Previous cesarean section | Yes | No | No | No | No | No | No |
| Spontaneous conception | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| H/o previous EP | No | No | Yes | No | No | No | No |
| TVS | CSP 40 × 32 × 40 mm | Ruptured EP | Ruptured EP | Ruptured EP | Ruptured EP | Ruptured EP | Ruptured EP |
| TVS after 48 days | Complete resolution | — | — | — | — | — | — |
| β-hCG, mIU/mL (at the time of admission) | 270.27 | 3219.12 | Not done | Not done | Not done | Not done | Not done |
| Hb, g/dL | 12.8 | 8.5 | 7.6 | 7.9 | 7.6 | 5.1 | 8.7 |
| TLC | 5280/µL | 10400/µL | 9600/µL | 6,000 | 7,000 | 9,200 | 14,500 |
| Blood type and Rh | O+ | O+ | AB+ | A+ | B+ | O− | AB+ |
| Treatment | Medical | Surgical | Surgical | Surgical | Surgical | Surgical | Surgical |
| Blood transfusion | No | Yes | Yes | Yes | Yes | Yes | Yes |
| Duration of hospital stay | 20 | 7 | 7 | 4 | 6 | 4 | 8 |
DISCUSSION
In the present study, we have shown a higher frequency of EP during the second wave of the COVID-19 pandemic in India. The majority of the EPs during COVID-19 pandemic were ruptured EPs. All the EP cases reported during the second wave were ruptured EPs. NH received seven patients with EP with COVID-19 and all were referred from multiple peripheral/private hospitals. Similar findings have been reported for comparative study on EP’s in Israel where they reported COVID-19 pandemic delayed the presentation of EP, resulting in subsequent emergency surgery and more blood loss.7,8 The exact causes of the increase in ruptured EPs during the second wave of the COVID-19 pandemic are unknown. Several variants of concern that are more infectious than the original strain of SARS-CoV-2 are being reported from many parts of the world and also in India. New variant of concern B.1.617.2 is reported to be responsible for the second wave in India.9 The evidence on increased incidence of ruptured EPs during the second wave of COVID-19 pandemic is important as B.1.617.2 variant is now being reported in several parts of the world.
Ruptured EPs are an important cause of pregnancy-related complications despite improvements in diagnostic and treatment modalities.10 Thus, travel restrictions during the ongoing COVID-19 pandemic and reduced number of accessible healthcare facilities led to a significant delay in receiving treatment for emergency health conditions like EP. Because all the resources were used in an attempt to understand the clinical nature of the disease, its management, and the prevention of its transmission; the other health conditions which also need emergency care were invariably ignored. All these factors collectively caused patients to lose the critical time in seeking medical care,11,12 thus increasing morbidity and mortality. Studies from Italy and Israel demonstrated an increased proportion of ruptured EPs during the COVID-19 pandemic as compared to that of the prepandemic period.8,13
The first-trimester scan is rarely performed in India, which causes a delay in diagnosing unruptured EP.14–16 This is also depicted in our data that show a higher incidence of ruptured EP in both prepandemic (91%) as well as pandemic period (85.7%). Although higher rates of EP were reported during the second wave of the pandemic, the overall EP rates were comparatively lower than the prepandemic period at NH. This may indicate that couples were avoiding pregnancies due to the COVID-19 pandemic and thereby lower rates of EPs than the prepandemic period.
Of the seven EPs, a woman with CSP was managed medically, whereas in six cases of ruptured EP, emergency laparotomy was performed under regional anesthesia. The management option to deal with these conditions need to be weighed to prevent occupational hazards and transmission of the disease. In the current pandemic era of COVID-19, we believe that it is reasonable to opt for a conservative option in the management of EP whenever possible, to avoid unnecessary surgical intervention which can increase the risk of disease transmission to healthcare workers (HCWs). It is always prudent to balance the benefits and risks of various surgical routes in choosing the safest one for the patient, and in the current scenario, HCWs. Performing laparotomy under regional anesthesia and avoiding general anesthesia, which is a potential aerosol-generating procedure, can help in maintaining patient safety as well as in curtailing the risk of virus transmission among HCWs.
Ours is a single-center retrospective study with a smaller sample size, which is a limitation of this study. Although the numbers are small, the trend of increased EPs is similar to other populations.
CONCLUSION
The COVID-19 pandemic had posed a challenge in undertaking endoscopic surgeries as there were no clear guidelines from endoscopic societies worldwide on the use of laparoscopy. As the pandemic reached its peak, more and more HCWs were deputed in managing COVID-19 patients which caused a deficit of experienced HCWs who could undertake emergency laparoscopy surgeries. Laparoscopy, which is the most prevalent route opted for managing EP cases in the pre-COVID-19 era, can have a possible risk of virus transmission via surgical fumes and CO2 leakage through the ports while changing instruments or while desufflation. Open surgeries (laparotomy) can help to curtail such risk of exposure to the SARS-CoV-2 in the operation theatre.14 Hence, it may be suggested that laparotomy under regional anesthesia is a safer approach in managing EPs in LMICs/resource-limited countries and especially in COVID-19 pandemic situations in preventing virus transmission to HCWs. A similar approach was also reported from China and Italy.15,16 However, larger studies are required to establish our recommendations.
CLINICAL SIGNIFICANCE
The second wave of COVID-19 pandemic has increased higher risk of tubal rupture and morbidity. The obstetricians should be prepared for delayed presentation of symptomatic EPs and should act accordingly. The COVID-19 pandemic is likely to last longer and hence healthcare providers should ensure that pregnant women have access to medical assistance whenever needed.
Registration number of clinical trial: PregCovid study is registered with the Clinical Trial Registry of India (Registration no: CTRI/2020/05/025423).
Name of the registry: PregCovid Registry.
URL of the registry: https://pregcovid.com/.
Declaration statement: Manuscript has been read and approved by all the authors and requirements for authorship have been met, and each author believes that the manuscript represents honest work.
Author’s contribution: NM and RG are the guarantors and have full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. NM and RP structured the concept and design. NM defines the intellectual content, literature search, and clinical studies. Acquisition of data was proposed by RP, GK, SS, MA, and PK. All authors are involved in analysis and interpretation of data. The statistical analysis was done by RP and NM. RP, RG, and NM were responsible for drafting the manuscript. NM, RP, RG, SJK, and SS helped in manuscript preparation, editing, and review. Administrative and technical or material support were provided by NM, RG, SM, and SJK.
Ethics Approval and Consent to Participate
The study was approved by the Ethics Committees of TNMC (No. ECARP/2020/63 dated May 27, 2020) and ICMR-NIRRH (IEC No. D/ICEC/Sci-53/55/2020 dated June 4, 2020). A waiver of consent was granted by the IECs as the data were collected from the medical case records of the pregnant women with COVID-19.
SUPPLEMENTARY MATERIAL
The supplementary material Table 1 are available online on the website of www.jsafog.com
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