Evaluating practice trend changes in laparoscopic surgical management of ectopic pregnancy at Charlotte Maxeke Johannesburg Academic Hospital

Abstract

Background Ectopic pregnancy is, by definition, a pregnancy in which implantation of a fertilized oocyte occurs outside the uterus. Globally, a ruptured ectopic pregnancy is the root of maternal mortality in early pregnancy (1). Ectopic pregnancies also increase the risk of infertility as well as subsequent ectopic pregnancies. Laparoscopic surgical approach has been shown to be better in terms of outcome to laparotomy and, therefore, should be gold-standard in the diagnosis and treatment of ectopic pregnancies in gynecological departments (2,3,4). Laparoscopy has been used for many years now, for the diagnosis of ectopic pregnancy, more so in first world countries, it is now being used habitually in the surgical treatment of ectopic pregnancy (5). The use of laparoscopic surgery globally is variable, with high-income countries using laparoscopy routinely and more commonly than low to middle-income countries (6). However, there seems to be expansion and growth in the use of laparoscopy as a diagnostic and treatment modality for ectopic pregnancy, even in low to middle-income countries (7). Most institutions bargain about the overall cost-effectiveness of laparoscopy. The rate of laparoscopic surgery was low in our center, and this led to the issue of a directive that made it compulsory for all surgeries for ectopic pregnancy if meeting criteria, to reduce the number of open surgeries for ectopic pregnancy.

Methods This was a comparative, period-based, retrospective study using medical record review at Charlotte Maxeke Johannesburg Academic Hospital in Parktown, Johannesburg. This study included all patients admitted with ectopic pregnancy who were managed surgically and medically and those who met the criteria for laparoscopic surgery. In the study, we compared the trend in management for the time period January 2013 to December 2015 and January 2016 to December 2018, a period following a directive that all ectopic pregnancies should be laparoscopically managed if meeting criteria with regard to the use of laparoscopy for ectopic pregnancy. Both intraoperative and postoperative complications were followed up. The duration of the hospital stay was also anlaysed. The software of choice was STATA. It was used for the analysis of data, and quantitative methods were employed in data analysis, and significance was conceded as 5%.

Results A total of 255 women were retrospectively recruited for the study. Of which, 15 were excluded due to missing files and some patients having absconded or signed refusal of hospital treatment (RHT). The remaining files that met the criteria were 240 with 120 in each group (control/pre-MIS directive and study group/post-MIS directive). The mean age for the entire study population was 29.3 years (SD±4.65). The median parity and gravidity were not statistically different in both groups, with an overall median parity of 1(ranges 0-4) and gravidity of 3(ranges1-6). The groups also had similar characteristics in terms of co-morbid diseases and past surgical history. HIV infection being present in 31(12,9%) of the women. With 35(14,6%) of the patients having had previous abdomino-pelvic surgery.

In the study group, 107 (89,2%) of the patients were hemodynamically stable, of which 6(5,6%) had normal findings, and 101(94,4%) patients presented with pallor and abdominal pain. Only 13(10.8%) patients in the study group presented with hemodynamic instability. In the control group, only 14(11,7%) patients were recorded as meeting criteria for laparoscopic surgery, 106(88,3%) patients were said to not meet criteria for laparoscopy. With the advancement in technology, more and more surgeons are opting for minimally invasive gynecological surgery. Specialists in training are also being encouraged to assess patients that present to the emergency department as either meeting the criteria for laparoscopy or not, based on their individual clinical presentation. In the study group, there was a slight increase in the number of patients being identified as meeting criteria for laparoscopic surgery, with 21(17,5%) patients were identified as meeting criteria and 91(75,8%) were identified as not meeting criteria. There was no statistically significant difference in the number of patients treated medically for ectopic pregnancy in the two groups. Generally, the goal for medical treatment with Methotrexate is early diagnosis before the ectopic ruptures. Medical management also requires the patient to have normal biochemistry in terms of blood results as there is always a risk of toxicity if incorrectly used. Registrars are often met with turmoil when having to make this decision on their own, hence the reluctance to use Methotrexate over the years.

In the study group,21(17,5%) of the patients had laparoscopic surgery, 95 (79,2%) had open laparotomies. This shows a remarkable increase in the number of laparoscopic procedures for ectopic pregnancies being performed. There seems to also be an increase in the number of registrar lead cases, with 17(80,9%) of the laparoscopic surgeries that were performed by registrars and 4(19,4%) were performed by consultants. Implementation of a ProLaparoscopy directive has had a great impact in the work and training of Registrars.

There were no notable differences in the duration of hospital stay between the control and the study group. Perhaps clinicians were following a routine practice of discharging patients after a certain predetermined period.

Conclusion Patients are now likely to have laparoscopic surgery provided they meet the criteria for laparoscopy since the enforcement of the protocol. Registrars are leaning more towards laparoscopic surgery as the treatment of choice since the issued directive that prescribed that it is compulsory for patients who meet the criteria to be operated on laparoscopically. This is evidence that with good and directed protocols, support, and mobilisation of resources, performance of MIS can improve in our centre. This study also confirms that minimally invasive surgery overall reduces morbidity and mortality as compared to open surgery, even in centres with limited resources such as ours. There is a need for a prospective study to explore the reasons or challenges contributing to slow progress in adopting MIS technique for all ectopic pregnancies.