Current trends in management of ectopic pregnancy in the United Kingdom

Ectopic pregnancy hospitalisations: A national population-based study of rates, management and outcomes

OBJECTIVE

To determine whether there were changes in the incidence, management and outcomes of ectopic pregnancy hospitalisations in Ireland during 2005-2016.

STUDY DESIGN

Population-based study was carried out from January 2005 to December 2016. A total of 12,098 women hospitalised due to ectopic pregnancy. All acute maternity hospital settings in the Republic of Ireland. Electronic health records were retrieved using the Hospital In-Patient Enquiry database. Rates ratios were calculated to estimate trends, risk of blood transfusion and risk of extended stay at the hospital.

RESULTS

The rate of hospitalisation for ectopic pregnancy increased over the 12-year study period from 12.8/1,000 deliveries in 2005 to 17.7/1,000 deliveries in 2016. Risk of blood transfusion reduced over time (aIRR 0.8; 95%CI 0.6-0.9). Women aged at least 40 years had double the risk of hospitalisation and double the risk of blood transfusion. Women undergoing open surgical procedures were more likely to need a blood transfusion than those undergoing laparoscopic salpingectomy. Similar results were found for length of stay over two days. Blood transfusion was rare for patients who underwent medical management (aIRR 0.1; 95%CI 0.05-0.2).

CONCLUSION

Advanced maternal age increased risk of hospitalisation for ectopic pregnancy. While the overall rate of hospitalisations increased over time, there was a reduction in the risk of blood transfusion and length of stay over two days. Type of management significantly affected the risk of blood transfusion and length of stay over two days at the hospital.

Beyond Guidelines: Effectiveness of a Programme in Achieving Operative Laparoscopy for all Women Requiring Surgical Management of Ectopic Pregnancy

BACKGROUND/AIMS

Operative laparoscopy (OL) is considered the gold standard surgical treatment of ectopic pregnancy (EP). We questioned whether a training programme to foster OL treatment is able to ensure that all women needing surgical management are treated by OL irrespective of the site of EP, haemodynamic status and clinical complexity.

METHODS

A 13-year cohort study of 963 women who underwent surgical management was conducted. We instituted a 'universal OL' programme in 2003 for the management of all the types of EP irrespective of the haemodynamic status.

RESULTS

There were 802 women in the prospective (2003-2013) and 161 in the retrospective arm (2000-2002). The rate of OL before 2003 was 34%. During the year of programme implementation, the OL rate rose from 89% in 2003 to 96% in 2004. It took 4 years to achieve a 100% OL rate in haemodynamically stable patients. In 2013, we were able to achieve OL treatment for all patients irrespective of haemodynamic status, the complexity of surgery or the location of EP.

CONCLUSION

Our study demonstrates that a dedicated team with special training in minimal invasive surgery can improve surgical management of all categories of EPs, and this goal should be achievable across most units.

The importance of gestational sac size of ectopic pregnancy in response to single-dose methotrexate

This retrospective cohort study was designed in a selective group of 185 patients diagnosed with and treated for ectopic pregnancy. Intramuscular administration of a single dose of methotrexate (50 mg/m²) was performed to measure predictors of failure or resistance to treatment necessitating surgical intervention. During the time of treatment with a single dose of MTX, 20 patients (10.8%) failed to response, in which 6 of 20 (30%) indicated side effects to MTX and rupture of the ectopic pregnancy. Remaining cases (n = 14) showed resistance to the drug; the level of β-hCG did not fall at least 15% during 7 days after treatment and necessitated laparotomy. In backward-step analysis by multiple logistic regressions of various types of predictor factors, size of gestational sac (coefficient = 1.91, OR = 6.78, 95% confidence interval = 3.18–8.22) and baseline level β-hCG (coefficient = 1.60, OR = 5.0, 95% confidence interval = 4.26–6.72) had significant correlation with leading EP patients failing to response to MTX. This study suggests that further investigation for finding relative contraindications of MTX treatment in EP women should be considered on the gestational sac size because other variables are in the causal pathway of this variable.

Changing trends in the laparoscopic management of ectopic pregnancy in a London district general hospital: 7-years experience

We set out to evaluate the effect of a programme introduced in January 2003 to make operative laparoscopy the standard surgical treatment for women requiring surgery for ectopic pregnancy. This was a retrospective and prospective clinical data analysis performed at The Whipps Cross University Hospital in London, with a comparison of data taken before and after the introduction of the programme. A total of 116 women who had surgical management for ectopic pregnancy from January 2000 to December 2002 and 313 women who had surgery for ectopic pregnancy between January 2003 and December 2006 took part in the study. A programme was started in January 2003 to make operative laparoscopy the surgical management of choice. The main outcome measure was the proportion of women requiring surgery who had operative laparoscopy in the two study periods. The chi(2)-test was used to determine if there was any statistically significant difference between proportions. A difference was deemed statistically significant if p < 0.05. The results showed that there was a progressive rise in the proportion of ectopic pregnancies managed by operative laparoscopy following the change in January 2003. A total of 34% of women were managed laparoscopically between 2000 and 2002, increasing to 90% between 2003 and 2006. This difference was statistically significant (p < 0.001). In 2006, some 96% of women requiring surgery were managed by laparoscopic surgery. The findings of this study indicate that it is possible to implement changes which increase and sustain a high rate of laparoscopic surgery for women with ectopic pregnancy requiring surgery in a district general hospital setting.

The benefits of virtual reality simulator training for laparoscopic surgery

PURPOSE OF REVIEW

Virtual reality is a computer-generated system that provides a representation of an environment. This review will analyse the literature with regard to any benefit to be derived from training with virtual reality equipment and to describe the current equipment available.

RECENT FINDINGS

Virtual reality systems are not currently realistic of the live operating environment because they lack tactile sensation, and do not represent a complete operation. The literature suggests that virtual reality training is a valuable learning tool for gynaecologists in training, particularly those in the early stages of their careers. Furthermore, it may be of benefit for the ongoing audit of surgical skills and for the early identification of a surgeon's deficiencies before operative incidents occur. It is only a matter of time before realistic virtual reality models of most complete gynaecological operations are available, with improved haptics as a result of improved computer technology.

SUMMARY

It is inevitable that in the modern climate of litigation virtual reality training will become an essential part of clinical training, as evidence for its effectiveness as a training tool exists, and in many countries training by operating on live animals is not possible.

Virtual reality simulation training can improve technical skills during laparoscopic salpingectomy for ectopic pregnancy

OBJECTIVES

To assess the first commercially available virtual reality (VR) simulator to incorporate procedural modules for training of inexperienced gynaecological surgeons to perform laparoscopic salpingectomy for ectopic pregnancy.

DESIGN

Prospective cohort study.

SETTING

Departments of surgery and gynaecology in central London teaching hospitals.

SAMPLE

Thirty gynaecological surgeons were recruited to the study, and were divided into novice (<10 laparoscopic procedures), intermediate (20-50) and experienced (>100) groups.

METHODS

All subjects were orientated to the VR simulator with a basic skills task, followed by performing ten repetitions of the virtual ectopic pregnancy module, in a distributed manner.

MAIN OUTCOME MEASURES

Operative performance was assessed by the time taken to perform surgery, blood loss and total instrument path length.

RESULTS

There were significant differences between the groups at the second repetition of the ectopic module for time taken (median 551.1 versus 401.2 versus 249.2 seconds, P = 0.001), total blood loss (median 304.2 versus 187.4 versus 123.3 ml, P = 0.031) and total instrument path length (median 17.8 versus 8.3 versus 6.8 m, P = 0.023). The learning curves of the experienced operators plateaued at the second session, although greater numbers of sessions were necessary for intermediate (seven) and novice (nine) surgeons to achieve similar levels of skill.

CONCLUSIONS

Gynaecological surgeons with minimal laparoscopic experience can improve their skills during short-phase training on a VR procedural module. In contrast, experienced operators showed nonsignificant improvements. Thus, VR simulation may be useful for the early part of the learning curve for surgeons who wish to learn to perform laparoscopic salpingectomy for ectopic pregnancy.

Successful laparoscopic management of ectopic pregnancy in a district general hospital

A retrospective analysis of the management of ectopic pregnancy was undertaken at Billinge Hospital, Wigan from June 1999 to June 2002. A total of 114 cases of ectopic pregnancy were identified. Diagnosis was usually confirmed by laparoscopy (89.4%) and 102 cases (82.4%) were managed by laparoscopic salpingectomy. A total of 7.08% of patients needed a laparotomy after the initial laparoscopy and two (1.75%) had laparotomy performed as the primary approach. Medical treatment was given to eight women (7.0%). All the consultants were competent in performing laparoscopic surgery and 71.3% of cases were performed laparoscopically by a consultant. The diagnostic accuracy was high using a combination of urine pregnancy tests, serum beta-hCG and transvaginal scan.

Laparoscopic surgery

The generic advantages of avoiding a large laparotomy incision are now well established. For the patient, a laparoscopic procedure is invariably less painful, and recovery and return to full normal activities is more rapid. There are also significant gains in short-term quality of life measures associated with the laparoscopic approach. For the surgeon, improved visualisation offers the opportunity of more precise and accurate surgery. These advantages are usually offset by longer operating times, the use of complex and expensive equipment, and the possibility of new types of complications and increased risk of standard operative morbidity. The aim of this chapter is to identify areas of general technique in which the risks associated with laparoscopic surgery can be minimised while retaining all the advantages of the approach. This is being achieved partly by improved and simplified instrumentation, partly by refinement in techniques, and partly by an increasing awareness of the potential pitfalls of the approach and by adopting strategies to avoid these problems. The majority of gynaecological procedures are already performed endoscopically and all gynaecologists who operate will need to become proficient in these techniques. This chapter outlines techniques for safe laparoscopic entry and safe bipolar diathermy techniques, and describes how to undertake some of the simpler laparoscopic procedures; the evidence supporting these approaches is also presented. Surgical proficiency in safe laparoscopic entry and laparoscopic tubal surgery should lead to the confidence to then undertake more complex procedures.