Pregnancy outcomes following medical vs surgical treatment of tubal ectopic pregnancy: a population-based retrospective cohort study.

Abstract

Tubal ectopic pregnancy is a common cause of maternal morbidity and mortality in the first trimester. Multiple effective treatment options are available for tubal ectopic pregnancy, including medical treatment with methotrexate and surgical treatment with salpingectomy or salpingotomy. In general, medical management is preferred because it is considered less invasive and less morbid, but differences in long-term fertility and recurrence outcomes between the 2 management strategies are unclear and inconsistently reported in the literature. This study aimed to determine future birth outcomes among patients treated medically and surgically for tubal ectopic pregnancy. Maternal morbidity, including recurrent tubal ectopic pregnancy and treatment complications, was also compared. A subanalysis was conducted comparing salpingectomy and salpingotomy for the patients treated surgically. This population-based retrospective cohort study used validated, large administrative data sets from Ontario, Canada's single-payer publicly funded healthcare system. Patients treated for ectopic pregnancy between January 1, 2008 and December 31, 2019 were included and compared according to type of treatment (medical vs surgical). Baseline characteristics were collected and compared using standardized differences. Multivariable logistic regression was used to determine if there was an association between treatment type and outcomes. A total of 17,090 cases of tubal ectopic pregnancy were reported, of which 8204 were managed medically, 8737 were managed surgically, and 149 received both treatments. Patients receiving medical management had a 51.6% future live birth rate, as opposed to 45.1% of patients who received surgical management. The recurrent tubal ectopic pregnancy rates in these groups were 7.4% and 6.4%, respectively. After controlling for baseline characteristics, the future live birth rate and the recurrence rate were higher in the group treated with methotrexate than in the surgically treated group (future live birth: odds ratio, 1.3; 95% confidence interval, 1.22-1.38; P<.001; recurrence: odds ratio, 1.17; 95% confidence interval, 1.04-1.32; P<.001). The incidence of tubal ectopic pregnancy in Ontario increased during the study period, and with time, a larger proportion of patients were treated medically. The medical management failure rate was 15.3%. Overall, healthcare utilization was higher in the group treated with methotrexate. This study demonstrates that, for patients with tubal ectopic pregnancy, medical management with methotrexate has the potential to increase live birth rates compared with surgical treatment. This comes at the cost of increased risk of tubal ectopic recurrence and increased healthcare utilization.