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

Abstract

BACKGROUND Tubal ectopic pregnancy (TEP) is a common cause of maternal morbidity and mortality in the first trimester. Multiple effective treatment options are available for tubal ectopic, including medically with methotrexate, and surgically with salpingectomy or salpingotomy. In general, medical management is preferred because it is thought to be less invasive and less morbid, but long-term fertility and recurrence outcomes between the two management strategies are unclear and inconsistently reported in the literature. OBJECTIVE The current study aims to determine future birth outcomes in patients being treated medically and surgically for tubal ectopic pregnancy. Maternal morbidity including recurrent tubal ectopic pregnancy and treatment complications were also compared. A sub-analysis was conducted between salpingectomy and salpingotomy for the patients treated surgically. STUDY DESIGN This population-based retrospective cohort study used validated, large administrative datasets from Ontario, Canada, a single payer publicly funded healthcare system. Patients were included who were treated for ectopic pregnancy between January 1st 2008 and December 31st 2019 and compared based on type of treatment, medical versus 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. RESULTS 17, 090 cases of TEP were reported, 8 204 managed medically, 8 737 managed surgically and 149 receiving both treatments. Patients receiving medical management had a 51.6% future live birth rate, compared to 45.1% with surgical management and a recurrent TEP rate of 7.4% compared to 6.4% respectively. After controlling for baseline characteristics, future live birth rate was higher in the group treated with methotrexate compared to surgically (OR 1.3, CI1.22-1.38, p<0.001). The recurrence rate was also higher in the group treated with methotrexate compared to surgery (OR 1.17 CI 1.04-1.32, p<0.001). 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. CONCLUSION The present study demonstrates that, for patients with tubal ectopic pregnancy, medical management with methotrexate has potential for increased live birth rate compared to treatment with surgery. This comes at the cost of increased risk of tubal ectopic recurrence, and increased healthcare utilization.