Disparities in the management of ectopic pregnancy

Abstract

Background Ectopic pregnancy is common among young women. Treatment can consist of either surgery with salpingectomy or salpingostomy or medical management with methotrexate. In addition to acute complications, treatment of ectopic pregnancy can result in long term sequelae including decreased fertility. Little is known about the patterns of care and predictors of treatment in women with ectopic pregnancy. Similarly, data on outcomes for various treatments are limited. Objective We examined the patterns of care and outcomes for women with ectopic pregnancy. Specifically, we examined predictors of medical (vs. surgical) management of ectopic pregnancy and tubal conservation (salpingostomy vs. salpingectomy) among women who underwent surgery. Study Design The Perspective database was used to identify women with a diagnosis of tubal ectopic pregnancy treated from 2006–2015. Perspective is an all-payer database that collects data on patients at hospitals from throughout the U.S. Women were classified as having undergone medical management if they received methotrexate and surgical management if treatment consisted of salpingostomy or salpingectomy. Multivariable models were developed to examine predictors of medical treatment and of tubal conserving salpingostomy among women treated surgically. Results Among the 62,588 women, 49,090 (78.4%) were treated surgically and 13,498 (21.6%) received methotrexate. Use of methotrexate increased from 14.5% in 2006 to 27.3% by 2015 (P<0.001). Among women who underwent surgery, salpingostomy decreased over time from 13.0% in 2006 to 6.0% in 2015 (P<0.001). Treatment in more recent years, at a teaching hospital, and at higher volume centers were associated with increased use of methotrexate (P<0.05 for all). In contrast, Medicaid recipients (aRR=0.92; 95% CI, 0.87–0.98) and uninsured women (aRR=0.87; 95% CI, 0.82–0.93) were less likely to receive methotrexate than commercially insured patients. Among those who underwent surgery, black (aRR=0.76; 95% CI, 0.69–0.85) and Hispanic (aRR=0.80; 95% CI, 0.66–0.96) patients were less likely to undergo tubal conserving surgery than white women and Medicaid recipients (aRR=0.69; 95% CI, 0.64–0.75) and uninsured women (aRR=0.60; 95% CI, 0.55–0.66) less frequently underwent salpingostomy than commercial insured patients. Conclusion There is substantial variation in the management of ectopic pregnancy. There are significant racial and insurance related disparities associated with treatment.

Predictors and clinical features of methotrexate (MTX) therapy for ectopic pregnancy

“…Meanwhile, MTX does not damage ovarian function or increase the incidence of subsequent adverse pregnancy and birth outcomes in patients [ 13 – 15 ]. An increasing number of patients with unruptured ectopic pregnancies are seeking MTX treatment [ 16 ]; however, it is unknown which patients will benefit the most from it. Many studies have tried to identify the factors that influence the success rate before starting treatment with MTX, such as the initial β-hCG concentration, the size of the ectopic mass and a history of previous ectopic pregnancy [ 17 ].…”

Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil

“…In addition, in well-selected patients, treatment with methotrexate had a better cost-bene t ratio than surgery [3,10,12,14]. Because ectopic pregnancy is being diagnosed earlier and treatment protocols based on methotrexate have been developed, there is a trend toward an increase in the number of clinical treatments, in comparison with that of surgical treatments, in several countries [3,9,12,15,16,17]. In line with worldwide standards, the trends over the years at the university hospital studied were toward an increase in the rates of clinical treatment, possibly due to earlier diagnosis.…”

Predictors and clinical features of methotrexate (MTX) therapy for ectopic pregnancy

“…Meanwhile, MTX does not damage ovarian function or increase the incidence of subsequent adverse pregnancy and birth outcomes in patients [8][9][10]. An increasing number of patients with unruptured ectopic pregnancies are seeking MTX treatment [11] ; however, it is unknown which patients will benefit the most from it. Many studies have tried to identify the factors that influence the success rate before starting treatment with MTX, such as the initial β-hCG concentration, the size of the ectopic mass and a history of previous ectopic pregnancy [12] .…”