Race, socioeconomic status, and response to methotrexate treatment of ectopic pregnancy in an urban population

Abstract

On the basis of the documented racial disparities in ectopic pregnancy incidence and mortality we hypothesized that African-American women with ectopic pregnancy would be more likely than white women to have treatment failure with methotrexate. In this retrospective cohort study, a racial disparity in methotrexate effectiveness was not found, but a significant relationship between low socioeconomic status and methotrexate failure was demonstrated. KeywordsEctopic pregnancy; methotrexate; diagnosis; race; health disparity; socioeconomic statusThe incidence of ectopic pregnancy (EP) and its associated mortality represent a persistent racial health disparity in gynecology. According to the most recent estimates from the Centers for Disease Control and Prevention, minority women have a nearly twofold increased incidence of EP and a nearly fourfold greater risk of EP-related mortality than white women (1,2). This racial divide has been attributed to differential health care access that allows for elaboration of risk factors for EP and delays the diagnosis of incident EPs (1,(3)(4)(5)(6)(7)(8). Both gonorrheal and chlamydial infections are more prevalent in samples of African-American women than whites (3-8); the fact that these infections are often asymptomatic (9) suggests that African-American women are likely undertreated relative to whites. The sequelae of increased pelvic infections are reflected in the assisted reproductive technology literature, with numerous reports demonstrating higher proportions of tubal factor infertility in African-American women seeking care and more EPs resulting from treatment compared with white patients (2,10-12). In addition, population-based studies have demonstrated that self-reported infertility is up to twofold higher in African-American women than whites, which may be attributable in part to tubal damage from pelvic infections (10,(13)(14)(15) Despite the well-documented racial disparities in EP incidence and mortality, there is little extant literature specifically comparing outcomes of medical management of EP by race or ethnicity. Although extensive research has demonstrated methotrexate (MTX) to be highly effective, failure rates have been variable from as low as 4% to as high as 36% depending on the treatment protocol used (16)(17)(18)(19)(20). Anticipated poor patient follow-up is a notable contraindication to the administration of MTX for EP treatment (19,20). Thus, it is plausible to consider that the documented association between race and barriers to health care access (1,3,4,17,18,(21)(22)(23)(24) may increase the risk of MTX failure of EP treatment.The primary objective of this investigation was to test the hypothesis that African Americans have a higher risk of MTX treatment failure of EP than whites. Socioeconomic status (SES) is known to differ across racial strata and to contribute to health disparities, at times predicting health outcomes more powerfully than race (21,22,25). Therefore, an additional aim of this study was to test the association betwee...

Medical Management of Ectopic Pregnancy

“…In one study, patients with low socioeconomic status were 5 times more likely to fail methotrexate treatment. 16 It is not clear if this increased failure rate is due to a later presentation in the course of the disease, lower compliance, or true biological disparity.…”

A cohort study to evaluate the effectiveness of laparoscopic-guided local injection of etoposide in the management of women with unruptured tubal pregnancy

“…Although the favored medical treatment is MTX, there are many potential side effects that accompany its use; side effects with the systemic approach especially have been reported (2). In addition, a consistent percentage of failures after systemic MTX treatment have been reported (4,5).…”

“…Some factors related to the patient and the disease itself may affect the therapeutic outcome, including the size of the gestational mass, presence or absence of embryonic cardiac activity, pretreatment serum level of b-hCG or other biomarkers, and even socioeconomic status (4,5,12,13). Although systemic MTX treatment is effective, many potential side effects, including bone marrow depression, stomatitis, anorexia, nausea, vomiting, and diarrhea, have been reported, with an incidence up to 15% (14).…”

“…Some alternative approaches have been proposed (e.g., local injection of MTX or selection of other potential agents, including potassium chloride or etoposide ). Local injection with MTX or others can be performed with either ultrasound or laparoscopic guidance (5).…”

Adherence to the Single-Dose Methotrexate Protocol for the Management of Ectopic Pregnancy in an Inner City Population: A retrospective cohort and protocol analysis

“…Alternate follow up options, such as the 'Day 4' and 'Day 7' protocols appear safe and effective and should be further explored as an adjunct to the current standard protocol especially in this patient population. Alternative follow-up protocols may offer patients greater flexibility without compromising patient care [2,[6][7][8].…”