Disparities In The Management Of Ectopic Pregnancy

Ectopic pregnancy commonly occurs among young women. Its incidence varies between 1% and 2%. Patients are usually treated surgically with salpingectomy or salpingostomy (with tubal preservation) or managed medically using methotrexate. Treatment is associated with acute complications and can result in long-term sequelae including decreased fertility. There are only limited data on the patterns of care and predictors of treatment outcomes in women with ectopic pregnancy. Recent studies have promoted the benefits of tubal conservation to optimize future fertility without excessive risk of recurrent ectopic pregnancy. With respect to the effect of tubal conservation on actual fertility outcomes, some studies suggest no difference in intrauterine pregnancy rates between conservative management and salpingectomy, whereas others have reported significant improvement in fertility with conservative management.The aimof this population-based analysis was to examine patterns of care and outcomes for women with ectopic pregnancy. Predictors of medical (vs surgical) management of ectopic pregnancy and tubal conservation (salpingostomy vs salpingectomy) were examined. Perspective-an all-payer database that collects data on patients at hospitals from throughout the United States-was used to identify women 15 to 60 years of age with tubal ectopic pregnancy treated from 2006 to 2015. Demographic and clinical characteristics were compared between women with medical (methotrexate) versus surgical treatment and between salpingostomy versus salpingectomy. Predictors of medical treatment and of tubal-conserving salpingostomy among women treated surgically were examined with multivariable models.Of the 62,588 women with ectopic pregnancy, 49,090 (78.4%) underwent surgery, and 13,498 (21.6%) receivedmethotrexate. Between 2006 and 2015, use of methotrexate increased from 14.5% to 27.3% (P < 0.001). Over the same period, use of salpingostomy decreased from 13.0% to 6.0%(P < 0.001). Increased use of methotrexate in more recent years was associated with treatment at a teaching hospital and at higher-volume centers (P < 0.05 for both comparisons). Medicaid recipients were 8% (adjusted risk ratio [aRR], 0.92; 95% confidence interval [CI], 0.87-0.98) less likely and uninsured women 13% (aRR, 0.87; 95% CI, 0.82-0.93) less likely to receive methotrexate compared with women with commercial insurance. 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 comparedwith white women and Medicaid recipients (aRR, 0.69; 95% CI, 0.64-0.75). Uninsured women less frequently underwent salpingostomy than commercial insured patients (aRR, 0.60; 95% CI, 0.55-0.66).These findings show substantial variation in the management of ectopic pregnancy in the United States. The data highlight significant racial and insurance-related disparities associated with treatment. Further studies are needed to better understand mechanisms underlying the disparities. Targeted interventions should be investigated to reduce the morbidity associated with the treatment of ectopic pregnancy.