Effectiveness of treatment options for tubal ectopic pregnancy: A systematic review and network meta-analysis

Background: Tubal ectopic pregnancy (TEP) is a common gynaecological emergency. Several medical and surgical treatment options exist, but it is not clear which is the safest and most effective treatment.Objectives: To compare the effectiveness of expectant, medical and surgical treatment options for TEP using a systematic review and network meta-analysis.Search Strategy: MEDLINE, EMBASE, and CENTRAL from inception till September 2022.Selection Criteria: Randomised trials that evaluated any treatment option for woman with a TEP.Data Collection and Analysis: We performed pairwise and network meta-analyses using a random effect model. We assessed the studies' risk of bias, heterogeneity and network inconsistency. We reported primarily on TEP resolution and treatment failure using relative risk (RR) and 95% confidence-intervals (CI).Main Results: We included 31 randomised trials evaluating ten treatments (n = 2938 women). Direct meta-analysis showed no significant benefit for using methotrexate compared to expectant management for TEP resolution. Network meta-analysis showed similar effect -size for most conservative treatment options compared to expectant management for TEP resolution (glucose intra- sac instillation vs. expectant RR 0.84, 95% CI 0.63- 1.12; methotrexate intra- sac instillation vs. expectant RR 0.91, 95% CI 0.75- 1.10; multi -dose methotrexate vs. expectant RR 1.00, 95% CI 0.88- 1.15; prostaglandin intra- sac instillation vs. expectant RR 0.75, 95% CI 0.53- 1.07; salpingotomy vs. expectant RR 0.99, 95% CI 0.84- 1.16; single dose methotrexate vs. expectant RR 0.97, 95% CI 0.85- 1.10; single dose methotrexate + mifepristone vs. expectant RR 1.09, 95% CI 0.89- 1.33). All treatment options showed a higher risk of failure compared to salpingectomy.Conclusions: There is insufficient evidence to support the use of any medical treatment option for TEP over expectant management.