Outcomes of Medical versus Surgical Management of Ectopic Pregnancy in Emergency Settings: A Systematic Review

Authors

  • Mazi Mohammed Alanazi Saudi and Jordanian Board Emergency Medicine, Emergency Department, Head of Emergency Research Unit, First Health Cluster, Riyadh, Saudi Arabia. ORCID: 0009-0003-5836-8086. Author
  • Ghadeer Yahya Aljaber Medical Intern, College of Medicine, King Khalid University, Abha, Saudi Arabia Author
  • Sara Ahmed Almajed Medical intern, College of Medicine, King Saud University, Riyadh , Saudi Arabia Author
  • Israa Murtada Elsheikh Medical intern, College of Medicine, National University of Sudan, Khartoum, Sudan Author
  • Raghad Faisal Almuwallad Medical intern, college of medicine and surgery, Umm alqura university, Makkah, Saudi Arabia Author
  • Rania Saleh Alzahrani Medical intern, college of medicine and surgery, Umm alqura university, Makkah, Saudi Arabia Author
  • Basil Kateb Alshammari Medical intern, College of Medicine, Jouf University, Sakaka, Saudi Arabia Author
  • Missan Samih Felemban Medical intern, College of Medicine, Ulm University, Ulm, Germany Author
  • Shaden Mufleh Alosaimi Medical Intern, College of Medicine, Majmaah University, Majmaah, Saudi Arabia Author

DOI:

https://doi.org/10.65759/y3wd1x29

Keywords:

Ectopic pregnancy, methotrexate, surgical management, emergency care, salpingectomy

Abstract

Background: Ectopic pregnancy requires early assessment of hemorrhage risk, treatment suitability, and future reproductive priorities. Medical and surgical approaches differ in immediate effectiveness, surveillance requirements, and subsequent fertility This review compares outcomes of methotrexate and surgery for tubal ectopic pregnancy, emphasizing applicability to emergency care. Methods: This study was conducted according to PRISMA guidelines and we analyzed twelve comparative studies published before June 2026. Randomized trials and comparative cohorts were examined for treatment success, additional intervention, biochemical resolution, complications, subsequent pregnancy, recurrence, and resource use. Results were synthesized narratively because treatment regimens, surgical procedures, eligibility criteria, and outcome definitions differed. Results: Seven randomized trials and five observational studies informed the comparison. Individual trials reported methotrexate success of 65%-94.7%, with definitions differing regarding repeat doses. Surgery produced faster biochemical resolution, while additional methotrexate or rescue surgery remained necessary in some medically treated patients. Randomized fertility comparisons identified no statistically significant advantage for either strategy. A large population cohort associated methotrexate with higher subsequent live birth and recurrent ectopic pregnancy, alongside greater healthcare utilization. Treatment selection and baseline severity complicated observational comparisons. Conclusion: Methotrexate provides an effective option for selected stable patients with unruptured tubal pregnancy and reliable follow-up. Surgery provides rapid definitive treatment and remains essential for instability or suspected rupture.

References

1. Barnhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med. 2009;361(4):379-387. doi: 10.1056/NEJMcp0810384.

2. Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update. 2014;20(2):250-261. doi: 10.1093/humupd/dmt047.

3. Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005;173(8):905-912. doi: 10.1503/cmaj.050222.

4. Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. J Fam Plann Reprod Health Care. 2011;37(4):231-240. doi: 10.1136/jfprhc-2011-0073.

5. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol. 2018;131(3):e91-e103. doi: 10.1097/AOG.0000000000002560.

6. Hendriks E, Rosenberg R, Prine L. Ectopic pregnancy: diagnosis and management. Am Fam Physician. 2020;101(10):599-606. PMID: 32412215.

7. Farren J, Al Wattar BH, Jurkovic D. The diagnosis and management of extrauterine and uterine ectopic pregnancy. Hum Reprod Update. 2026;32(1):2-32. doi: 10.1093/humupd/dmaf024.

8. Zilber U, Pansky M, Bukovsky I, Golan A. Laparoscopic salpingostomy versus laparoscopic local methotrexate injection in the management of unruptured ectopic gestation. Am J Obstet Gynecol. 1996;175(3 Pt 1):600-602. doi: 10.1053/ob.1996.v175.a74249.

9. Hajenius PJ, Engelsbel S, Mol BW, van der Veen F, Ankum WM, Bossuyt PM, et al. Randomised trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. Lancet. 1997;350(9080):774-779. doi: 10.1016/S0140-6736(97)05487-1.

10. Fernandez H, Yves Vincent SC, Pauthier S, Audibert F, Frydman R. Randomized trial of conservative laparoscopic treatment and methotrexate administration in ectopic pregnancy and subsequent fertility. Hum Reprod. 1998;13(11):3239-3243. doi: 10.1093/humrep/13.11.3239.

11. Saraj AJ, Wilcox JG, Najmabadi S, Stein SM, Johnson MB, Paulson RJ. Resolution of hormonal markers of ectopic gestation: a randomized trial comparing single-dose intramuscular methotrexate with salpingostomy. Obstet Gynecol. 1998;92(6):989-994. doi: 10.1016/S0029-7844(98)00324-X.

12. Sowter MC, Farquhar CM, Petrie KJ, Gudex G. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. BJOG. 2001;108(2):192-203. doi: 10.1111/j.1471-0528.2001.00038.x.

13. Krag Moeller LB, Moeller C, Thomsen SG, Andersen LF, Lundvall L, Lidegaard O, et al. Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies: a randomized trial. Acta Obstet Gynecol Scand. 2009;88(12):1331-1337. doi: 10.3109/00016340903188912.

14. de Bennetot M, Rabischong B, Aublet-Cuvelier B, Belard F, Fernandez H, Bouyer J, et al. Fertility after tubal ectopic pregnancy: results of a population-based study. Fertil Steril. 2012;98(5):1271-1276.e3. doi: 10.1016/j.fertnstert.2012.06.041.

15. Fernandez H, Capmas P, Lucot JP, Resch B, Panel P, Bouyer J; GROG. Fertility after ectopic pregnancy: the DEMETER randomized trial. Hum Reprod. 2013;28(5):1247-1253. doi: 10.1093/humrep/det037.

16. Baggio S, Garzon S, Russo A, Ianniciello CQ, Santi L, Laganà AS, et al. Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management. Arch Gynecol Obstet. 2021;303(1):259-268. doi: 10.1007/s00404-020-05749-2.

17. Asgari Z, Chegini V, Hosseini R, Mohajeri M, Ansari I. Fertility outcomes subsequent to medical and surgical treatment for ectopic pregnancy: a retrospective cohort study in Iran. Int J Reprod Biomed. 2021;19(10):881-888. doi: 10.18502/ijrm.v19i10.9820.

18. Scarpelli E, Capozzi VA, Roberto L, Gallinelli A, Pezzani A, Monica M, et al. Predictors of methotrexate success and fertility outcomes in tubal ectopic pregnancy: a retrospective cohort study. Medicina (Kaunas). 2025;61(6):1058. doi: 10.3390/medicina61061058.

19. Rosen A, Palma L, Ordon M, Melamed N, Saskin R, Page A, et al. Pregnancy outcomes following medical vs surgical treatment of tubal ectopic pregnancy: a population-based retrospective cohort study. Am J Obstet Gynecol. 2025;233(6):625.e1-625.e17. doi: 10.1016/j.ajog.2025.07.008.

20. Hajenius PJ, Mol F, Mol BWJ, Bossuyt PMM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007;(1):CD000324. doi: 10.1002/14651858.CD000324.pub2.

21. Mol F, Mol BW, Ankum WM, van der Veen F, Hajenius PJ. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Update. 2008;14(4):309-319. doi: 10.1093/humupd/dmn012.

22. Mol F, van Mello NM, Strandell A, Strandell K, Jurkovic D, Ross J, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet. 2014;383(9927):1483-1489. doi: 10.1016/S0140-6736(14)60123-9.

23. Lipscomb GH, McCord ML, Stovall TG, Huff G, Portera SG, Ling FW. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med. 1999;341(26):1974-1978. doi: 10.1056/NEJM199912233412604.

24. Davenport MJ, Lindquist A, Brownfoot F, Pritchard N, Tong S, Hastie R. Time to resolution of tubal ectopic pregnancy following methotrexate treatment: a retrospective cohort study. PLoS One. 2022;17(5):e0268741. doi: 10.1371/journal.pone.0268741.

25. Sowter MC, Farquhar CM, Gudex G. An economic evaluation of single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy. BJOG. 2001;108(2):204-212. doi: 10.1111/j.1471-0528.2001.00037.x.

Downloads

Published

2026-10-27

Issue

Vol. 3 No. 04 (2026): Journal of Tazeez for Public Health

Section

Articles