Methotrexate Use in the Management of Ectopic Pregnancies: A Retrospective Study

Introduction Ectopic pregnancy (EP), most commonly located in the fallopian tube, presents with symptoms such as abdominal pain, vaginal bleeding, and nausea, which often result in delayed diagnosis, increasing the risk of rupture and life-threatening complications. Methotrexate (MTX) is frequently used to treat stable, unruptured EPs, but success rates vary widely, and optimal dosing strategies and predictive factors remain unclear. This study evaluates MTX efficacy in managing tubal EPs and identifies factors that may guide treatment decisions to improve outcomes and standardize care at an urban academic hospital, with attention to clinical predictors of treatment success and real-world barriers to medical management.  Methods This retrospective cohort study analyzed cases at Sinai Hospital between June 1, 2019, and May 31, 2024. Thirty-seven women aged 18-45 with confirmed tubal EP were included, encompassing those treated with methotrexate, managed expectantly, or treated surgically. Data collected included initial beta-human chorionic gonadotropin (β-hCG) levels, ultrasound findings, MTX dosing regimen, and serial β-hCG values on days four, seven, and 10. Primary outcomes were time to resolution and need for surgical intervention; secondary outcomes included predictors of MTX failure. Continuous variables were analyzed using t-tests and reported as mean and SD, while categorical variables were evaluated with chi-square or Fisher's exact tests. Results Thirty-seven patients (mean age 29.7 ± 5.9 years, gestational age 7.1 ± 2.2 weeks) were analyzed. Initial β-hCG was <1578 mIU/mL in 13 (35%), 1578-4340 in 12 (32%), and >4340 in 12 (32%). MTX success occurred in 9 (24%) patients, most commonly within the 1578-4340 range (n = 7, 58%) and not observed when β-hCG exceeded 4340 mIU/mL. Surgery was required in 22 (60%) patients, predominantly in those with the highest β-hCG. Elevated baseline β-hCG significantly predicted surgical intervention (p = 0.043) and MTX failure; mass size and pelvic free fluid were not significant. The mean surgical length of stay was 1.6 days. Conclusion  Lower baseline β-hCG levels were the strongest predictor of methotrexate treatment success, whereas elevated β-hCG was significantly associated with treatment failure and the need for surgical intervention. Despite eligibility for medical management, many patients required surgery due to follow-up limitations or institutional preference, underscoring the need for systems that better support outpatient management and optimize patient selections for medical therapy.