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