Cost-effectiveness analysis of expectant vs active management for treatment of persistent pregnancies of unknown location

Persistent pregnancies of unknown location (PUL) present a significant clinical challenge, as they involve nonviable pregnancies with inconclusive ultrasound findings. Clinicians must decide between three primary management strategies: expectant management (monitoring), empirical 2-dose methotrexate (medical treatment), or uterine evacuation (surgical treatment). This study conducted a prospective economic evaluation alongside the ACT or NOT multicenter randomized trial to determine which of these strategies provides the highest value from a healthcare sector perspective.

Researchers analyzed data from 255 hemodynamically stable women, measuring effectiveness through quality-adjusted life years (QALYs) and the rate of salpingectomy. Costs were calculated using 2018 Medicare reimbursement rates, and the analysis accounted for the high rate of treatment crossover observed in the clinical trial.

The study found that uterine evacuation was the least cost-effective strategy, as it was associated with the highest costs and the lowest QALYs, effectively being dominated by the other two options. While expectant management yielded slightly higher QALYs than methotrexate, it was not considered cost-effective at standard willingness-to-pay thresholds, primarily due to a higher rate of surgical interventions (such as salpingectomy) required when expectant management failed to resolve the pregnancy. The 2-dose methotrexate protocol emerged as the most economically favorable approach.

As healthcare systems increasingly prioritize high-value care, these findings suggest that empirical methotrexate is a superior management strategy for persistent PULs compared to surgical evacuation or observation. However, the economic advantage is not absolute. The study highlights that clinical decisions should be tailored to the patient's risk profile; in populations with a low risk of ectopic pregnancy (less than 4%), expectant management remains a viable and potentially cost-effective alternative. The sensitivity of these results to minor changes in treatment costs underscores the need for clinicians to consider local resource availability and patient-specific risk factors when choosing a management path.