Introduction: Early detection of ectopic pregnancy and careful management is critical to prevent adverse clinical outcomes, including fallopian tube rupture and future decreased fertility, in patients presenting to the ED with symptoms suggestive of ectopic pregnancy. Methotrexate therapy is widely accepted as a first line treatment of ectopic pregnancy, with success rates greater than 90% if used according to published guidelines. This study aims to determine the outcomes of pregnant women who presented to the ED with suspected ectopic pregnancy whom received methotrexate as first line treatment. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of 612 included patients, 30 (4.9%) were diagnosed with a ruptured ectopic pregnancy at the index ED visit. Of the remaining 582 patients, 256 (44.0%) were diagnosed with an ectopic pregnancy at the index ED visit, the Early Pregnancy Clinic, or a subsequent ED visit. Of these patients diagnosed with ectopic pregnancy, their initial treatments at time of discharge from the index ED visit were as follows: 102 (39.8%%) received methotrexate, 132 (51.6%) underwent expectant management, and 22 (8.6%) underwent surgical management. Of the 132 patients discharged with an expectant management plan, only 42 (31.8%) had a final outcome of expectant management; the others went on to be treated surgically or with methotrexate. Of the 165 patients treated with methotrexate at index visit or in follow-up, 30 (18.2%) went on to require surgical management with 17 (10.3%) documented as having ruptured on surgical evaluation. Clinical characteristics of patients treated with methotrexate include the following: mean age 32.8 years (SD 5.7), gestational age of 6.2 weeks (SD 1.2) and serum beta human chorionic gonadotropin level of 2702 mIU/mL (SD 8800). Conclusion: The proportion of patients receiving methotrexate as first-line treatment that resulted in rupture or required further surgical management is higher than reported literature at this institution. Further investigation is needed to determine if there was a relationship between methotrexate failure and non-adherence to recommended guidelines. Given the risk of a possible rupture, patient education of these risks is critical on discharge from the ED.