Management of cesarean scar pregnancy: Manual vacuum aspiration VS local and systemic methotrexate - A retrospective study

To compare treatment strategies for cesarean scar pregnancy (CSP) manual vacuum aspiration (MVA), intracavitary methotrexate (Methotrexate), and intramuscular MTX and identify factors for treatment failure and prolonged course.

This retrospective cohort included CSP cases managed at a tertiary center. Initial management was categorized as MVA, intracavitary or intramuscular MTX. Primary failure was the need for rescue treatment. Secondary outcomes were hospital stay and time to β-hCG negativization. Additional analyses examined associations between baseline clinical/ultrasound variables and outcomes.

Most patients were asymptomatic at presentation. The need for additional treatment differed across initial strategies (p = 0.008), with the lowest failure after MVA. Hospital stay differed significantly (p < 0.001) and was shorter after MVA than MTX-based strategies. Time to β-hCG negativization also differed (p = 0.002) and was shorter after MVA. Intracavitary and intramuscular MTX showed no significant differences in hospital stay or β-hCG negativization (both p > 0.05). After excluding cases requiring rescue therapy, hospital stay remained different (p < 0.001), whereas time to β-hCG negativization no longer differed (p = 0.118). Treatment strategy remained associated with failure after adjustment (p < 0.05). MTX-based management was associated with longer hospitalization and delayed β-hCG negativization (both p < 0.001); residual myometrial thickness ≤3 mm was associated with longer hospitalization (p = 0.026), and gestational sac diameter ≥20 mm with delayed β-hCG negativization (p < 0.001).

In this cohort, MVA was associated with less frequent escalation and a shorter course than MTX-based strategies, while intracavitary and intramuscular MTX showed similar outcomes. Ultrasound markers of scar integrity and implantation burden were linked to prolonged course and may guide management.