Comparison of systemic and local methotrexate treatments in cesarean scar pregnancies: time to change conventional treatment and follow-up protocols

Eur J Obstet Gynecol Reprod Biol. 2016 Nov;206:131-135. doi: 10.1016/j.ejogrb.2016.09.010. Epub 2016 Sep 21.


Objective: The aim of this study was to compare the use of systemic and local methotrexate in the treatment of cesarean scar pregnancy.

Study design: In this retrospective cohort study, we collected the data of 44 patients with cesarean scar pregnancy. The patients were grouped according to treatment modality: Group 1, local methotrexate injection (n=17) and Group 2, systemic methotrexate (n=27). The groups were compared with respect to side effects, recovery time, reproductive outcome, and treatment cost.

Results: The mean gestational age at diagnosis (6.4±0.93 vs. 5.4±0.80 weeks, p=0.001), pretreatment serum β-human chorionic gonadotrophin level [27,970 (11,010-39,421) vs. 7606 (4725-16,996) mIU/mL, p=0.001], and lesion size (2.74±1.36 and 1.28±0.55cm, p=0.001) were higher in Group 1. All patients were cured by primary therapy without additional surgery. The mean times for β-human chorionic gonadotrophin normalization, the uterine-mass disappearance, were significantly shorter in Group 1 than in Group 2 (6.17±1.55 vs. 8.11±2.0 weeks, p=0.001 and 10.47±4.14 vs. 13.40±4.44 weeks, p=0.002, respectively). The cost of treatment was similar between groups (281.133±112.123$ vs. 551.134±131.792$, p=0.76). The total pregnancy rates were not different between groups (5/16, 31.4% vs. 6/11, 54.6%, p=0.301). One recurrent cesarean scar pregnancy occurred after systemic methotrexate. Oral ulcers, the most common side effect, were seen in seven patients in Group 2.

Conclusion: Even though treatment success and reproductive outcomes are similar, local methotrexate is superior to systemic methotrexate with regard to recovery time, side effects, and treatment costs, even in patients with unfavorable pretreatment prognostic predictors.

Keywords: Cesarean scar pregnancy; Ectopic pregnancy; Local methotrexate; Systemic methotrexate.

MeSH terms

  • Abortifacient Agents, Nonsteroidal / administration & dosage*
  • Abortifacient Agents, Nonsteroidal / therapeutic use
  • Adult
  • Cesarean Section / adverse effects*
  • Cicatrix / etiology*
  • Databases, Factual
  • Female
  • Humans
  • Methotrexate / administration & dosage*
  • Methotrexate / therapeutic use
  • Pregnancy
  • Pregnancy, Ectopic / drug therapy*
  • Retrospective Studies
  • Treatment Outcome


  • Abortifacient Agents, Nonsteroidal
  • Methotrexate