Management of Cesarean Scar Pregnancy: Manual Vacuum Aspiration vs Local and Systemic Methotrexate - A Retrospective Study.

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