Zhuang, Y., & Huang, L. (2009).

Uterine artery embolization compared with methotrexate for the

management of pregnancy implanted within a cesarean scar. American Journal of Obstetrics and
Gynecology, 201(2), 152.e1–152.e3. doi:10.1016/j.ajog.2009.04.038

MTX treatment was found to be inferior because it doesn’t decrease beta HCG serum levels quickly
than other treatment modalities, and also can cause such massive bleeding in some patients.

Hospitalisation time also was longer when patient is treated with methotrexate, because the
absorption rate of POC is sower and needed to be evaluated closely with routine examination of
beta HCG levels.

Timor-Tritsch, I. E., & Monteagudo, A. (2012). Unforeseen consequences of the increasing rate of
cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. American Journal
of Obstetrics and Gynecology, 207(1), 14–29. doi:10.1016/j.ajog.2012.03.007

Systemic methotrexate as a single treatment of choice should be avoided. The argument is: waiting
days for its effect to stop the heart beats, which may not happen. It also led to the additional growth
of the embryo/fetus as well as the vascularization of the sac and wastes precious time because a
subsequent, second-line treatment approach with a possibly higher complication rate may endanger
the patient.

Kanat-Pektas, M., Bodur, S., Dundar, O., & Bakır, V. L. (2016). Systematic review: What is the best
first-line approach for cesarean section ectopic pregnancy? Taiwanese Journal of Obstetrics and
Gynecology, 55(2), 263–269. doi:10.1016/j.tjog.2015.03.009

Inappropriateness of recommending systemic methotrexate as a first-line approach for CSEP. The

reason is that it may take a long time before systemic methotrexate exerts its effects on embryonic
cardiac activity and placental growth, and there is a possibility that these effects may never occur.

If this is the case, complementary treatment is aimed at a larger gestational sac with an enriched
vascularization. Wasting such precious time may eventually result in with more severe complications
that may harm the patients.

Gonzalez, N., & Tulandi, T. (2017). Cesarean Scar Pregnancy: A Systematic Review. Journal of
Minimally Invasive Gynecology, 24(5), 731–738. doi:10.1016/j.jmig.2017.02.020

While local injection of methotrexate is associated with several complications, some studies suggest
that systemic injection of methotrexate is safe for the first-line treatment of RPOC if b-hCG levels
<20,000mIU/mL and uterine mass below 3cm in diameter.