Background: Placenta Accreta Spectrum (PAS) is a life-threatening obstetric condition characterized by abnormal placental invasion into the myometrium, frequently resulting in severe hemorrhage. Its incidence has increased significantly, primarily due to rising cesarean delivery rates. While cesarean hysterectomy remains the standard treatment, it eliminates future fertility, prompting interest in conservative alternatives such as methotrexate therapy.

Objective: To evaluate the effectiveness and safety of methotrexate-based conservative management in patients with PAS who desire fertility preservation.

Methods: Studies involving patients with PAS managed conservatively using methotrexate were included. Outcomes assessed included changes in β-hCG levels, imaging findings, resolution of placental tissue, and avoidance of hysterectomy.

Results: Evidence is primarily derived from case reports and small case series. Methotrexate, typically administered at a dose of 50 mg/m², demonstrated consistent reductions in β-hCG levels and gradual resolution of placental vascularity on ultrasound with Doppler. Many cases reported successful avoidance of hysterectomy, particularly in hemodynamically stable patients diagnosed early in gestation. However, treatment duration varied, and complications such as delayed hemorrhage and infection were reported in some cases. No standardized treatment protocol was identified.

Conclusion: Methotrexate-based conservative management may be a viable option for selected PAS patients who wish to preserve fertility, particularly when diagnosed early and managed with close monitoring. However, current evidence remains limited and heterogeneous, highlighting the need for prospective studies and standardized clinical guidelines.

Eric Edwin Yuliantara is a senior consultant in obstetrics and gynecology with subspecialty expertise in fetomaternal medicine. He completed his obstetrics and gynecology specialist training at Universitas Sebelas Maret, Indonesia, in 2007, followed by a fetomaternal medicine fellowship at Universitas Airlangga in 2015. He currently serves as a lecturer in the department of obstetrics and gynecology at RSUD Dr. Moewardi. In addition, he holds a regional leadership role as the chief of the Obstetrics Collegium, where he contributes to the development of curriculum, training standards, and competency frameworks for obstetrics and gynecology education in Indonesia. He is also actively involved in advocacy efforts to improve maternal health services and clinical practice standards. He has been an invited speaker at numerous national and international conferences in obstetrics and gynecology and is widely recognized for his contributions to both academic and clinical advancement, particularly in the field of placenta accreta spectrum. His research interests include fetomaternal medicine, obstetric emergencies, and PAS, with multiple publications in reputable peer-reviewed journals.