Surgical Morbidity following Planned Hysterectomy versus Conservative Management for Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

Itamar D. Futterman; Cintia Gomes; Olivia Sher; Julia Fisher; Rodney A. McLaren Jr; Shoshana Haberman; Scott Chudnoff

doi:10.1055/a-2491-4328

American Journal of Perinatology, Table of Contents

Am J Perinatol
DOI: 10.1055/a-2491-4328

SMFM Fellowship Series Article

Surgical Morbidity following Planned Hysterectomy versus Conservative Management for Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

Itamar D. Futterman

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York

²Division of Complex Obstetrical Surgery, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York

,

Cintia Gomes

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York

³Department of Medicine, Federal University of Santa Maria, Santa Maria, Brazil

,

Olivia Sher

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York

,

Julia Fisher

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York

⁴College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York

,

Rodney A. McLaren Jr

⁵Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania

,

Shoshana Haberman

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York

,

Scott Chudnoff

⁶Division of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn

› Author Affiliations

Abstract

Objective In recent years, the management of placenta accreta spectrum (PAS) has fallen into two categories: planned hysterectomy and conservative management to preserve fertility. However, optimal management remains unclear. Therefore, we conducted a systematic review and meta-analysis comparing the two to evaluate which approach was associated with lower surgical morbidity.

Study Design MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from inception to July 31, 2023, for trials comparing conservative management versus planned hysterectomy. We included all prospective or retrospective cohort studies, case–control studies, and randomized control studies that reported outcomes related to surgical morbidity in cases of PAS. Surgical morbidity was defined as rates of intensive care unit (ICU) admission, disseminated intravascular coagulation (DIC)/coagulopathy, bladder injury, number of units of packed red blood cells (PRBCs) transfused, estimated blood loss (EBL), and maternal mortality.

Results Odds ratios (ORs) were computed with 95% confidence intervals (CIs) using a fixed or random effects model. Among 839 studies initially retrieved, 12 were included with a total of 1,167 patients. Of these, 669 (57.3%) underwent conservative management and 498 (42.7%) underwent a planned hysterectomy. Conservative management resulted in lower rates of ICU admission (OR = 0.11; 95% CI: 0.04, 0.35), lower rates of bladder injury (OR = 0.31; 95% CI: 0.2, 0.48), lower incidence of DIC or coagulopathy (OR = 0.22; 95% CI: 0.10, 0.48), lower mean difference EBL (−1,292.81 mL; 95% CI: −1,922.16 to −593.46), as well as lower number of PRBC units transfused (−1.54 units; 95% CI: −2.29 to −0.78).

Conclusion Our findings suggest that conservative management of PAS may be associated with reduced surgical morbidity.

Key Points

management of PAS has fallen into two categories: planned hysterectomy and conservative management.
Optimal management for PAS remains unclear.
conservative management of PAS may be associated with reduced surgical morbidity.

Keywords

cesarean hysterectomy - conservative management - placenta accreta spectrum

Full Text

References

References
1 American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 7: placenta accreta spectrum. Obstet Gynecol 2018; 132 (06) e259-e275
2 Silver RM, Branch DW. Placenta accreta spectrum. N Engl J Med 2018; 378 (16) 1529-1536
3 Jauniaux E, Bunce C, Grønbeck L, Langhoff-Roos J. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol 2019; 221 (03) 208-218
4 Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005; 192 (05) 1458-1461
5 Matsuzaki S, Mandelbaum RS, Sangara RN. et al. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am J Obstet Gynecol 2021; 225 (05) 534.e1-534.e38
6 Erfani H, Fox KA, Clark SL. et al. Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team. Am J Obstet Gynecol 2019; 221 (04) 337.e1-337.e5
7 D'Arpe S, Franceschetti S, Corosu R. et al. Emergency peripartum hysterectomy in a tertiary teaching hospital: a 14-year review. Arch Gynecol Obstet 2015; 291 (04) 841-847
8 Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199 (01) 36.e1-36.e5 , discussion 91–92, e7–e11
9 Fox KA, Shamshirsaz AA, Carusi D. et al. Conservative management of morbidly adherent placenta: expert review. Am J Obstet Gynecol 2015; 213 (06) 755-760
10 Shellhaas CS, Gilbert S, Landon MB. et al; Eunice Kennedy Shriver National Institutes of Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network (MFMU). The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol 2009; 114 (2 Pt 1): 224-229
11 Warshak CR, Ramos GA, Eskander R. et al. Effect of predelivery diagnosis in 99 consecutive cases of placenta accreta. Obstet Gynecol 2010; 115 (01) 65-69
12 Shamshirsaz AA, Fox KA, Erfani H. et al. Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time. Am J Obstet Gynecol 2017; 216 (06) 612.e1-612.e5
13 Shamshirsaz AA, Fox KA, Salmanian B. et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol 2015; 212 (02) 218.e1-218.e9
14 Collins SL, Alemdar B, van Beekhuizen HJ. et al; International Society for Abnormally Invasive Placenta (IS-AIP). Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta. Am J Obstet Gynecol 2019; 220 (06) 511-526
15 Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern Fetal Neonatal Med 2023; 36 (01) 2183741
16 Palacios-Jaraquemada JM, Nieto-Calvache Á, Aryananda RA, Basanta N. Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location. J Matern Fetal Neonatal Med 2023; 36 (01) 2183764
17 Jauniaux E, Fox KA, Einerson B, Hussein AM, Hecht JL, Silver RM. Perinatal assessment of complex cesarean delivery: beyond placenta accreta spectrum. Am J Obstet Gynecol 2023; 229 (02) 129-139
18 Lucidi A, Jauniaux E, Hussein AM. et al. Urological complications in women undergoing cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2023; 62 (05) 633-643
19 Angstmann T, Gard G, Harrington T, Ward E, Thomson A, Giles W. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol 2010; 202 (01) 38.e1-38.e9
20 Sentilhes L, Ambroselli C, Kayem G. et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol 2010; 115 (03) 526-534
21 Han X, Guo Z, Yang X, Yang H, Ma J. Association of placenta previa with severe maternal morbidity among patients with placenta accreta spectrum disorder. JAMA Netw Open 2022; 5 (08) e2228002
22 Amsalem H, Kingdom JCP, Farine D. et al. Planned caesarean hysterectomy versus “conserving” caesarean section in patients with placenta accreta. J Obstet Gynaecol Can 2011; 33 (10) 1005-1010
23 Aryananda RA, Aditiawarman A, Gumilar KE. et al. Uterine conservative-resective surgery for selected placenta accreta spectrum cases: surgical-vascular control methods. Acta Obstet Gynecol Scand 2022; 101 (06) 639-648
24 El Gelany S, Mosbeh MH, Ibrahim EM. et al. Placenta accreta spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study. BMC Pregnancy Childbirth 2019; 19 (01) 313
25 Mohamed Siraj SH, Tan KH, Wright AM. Conservative surgical approach towards placenta accreta spectrum disorders for uterine preservation. BMC Pregnancy Childbirth 2023; 23 (01) 28
26 Srinivasan B, Balasubramanian N, Vijayaraghavan J. et al. Study on outcomes of pregnancy in women with placenta accreta spectrum: a 10-year study in a tertiary care center. J South Asian Feder Obst Gynae 2021; 13 (03) 94-97
27 Üstünyurt E. Local uterine resection with Bakri balloon placement in placenta accreta spectrum disorders. Turk J Obstet Gynecol 2020; 17 (02) 108-114
28 Karaçor T, Bülbül M, Nacar MC. et al. The parameters affecting the success of uterus-sparing surgery in cases of placenta adhesion spectrum disorder. J Matern Fetal Neonatal Med 2021; 34 (07) 1091-1098
29 Kutuk MS, Ak M, Ozgun MT. Leaving the placenta in situ versus conservative and radical surgery in the treatment of placenta accreta spectrum disorders. Int J Gynaecol Obstet 2018; 140 (03) 338-344
30 Lional KM, Tagore S, Wright AM. Uterine conservation in placenta accrete spectrum (PAS) disorders: a retrospective case series: Is expectant management beneficial in reducing maternal morbidity?. Eur J Obstet Gynecol Reprod Biol 2020; 254: 212-217
31 Nieto-Calvache AJ, Zambrano MA, Herrera NA. et al. Resective-reconstructive treatment of abnormally invasive placenta: Inter Institutional Collaboration by telemedicine (eHealth). J Matern Fetal Neonatal Med 2021; 34 (05) 765-773
32 Sentilhes L, Seco A, Azria E. et al; PACCRETA Study Group. Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study. Am J Obstet Gynecol 2022; 226 (06) 839.e1-839.e24
33 Wang Q, Ma J, Zhang H. et al. Conservative management versus cesarean hysterectomy in patients with placenta increta or percreta. J Matern Fetal Neonatal Med 2022; 35 (10) 1944-1950
34 Bręborowicz GH, Markwitz W, Gaca M. et al. Conservative management of placenta previa complicated by abnormal placentation. J Matern Fetal Neonatal Med 2013; 26 (10) 1012-1015
35 Piñas-Carrillo A, Chandraharan E. Conservative surgical approach: the Triple P procedure. Best Pract Res Clin Obstet Gynaecol 2021; 72: 67-74
36 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Pre- ferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62 (10) 1006-1012
37 Higgins JPT, Thomas J, Chandler J. et al, eds. Cochrane Handbook for Systematic Reviews of Interventions. 2nd ed.. Wiley-Blackwell; 2020
38 Sterne JA, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919
39 Abi Habib P, Goetzinger K, Turan OM. Placenta accreta spectrum conservative management and coagulopathy: case series and systematic review. Ultrasound Obstet Gynecol 2024; 63 (06) 731-737
40 Matsuzaki S, Yoshino K, Endo M, Kakigano A, Takiuchi T, Kimura T. Conservative management of placenta percreta. Int J Gynaecol Obstet 2018; 140 (03) 299-306
41 Mei J, Wang Y, Zou B. et al. Systematic review of uterus-preserving treatment modalities for abnormally invasive placenta. J Obstet Gynaecol 2015; 35 (08) 777-782
42 Youssefzadeh AC, Matsuzaki S, Mandelbaum RS. et al. Trends, characteristics, and outcomes of conservative management for placenta percreta. Arch Gynecol Obstet 2022; 306 (03) 913-920
43 Bassetty KC, Vijayaselvi R, Yadav B, David LS, Beck MM. Placenta accreta spectrum: management and outcomes in a tertiary centre in India: an observational cross-sectional study. Trop Doct 2021; 51 (03) 398-403
44 Bailit JL, Grobman WA, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Morbidly adherent placenta treatments and outcomes. Obstet Gynecol 2015; 125 (03) 683-689
45 Sentilhes L, Goffinet F, Kayem G. Management of placenta accreta. Acta Obstet Gynecol Scand 2013; 92 (10) 1125-1134
46 Alchalabi H, Lataifeh I, Obeidat B, Zayed F, Khader YS, Obeidat N. Morbidly adherent placenta previa in current practice: prediction and maternal morbidity in a series of 23 women who underwent hysterectomy. J Matern Fetal Neonatal Med 2014; 27 (17) 1734-1737
47 Guo Z, Han X, Zhang H, Zheng W, Yang H, Ma J. Association between pre-delivery coagulation indicators and invasive placenta accreta spectrum. Clin Appl Thromb Hemost 2022;28:10760296211070580
48 Jauniaux E, Zosmer N, Subramanian D, Shaikh H, Burton GJ. Ultrasound-histopathologic features of the utero-placental interface in placenta accreta spectrum. Placenta 2020; 97: 58-64 [published correction appears in Placenta. 2021 Jan 1;103:246]
49 Jauniaux E, Hussein AM, Elbarmelgy RM, Elbarmelgy RA, Burton GJ. Failure of placental detachment in accreta placentation is associated with excessive fibrinoid deposition at the utero-placental interface. Am J Obstet Gynecol 2022; 226 (02) 243.e1-243.e10
50 Shamshirsaz AA, Fox KA, Erfani H. et al. Coagulopathy in surgical management of placenta accreta spectrum. Eur J Obstet Gynecol Reprod Biol 2019; 237: 126-130
51 Eller AG, Bennett MA, Sharshiner M. et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol 2011; 117 (2 Pt 1): 331-337
52 Giuseppe C, Salvatore P, Federica C. et al. Urinary tract injuries during surgery for placenta accreta spectrum disorders. Eur J Obstet Gynecol Reprod Biol 2023; 287: 93-96
53 Erfani H, Salmanian B, Fox KA. et al. Urologic morbidity associated with placenta accreta spectrum surgeries: single-center experience with a multidisciplinary team. Am J Obstet Gynecol 2022; 226 (02) 245.e1-245.e5
54 Mehrabadi A, Hutcheon JA, Liu S. et al; Maternal Health Study Group of the Canadian Perinatal Surveillance System (Public Health Agency of Canada). Contribution of placenta accreta to the incidence of postpartum hemorrhage and severe postpartum hemorrhage. Obstet Gynecol 2015; 125 (04) 814-821
55 Mohammad Jafari R, Najafian M, Barati M, Saadati N, Jalili Z, Poolad A. Comparison of uterine preservation versus hysterectomy in women with placenta accreta: a cross-sectional study. Int J Reprod Biomed 2022; 20 (09) 739-744
56 Pineles BL, Sibai BM, Sentilhes L. Is conservative management of placenta accreta spectrum disorders practical in the United States?. Am J Obstet Gynecol MFM 2023; 5 (03) 100749
57 Esakoff TF, Handler SJ, Granados JM, Caughey AB. PAMUS: placenta accreta management across the United States. J Matern Fetal Neonatal Med 2012; 25 (06) 761-765
58 Einerson BD, Gilner JB, Zuckerwise LC. Placenta accreta spectrum. Obstet Gynecol 2023; 142 (01) 31-50
59 Durukan H, Durukan ÖB, Yazıcı FG. Placenta accreta spectrum disorder: a comparison between fertility-sparing techniques and hysterectomy. J Obstet Gynaecol 2021; 41 (03) 353-359
60 Zuckerwise LC, Craig AM, Newton JM, Zhao S, Bennett KA, Crispens MA. Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum. Am J Obstet Gynecol 2020; 222 (02) 179.e1-179.e9
61 Su HW, Yi YC, Tseng JJ. et al. Maternal outcome after conservative management of abnormally invasive placenta. Taiwan J Obstet Gynecol 2017; 56 (03) 353-357

Supplementary Material

Supplementary Material