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

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

Am J Perinatol. 2024 Dec 28. doi: 10.1055/a-2491-4328. Online ahead of print.

Authors

Itamar D Futterman^{1

2}, Cintia Gomes^{1

3}, Olivia Sher¹, Julia Fisher^{1

4}, Rodney A McLaren Jr⁵, Shoshana Haberman¹, Scott Chudnoff⁶

Affiliations

¹ Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York.
² Division of Complex Obstetrical Surgery, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York.
³ Department of Medicine, Federal University of Santa Maria, Santa Maria, Brazil.
⁴ College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York.
⁵ Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.
⁶ Division of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn.

PMID: 39732143
DOI: 10.1055/a-2491-4328

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..