Conservative management of placenta accreta spectrum is associated with improved surgical outcomes compared to cesarean hysterectomy: a systematic review and meta-analysis.

OBJECTIVE

To compare maternal and surgical outcomes between patients with placenta accreta spectrum who underwent conservative management and those who underwent cesarean hysterectomy.

DATA SOURCES

We performed a systematic search in PubMed, Embase, and Web of Science from inception up to June 2, 2024.

STUDY ELIGIBILITY CRITERIA

Studies comparing clinical outcomes among patients with placenta accreta spectrum undergoing conservative management vs cesarean hysterectomy were included. Conservative management was defined as leaving the placenta in situ and local myometrial resection.

STUDY APPRAISAL AND SYNTHESIS METHODS

A random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I statistic.

RESULTS

The meta-analysis included 16 studies, with a total of 2300 women diagnosed with placenta accreta spectrum. Of this pooled sample, 1072 patients underwent cesarean hysterectomy and 1228 were managed conservatively. In pregnancies affected by placenta accreta spectrum, cesarean hysterectomy was associated with significantly higher estimated blood loss compared to placenta in situ (mean difference 973.5 mL, 95% confidence interval 615.4-1331.7, 95% prediction interval [PI] -50.2 to 1997.2, P<.001) and local resection (mean difference 739.7 mL, 95% confidence interval 287.7-1191.7, 95% PI -911.5 to 2390.9, P<.001). Additionally, cesarean hysterectomy resulted in more intraoperative transfused red blood cell units than the local resection (mean difference 1.54 units, 95% confidence interval 1.06-2.01, 95% PI 0.27-2.81, P=.001) but had similar rates as compared to placenta in situ group (mean difference 0.72 units, 95% confidence interval -0.21 to 1.64, 95% PI -2.21 to 3.64, P=.065). The risk of genitourinary injury was significantly higher for cesarean hysterectomy compared to both placenta left in situ (odds ratio 3.79, 95% confidence interval 1.88-7.61, 95% PI 1.52-9.46, P<.001) and local resection (odds ratio 4.11, 95% confidence interval 2.57-6.56, 95% PI 2.34-7.22, P<.001). Patients undergoing cesarean hysterectomy, as compared to placenta in situ group, were more likely to be admitted to intensive care unit (odds ratio 7.98, 95% confidence interval 2.23-28.51, 95% PI 0.34-188.50, P<0.001); however, there was no significant difference between cesarean hysterectomy and local resection group in terms of intensive care unit admission. There were no significant differences between cesarean hysterectomy and conservative approaches regarding the risk of gastrointestinal injury and thromboembolic events.

CONCLUSION

This meta-analysis strengthens the evidence supporting conservative management for pregnancies with placenta accreta spectrum, demonstrating that it is associated with reduced surgical morbidity and may offer an effective alternative to cesarean hysterectomy, particularly for patients seeking fertility preservation. However, further research, including randomized controlled trials and longitudinal studies, is necessary to more definitively evaluate conservative management approaches for pregnancies with placenta accreta spectrum and assess long-term clinical outcomes after conservative management.