Adverse maternal outcomes occur in approximately 1 in 4 pregnant patients with placenta accrete spectrum (PAS) following conservation of the uterus, according to a recent study published in the American Journal of Obstetrics & Gynecology.1
Takeaways
- Placenta accreta spectrum (PAS) poses significant risks to pregnant patients, with approximately 1 in 4 experiencing adverse outcomes following uterine conservation.
- Conservative management techniques, such as leaving the placenta in situ and resection surgery, are commonly used but may not always prevent adverse outcomes.
- The incidence of PAS has increased significantly over recent decades, likely because of rising rates of cesarean section deliveries.
- Despite efforts to standardize diagnostic criteria and management approaches, there is considerable variation in techniques and definitions among studies.
- Multidisciplinary care by experts in longitudinal and surgical management is crucial for optimizing outcomes in patients with PAS.
PAS, characterized by abnormal placental adherence to the uterus, is a severe and potentially life-threatening obstetrical complication. Adverse outcomes of PAS include coagulopathy, hemorrhagic shock, intensive care unit (ICU) admission, and adjacent organ injury at emergency hysterectomy.
According to the National Accreta Foundation, PAS occurred in 1 in 272 pregnancies in 2016, a significant increase from 1 in 1250 pregnancies in 1980.2 Additionally, a cesarean section was reported in 31.9% of US births in 2016, with 87.6% having a repeat cesarean section that increased PAS risk in future pregnancies.
Cesarean delivery and conservative management are the primary treatment methods for patients with PAS.1 Conservative management, defined as any “uterine-sparing” technique, can prevent consequences of hysterectomy such as infertility. While recent research has focused on conservative management for PAS, data about future impact remains limited.
Investigators conducted a review to evaluate pregnancy outcomes among patients receiving conservative management for PAS. Studies were identified through searches of the PubMed, Web of Sciences, and Scopus databases from inception to September 2022.
Included studies had patients with a PAS history and subsequent pregnancy, a uterine-sparing technique used for intervention, and outcomes including PAS recurrence, uterine rapture, hysterectomy, maternal blood transfusion, postpartum hemorrhage, cesarean delivery, and mortality.
Studies not specifying first subsequent delivery and only reporting outcomes in patients with cesarean hysterectomy were excluded. Two reviewers independently performed title and abstract screening, full-text screening, and data extraction, with a third reviewer consulted during conflicts.
Extracted study and demographic data included author, country, publication year, institution, study design, number of patients with PAS history and in the control group, and maternal age. Obstetrical history included interpregnancy interval, parity, dilation and curettage history, assisted reproductive technology, prior cesarean deliveries, prior uterine surgery, PAS diagnostic criteria, and uterine-sparing techniques.
Delivery outcomes included postpartum hemorrhage, PAS recurrence, uterine rupture, hysterectomy, cesarean delivery, maternal blood transfusion, and death. Individual study definitions were used to assess maternal composite adverse outcomes.
There were 5 studies evaluating 1458 patients included in the analysis. Conservative management techniques reported included leaving the placenta in situ and resection surgery. However, 3 studies did not report conservative management techniques. Additionally, PAS diagnostic criteria differed between studies.
The rates of PAS recurrence, hysterectomy, and uterine rapture were 11.8%, 1.9%, and 1.3%, respectively. Notably, a precise definition for uterine rupture was not provided in each study. Additional rates included 10.3% for postpartum hemorrhage, 4.2% for maternal blood transfusion and 36.5% for cesarean delivery.
Of cases, 22.7% had a study-specific maternal composite adverse outcome. Maternal death was not reported in the studies, but 2 reported perinatal death, which had a rate of 2.1%.
These results indicated a high rate of adverse outcomes following conservation of the uterus. Investigators concluded conservative management for PAS should be performed, “by a multidisciplinary team with expertise in longitudinal and surgical care of patients with PAS.”
References
- Javinani A, Qaderi S, Hessami K, et al. Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology. 2024;230(5):485-492.E7. doi:10.1016/j.ajog.2023.10.047
- Prevent Accreta. National Accreta Foundation. Accessed May 9, 2024. https://www.preventaccreta.org/
