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4: Conservative management versus cesarean hysterectomy for placenta accreta spectrum; the PACCRETA prospective population-based study

      Objective

      To compare maternal outcomes following conservative management (CM) versus cesarean hysterectomy (CH) for placenta accreta spectrum (PAS).

      Study Design

      PACCRETA is a prospective population-based study conducted in 182 maternity hospitals of eleven regional perinatal networks in France between 11/01/2013 and 10/31/2015 (source population of 537 793 deliveries) including all women with a previous cesarean and a placenta previa and/or women with PAS (n=634). Among women with PAS (n= 246, population-based incidence of 1 in 2174 deliveries), we included for this analysis those with cesarean delivery (n=147). Exclusion criteria were women with vaginal delivery (n=35) and those who had neither CM (leaving the placenta in situ) nor CH (n=64). Maternal outcomes were compared between women who had CM (n=85) and those who had CH (n=62), up to 6 months postpartum. The primary outcome was transfusion of more than 4 packed red blood cell (RBC) units. Secondary outcomes were other measures of postpartum blood loss and surgical complications.

      Results

      Maternal characteristics did not differ except for parity >2 that was more frequent in CH group. The primary outcome occurred in 14 women (16.5%) in the CM group and in 36 women (58.1%) in the CH group (p< 0.0001). Hysterectomy (primary or secondary) (22.4% versus 100%; p< 0.0001), any RBC transfusion (38.8% versus 86.4%); p< 0.0001), total estimated blood loss > 1500 mL (16.9% versus 67.2%; p< 0.0001) and adjacent organ injury (4.7% versus 12.9%; p=0.03) were less frequent in the CM compared to the CH group. Arterial embolization (24.7% versus 3.2%; p< 0.0001), endometritis (10.8% versus 0%; p=0.01) and readmission after discharge from delivery stay (28.9% versus 3.4%; p< 0.0001) were more frequent in the CM compared to the CH group.

      Conclusion

      Among women with PAS who had a cesarean delivery, CM was associated with lower incidences of transfusion of more than 4 packed RBCs and other indicators of severe blood loss than CH. Nevertheless, CM was also associated with higher incidences of embolization, endometritis and readmission.
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