Advertisement

Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study

Published:December 13, 2021DOI:https://doi.org/10.1016/j.ajog.2021.12.013

      Background

      Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management.

      Objective

      This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ).

      Study Design

      From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias.

      Results

      Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19–0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy.

      Conclusion

      Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Silver R.M.
        • Branch D.W.
        Placenta accreta spectrum.
        N Engl J Med. 2018; 378: 1529-1536
        • Sentilhes L.
        • Goffinet F.
        • Kayem G.
        Management of placenta accreta.
        Acta Obstet Gynecol Scand. 2013; 92: 1125-1134
        • Fitzpatrick K.E.
        • Sellers S.
        • Spark P.
        • Kurinczuk J.J.
        • Brocklehurst P.
        • Knight M.
        Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study.
        PloS One. 2012; 7: e52893
        • Colmorn L.B.
        • Petersen K.B.
        • Jakobsson M.
        • et al.
        The Nordic Obstetric Surveillance Study: a study of complete uterine rupture, abnormally invasive placenta, peripartum hysterectomy, and severe blood loss at delivery.
        Acta Obstet Gynecol Scand. 2015; 94: 734-744
        • Kayem G.
        • Seco A.
        • Beucher G.
        • et al.
        Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.
        BJOG. 2021; 128: 1646-1655
        • Belfort M.A.
        • Publications Committee, Society for Maternal-Fetal Medicine
        Placenta accreta.
        Am J Obstet Gynecol. 2010; 203: 430-439
        • Committee on Obstetric Practice
        Committee Opinion No. 529: placenta accreta.
        Obstet Gynecol. 2012; 120: 207-211
        • Royal College of Obstetricians and Gynaecologists
        Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management (Green-top Guideline No. 27).
        Royal College of Obstetricians and Gynaecologists. Greentop, London, United Kingdomm2011
        • Kayem G.
        • Davy C.
        • Goffinet F.
        • Thomas C.
        • Clément D.
        • Cabrol D.
        Conservative versus extirpative management in cases of placenta accreta.
        Obstet Gynecol. 2004; 104: 531-536
        • Bretelle F.
        • Courbière B.
        • Mazouni C.
        • et al.
        Management of placenta accreta: morbidity and outcome.
        Eur J Obstet Gynecol Reprod Biol. 2007; 133: 34-39
        • Sentilhes L.
        • Ambroselli C.
        • Kayem G.
        • et al.
        Maternal outcome after conservative treatment of placenta accreta.
        Obstet Gynecol. 2010; 115: 526-534
        • Sentilhes L.
        • Kayem G.
        • Ambroselli C.
        • et al.
        Fertility and pregnancy outcomes following conservative treatment for placenta accreta.
        Hum Reprod. 2010; 25: 2803-2810
        • Sentilhes L.
        • Kayem G.
        • Silver R.M.
        Conservative management of placenta accreta spectrum.
        Clin Obstet Gynecol. 2018; 61: 783-794
        • Marcellin L.
        • Delorme P.
        • Bonnet M.P.
        • et al.
        Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta.
        Am J Obstet Gynecol. 2018; 219: 193.e1-193.e9
        • Sentilhes L.
        • Kayem G.
        • Chandraharan E.
        • Palacios-Jaraquemada J.
        • Jauniaux E.
        FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: conservative management.
        Int J Gynaecol Obstet. 2018; 140: 291-298
        • Palacios Jaraquemada J.M.
        • Pesaresi M.
        • Nassif J.C.
        • Hermosid S.
        Anterior placenta percreta: surgical approach, hemostasis and uterine repair.
        Acta Obstet Gynecol Scand. 2004; 83: 738-744
        • Chandraharan E.
        • Rao S.
        • Belli A.M.
        • Arulkumaran S.
        The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta.
        Int J Gynaecol Obstet. 2012; 117: 191-194
        • Women’s Health Committee
        Placenta accreta. Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
        (Available at:)
        • Sentilhes L.
        • Vayssière C.
        • Deneux-Tharaux C.
        • et al.
        Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR).
        Eur J Obstet Gynecol Reprod Biol. 2016; 198: 12-21
        • Jauniaux E.
        • Alfirevic Z.
        • Bhide A.G.
        • et al.
        Placenta praevia and placenta accreta: diagnosis and management: Green-top Guideline No. 27a.
        BJOG. 2019; 126: e1-e48
        • Collins S.L.
        • Alemdar B.
        • van Beekhuizen H.J.
        • et al.
        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: 511-526
        • Amsalem H.
        • Kingdom J.C.P.
        • Farine D.
        • et al.
        Planned caesarean hysterectomy versus “conserving” caesarean section in patients with placenta accreta.
        J Obstet Gynaecol Can. 2011; 33: 1005-1010
        • Kutuk M.S.
        • Ak M.
        • Ozgun M.T.
        Leaving the placenta in situ versus conservative and radical surgery in the treatment of placenta accreta spectrum disorders.
        Int J Gynaecol Obstet. 2018; 140: 338-344
        • Lional K.M.
        • Tagore S.
        • Wright A.M.
        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
        • Kayem G.
        • Deneux-Tharaux C.
        • Sentilhes L.
        • PACCRETA group
        PACCRETA: clinical situations at high risk of placenta accreta/percreta: impact of diagnostic methods and management on maternal morbidity.
        Acta Obstet Gynecol Scand. 2013; 92: 476-482
      1. The National Institute of Health and Medical Research and by the Executive Board of Research, Studies, Evaluation and Statistics. Enquête nationale périnatale 2016 (National perinatal survey 2016). The French Ministry of Health. 2017. Available at: http://www.epopé-inserm.fr/wp-content/. Accessed December 28, 2021.

        • Meher S.
        • Cuthbert A.
        • Kirkham J.J.
        • et al.
        Core outcome sets for prevention and treatment of postpartum haemorrhage: an international Delphi consensus study.
        BJOG. 2019; 126: 83-93
        • Brooks M.
        • Legendre G.
        • Brun S.
        • et al.
        Use of a visual aid in addition to a collector bag to evaluate postpartum blood loss: a prospective simulation study.
        Sci Rep. 2017; 7: 46333
        • Legendre G.
        • Richard M.
        • Brun S.
        • Chancerel M.
        • Matuszewski S.
        • Sentilhes L.
        Evaluation by obstetric care providers of simulated postpartum blood loss using a collector bag: a French prospective study.
        J Matern Fetal Neonatal Med. 2016; 26: 1-7
      2. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.
        Crit Care Med. 1992; 20: 864-874
        • Rosenbaum P.R.
        • Rubin D.B.
        The central role of the propensity score in observational studies for causal effects.
        Biometrika. 1983; 70: 41-55
        • Rosenbaum P.R.
        Model-based direct adjustment.
        J Am Stat Assoc. 1987; 82: 387-394
        • Silver R.M.
        • Fox K.A.
        • Barton J.R.
        • et al.
        Center of excellence for placenta accreta.
        Am J Obstet Gynecol. 2015; 212: 561-568
        • Eller A.G.
        • Porter T.F.
        • Soisson P.
        • Silver R.M.
        Optimal management strategies for placenta accreta.
        BJOG. 2009; 116: 648-654
        • Fitzpatrick K.E.
        • Sellers S.
        • Spark P.
        • Kurinczuk J.J.
        • Brocklehurst P.
        • Knight M.
        The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study.
        BJOG. 2014; 121: 62-71
        • Benjamini Y.
        • Hochberg Y.
        Controlling the false discovery rate: a practical and powerful approach to multiple testing.
        J R Stat Soc Series B Stat Methodol. 1995; 57: 289-300
        • Warshak C.R.
        • Ramos G.A.
        • Eskander R.
        • et al.
        Effect of predelivery diagnosis in 99 consecutive cases of placenta accreta.
        Obstet Gynecol. 2010; 115: 65-69
        • Shamshirsaz A.A.
        • Fox K.A.
        • 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: 218.e1-218.e9