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
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Article Info
Publication History
Published online: December 13, 2021
Accepted:
December 9,
2021
Received in revised form:
November 24,
2021
Received:
July 16,
2021
Footnotes
C.D.T. and G.K. contributed equally to this work.
L.S. was carrying out consultancy work and was performing lectures for Ferring Laboratories in the previous 3 years. The other authors report no conflict of interest.
The PACCRETA study was funded by the French Health Ministry under its Hospital Clinical Research Program and by the Angers University Hospital.
This study is registered on ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT02010229).
Cite this article as: Sentilhes L, Seco A, Azria E, et al. Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study. Am J Obstet Gynecol 2022;226:839.e1-24.
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