Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: A systematic review and meta-analysis

Ali Javinani, Maternal Fetal Care Center (MFCC), Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Shohra Qaderi, Maternal Fetal Care Center (MFCC), Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
Kamran Hessami, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas, USA.
Scott A. Shainker, Division of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
Amir A. Shamshirsaz, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas, USA.
Karin A. Fox, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas, USA.
Hiba J. Mustafa, Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, IN & The Fetal Center at Riley Children and Indiana University Health, Indianapolis, IN, USA.
Akila Subramaniam, University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Birmingham, AL, USA.
Meena Khandelwal, Cooper Medical School of Rowan University, Camden, NJ, USA.
Adam T. Sandlin, University of Arkansas for Medical Sciences, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Little Rock, AR, USA.
Christina M. Duzyj, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.
Deirdre J. Lyell, Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, California, USA.
Lisa C. Zuckerwise, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA.
J M. Newton, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA.
John C. Kingdom, Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, ON, Canada.
Rachel K. Harrison, Advocate Aurora HealthFollow
Vineet K. Shrivastava, Miller Children's & Women's Hospital/Long Beach Memorial, Long Beach, CA, USA.
Andrea L. Greiner, Department of Obstetrics and Gynecology, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA.
Ryan Lotfin, Allina Health System, Minneapolis, MN, USA.
Mehmet R. Genc, University of Florida College of Medicine, Department of Obstetrics and Gynecology, Gainesville, FL, USA.
Lamia K. Atasi, Mercy Hospital, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, St. Louis, MO, USA.
Sonya S. Abdel-Razeq, Yale University, Department of Obstetrics, Gynecology, and Reproductive Science, Division of Maternal-Fetal Medicine, New Haven, CT, USA.
Kelly A. Bennett, The Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA.
Daniela A. Carusi, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
Brett D. Einerson, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
Jennifer B. Gilner, Duke University, Department of OB/Gyn, Division of Maternal-Fetal Medicine, Durham, NC, USA.
Alissa R. Carver, Wilmington Maternal-Fetal Medicine, Wilmington, NC, USA.
Robert M. Silver, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
Alireza A. Shamshirsaz, Maternal Fetal Care Center (MFCC), Boston Children's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: alireza.shamshirsaz@childrens.harvard.edu.

Abstract

Objective: Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder (PAS). Recently, uterine-sparing techniques have been introduced in conservative management of PAS to preserve fertility and potentially reduce surgical complications. However, despite often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcome after conservative management of PAS. Thus, we aimed to perform a systematic review and meta-analysis to assess the subsequent pregnancy outcomes following conservative management of PAS.

Data sources: PubMed, Scopus, and Web of Science databases were searched from inception to September 2022.

Study eligibility criteria: We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a previous history of PAS who underwent any type of conservative management.

Study appraisal and synthesis method: The R programming language with the "meta" package was used. The random effects model and inverse variance method were used to pool the proportion of pregnancy outcomes.

Results: We identified five studies involving 1,458 subjects that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1), resection surgery (n=1), and not reported in three studies. The PAS recurrence rate in the subsequent pregnancy was 11.8% (95% CI: 1.1-60.3, I2 = 86.4%), and 1.9% (95% CI: 0.0-34.1, I2 = 82.4%) underwent Cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% CI: 0.3-81.4, I2 = 96.7%). A composite adverse maternal outcome was reported in 22.7% of subjects (95% CI: 0.0-99.4, I2 = 56.3%).

Conclusion: Favorable pregnancy outcome is possible following successful conservation of the uterus in a PAS pregnancy. Approximately one out of four subsequent pregnancies following conservative management of PAS experienced significant adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.

Document Type

Article

PubMed ID

37918506

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