Placenta accreta spectrum disorder: A systematic review and meta‐analysis on conservative surgery
Pedro Viana Pinto, Gonçalo Freitas, Rafael José Vieira, Rozi Aditya Aryananda, Albaro José Nieto‐Calvache, José M. Palacios‐Jaraquemada
Abstract
BACKGROUND: Placenta accreta spectrum (PAS) disorders are a complex clinical entity with significant morbidity. The most widely accepted treatment for PAS is cesarean hysterectomy. However, uterus-preserving procedures have also been reported worldwide with variable results. OBJECTIVES: To assess the published evidence on feasibility of conservative surgery in PAS and its safety by assessing the associated morbidity. SEARCH STRATEGY: We conducted a systematic review of the literature, including a search in MEDLINE, Cochrane Library, Scopus, Web of Science, and LILAC databases electronically from January 1, 2000, to August 31, 2023, as well as reference lists of relevant studies. SELECTION CRITERIA: Pregnant woman with a PAS diagnosis, either histologic or surgical, with conservative surgical procedures performed. We also assessed maternal and/or neonatal outcomes. DATA COLLECTION AND ANALYSIS: Primary outcomes were blood loss and incidence of hysterectomy. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tool. A meta-analysis of continuous (blood loss and gestational age) and dichotomous variables (proportion of pregnant women undergoing hysterectomy) was also performed. The included studies were grouped according to the type of conservative surgical management used and were divided into those applying resection of the uterine area affected by PAS (myometrial resection group) and those using other types of conservative surgical techniques (conservative surgery group). MAIN RESULTS: Forty-nine articles were included in the systematic review, with 2666 patients, the majority conducted in low- and middle-income countries. Most cases (n = 1850; 69.4%) were treated with myometrial resection and repair techniques. Hysterectomy was needed in 259/2312 (11.2%), and we found an overall rate of urologic complications of 8.8%. The meta-analysis showed that patients from the myometrial resection group presented similar blood losses (1801.28 mL, 95% confidence interval [CI] 1443.47-2159.09 mL) to the other conservative surgery group (1753.85 mL, 95% CI 1353.66-2154.04 mL); the hysterectomy rate for failure of conservative treatment was also similar between the two groups (estimated hysterectomy rate of 5%, 95% CI 3%-8%). CONCLUSIONS: Uterine-sparing surgery for PAS seems feasible in a high percentage of PAS patients, even though it may not be possible to perform in every situation. The clinical outcomes reported are similar to those reported in the literature for cesarean hysterectomy.