Conservative management of placenta accreta spectrum is associated with improved surgical outcomes compared to cesarean hysterectomy: A systematic review and meta-analysis.

Objective: To compare maternal and surgical outcomes between patients with placenta accreta spectrum (PAS) who underwent conservative management and those who underwent cesarean hysterectomy (CH).

Data Sources: We performed a systematic search in PubMed, Embase and Web of Science from inception up to June 2, 2024.

Study Eligibility Criteria: Studies comparing clinical outcomes among patients with PAS undergoing conservative management versus CH were included. Conservative management was defined as leaving the placenta in situ and local myometrial resection.

Study Appraisal And Synthesis Methods: A random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CI). Heterogeneity was assessed using the I statistic.

Results: The meta-analysis included 16 studies, with a total of 2,300 women diagnosed with PAS. Of this pooled sample, 1,072 patients underwent CH and 1,228 were managed conservatively. In pregnancies affected by PAS, CH was associated with significantly higher estimated blood loss (EBL) compared to placenta in situ (mean difference (MD) 973.5 mL, 95% CI 615.4-1331.7, 95% PI -50.2 - 1997.2, P <0.001) and local resection (MD 739.7 mL, 95% CI 287.7-1191.7, 95% PI -911.5 - 2390.9, P <0.001). Additionally, CH resulted in more intraoperative transfused red blood cell units than the local resection (MD 1.54 units, 95% CI 1.06-2.01, 95% PI 0.27 - 2.81, P = 0.001) but had similar rates as compared to placenta in situ group (MD 0.72 units, 95% CI -0.21-1.64, 95% PI -2.21 - 3.64, P = 0.065). The risk of genito-urinary (GU) injury was significantly higher for CH compared to both placenta left in situ (OR 3.79, 95% CI 1.88-7.61, 95% PI 1.52 - 9.46, P< 0.001) and local resection (OR 4.11, 95% CI 2.57-6.56, 95% PI 2.34 - 7.22, P < 0.001). Patients undergoing CH, as compared to placenta in situ group, were more likely to be admitted to intensive care unit (ICU) (OR 7.98, 95% CI 2.23-28.51, 95% PI 0.34 - 188.50, P < 0.001), however, there was no significant difference between CH and local resection group in terms of ICU admission. There were no significant differences between CH and conservative approaches regarding the risk of gastro-intestinal injury and thrombo-embolic events.

Conclusion: This meta-analysis strengthens the evidence supporting conservative management for pregnancies with PAS, demonstrating that it is associated with reduced surgical morbidity and may offer an effective alternative to cesarean hysterectomy, particularly for patients seeking fertility preservation. However, further research, including randomized controlled trials and longitudinal studies, is necessary to more definitively evaluate conservative management approaches for pregnancies with PAS and assess long-term clinical outcomes after conservative management.