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Matsuzaki S, Einerson BD, Sentilhes L, Sibai BM, Saade GR, Saad AF, Mimura K, Matsuzaki S, Buckley de Meritens A, Hobson SR, Ouzounian JG, Silver RM, Wright JD, Matsuo K. Local Resection After Cesarean Delivery for Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis. Obstet Gynecol 2025; 145:639-653. [PMID: 40245405 DOI: 10.1097/aog.0000000000005921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Accepted: 03/13/2025] [Indexed: 04/19/2025]
Abstract
OBJECTIVE To compare maternal and surgical outcomes between local resection and immediate hysterectomy after cesarean delivery in patients with placenta accreta spectrum (PAS). DATA SOURCES Four public databases (PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were systematically searched for relevant publications up to July 31, 2024. Because the Cochrane Library included all the identified clinical trials, it was unnecessary to search ClinicalTrials.gov . The search strategy included the terms "placenta accreta" or "placenta accreta spectrum" and "pregnancy outcomes" and related key words about local resection and cesarean hysterectomy. METHODS OF STUDY SELECTION With the use of established inclusion criteria, 4,889 studies were reviewed. The included studies evaluated surgical and maternal outcomes associated with immediate hysterectomy compared with local resection. TABULATION, INTEGRATION, AND RESULTS Data extraction was conducted with the Patient/Population, Intervention, Comparison, Outcome, and Study design framework. Both fixed-effects and random-effects models were used to synthesize the findings. A total of 11 studies published between 2018 and 2024 were analyzed (nine retrospective studies, one randomized controlled trial, and one prospective cohort study). The quality of the included studies was globally low, and 7 of 11 studies had severe bias. The immediate hysterectomy group had a significantly higher prevalence of placenta percreta compared with the local resection group (69.4% vs 44.3%, P <.01). In contrast to immediate hysterectomy, local resection yielded improved surgical outcomes, demonstrated by the following metrics: transfusion rate (six studies, 375 vs 205 patients, odds ratio [OR] 0.47, 95% CI, 0.29-0.75), estimated blood loss (seven studies, 416 vs 246 patients, mean difference -396 mL, 95% CI, -534 to -257), urologic complications (seven studies, 408 vs 241 patients, OR 0.18, 95% CI, 0.10-0.33), and intensive care unit admission (three studies, 87 vs 79 patients, OR 0.19, 95% CI, 0.07-0.53). One study recorded three maternal deaths: two in the immediate hysterectomy group and one in the local resection group. The results of subgroup analyses focused on patients with severe forms of PAS (placenta increta and percreta) were similar in the overall analysis. CONCLUSION In this systematic review and meta-analysis, eligible studies comparing the local resection with immediate hysterectomy at cesarean hysterectomy for PAS were overall low quality because of the lack of intention-to-treat information. Despite these limitations, local resection for PAS may possibly be an option for appropriately selected patients to reduce surgical morbidity. Because the indication criteria, safety, surgical techniques, and necessity of adjunctive therapies for local resection remain understudied, further prospective studies are warranted. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42024594315.
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Affiliation(s)
- Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, the Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, and the Department of Obstetrics and Gynecology, Osaka General Medical Center, Osaka, Japan; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah; the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France; the Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UTHealth Houston, Houston, Texas; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax, Fairfax, Virginia; the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York; the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; and the Division of Maternal-Fetal Medicine, the Division of Gynecologic Oncology, and the Norris Comprehensive Cancer Center, University of Southern California, and the Department of Obstetrics and Gynecology, Los Angeles General Medical Center, Los Angeles, California
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Zhang S, Li X, Jin Y, Cheng L, Wu T, Hou X, Wei S, Li Y, Xiao X, Liu T, Wang L. The role of MRI in "estimating" intraoperative bleeding during cesarean section for placenta accreta: A prospective cohort study. Heliyon 2024; 10:e36480. [PMID: 39281574 PMCID: PMC11395750 DOI: 10.1016/j.heliyon.2024.e36480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 08/14/2024] [Accepted: 08/16/2024] [Indexed: 09/18/2024] Open
Abstract
Objectives The prenatal detection of placenta accreta spectrum (PAS) disorder is crucial for treatment strategy formulation. MRI descriptors may offer a more objective method for predicting PAS and clinical outcomes. The aim of this study is to investigate the predictive value of MRI examination for intraoperative blood loss in PAS cesarean section and elucidating the MRI descriptors that are more valuable for predicting intraoperative blood loss. Methods A prospective study was carried out on 164 pregnant women diagnosed with PAS. Maternal and neonatal perioperative characteristics were systematically collected. To evaluate the relationship between maternal and perioperative characteristics and intraoperative blood loss, as well as the predictive value of MRI descriptors on intraoperative blood loss, a multivariable linear regression analysis was performed. Results Patients were pre-grouped based on a combined ultrasound-MRI evaluation, with 108 cases (65.9 %) classified as placenta accreta, 47 cases (28.7 %) as placenta increta, and 9 cases (5.4 %) as placenta percreta. The results demonstrated that intraoperative blood loss was positively associated with partial MRI descriptors (F = 9.751, df = 15), such as placenta accreta (OR: 243.33, p = 0.006), cross-border blood vessels that pass through the uterine muscle layer (OR: 297.76, p = 0.012), interruption of hyperechoic uterus-bladder interface (bladder line) (OR: 342.59, p = 0.011), and subplacental hypervascularity (OR: 365.96, p = 0.027). Conclusions Preoperative MRI demonstrates promising predictive capabilities in estimating intraoperative blood loss for PAS patients. Pregnant women identified as having a high risk of intraoperative bleeding based on MRI findings should undergo closer antenatal monitoring in late pregnancy, along with more comprehensive preoperative blood preparation, to better ensure maternal and fetal safety.
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Affiliation(s)
- Shimao Zhang
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xin Li
- West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Ying Jin
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Linbo Cheng
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Tenglan Wu
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xi Hou
- Department of Obstetrics and Gynaecology, Chengdu Xindu Maternal and Child Health Hospital, Sichuan province, China
| | - Sumei Wei
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Yalan Li
- The Fourth People's Hospital of Chengdu, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xue Xiao
- West China Second University Hospital, Sichuan University, Chengdu, 610041, China
| | - Tianjiao Liu
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Luying Wang
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
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Zhao B, Chen J, Luo Q. A new technique to preserve the uterus in placenta accreta spectrum. Am J Obstet Gynecol 2024; 231:e52. [PMID: 38462145 DOI: 10.1016/j.ajog.2024.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Baihui Zhao
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, China; Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
| | - Jiamin Chen
- School of Medicine, Zhejiang University, Zhejiang, China
| | - Qiong Luo
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, China; Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China.
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Barinov S, Di Renzo GC. A new technique to preserve the uterus in placenta accreta spectrum: a reply. Am J Obstet Gynecol 2024; 231:e53-e54. [PMID: 38462146 DOI: 10.1016/j.ajog.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Sergey Barinov
- Department of Obstetrics and Gynecology, Omsk State Medical University, Omsk, Russian Federation
| | - Gian Carlo Di Renzo
- International and European Schoon of Perinatal, Neonatal and Reproductive Medicine, Florence, Italy.
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Nieto-Calvache ÁJ, Aryananda RA, Palacios-Jaraquemada JM, Cininta N, Grace A, Benavides-Calvache JP, Campos CI, Messa-Bryon A, Vallecilla L, Sarria D, Galindo JS, Galindo-Velasco V, Rivera-Torres LF, Burgos-Luna JM, Bhide A. One-step conservative surgery vs hysterectomy for placenta accreta spectrum: a feasibility randomized controlled trial. Am J Obstet Gynecol MFM 2024; 6:101333. [PMID: 38458362 DOI: 10.1016/j.ajogmf.2024.101333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Placenta accreta spectrum is a serious condition associated with significant maternal morbidity and even mortality. The recommended treatment is hysterectomy. An alternative is 1-step conservative surgery, which involves the en bloc resection of the myometrium affected by placenta accreta spectrum along with the placenta, followed by uterine reconstruction. Currently, there are no studies comparing the 2 techniques in the setting of a randomized controlled trial. OBJECTIVE We performed a prospectively registered multicenter randomized controlled trial comparing hysterectomy with 1-step conservative surgery. The aim was to collect feasibility and clinical outcomes of the 2 techniques in women assigned to hysterectomy or 1-step conservative surgery. In addition to assessing participants' willingness to be randomized, we also collected data on intraoperative blood loss, transfusion requirement, serious adverse event, and other clinical outcomes. STUDY DESIGN Sixty women with strong antenatal suspicion of placenta accreta spectrum were assigned randomly to either hysterectomy (n=31) or 1-step conservative surgery (n=29). RESULTS During a 20-month period, 60 of the 64 eligible patients (93.7%) underwent randomization. Intention-to-treat analysis showed that the clinical outcomes for 1-step conservative surgery were comparable to those of hysterectomy (median intraoperative blood loss, 1740 mL [interquartile range, 1010-2410] vs 1500 mL [interquartile range, 1122-2753]; odds ratio, 1 [1-1]; P=.942; median duration of surgery, 135 minutes [interquartile range, 111-180] vs 155 minutes [interquartile range, 120-185]; odds ratio, 0.99 [0.98-1]; P=.151; transfusion rate, 58.6% vs 61.3%; odds ratio, 0.96 [0.83-1.76]; P=.768; and adverse event rate, 17.2% vs 9.7%; odds ratio, 1.77 [0.43-10.19]; P=.398; respectively). In the subgroup of women with type 1 class on topographic classification, all participants allocated to 1-step surgery had successful outcomes, which were superior to those of hysterectomy. This was evidenced by the shorter surgery duration (median, 125 [interquartile range, 98-128] vs 180 [129-226] minutes; P=.002), lower transfusion rates (46.2% vs 82.4%), and fewer units of red blood cells transfused (median, 1 [interquartile range, 1-1.8] vs 3 [interquartile range, 2-4] units; P=.007). CONCLUSION A randomized controlled trial comparing 2 surgical techniques for the treatment of placenta accreta spectrum is feasible. One-step conservative repair is a valid alternative to hysterectomy in the large majority of cases, but this can only be ascertained following intraoperative surgical staging. El resumen está disponible en Español al final del artículo.
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Affiliation(s)
- Álbaro José Nieto-Calvache
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna).
| | - Rozi Aditya Aryananda
- Obstetrics & Gynecology department of Dr. Soetomo General Academic Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia (Drs Aryananda and Cininta)
| | | | - Nareswari Cininta
- Obstetrics & Gynecology department of Dr. Soetomo General Academic Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia (Drs Aryananda and Cininta)
| | - Ariani Grace
- Anatomical Pathology Department, Dr. Soetomo General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Grace)
| | - Juan Pablo Benavides-Calvache
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna)
| | - Clara Ivette Campos
- Departamento de Patología, Fundación Valle del Lili, Cali, Colombia (Dr Campos)
| | - Adriana Messa-Bryon
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna)
| | - Liliana Vallecilla
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | - Daniela Sarria
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | - Juan Sebastian Galindo
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | - Valentina Galindo-Velasco
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | | | - Juan Manuel Burgos-Luna
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna)
| | - Amarnath Bhide
- Fetal Medicine Unit, Division of Developmental Sciences, St George's, University of London, London, United Kingdom (Dr Bhide)
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Matsubara S. Letter to the editor regarding placenta accreta spectrum: treatment consensus in a resource-limited setting: classification and registration of surgeries are necessary. AJOG GLOBAL REPORTS 2024; 4:100291. [PMID: 38313555 PMCID: PMC10835308 DOI: 10.1016/j.xagr.2023.100291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Affiliation(s)
- Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan
- Department of Obstetrics and Gynecology, Koga Red Cross Hospital, Ibaraki, Japan
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