Local Resection After Cesarean Delivery for Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis.

Abstract

OBJECTIVE To compare maternal and surgical outcomes between local resection and immediate hysterectomy after cesarean delivery in patients with placenta accreta spectrum. 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 placenta accreta spectrum (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 placenta accreta spectrum were overall low quality because of the lack of intention-to-treat information. Despite these limitations, local resection for placenta accreta spectrum 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.