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Article Dans Une Revue American Journal of Obstetrics and Gynecology Année : 2022

Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study

Loïc Sentilhes
Gaël Beucher
  • Fonction : Auteur
Marie-Pierre Bonnet
Michel Dreyfus
  • Fonction : Auteur
Sophie Patrier
  • Fonction : Auteur
Isabelle Avril
  • Fonction : Auteur
Sophie Bazire
  • Fonction : Auteur
Sophie Bedel
  • Fonction : Auteur
Fanny de Marcillac
  • Fonction : Auteur
Maëlle Guitton
  • Fonction : Auteur
Catherine Guerin
  • Fonction : Auteur
Laurence Lecomte
  • Fonction : Auteur
Marine Pranal
  • Fonction : Auteur
Laetitia Rault
  • Fonction : Auteur
Anne Viallon
  • Fonction : Auteur
Myriam Virlouvet
  • Fonction : Auteur
Justine Schwanka
  • Fonction : Auteur

Résumé

Background Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management. Objective This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ). Study Design From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias. Results Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19–0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy. Conclusion Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy.

Dates et versions

hal-04177972 , version 1 (07-08-2023)

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Loïc Sentilhes, Aurélien Seco, Elie Azria, Gaël Beucher, Marie-Pierre Bonnet, et al.. Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study. American Journal of Obstetrics and Gynecology, 2022, 226 (6), pp.839.e1-839.e24. ⟨10.1016/j.ajog.2021.12.013⟩. ⟨hal-04177972⟩
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