Comparison of uterine preservation versus hysterectomy in women with placenta accreta: A cross-sectional study

Abstract Background Placenta accreta spectrum (PAS) is a major cause of obstetric bleeding in third trimester of pregnancy. Objective This study aimed to compare the outcomes of uterine preservation surgery vs. hysterectomy in women with PAS. Materials and Methods In this retrospective cross-sectional study, the records of 68 women with PAS referred to the Imam Khomeini hospital in Ahvaz, Iran, between March 2015 and February 2020 were included. The women were divided into 2 groups according to surgical approach: hysterectomy vs. uterine preservation (including just removing the lower segment, removing the lower segment with uterine artery ligation, or removing the lower segment with hypogastric artery ligation during cesarean section). The need for blood components transfusion (whole blood, packed cells, and fresh frozen plasma), maternal mortality, duration of surgery, and length of hospitalization were compared between groups. Results In total, we investigated 68 women between the ages of 24-45 yr (mean age of 32.88 ± 5.08 yr). All participants were multiparous and underwent cesarean section. Furthermore, 28 women (41.2%) had a history of curettage. In total, 24 women (35.3%) underwent a hysterectomy, and 44 (64.7%) underwent uterine preservative surgeries. There were no significant differences between groups of hysterectomy and uterine preservative surgeries in terms of the need for blood components transfusion, maternal mortality, duration of surgery, and length of hospitalization. Conclusion The results of this study showed no significant difference between groups regarding the studied outcomes. Therefore, conservative surgeries could be used to preserve the uterus instead of hysterectomy in women with PAS.


Introduction
Abnormal adhesion of the placenta involves the invasion of placental tissue into the myometrium and even serosis of the uterus, extending beyond the uterus and invading adjacent organs such as the bladder and intestines (1). The degree of placental invasion in the myometrium consists of 3 levels: the placenta accreta, increta, and percreta accrete, all known as the placenta accreta spectrum (PAS) (2). Placenta accreta has an overall incidence of approximately 1 in 500, and its occurrence is closely related to having had previous uterus surgeries (3). Furthermore, with the high prevalence of cesarean delivery, the incidence of placenta accreta has increased significantly in recent years (4).
The main issue with this type of pregnancy complication is massive bleeding during cesarean section (CS) and the necessity of hysterectomy and blood transfusion, which may exacerbate the patient's condition through complications such as bladder and ureter injuries, disseminated intravascular coagulation, massive blood transfusion, and even maternal death (5 Because there is no cure for placenta accreta, contemporary management methods include intense procedures such as elective cesarean hysterectomy, compression sutures, myometrial excision, and leaving the placenta in situ (10,11).
Uterine preservation is particularly important in young reproductive-aged women. Uterine artery ligation is one of the methods that has been recently proposed to prevent or treat severe bleeding during CS and to try to preserve the uterus in these participants. Effective procedures must be adopted immediately to deal with this life-threatening condition (9).

Materials and Methods
In this retrospective cross-sectional study, the

Results
A total of 68 women with PAS were studied in 2 groups: group I (n = 24; 35.3%) and group II (n = 44; 64.7%). The mean age of participants was 32.88 ± 5.08 yr (range: 24-45). There were no significant differences between the 2 groups regarding age, gravidity, history of abortion, CS, curettage, and myomectomy (Table I) (Table II).

International Journal of Reproductive BioMedicine
Mohammad Jafari et al. In this study, all participants were multiparous, and delivery was by CS in all individuals, consistent with previous studies (13)(14)(15)(16). In a previous study that examined variables affecting placenta previa, a strong association was identified between a history of CS, a history of induced abortion, and a history of placenta previa (14). In our study, all participants There are many differences in the definitions of PAS disorders used by specialists. One study showed that hysterectomy was the most common choice of treatment for PAS among the specialists studied (61%) (17). In another study, hysterectomy was the first treatment choice for PAS patients (18). In a systematic cohort study of high-risk women with PAS disorders, hysterectomy was performed in 208 cases, and conservative surgery was performed in 7 cases with local resection of the PAS myometrium (19). However, in our study, conservative surgery was the most common method used by the specialists (63.8%). Among the conservative surgeries, 28 cases (41.2%) underwent a CS and resection of the lower section by closing the uterine artery, the most common approach in this group.
In the present study, there was no significant difference between the 2 groups regarding the need for blood components transfusion (whole blood, packed cells, and FFP), which is consistent with previous study (20). Although blood products can save lives, they can also be associated with critical maternal complications and can lead to maternal death (21). Also, one of the essential indicators in determining maternal complications is the duration of surgery.
Women who have longer surgeries need longer hospital stays (22). In one study the hysterectomy group had a higher morbidity rate than the conservative uterine surgery groups. There were also significant differences in operative time, the amount of transfused blood products including the number of red blood cells and FFP, and length of postoperative intensive care unit and hospital stays, which is inconsistent with our findings (23). These differences in the results can be due to differences in the patients characteristics, treatment modality, PAS severity and also the experience of the surgeons.
Due to the need to maintain the reproductive capacity of individuals, several surgical methods have been introduced to preserve the uterus.
Conservative therapies show fewer adverse effects than hysterectomies (8,(23)(24)(25). For example, one study found that when using the resective-reconstructive technique, in 80% of cases, bleeding was reduced in addition to preserving the uterus (25). However, due to the differences in degrees of PAS disorders and the existence of other conservative treatments, there is a need for further studies and reviews of these treatments in standardized conditions.
In general, alternative conservative therapies to preserve the uterus also increase the chance that the woman will be able to reproduce in the future, which affects a person's social status and self-esteem (26). However, compared to cesarean hysterectomy, the conservative approach's major drawback is the length of therapy and the necessity for long-term follow-up. Conservative management is a valid treatment option for patients and could be performed based on their clinical conditions.

Conclusion
This study showed no significant difference between the 2 groups regarding the need for blood components transfusion (whole blood, packed cells, and FFP), maternal mortality, and duration of surgery and hospitalization. Based on these results, conservative surgeries can be used instead of hysterectomy in patients with PAS, which can help to maintain fertility.