Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study
2022
Sentilhes, Loïc | Seco, Aurélien | Azria, Elie | Beucher, Gaël | Bonnet, Marie Pierre | Branger, Bernard | Carbillon, Lionel | Chiesa, Coralie | Hebert, Catherine Crenn | Dreyfus, Michel | Dupont, Corinne | Fresson, Jeanne | Huissoud, Cyril | Langer, Bruno | Morel, Olivier | Patrier, Sophie | Perrotin, Franck | Raynal, Pierre | Rozenberg, Patrick | Rudigoz, René Charles | Vendittelli, Francoise | Winer, Norbert | Deneux-Tharaux, Catherine | Kayem, Gilles | Centre Hospitalier Universitaire de Bordeaux (CHU Bordeaux) | Obstetrical, Perinatal and Pediatric Epidemiology | Épidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé [CRESS - U1153 / UMR_A 1125]) ; Centre for Research in Epidemiology and Statistics | Centre de Recherche Épidémiologie et Statistiques (CRESS (U1153 / UMR_A 1125)) ; Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE) | Unité de recherche clinique / Centre d'investigation clinique [CHU Necker] ; Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Necker - Enfants Malades [AP-HP] ; Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP) | CIC - Mère Enfant Necker Cochin Paris Centre (CIC 1419) ; Hôpital Cochin [AP-HP] ; Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité) | Institut National de la Santé et de la Recherche Médicale (INSERM) | Service de Gynécologie-Obstétrique et Médecine de la Reproduction [CHU Caen] ; Université de Caen Normandie (UNICAEN) ; Normandie Université (NU)-Normandie Université (NU)-CHU Caen Normandie – Centre Hospitalier Universitaire de Caen Normandie (CHU Caen Normandie) ; Normandie Université (NU)-Tumorothèque de Caen Basse-Normandie (TCBN)-Tumorothèque de Caen Basse-Normandie (TCBN) | CHU Caen Normandie – Centre Hospitalier Universitaire de Caen Normandie (CHU Caen Normandie) ; Normandie Université (NU)-Tumorothèque de Caen Basse-Normandie (TCBN) | CHU Trousseau [APHP] ; Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Sorbonne Université (SU) | Réseau Sécurité Naissance des Pays de la Loire | Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO) | Université Claude Bernard Lyon 1 (UCBL) ; Université de Lyon | Research on Healthcare Performance (RESHAPE - Inserm U1290 - UCBL1) ; Université Claude Bernard Lyon 1 (UCBL) ; Université de Lyon-Université de Lyon-Institut National de la Santé et de la Recherche Médicale (INSERM) | Hospices Civils de Lyon (HCL) | Institut cellule souche et cerveau / Stem Cell and Brain Research Institute (SBRI) ; Université Claude Bernard Lyon 1 (UCBL) ; Université de Lyon-Université de Lyon-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE) | Centre Hospitalier Universitaire [Strasbourg] (CHU Strasbourg) ; Hôpitaux Universitaires de Strasbourg (HUS) | Centre Hospitalier Régional Universitaire de Nancy (CHRU Nancy) | CHU Rouen ; Normandie Université (NU) | Centre Hospitalier Régional Universitaire de Tours (CHRU Tours) | Centre Hospitalier de Versailles André Mignot (CHV) | Centre hospitalier intercommunal de Poissy/Saint-Germain-en-Laye - CHIPS [Poissy] | Risques cliniques et sécurité en santé des femmes et en santé périnatale (RISCQ) ; Université de Versailles Saint-Quentin-en-Yvelines (UVSQ) | CHU Estaing [Clermont-Ferrand] ; CHU Clermont-Ferrand | Institut Pascal (IP) ; Centre National de la Recherche Scientifique (CNRS)-Université Clermont Auvergne (UCA)-Institut national polytechnique Clermont Auvergne (INP Clermont Auvergne) ; Université Clermont Auvergne (UCA)-Université Clermont Auvergne (UCA) | Physiopathologie des Adaptations Nutritionnelles (PhAN) ; Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Nantes Université - UFR de Médecine et des Techniques Médicales (Nantes Univ - UFR MEDECINE) ; Nantes Université - pôle Santé ; Nantes Université (Nantes Univ)-Nantes Université (Nantes Univ)-Nantes Université - pôle Santé ; Nantes Université (Nantes Univ)-Nantes Université (Nantes Univ) | CHU Clermont-Ferrand
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Show more [+] Less [-]English. 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.
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