LAUSR

BACKGROUND The incidence of placenta accreta spectrum is rising. Management is most commonly with cesarean hysterectomy. These deliveries are often complicated by massive hemorrhage, urinary tract injury, and admission to the intensive care unit. Up to 60% of patients require transfusion of ≥ 4 units of packed red blood cells. There is also a significant risk of death of up to 7%. OBJECTIVE To assess the outcomes of patients with antenatal diagnosis of placenta percreta managed with delayed hysterectomy as compared to those who underwent immediate cesarean hysterectomy. STUDY DESIGN We performed a retrospective study of all patients with an antepartum diagnosis of placenta percreta at our large academic institution from January 1, 2012 to May 30, 2018. Patients were managed according to standard clinical practice including scheduled cesarean delivery at 34 to 35 weeks gestational age and intra-operative multidisciplinary decision making regarding immediate versus delayed hysterectomy. In cases of delayed hysterectomy, the hysterotomy for cesarean birth utilized a fetal surgery technique to minimize blood loss, with a plan for hysterectomy 4 to 6 weeks after delivery. We collected data regarding demographics, maternal comorbidities, time to interval hysterectomy, blood loss, need for transfusion, occurrence of urinary tract injury and other maternal complications, and maternal and fetal mortality. Descriptive statistics were performed, and Wilcoxon rank-sum and chi-square tests were used as appropriate. RESULTS We identified 49 patients with an antepartum diagnosis of placenta percreta treated at Vanderbilt University Medical Center during the specified period. Of these patients, 34 were confirmed to have severe placenta accreta spectrum, defined as increta or percreta at the time of delivery. Delayed hysterectomy was performed in 14 patients, 9 as scheduled and 5 prior to the scheduled date. Immediate cesarean hysterectomy was completed in 20 patients, 16 due to intraoperative assessment of resectability and 4 due to preoperative or intraoperative bleeding. The median [IQR] estimated blood loss (EBL) at delayed hysterectomy of 750 ml [650 - 1450], and the sum total for delivery and delayed hysterectomy of 1300 ml [700 - 2150] were significantly lower than the EBL at immediate hysterectomy of 3000mL [2375 - 4250] (p<.01 and p = .037, respectively). The median [IQR] units of packed red blood cells (RBC) transfused at delayed hysterectomy was 0 [0-2], which was significantly lower than units transfused at immediate cesarean hysterectomy (4 [2-8.25], p < .01). Nine out of twenty (45%) patients required transfusion of 4 or more units of RBC at immediate cesarean hysterectomy, whereas only 2 of 14 (14.2%) patients required transfusion of 4 or more units of RBC at time of delayed hysterectomy (p = .016). There was 1 maternal death in each group, giving incidences of 7% and 5% in the delayed and immediate hysterectomy patients, respectively. CONCLUSIONS Delayed hysterectomy may represent a strategy for minimizing the degree of hemorrhage and need for massive blood transfusion in patients with an antenatal diagnosis of placenta percreta by allowing time for uterine blood flow to decrease and for the placenta to regress from surrounding structures.