Leaving Placenta In Situ for Management of Placenta Accreta Spectrum Disorder

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OBJECTIVE: To evaluate maternal outcomes when leaving the placenta in situ for placenta accreta spectrum (PAS) according to planned surgical management. METHODS: We conducted a single-center retrospective cohort study of patients with PAS managed by leaving the placenta in situ from January 2015 to October 2024. At our center, patients are given options other than cesarean hysterectomy for the management of PAS. These include leaving the placenta in situ for either planned uterine preservation or planned delayed hysterectomy. We analyzed maternal outcomes with leaving the placenta in situ, including risk of infection, significant bleeding resulting in hysterectomy, blood transfusion rates, and serious maternal morbidity. We also analyzed outcomes according to planned procedure (uterine preservation or delayed hysterectomy) and final procedure performed (successful uterine preservation or interval hysterectomy). RESULTS: Of 180 patients with antenatal diagnosis of PAS, 50 were planned for leaving the placenta in situ: seven (14%) underwent cesarean hysterectomy because of antepartum or intraoperative hemorrhage, and 43 (86%) were managed by leaving the placenta in situ. In the 43 managed with leaving the placenta in situ, five (12%) had bleeding necessitating a hysterectomy, and four (9%) had endometritis. There were no cases of venous thromboembolism or maternal death. Twenty-nine patients were planned for uterine preservation, and 14 were planned for delayed hysterectomy. Among the 29 patients planned for uterine preservation, 13 (45%) were successful, with median time to expulsion or resorption of 17 weeks, and 16 (55%) underwent interval hysterectomy (9/16 indicated and 7/16 patient request). According to the final procedure performed, compared with the 30 patients who ultimately underwent an interval hysterectomy, those with successful uterine preservation (n=13) had lower median estimated total blood loss (700 mL vs 1,950 mL, P <.01), blood transfusion rates (31% vs 73%, P <.01), and blood transfusion exceeding 4 units (8% vs 47%, P =.01). Five patients had subsequent pregnancies, with no placenta previa or PAS. When analyses were conducted by planned procedure (planned uterine preservation vs planned interval hysterectomy), there were no differences in median estimated total blood loss, blood transfusion rates, and blood transfusion exceeding 4 units. CONCLUSION: The majority of patients with PAS who were managed by leaving the placenta in situ did not experience complications of infection or bleeding necessitating hysterectomy. Leaving placenta in situ may be appropriate to offer as an alternative to cesarean hysterectomy in those desiring uterine preservation or those who have PAS with concern for life-threatening bleeding if cesarean hysterectomy is performed. These results should be interpreted with caution given the small sample size, which could preclude detection of rare but potentially serious complications.

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