Obstetric characteristics and maternal outcomes of early second-trimester placenta accreta spectrum

Abstract

Objective: To describe early second-trimester placenta accreta spectrum (PAS) management and outcomes.

Methods: This cross-sectional study queried the US Healthcare Cost and Utilization Project's National Inpatient Sample from 2016 to 2021, finding 905 cases with a diagnosis of PAS between 14 and 22 weeks of gestation and in-hospital management. Descriptive analysis was performed to: (1) characterize PAS management variations at the intention-to-treat level and need for conversion to hysterectomy at the per-procedure level, and (2) evaluate maternal morbidity compared with 5365 cesarean hysterectomies for PAS between 34 and 36 weeks of gestation via generalized linear modeling.

Results: Early second-trimester PAS was managed most frequently via induction abortion (29.8%), followed by gravid hysterectomy (23.2%), dilation and evacuation (13.3%), and hysterotomy alone (6.6%). Per-procedure analysis noted an unplanned hysterectomy rate of 51.9% and 45.8% following induced abortion and dilation and evacuation, respectively. Comparing 14-16 weeks with 20-22 weeks of gestation, the proportion of cases managed via induction abortion (22.6%-33.3%), gravid hysterectomy (12.9%-29.8%), and hysterotomy alone (0%-9.5%) increased while dilation and evacuation (22.6% to <3.0%) decreased (P-trend <0.01). Increta and percreta were more frequently implicated in second-trimester gravid versus third-trimester cesarean hysterectomy (adjusted prevalence ratio, 1.69 [95% confidence interval (CI), 1.40-2.05]). Compared with third-trimester cesarean hysterectomy, second-trimester gravid hysterectomy demonstrated higher incidences of hemorrhage/blood transfusion (adjusted incidence ratio [aIR], 1.17 [95% CI, 1.01-1.36]); shock/coagulopathy (aIR, 3.57 [95% CI, 2.75-4.63]); and hospitalization ≥7 days (aIR, 2.27 [95% CI, 1.87-2.75]).

Conclusion: These data suggest heterogeneity in the management of early second-trimester PAS. Morbidity associated with early second-trimester PAS was substantial regardless of the management approach, highlighting the need for standardized guidelines.

Keywords: abortion; early second trimester; gravid hysterectomy; obstetric outcomes; placenta accreta spectrum; pregnancy characteristics; pregnancy termination.