981: Planned interval hysterectomy: strategic patience in the management of the morbidly adherent placenta

Abstract

To determine whether delayed interval hysterectomies (IH) decreased blood loss and morbidity compared to immediate cesarean hysterectomies (CH) in women with morbidly adherent placentas. Retrospective cohort study comparing CH versus IH in women with morbidly adherent placentas diagnosed on ultrasound/MRI, who delivered between 2010-2018. Women were excluded if final pathology found no accreta, no hysterectomy performed, or if pregnancy was terminated prior to hysterectomy. A multidisciplinary team managed all cases. CH was performed if pregnancy occurred prior to 2014, accreta was suspected with no evidence of increta/percreta, patient was non-compliant, or if residual bleeding noted after hysterotomy closure. Placenta was left in situ for suspected increta/percreta, with plan for immediate uterine artery embolization (UAE) and subsequent IH at approximately 6 weeks. Primary outcome measure was quantitative blood loss (QBL). Linear regression was used to assess the relationship between QBL and significant variables, adjusting for potential confounders. Further analysis was performed with propensity score matching. Out of 84 women included, 67 had CH and 17 IH. There were more percretas in the IH than CH group (59% vs 19%) (p=0.01). A total of 25 increta/percretas counseled on possible IH had a CH, 3 (12%) due to residual bleeding, 10 (40%) for suspected accreta, and 12 (48%) for patient characteristics/provider preference. There was on average 2700 mLs more blood loss in the CH compared to IH group (p=0.006). Sub-group analysis of percretas/incretas showed an average of 2000 mLs more blood loss with CH than IH (p=0.003). Matched propensity scoring confirmed our findings (Table 2). Women in the CH group required more blood transfusions compared to the IH group (87% vs 65%; p=0.04). Complications were similar between groups (Table 2). IH was performed on average, 47 days after cesarean delivery. There were 5 unplanned early IH, all of which occurred after at least 21 days postpartum. IHs appear safe and are associated with lower blood loss and morbidity in women requiring cesarean hysterectomies for morbidly adherent placentas. Optimal timing of IH at 3 weeks postpartum appears most ideal to decrease the risk of needing an unplanned IH.View Large Image Figure ViewerDownload Hi-res image Download (PPT)