Association Between Myomectomy and Placenta Accreta Spectrum

Abstract

Study Objective To examine the relationship between prior myomectomy and placenta accreta spectrum (PAS). Design A retrospective chart review of all laparoscopic and abdominal myomectomies performed between 2014 - 2016. Obstetrical outcomes following surgery were collected through April 2019. Setting An academic hospital with a comprehensive fibroid treatment center and a multidisciplinary treatment team dedicated to the management of placenta accreta. Patients or Participants All patients who underwent a laparoscopic myomectomy (standard and robotic-assisted) or abdominal myomectomy between 2014 - 2016. Interventions Demographics, pelvic imaging, intraoperative findings, fibroid burden on final pathology, and future mode of delivery recommendations were collected for each procedure. Subsequent obstetrical outcomes including clinical pregnancy, antepartum imaging suspicious for PAS, mode of delivery, clinical diagnosis of PAS, and pathologic PAS were collected for all patients. Measurements and Main Results Of 315 patients who underwent myomectomy between 2014 - 2016, 43 patients subsequently became pregnant, resulting in 23 deliveries (7.3%). 16 of 20 patients underwent a cesarean delivery due to history of a prior myomectomy, 13 of which had a documented endometrial cavity entry at time of myomectomy. There were three cases of clinical PAS at time of delivery, all associated with a prior abdominal myomectomy. Two cases had PAS confirmed on final pathology. Two cases were associated with possible intrauterine synechiae identified during a uterine cavity evaluation following myomectomy, prior to conception. Only one case had antepartum imaging concerning for PAS. There were no cases of PAS amongst patients who had undergone a laparoscopic myomectomy. Conclusion PAS was associated with prior abdominal but not laparoscopic myomectomy. The subsequent development of intrauterine synechiae following abdominal myomectomy may be an identifiable finding during postoperative uterine cavity evaluation. This finding may help stratify the risk of PAS following myomectomy prior to conception, and better guide preoperative risk counseling prior to cesarean delivery.