Placenta Accreta Spectrum After Myomectomy: A Systematic Review and Meta-Analysis Stratified by Surgical Approach

Placenta Accreta Spectrum (PAS) occurs in approximately 0.17% pregnancies in the general obstetric population. We aimed to estimate the prevalence of PAS following myomectomy surgery and evaluate differences in the risks by myomectomy surgical approach.

PubMed, Embase, Scopus, and Web of Science were searched on prespecified dates (inception-March 2025).

Studies were eligible if they reported pregnancy outcomes in patients with a documented history of myomectomy in which the surgical approach was specified.

This systematic review and meta-analysis was conducted per PRISMA guidelines and registered on PROSPERO (CRD42024513596). Pooled prevalence estimates and 95% confidence intervals (CIs) were calculated using random-effects meta-analysis. Planned subgroup analyses were conducted for myomectomy surgical approach and PAS-accompanying morbidities of postpartum hemorrhage, placenta previa, placental abruption, and uterine rupture, and heterogeneity was assessed using I² statistics.

Seventy-six studies comprising 11065 pregnancies across 24 countries were included. The pooled prevalence of PAS following myomectomy was 1% (95% CI, 1-2%). Prespecified subgroup analyses demonstrated that PAS prevalence was highest after open myomectomy (2%; 95% CI, 1-4%; 111/4474) compared to laparoscopic (1%; 95% CI, 0-3%; 36/1172), robotic (1%; 95% CI, 0-4%; 4/262), and hysteroscopic approaches (<1%; 95% CI, 0-1%; 3/271), although differences between surgical groups were not statistically significant (P = 0.67). Secondary outcomes-including postpartum hemorrhage (2%), placenta previa (1%), placental abruption (1%), and uterine rupture (<1%)-showed similar prevalence patterns across surgical approaches.

In this meta-analysis of over 11,000 patients, the overall prevalence of PAS following myomectomy was approximately 1-2% and did not significantly differ by surgical approach. Likewise, major obstetric complications, including postpartum hemorrhage, placenta previa, and uterine rupture, showed no significant variations among open, laparoscopic, hysteroscopic, and robotic myomectomies. Therefore, the choice of surgical approach for myomectomy can be individualized based on patient characteristics, myoma features, and surgical expertise.