Nationwide patterns and surgical morbidity associated with delayed hysterectomy for placenta accreta spectrum

To describe utilization and surgical morbidity of delayed hysterectomy for placenta accreta spectrum.

This cross-sectional study queried the Healthcare Cost and Utilization Project's Nationwide Readmissions Database in the United States. The study included 9,089 patients who underwent hysterectomy for placenta accreta spectrum from 2016 to 2022. All had prior uterine scar and underwent cesarean delivery. Hysterectomy timing was grouped as (i) primary hysterectomy at the time of cesarean delivery or (ii) delayed hysterectomy within 60 days after discharge following cesarean delivery. Outcome measures included hemorrhage with or without blood transfusion, shock, coagulopathy, urinary tract injury, or maternal mortality, assessed with a propensity score-adjusted model.

Most hysterectomies were performed at the time of cesarean delivery (99.1%), and delayed hysterectomy after cesarean delivery was rarely performed (0.9%). Delayed hysterectomy was most frequent at 5 to 6 weeks (31.0%) and 3 to 4 weeks (29.8%) after cesarean delivery. Placenta increta or percreta was common in the delayed hysterectomy group compared to the primary hysterectomy group (63.9% vs 33.1%, p <.001). Delayed hysterectomy after cesarean delivery was associated with a lower rate of hemorrhage (53.0% vs 71.2%; adjusted-incidence rate ratio 0.72, 95% confidence interval 0.54 to 0.95) but a higher rate of coagulopathy (24.1% vs 7.8%; adjusted-incidence rate ratio 2.39, 95% confidence interval 1.23 to 4.64) compared to primary cesarean hysterectomy. When two admissions for cesarean delivery and subsequent hysterectomy were summed, delayed hysterectomy was associated with a longer hospitalization of more than 7 days (92.8% vs 28.2%, adjusted-incidence rate ratio 2.64, 95% confidence interval 2.35 to 2.97) and higher median costs ($63,777 vs $21,610; net difference $42,167, p <.001) compared to primary cesarean hysterectomy.

The results of this nationwide assessment suggest that primary hysterectomy at cesarean delivery is the mainstay of hysterectomy timing for placenta accreta spectrum in the United States and that delayed hysterectomy may be associated with decreased hemorrhage but increased coagulopathy compared to primary hysterectomy.