Risk of Placenta Accreta Spectrum Disorder After Prior Non–Cesarean Delivery Uterine Surgery

OBJECTIVE: To evaluate the association between previous non-cesarean uterine surgery and placenta accreta spectrum (PAS) in subsequent pregnancies. DATA SOURCES: PubMed, EMBASE, the Cochrane Library, ClinicalTrials.gov , CNKI (China National Knowledge Infrastructure), and Wan-fang Database were searched from inception to April 2024, supplemented by manual searches. METHODS OF STUDY SELECTION: Studies included prospective, retrospective cohort, case-control, and cross-sectional studies involving pregnant women diagnosed with PAS and reporting at least one risk factor associated with previous uterine surgery. TABULATION, INTEGRATION, AND RESULTS: Two authors independently screened potentially eligible studies and extracted data. The quality of the studies was assessed with the Newcastle-Ottawa Scale. The pooled odds ratios (ORs), adjusted ORs, and their 95% CIs were estimated with fixed- or random-effects models if the heterogeneity ( I2 ) was high. Sensitivity analyses were conducted to account for potential study bias. The main measures were myomectomy, uterine artery embolization, dilatation and curettage, hysteroscopic adhesiolysis, abortion, endometrial ablation, and operative hysteroscopy. A total of 38 studies involving 7,353,177 participants were included in the systematic review, with an overall prevalence of PAS of 0.16%, and 31 studies were included in the meta-analysis. Prior non-cesarean uterine surgeries were associated with PAS in subsequent pregnancy (pooled OR 2.29, 95% CI, 1.43-3.68). Distinct associations between specific uterine surgery and PAS included myomectomy (OR 2.29, 95% CI, 1.77-2.97), uterine artery embolization (OR 43.16, 95% CI, 20.50-90.88), dilatation and curettage (OR 2.28, 95% CI, 1.78-2.93), hysteroscopic adhesiolysis (OR 7.72, 95% CI, 4.10-14.53), abortion (OR 1.65, 95% CI, 1.43-1.92), endometrial ablation (OR 20.26, 95% CI, 17.15-23.93), and operative hysteroscopy (OR 3.10, 95% CI, 1.86-5.18). CONCLUSION: Prior non-cesarean uterine surgery is associated with a significantly increased odds for development of PAS in subsequent pregnancy, and the risk varies depending on the types of uterine surgery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42024552210.