Assessment of adjunctive procedures during cesarean hysterectomy for placenta accreta spectrum

Objective: Cesarean hysterectomy for placenta accreta spectrum is associated with significant morbidity. The role of adjunctive procedures, including tranexamic acid administration, ureteral stent placement, and endoarterial embolization or balloon placement, in mitigating surgical morbidity during cesarean hysterectomy for placenta accreta spectrum is currently under active investigation. This study aimed to assess temporal trends, characteristics, and outcomes associated with adjunctive procedures during cesarean hysterectomy for placenta accreta spectrum. Study Design: This retrospective study used the Premier Perspective database in the United States. The study population included pregnant patients who underwent cesarean hysterectomies for placenta accreta spectrum between 2016 and 2023. Targeted adjunctive procedures included tranexamic acid administration, ureteral stent placement, and endoarterial embolization or balloon placement. A multivariate model was created to assess the association between adjunctive procedures and surgical morbidity. Results: Among 4,337 cesarean hysterectomies for placenta accreta spectrum, 39.3%, 24.6%, and 16.1% received tranexamic acid, ureteral stent placement, and endoarterial embolization or balloon placement, respectively. During the 8-year study period, tranexamic acid administration increased 5.7-fold from 11.7% to 66.4%, and ureteral stent placement increased 1.6-fold from 19.2% to 30.3% (both P-trend<.001). Nearly two-thirds of patients had postpartum hemorrhage (62.6%), and nearly one in five had urinary tract injury (18.7%). These three adjunctive procedures were not associated with decreased postpartum hemorrhage or urinary tract injury. Conclusion: These data suggest that the utilization of tranexamic acid and ureteral stent placement is increasing during cesarean hysterectomy for placenta accreta spectrum in the United States. Reflecting the increases in real-world practice, whether these adjunctive procedures improve surgical morbidity of cesarean hysterectomy for placenta accreta spectrum warrants further investigation with prospective studies.