Current Evidence on Conservative Versus Cesarean Hysterectomy in the Management of Placenta Accreta Spectrum: A Narrative Review

Abstract

Placenta accreta spectrum (PAS) is a potentially life-threatening obstetric disorder characterized by abnormal placental adherence to, or invasion of, the myometrium and, in severe cases, adjacent pelvic organs. Rising cesarean delivery rates have contributed to a parallel increase in PAS incidence. Management remains complex because the principal strategies planned cesarean hysterectomy and uterine-preserving management differ substantially in immediate surgical risk, delayed morbidity, and reproductive consequences. This narrative review summarizes contemporary evidence on patient selection, multidisciplinary planning, cesarean hysterectomy, intentional placental retention, local or segmental resection, vascular control, tamponade, hemostatic sutures, postoperative surveillance, and maternal and neonatal outcomes. Cesarean hysterectomy with the placenta left in situ remains the most established definitive treatment for extensive PAS and when uterine preservation is not a priority. In carefully selected patients, conservative approaches may be associated with lower immediate blood loss, transfusion requirements, and urinary tract injury; however, the comparative evidence is predominantly observational and vulnerable to selection bias. Conservative management may also be followed by delayed hemorrhage, infection, readmission, reoperation, and secondary hysterectomy. No single uterine-preserving technique is appropriate for all patients. Management should therefore be individualized according to disease extent and location, hemodynamic stability, reproductive wishes, surgical expertise, and institutional resources. Delivery in an experienced multidisciplinary center and thorough counseling remain central to improving outcomes.