The role of gravid hysterectomy in managing placenta accreta spectrum between 14 0/7 and 26 6/7 weeks: Who, where, when, and how?

Abstract

Gravid hysterectomy is a management option for providing abortion care in the setting of placenta accreta spectrum. However, performing a gravid hysterectomy requires significant multidisciplinary coordination to ensure a safe outcome for the pregnant individual. In this Narrative Review, we review the limited data surrounding gravid hysterectomy, perioperative considerations for conducting a gravid hysterectomy, a case of perioperative outcomes for a patient who underwent a gravid hysterectomy, and recommendations for future directions in research and clinical innovations in the management of placenta accreta spectrum and procedural abortion care.

1. INTRODUCTION

Placenta accreta spectrum (PAS) has been reported in up to 0.17% of births and is associated with maternal morbidity and mortality. However, there are limited data to assess the prevalence of PAS among individuals seeking abortion care between 14 0/7 and 26 6/7 weeks (“the second trimester”) [1, 2, 3]. Several reports describe an increased risk of hemorrhage, spontaneous uterine rupture, and subsequent hysterectomy for individuals affected by PAS undergoing either procedural or medication abortion [4, 5, 6, 7, 8]. Because of these risks, individuals with suspected PAS are commonly referred out of freestanding abortion clinics and to hospital‐based abortion care for perioperative management [9]. The challenges faced by patients experiencing and healthcare teams managing PAS are further compounded by the current landscape of abortion restrictions, as patients are increasingly needing to leave abortion‐restrictive states to obtain care in abortion‐protective states [10].

While members of our group have previously described the need to accurately assess the risk for PAS among people seeking abortion care in the second trimester to determine the location of procedural abortion care [11], there is limited guidance to describe the recommended route of procedural abortion, namely dilation and evacuation or a gravid hysterectomy (GH). GH—or the removal of the uterus, placenta, and fetus in situ with or without removal of the cervix—has been described for decades in the literature [12, 13, 14, 15, 16]. However, given the need for exploratory laparotomy, multiple surgical teams with expertise in complex gynecological surgery, potential use of ancillary services, such as interventional radiology for vessel embolization, and the surgery's effects on future fertility, there is a need for guidance on appropriate patient candidacy and perioperative planning for a GH in the second trimester.

In this Narrative Review, we review a case example of perioperative outcomes for a patient who underwent a GH, as well as the limited data surrounding GH and perioperative considerations for conducting a GH. We conclude with recommendations for future directions in research and clinical innovations in the management of PAS and procedural abortion care. Of note, throughout the Narrative Review, we report on the severity of PAS using the preferred nomenclature proposed by the International Federation of Gynecology and Obstetrics (FIGO) [17]. However, when we discuss previously published literature, which does not employ FIGO grading, we will use the historical nomenclature (i.e., placenta accreta, increta, and percreta).

2. AN EXAMPLE CASE

A 29‐year‐old gravida 2, para 1 presented to a quaternary care facility at 17 0/7 weeks with a history of one prior cesarean delivery; the patient was referred to the institution's complex family planning (CFP) clinic from an out‐of‐state clinician for abortion care secondary to ultrasound findings at 16 1/7 weeks concerning for PAS.

Our institution's ultrasound confirmed an anterolateral placenta previa with evidence of suspected FIGO grade 1‐2 PAS (Figure 1, Videos S1 and S2). After multidisciplinary counseling, the patient elected for pregnancy termination. After consulting gynecologic oncology (GO) for advanced surgical planning, the patient was counseled regarding the need for a GH with possible partial cystectomy.

FIGURE 1.

Transvaginal ultrasound at 17 weeks’ gestation. Low‐flow color Doppler at the vesicouterine interface is notable for bridging vessels. A bulge is also noted into the bladder at the level of the vesicouterine segment (arrows). B = bladder, C = cervix, F = fetus, P = placenta.

The patient's insurance further complicated perioperative planning, as it was out of network and did not cover abortion care. In tandem with the surgical planning, the CFP team submitted a single‐case agreement request in attempt to cover the costs of care for the patient and worked with clinic, department, and hospital leadership to advocate for the patient's insurance to cover her care. Though the hospital approved the single‐case agreement, allowing the teams to proceed with the patient's care, her insurance denied coverage for the proposed care. Accordingly, hospital leadership appealed the insurance company's decision, and the patient was informed that she may have to cost‐share some of the expense of her care in partnership with our institution.

Eight days after her initial presentation to our institution (18 1/7), the patient underwent an exploratory laparotomy via midline vertical skin incision, GH, and bilateral salpingectomy under general anesthesia. Upon dissection of the bladder flap, the placenta was noted to be approximately one layer from traversing the uterine serosa and was densely adherent to the dome of the bladder. Therefore, the surgical team spent 2.5 h dissecting the bladder from the lower uterine segment. A 2‐cm unintentional cystotomy was identified and repaired in the standard manner. The total estimated blood loss for the procedure was 300 mL, and the patient was extubated and taken to recovery in stable condition (Figures 2 and 3).

FIGURE 2.

Anatomy during gravid hysterectomy. Placental bulge into the lower uterine segment, indicative of International Federation of Gynecology and Obstetrics (FIGO) grade 3 placenta accreta spectrum (PAS), is denoted with the arrow. C = cervix, V = vagina.

FIGURE 3.

Gross specimen. (A) The gross specimen is displayed. Evidence of placental invasion beyond the level of the serosa, consistent with International Federation of Gynecology and Obstetrics (FIGO) grade 3 placenta accreta spectrum (PAS), is denoted with the use of arrows. (B) The uterus is bivalved, with noted gross pathological invasion of the placenta (arrows) and a retroplacental hematoma, denoted with an asterisk. C = cervix, F = fundus, P = placenta.

The patient was well‐appearing with normal vital signs throughout postoperative day 0. However, a rapid response code was called in the early morning on postoperative day 1 due to the patient's acute onset of pain, hypotension, and tachycardia. A computed tomography scan was urgently performed and demonstrated a large‐volume hemoperitoneum with no arterial bleed or active extravasation. Hematologic parameters were consistent with a developing coagulopathy. After initial resuscitation, including transfusion of one unit of packed red blood cells, the patient was taken to the operating room for an emergent exploratory laparotomy, evacuation of 2 L hemoperitoneum, and re‐ligation of the right uterine artery. The patient's labs and vital signs subsequently stabilized and the patient reported feeling significant improvement in pain postoperatively the day after her second surgery. The patient received a total of four units of packed red blood cells during her hospitalization. The patient progressed postoperatively and was discharged home with a Foley catheter leg bag on postoperative day 3 from her original surgery. She was offered behavioral health referral, but the patient declined the referral at time of discharge. Final pathology was notable for placenta percreta (FIGO grade 3).

The patient was seen for follow‐up in her home state 2 days after discharge at which time her Foley catheter was removed. At her follow‐up visit in her home state 1 week later, she was recovering appropriately and accepted a referral to perinatal psychiatry. After several months of continued efforts by our institution and by the patient, her insurance finally agreed to cover her hospital care.

3. LITERATURE REVIEW OF GH BETWEEN 14 0/7 AND 26 6/7 WEEKS

We conducted a review of the literature, searching PubMed with the key terms “gravid hysterectomy,” “placenta accreta,” and “second‐trimester abortion” from inception to November 1, 2024 (n = 228). After reviewing 13 eligible manuscripts, we excluded 5 manuscripts because they were either not focused on PAS (n = 1) or reported on the use of hysterectomy after fetal expulsion or extraction (n = 4). Therefore, we identified 8 manuscripts reporting on the outcomes of 12 people who underwent GH in the setting of preoperatively suspected PAS in the second trimester (Table 1) [8, 13–16, 18–20]. Of the 12 identified patients, 10 (83.3%) cases reported more invasive forms of PAS (i.e., increta, percreta) on final pathology. Eleven (91.7%) cases were performed open, and one case was performed as a robot‐assisted laparoscopic GH and bilateral salpingectomy [19].

TABLE 1.

Review of published literature on GH for PAS between 14 0/7 and 26 6/7 weeks.

Author (location)	Study type	Results	Intervention	Gestational ages	Estimated blood loss	Complications
Bedaiwy (USA) [13]	Case report	21‐year‐old G6P5 with history of classical cesarean delivery with four subsequent pregnancies complicated by uterine rupture presenting for abortion care. Ultrasound notable for anterior placenta over prior classical scar without clear sonographic features of PAS but with thinner than expected lower uterine segment. Gross inspection of uterus with placenta visible through uterine window. Pathology with focal areas of placenta increta and diffuse placenta accreta.	GH	17 2/7	250 mL	None
Baucom (USA) [15]	Case report	34‐year‐old G4P2 with history of anal cancer (T3N1M0), treated with chemoradiation, as well as 2 prior cesarean deliveries and 1 D&C. Pregnancy conceived via IVF. Presented at 5 weeks GA after frozen embryo transfer with donor oocyte. Ultrasound and MRI with high concern for placenta increta at 19 weeks. Presented at 22 6/7—heavier vaginal bleeding, with subsequent GH. Pathology notable for placenta previa with increta on pathology	GH	22 6/7	2000 mL	Hemorrhage
Borgotta (USA) [18]	Case series	32‐year‐old G4P3 with suspected placenta accreta presenting for abortion care. No final pathology available in the report.	Preoperative UAE with GH	19 0/7	800 mL	None
Cheng [16] and Chou [8] (Taiwan)	Case series	Six patients undergoing planned UAE with GH. All patients had suspected PAS (one accreta, three increta, two percreta).	Preoperative UAE with GH	14 0/7–24 6/7	1770 mL (mean)	Four cases experienced blood loss greater than 1500 mL
Elfeky (USA) [19]	Case report	40‐year‐old G6P3 with ultrasonographic and MRI findings concerning for anterior placenta previa with suspected PAS. Pathology consistent with placenta percreta.	Robot‐assisted laparoscopic GH, bilateral salpingectomy	16 0/7	300 mL	None
Kohl (USA) [14]	Case report	35‐year‐old G6P4 presenting with vaginal bleeding. History notable for four prior cesarean deliveries and one D&C. Ultrasound was notable for life‐limiting fetal anomalies. Ultrasound and MRI notable for anterior placenta previa with high concern for placenta percreta. Pathology consistent with placenta increta without percreta.	Pre‐operative UAE with GH	26 0/7	1,000 mL	2 units packed red blood cell transfusion
Tocce (USA) [20]	Case report	35‐year‐old G2P1 with multiple medical comorbidities presenting for abortion care. History was notable for one prior cesarean delivery. Ultrasound unable to discern presence of PAS, which was subsequently confirmed on MRI with concern for placenta increta. Pathology consistent with placenta increta.	GH	17 5/7	300 mL	None

Abbreviations: D&C, dilation and curettage; GH, gravid hysterectomy; IVF, in vitro fertilization; MRI, magnetic resonance imaging, PAS, placenta accreta spectrum; UAE, uterine artery embolization.

Eight out of 12 (75%) patients underwent preoperative uterine artery or iliac artery embolization [14, 16, 18]. Though current data focused on prophylactic artery embolization at later gestations demonstrate a potential benefit in reduction of overall blood loss at the time of cesarean hysterectomy [21], there is significant heterogeneity in the literature due to differing practice patterns and resource availability [22, 23, 24, 25, 26].

The limited data available on the outcomes of GH highlight multiple questions related to optimal perioperative management and relevant outcomes related to management of PAS in the setting of abortion care. In the next section, we outline perioperative considerations from a multidisciplinary perspective for the safe provision of a GH.

4. CANDIDACY FOR GH

Given the limitations in the extant data related to the optimal evaluation of candidacy for GH, as opposed to other conservative measures (e.g., dilation and evacuation, hysterotomy with wedge resection, and/or leaving the placenta in situ), we propose criteria for who should be recommended to undergo GH in the second trimester. These criteria aim to balance the morbidity of GH with the potential morbidity incurred through alternative management strategies. Of note, all criteria should be fulfilled before the discussion of GH with any patient.

1. The patient does not desire future fertility OR there is evidence of suspected nonfocal FIGO grade 1 or higher grade PAS (i.e., suspected FIGO grade 2 or grade 3 [27]).

2. The patient has an adequate performance status to tolerate GH.

3. There is a multidisciplinary team available to perform a GH.

If all criteria are not fulfilled, clinicians should either (a) broach conservative management measures (i.e., if #1 and/or #2 are not fulfilled) and/or (b) transfer of care to a PAS center of excellence [28] (i.e., if #3 is not fulfilled). Importantly, data are unavailable to inform the route of uterine evacuation for conservative management and discussions about the route of uterine evacuation should defer to local clinical expertise. In our clinical experience, suspected focal FIGO grade 1 PAS, especially at earlier gestational durations with a good performance status, can be safely managed with dilation and evacuation, with or without the use of vessel embolization [29]. However, if facilities do not have trained personnel who are comfortable with complex dilation and evacuation procedures, hysterotomy may be the safest option for uterine conservation in the setting of focal FIGO grade 1 PAS. In the next section, we delineate the goals for each of the multidisciplinary team members for the safe provision of GH.

5. MULTIDISCIPLINARY MANAGEMENT

5.1. Maternal–fetal medicine

As experts in obstetric imaging, the maternal–fetal medicine (MFM) will provide consultation about imaging findings for surgical planning [11]. Preoperative counseling is particularly important to determine the patient's desires for fertility if there are options for conservative management, after discussion with CFP (if available at the institution where the patient is receiving care). However, if PAS is thought to be severe (e.g., FIGO grade 2 or 3 PAS), the MFM can counsel the patient about the risks of uterine preservation during procedural abortion (e.g., hemorrhage, uterine perforation, bowel, and/or bladder injury) and the recommendation for a GH. The latter recommendation adds another layer of complexity to abortion care, given the inability of the individual to conceive in the future. Historically, postabortion permanent contraception techniques have been described in the literature, though recent data on the frequency of these procedures and the patient perspective are unavailable [30]. MFM, in concert with CFP, can discuss the utility of induction of fetal asystole before GH on a case‐by‐case basis [31]. If a patient ultimately proceeds with the pregnancy after counseling about the risks of PAS at later gestational durations (e.g., hemorrhage, need for inpatient admission, bowel, and/or bladder injury) the MFM can counsel and work with the patient to coordinate plans for a cesarean hysterectomy in the late preterm period [23, 26].

5.2. Complex family planning

As experts in abortion care, CFP's role lies in determining the route, location, and preoperative planning for the termination. Using a patient‐centered approach, they discuss the possible morbidity of each procedure (e.g., dilation and evacuation, hysterotomy, or GH) and the importance of performing the procedure that is chosen by the patient in a healthcare setting that is equipped to manage potential complications. Further, in concert with consultation with MFM and advanced pelvic surgeons, CFP should dictate perioperative procedures aimed at reducing the risk of hemorrhage, such as uterine artery embolization.

5.3. Advanced pelvic surgeon (MFM, CFP, GO, minimally invasive gynecologic surgeon, urogynecologist, or senior obstetrician/gynecologist)

An experienced gynecologic surgeon is crucial for safe perioperative care. This person should meet and counsel the patient in advance, independently assess radiology studies, determine the need for preoperative procedures (e.g., ureteral stent placement or vessel embolization), and be facile with complex urologic and bowel surgery. Further, depending on the severity of PAS, the advanced pelvic surgeon should discuss preoperative cystoscopy with the potential for stent placement, planned cystotomy, and/or partial cystectomy with implications for prolonged postoperative catheter placement. Additionally, depending upon the gestational duration and patient factors, there may be an option for minimally invasive surgical care.

In the next section, we discuss unique physiological changes during pregnancy which obstetric anesthesiology takes into consideration in preparation for a GH.

6. PERIOPERATIVE PHYSIOLOGIC CONSIDERATIONS FOR OBSTETRIC ANESTHESIOLOGY

Anesthetic management for a GH poses several critical anesthetic challenges. Patients undergoing GH are approaching peak physiologic changes of pregnancy with increases in cardiac output, increases in plasma volume, and increased minute ventilation [32]. At the time of the procedure, patients are at risk for large‐volume hemorrhage, which can result in significant reductions in preload, leading to hypotension and strain and may require large‐volume resuscitation. A detailed physical exam with particular attention to the airway is essential given the known association of pregnancy and risk of difficult airway [33]. Preoperative evaluation and optimization of anemia with intravenous iron should be considered, if time allows, and baseline evaluation of coagulation factors can help to guide intraoperative transfusion.

Pregnant patients in the second trimester, as compared to nonpregnant individuals, may be at increased risk of aspiration due to high rates of gastroesophageal reflux caused by the elevation of the stomach and diaphragm and relaxation of the lower esophageal sphincter [34]. Rapid sequence intubation due to the risk of aspiration should be considered. As patients are unlikely to require prolonged vasoactive support necessitating long‐term central access after GH, intraoperative, goal‐directed volume resuscitation with large‐bore intravenous and arterial access should be considered to avoid pneumothorax and infection risks associated with central line placement. If large‐bore intravenous access is difficult to obtain, or if central access for volume resuscitation is required, jugular or subclavian venous access should be prioritized over femoral venous access. This is due to the risk of venous bleeding into the abdomen during the GH leading to a reduction in venous return to the heart, in addition to marked compression of the venous structures by the gravid uterus leading to a reduction in flow through the inferior vena cava [35, 36]. Extubation criteria should pay particular attention to the presence of airway edema via the evaluation of an endotracheal tube cuff leak as a marker of airway patency if large‐volume resuscitation was required. If no cuff leak is present, coagulopathy persists, or the patient has an ongoing transfusion requirement, postoperative admission to the intensive care unit may be indicated. If the surgical team is planning a vertical midline incision, a low thoracic or high lumbar epidural catheter placement for postoperative pain may be efficacious. Benefits of opioid‐sparing pain control with neuraxial analgesia should be weighed against the risks of coagulopathy associated with bleeding.

7. FUTURE DIRECTIONS

The role of a GH in the management of suspected PAS in the second trimester is continuing to evolve, particularly as ultrasonographic diagnoses of PAS improve and the natural history of PAS continues to be elucidated. However, given the substantial coordination required to safely perform a GH and the risks of maternal morbidity and mortality if performed by less‐experienced or unprepared teams, there are a variety of recommendations our team has for future inquiries into the role of GH in abortion care.

7.1. Research needs

Currently, there are no prospectively collected, multisite data on health outcomes, inclusive of long‐term behavioral health outcomes [37], related to PAS and abortion care, let alone the utilization of GH. Ongoing work by the Pan‐American Society for Placenta Accreta Spectrum (PAS²) aims to capture perinatal and maternal health outcomes related to PAS, but publications have focused on outcomes at later gestational durations. We recommend that groups like PAS² or other multisite collaborations focused on PAS begin to prospectively collect and report data on the management of PAS during the second trimester. Work on this front is being spearheaded by the Complex Abortion Regional Line for Access Placental Evaluation Program (CARLA PEP) in Illinois, with support from the Illinois Department Public of Health [38]. CARLA PEP aims to rapidly connect people with suspected PAS seeking abortion care with ultrasonographic evaluation, performed by a MFM, at a tertiary or quaternary maternal care center [39]. Imaging, ultrasonographic reports, and perioperative health outcomes are input into a registry, which will aid researchers and clinicians working at the intersection of PAS and abortion care. Importantly, these datasets can help researchers and clinicians provide tailored recommendations for perioperative management based on relevant covariates, such as duration of gestation at the time of presentation, which may be associated with the maturation of the placenta and an increased risk of adverse health outcomes. Further, these datasets, in concert with larger studies on PAS at later gestational durations, can provide further data to inform clinical recommendations for abortion care based on the severity of PAS identified in the second trimester.

7.2. Care coordination needs

To safely provide GH, it is paramount to engage the multidisciplinary surgical team through a case conference, similar in style to a tumor board or preoperative gynecological conference. Many sites performing cesarean hysterectomies in the setting of PAS at later gestations engage in multidisciplinary case review; however, given the rarity of performing a GH and the substantial work required to safely care for a patient seeking abortion care in the setting of PAS, we believe it is necessary to engage all relevant stakeholders to ensure optimal care of the patient. Part of this engagement is also utilizing existing checklists and system preparedness bundles for management of PAS at later gestations with modifications to fit the unique considerations pertinent to performing a GH (Figure 4) [40].

FIGURE 4.

Sample gravid hysterectomy worksheet. GO, gynecologic oncology; MFM, maternal–fetal medicine; MIGS, minimally invasive gynecologic surgeon; OB, obstetric. Source: Adapted from Einerson et al. [40].

A major barrier to care coordination is the current legal landscape on limitations to providing abortion care [41]. When patients are diagnosed with PAS, the state they reside in may dictate the care they receive due to hesitation and lack of legal clarity among providers in restricted states to discuss complete pregnancy options counseling and the ability for a patient to travel to receive care [42, 43]. Moreover, if they are referred to another state for management of PAS, coordinating postoperative care in the patient's home state may be challenging due to concerns for privacy and possible legal implications for seeking abortion care out of state. The Reproductive Health Project (https://www.reproformfm.org/), a joint endeavor through the Society for Maternal‐Fetal Medicine (SMFM) and the Society of Family Planning (SFP), has resources available to guide clinicians on legal concerns related to abortion care.

Another barrier to care coordination is the potential inability of a patient to be referred to a PAS center of excellence [28] or that the patient needs to be referred to a low‐resource hospital, given the relative lack of high‐risk obstetrical care in many parts of the United States [44]. We urge clinicians at these centers to rely upon clinician networks through formal organizations—such as the SFP, the SMFM, and the Society for Obstetric Anesthesiology and Perinatology (SOAP)—for expert opinions on perioperative guidance.

It is critical to identify faculty members within MFM, CFP, GO, minimally invasive gynecologic surgery, urogynecology, other advanced pelvic surgeons, and obstetric anesthesiology who want to be involved in PAS cases. Mentorship of junior faculty interested in this unique intersection is critical to foster development of ultrasonographic, perioperative, and surgical skills required to maintain a safe, effective program for PAS in the setting of abortion care. Further, given that performing a GH is a high‐stakes situation, with substantial risk for morbidity, departmental chairs should consider how to acknowledge and support faculty for dedication in fostering and sustaining a program which can provide GHs.

Finally, as we described in our case, insurance coverage of abortion care is varied, depending heavily on type of insurance payor and state of residence. As a GH is an extremely costly endeavor, working with institutional billing and coding is important to help patients understand the financial implications of a GH. Furthermore, clinicians should advocate for insurance coverage for abortion care and support local and national abortion funds in providing coverage for costs of travel, housing, and childcare to reduce the financial burden associated with abortion care [45].

7.3. Working group on PAS and abortion care

In a previous report, members of our team have discussed the need for national leadership organizations—SFP, SMFM, SOAP, PAS², the American College of Obstetricians and Gynecologists, the Society of Gynecologic Oncology, the American Association of Gynecologic Laparoscopists, the American Urogynecology Society, and the Society of OB/GYN Hospitalists—to provide guidance on perioperative considerations for abortion in the setting of suspected PAS [11]. Importantly, these guidelines should be in distinction to existing documents related to management of cesarean scar ectopic pregnancy [46]. We recommend this guidance take into consideration not only standardization of language related to PAS but also where an abortion should take place, as well as the route of abortion. This guidance should also set core clinical outcomes for safe provision of an abortion in the setting of PAS to allow for the measurement of adverse outcomes and the opportunity for quality improvement initiatives. Finally, these national leadership organizations can help to organize legislative and policy advocacy related to equitable access to abortion care, especially in medically complex situations, like PAS, wherein the risk of maternal morbidity and mortality is substantial.

8. CONCLUSION

GH is a complex surgical procedure for the management of PAS between 14 0/7 and 26 6/7 weeks for individuals seeking abortion care. Though data are limited on its use, our case and insights into institutional and workforce requirements for the safe provision of a GH demonstrate a need for further research, training, and advocacy related to safe provision of abortion care in the setting of PAS.

CONFLICT OF INTEREST STATEMENT

Ashish Premkumar (MD, PhD) is on the scientific advisory board for GenBioPro. The other authors declare no conflicts of interest.

ETHICS STATEMENT

Informed consent was obtained from the patient described in this Clinical Perspective.

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