(1068) Effectiveness of delivery strategies for placenta accreta spectrum patients presenting with vaginal bleeding

Objective: Vaginal bleeding (VB) is a common symptom experienced by patients with placenta accreta spectrum (PAS). No guideline exists in directing immediate delivery (ID) versus expectant management (EM) when patients present with non-persistent VB. We compared the quality-adjusted life years (QALYs) and life years gained (LYG) between ID and EM.

Study Design: We constructed a decision analysis model (Fig. 1) on a hypothetical cohort of patients presenting with non-persistent VB at gestational age (GA) from 28+0 to 36+6 weeks comparing EM vs ID. Outcomes factored into the model included maternal intensive care unit (ICU) admission, perinatal mortality, unintended cystotomy, ureteral injury, wound complications, neonatal ICU admission, infant mortality, respiratory distress syndrome, bronchopulmonary dysplasia, mental retardation, and cerebral palsy. Probability and health state utility was derived from the literature and our patient outcomes. We assumed that patients gain at least one additional GA week if EM is chosen, with delivery planned at the third episode of VB or, if no VB, at 37+0 weeks GA. A one-way sensitivity analysis was performed over low, medium, and high risk of VB recurrence (mean: 0.556, 95% confidence interval [0.308, 0.785]).

Results: When risk of VB recurrence was varied by low (0.308) or medium (0.556) in the one-way sensitivity analysis, EM was consistently favored over ID. However, when risk of VB recurrence is high (0.785), EM resulted lower QALYs and LYG when VB first occurs at ≥34+0 weeks gestation. (Fig. 2)

Conclusion: This decision analysis suggests the preferred strategy for management in individuals with PAS presenting with non-persistent VB under a variety of circumstances is EM over ID. Considerations may be given to ID when VB recurrence risk is high at ≥34+0 weeks gestation given higher QALYs and LYG.