Perioperative Outcomes Associated With Different Uterine Incision Techniques During Cesarean Delivery for Placenta Accreta Spectrum: A Systematic Review and Single-Arm Meta-Analysis

Background: Placenta accreta spectrum (PAS) is associated with high maternal and fetal morbidity due to massive hemorrhage. Optimal cesarean uterine incision techniques for PAS remain debated, particularly non–lower segment approaches aimed at avoiding direct placental transection. Objectives: To systematically review and synthesize perioperative outcomes associated with different non–lower segment uterine incisions, including transverse fundal uterine incision (TFUI), parallel transverse uterine incision (PTUI), and fundal longitudinal incision, in cesarean deliveries for PAS. Search Strategy: A systematic search of PubMed, Embase, and CENTRAL was performed from inception to December 30, 2025, without language restrictions. Reference lists of included studies were also screened. Selection Criteria: Observational and randomized studies reporting perioperative outcomes in PAS patients undergoing cesarean delivery with TFUI, PTUI, or fundal longitudinal incision. Studies had to report at least one prespecified outcome. Data Collection and Analysis: Two reviewers independently extracted data on maternal characteristics, PAS classification, surgical details, blood loss, postoperative hemoglobin, hysterectomy rates, operative time, and hospital stay. Single-arm meta-analyses were conducted using random-effects models. Subgroup analyses were performed according to incision type. Main Results: Eight studies (n = 228) were included. Mean maternal age was 33.4 years, gestational age 34.7 weeks, and previous cesarean rate 94.9%. Overall mean operative time was 152.5 minutes, mean estimated blood loss 2090 mL, mean postoperative hemoglobin 10.86 mg/dL, and cesarean hysterectomy rate 28%. TFUI was associated with lower blood loss (1471 mL) but longer operative time (177 minutes), whereas PTUI showed higher blood loss (2682 mL) but shorter surgery (146 minutes) and lower hysterectomy rates. Fundal longitudinal incision data were limited. Considerable heterogeneity was observed across studies. Conclusions: TFUI may reduce blood loss but is associated with longer surgery and higher hysterectomy rates, whereas PTUI may allow faster surgery with higher blood loss but lower hysterectomy rates. Individualized incision planning, guided by placental location, PAS depth, and surgical expertise, is essential to optimize maternal outcomes. High-quality prospective studies are needed for comparative evaluation of these techniques.