Surgical Management and Perinatal Outcomes in Placenta Accreta Spectrum: A Five-Year Single-Center Retrospective Cohort from Kayseri City Hospital

Surgical Management and Perinatal Outcomes in Placenta Accreta Spectrum: A Five-Year Single-Center Retrospective Cohort from Kayseri City Hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical Management and Perinatal Outcomes in Placenta Accreta Spectrum: A Five-Year Single-Center Retrospective Cohort from Kayseri City Hospital Merve Genco, Mehmet Genco, Hüseyin Aksoy, Harika Göçer, Emrah Göçer, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9011421/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Placenta accreta spectrum (PAS) is a leading cause of life-threatening obstetric haemorrhage. Whether planned versus emergency delivery alters outcomes once care is centralised and protocolised remains uncertain. Aims To compare maternal and neonatal outcomes by delivery timing (emergency vs planned) and by depth of invasion (accreta, increta, percreta) in a single-centre cohort. Materials and Methods Retrospective observational study of consecutive PAS cases ≥ 24 weeks managed at a tertiary referral centre (2021–2025). Antenatal diagnosis, operative metrics, transfusion surrogates, ICU/NICU admission, complications, and perinatal outcomes were abstracted from standardised records. Results Forty-three patients: 15 (34.9%) emergency, 28 (65.1%) planned. Percreta 23 (53.5%), increta 8 (18.6%), accreta 12 (27.9%). Antenatal suspicion 93% overall (100% planned; 80% emergency). Hysterectomy in 33/43 (76.7%); prophylactic double-J stents 8/43 (18.6%), all planned. Maternal haemorrhage surrogates, ICU admission (30.2%), and maternal/neonatal death (7.0%; 1 maternal, 2 neonatal) were similar between groups (all p ≥ 0.525). NICU admission in 17/43 (39.5%), largely gestational-age related. Postoperative complications 6/43 (14.0%): 4 bladder and 2 ureteral injuries, all recognised intraoperatively and repaired without reoperation. Conclusion In a multidisciplinary pathway with > 90% antenatal detection, maternal haemorrhage outcomes were similar for emergency and planned deliveries. Surgical risk rose with invasion depth not timing while urologic injuries clustered in deep invasion yet were manageable. Targeting later gestation in stable patients at experienced centres may improve neonatal outcomes without compromising maternal safety Placenta accreta spectrum percreta cesarean hysterectomy antenatal diagnosis NICU Introduction Placental invasion anomalies are currently classified under the Placenta Accreta Spectrum (PAS). They are characterized by insufficient development of the decidual layer (decidua basalis), allowing trophoblasts to invade the myometrium (accreta–increta) and, in severe cases, traverse the uterine serosa to involve adjacent organs (percreta). PAS is among the leading causes of life-threatening obstetric hemorrhage ( 1 ). The rapid global rise in cesarean delivery has markedly increased the frequency of PAS; between 1990 and 2014, the approximately threefold increase in cesarean rates has been associated with a significant rise in morbidity attributable to the accreta spectrum ( 2 ). This trend is corroborated by large U.S. cohort studies reporting that PAS accounts for a growing share of cesarean-related complications ( 3 ). In national, population-based studies, the prevalence of PAS has been reported as 0.017% in the United Kingdom and up to 0.034% in the Nordic countries ( 4 , 5 ). The fundamental mechanism in PAS pathogenesis is absence or defect of the decidua basalis at the utero-placental interface, which facilitates trophoblastic invasion beyond normal limits ( 6 ). The strongest risk factor is prior cesarean delivery: after two previous cesareans the risk increases by roughly eightfold, and with placenta previa plus a history of three or more cesareans the risk reaches 67% ( 7 ). Additional risk factors include placenta previa, prior uterine surgery, higher parity, and advanced maternal age. Morbidity is determined by the depth of invasion; in a multicenter study, severe maternal morbidity was approximately threefold higher in percreta than in accreta ( 8 ). Massive transfusion, complex pelvic surgery, and peripartum hysterectomy are frequently required. Antenatal diagnosis primarily by ultrasound (USG) and, when indicated, magnetic resonance imaging (MRI) reduces peripartum hemorrhage and the need for emergent hysterectomy ( 9 ). Current FIGO guidance recommends planned delivery at 34–36 weeks of gestation, a multidisciplinary team approach, and individualized conservative (leaving the placenta in situ) or radical (cesarean hysterectomy) strategies ( 10 ). Even in resource-limited settings, antenatal diagnosis and standardized surgical protocols have been shown to improve maternal and neonatal outcomes ( 11 ). Turkey has the highest cesarean rates among OECD (Organisation for Economic Co-operation and Development) countries. This high rate increases the population-level burden of obstetric complications such as PAS ( 12 ). Protocols for the diagnosis and management of PAS vary substantially across the country: while high-volume referral centers can implement multidisciplinary care and planned surgery, access to antenatal diagnosis and systematic planning may be limited in resource-constrained provinces. Cases referred from surrounding provinces to tertiary centers such as Kayseri City Hospital increase the clinical load at these facilities, underscoring the importance of ensuring that experience with PAS management is adequately represented in national datasets. As most publications on PAS from Turkey are single-center with limited sample sizes, comprehensive series with detailed clinical outcomes remain scarce. This study aims to report maternal and neonatal outcomes of PAS surgeries performed at Kayseri City Hospital in detail, to compare them with the current international evidence, and to provide data-informed contributions to national health policy. Materials and Methods This retrospective observational study included all consecutive women with a diagnosis of placenta accreta spectrum (PAS) managed at the Department of Obstetrics and Gynecology, Kayseri City Hospital, between 01/01/2021 and 01/08/2025 . Ethics approval was obtained from the Kayseri City Hospital Non-Interventional Clinical Research Ethics Committee (decision no: 556, dated: 26.08.2025). Informed consent to participate was waived due to the retrospective design and the use of anonymized data. Human Ethics and Consent to Participate Ethical approval was obtained from the above ethics committee. Informed consent was waived due to the retrospective design and anonymized data. Consent to Publish: Not applicable. All procedures involving human participants complied with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Due to the retrospective nature of the study, informed consent was waived. Personal data were anonymized prior to analysis to maintain confidentiality. Study population Consecutive cases with a diagnosis of placenta accreta spectrum (accreta/increta/percreta) who delivered at our institution were included if gestational age was ≥ 24 weeks. To ensure comparability of neonatal outcomes, previable pregnancies (< 24 weeks) were excluded. In cases managed with hysterectomy, PAS was confirmed histopathologically; in those managed without hysterectomy or with a conservative approach, the diagnosis was established intraoperatively/clinically. Data were collected using a standardized case report form that captured demographic indicators (e.g., age) and risk factors (gravidity, prior cesarean delivery, myomectomy, antenatal diagnosis before the operation); operative characteristics (estimated blood loss, transfusion of blood products, duration of surgery, length of hospital stay, postoperative admission to the intensive care unit (ICU), and surgical complications); and neonatal outcomes, including Apgar scores. Following pregnancy termination, the excised tissues were submitted for pathological examination, and the postoperative diagnosis was rendered by an experienced pathologist. All patients in this cohort were managed using a multidisciplinary team approach. After admission to the obstetrics and gynecology service, additional specialties were consulted as needed based on imaging or laboratory findings. Statistical Analysis All statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). A 95% confidence interval was applied, and statistical significance was defined as p < 0.05. Categorical variables were summarized as frequencies (n) and percentages (%), while continuous variables were expressed as mean ± standard deviation or median (minimum–maximum), as appropriate. The distribution of continuous variables was assessed using the Shapiro–Wilk test and by evaluating skewness and kurtosis coefficients. Comparisons of categorical variables were carried out using the Chi-square test, and Fisher’s exact test was applied when Chi-square assumptions were not met. For comparisons of continuous variables between two independent groups, the independent samples t -test was used when normality assumptions were satisfied, whereas the Mann–Whitney U test was applied otherwise. For comparisons among three independent groups, one-way ANOVA was used for normally distributed variables, while the Kruskal–Wallis H test was employed for non-normally distributed data. When significant differences were observed in multiple group comparisons of non-normally distributed variables, the source of the difference was determined using the Bonferroni-adjusted Mann–Whitney U test ( p = 0.017 = 0.05/3). RESULTS A total of 43 PAS cases were evaluated; 15 were emergency and 28 were planned deliveries. By depth of invasion, the groups were: percreta 23 (53.5%), increta 8 (18.6%), and accreta 12 (27.9%). The mean maternal age was 35 ± 6 years; mean height 162 ± 6 cm, weight 78 ± 12 kg, and BMI (body mass index ) 29 ± 5 kg/m². Median gravidity was 4 ( 1 – 10 ), parity 3 (0–6), and prior cesarean number 2 (0–5). A history of myomectomy was present in 2/43 (4.7%) patients. The median gestational age at delivery was 34 (23–39) weeks. Placenta previa was documented in 39/43 (90.7%) cases. PAS was diagnosed at a median of 27 (0–39) weeks; diagnosis was established by ultrasound in 40/43 (93%), and preoperatively/intraoperatively in 3/43 (7%). TAH (Total Abdominal Hysterectomy) was performed in 33/43 (76.7%) cases. Prophylactic double-J ureteral stents were used in 8/43 (18.6%). The median operative time was 1 hour 42 minutes (0.8–4.0 h). ICU (Intensive Care Unit) admission was required in 13/43 (30.2%) patients. Pre- and postoperative hemoglobin values were 11 ± 2 and 10 ± 2 g/dL, respectively. Blood product replacement (red cell concentrates and cryoprecipitate) had a median of 2 ( 1 – 4 ) units for each component. For neonates, median length was 46 cm (26–51) and birthweight 2450 g (510–3580); NICU (Neonatal Intensive Care Unit) admission was required in 17/43 (39.5%). Maternal and/or neonatal death occurred in 3/43 (7.0%) one maternal and two neonatal deaths. Postoperative complications were recorded in 6/43 (14.0%) patients. These included 2 cases of ureteral injury and 4 cases of bladder perforation, all of which were recognized intraoperatively and repaired during the same surgical session. No patient required reoperation for these complications. Apgar scores at 1, 5, and 10 minutes were 7 ( 1 – 9 ), 8 (0–10), and 8 (0–10), respectively. These data are summarized in Table 1 . Table 1 Baseline characteristics and outcomes of the overall cohort (n = 43) Variable Mean ± SD or n (%) Delivery type Emergency 15 (34.9%) Planned 28 (65.1%) PAS depth of invasion Percreta 23 (53.5%) Increta 8 (18.6%) Accreta 12 (27.9%) Age, years 35 ± 6 BMI, kg/m² 29 ± 5 Gravidity 4 ( 1 – 10 ) Parity 3 (0–6) Prior cesarean, n 2 (0–5) Prior myomectomy,n 2 (4.7%) Gestational age at delivery, weeks 34 (23–39) Birth length, cm 46 (26–51) Birthweight, g 2450 (510–3580) Placenta previa Present 39/43 (90.7%) Absent 3/43 (7.0%) Gestational week at PAS diagnosis 27week (0–39) Diagnosis method Ultrasound 40 (93.0%) Pre-op/Intra-op 3 (7.0%) TAH performed Yes: 33 (76.7%) No:10 (23.3%) Prophylactic double-J stent Yes: 8 (18.6%) No: 35 (81.4%) Operative time, hours 1.7 (0.8–4.0) ICU admission Yes: 13 (30.2%) No: 30 (69.8%) NICU admission Yes: 17 (39.5%) No: 26 (60.5%) Preoperative hemoglobin, g/dL 11 ± 2 Postoperative hemoglobin, g/dL 10 ± 2 RBC transfusion, units 2 ( 1 – 4 ) Cryoprecipitate transfusion, units 2 ( 1 – 4 ) Maternal and/or neonatal death Yes: 3 (7.0%) No: 39 (90.7%) Postoperative complications Yes: 6 (14.0%) No: 37 (86.0%) Table 2 Comparison of emergency vs planned deliveries in PAS cohort. Variable Emergency (n = 15) Planned (n = 28) p-value Age, years 38 ± 6 34 ± 6 0.052 Maternal height, cm 161 ± 7 162 ± 4 0.583 Maternal weight, kg 74 ± 11 79 ± 12 0.213 BMI, kg/m² 29 ± 4 30 ± 5 0.609 Gravidity 5 ( 2 – 8 ) 4 ( 1 – 10 ) 0.123 Parity 3 ( 1 – 5 ) 3 (0–6) 0.383 Prior cesarean, n 3 ( 1 – 5 ) 2 (0–5) 0.419 Prior myomectomy, n 0 (0.0) 2 (7.1) 0.289 Gestational age at delivery, weeks 34w+3d (25.6–39) 34w+1d (23–39) 0.407 Birth length, cm 49 (32–51) 46 (26–49) 0.011 Birthweight, g 2630 (800–3170) 2290 (510–3580) 0.460 Placenta previa present, n 11 (73.3) 28 (100.0) 0.011 Gestational week at PAS diagnosis 31w (0–39) 27 (9.4–38) 0.050 Diagnosis by ultrasound, n 12 (80.0) 28 (100.0) 0.200 TAH performed, n 11 (73.3) 22 (78.6) 0.719 Prophylactic double-J ureteral stent,n 0 (0.0) 8 (28.6) 0.036 Operative time, hours 1.5 (0.8–3.0) 1.8 (1.0–4.0) 0.219 ICU admission, n 5 (33.3) 8 (28.6) 0.746 NICU admission, n 7 (46.7) 10 (35.7) 0.528 Preoperative hemoglobin, g/dL 11 ± 2 11 ± 1 0.889 Postoperative hemoglobin, g/dL 9 ± 2 10 ± 3 0.535 RBC transfusion, units 2 ( 1 – 4 ) 2 ( 1 – 4 ) 0.805 Cryoprecipitate, units 2 ( 1 – 4 ) 2 ( 1 – 4 ) 0.746 Maternal and/or neonatal death, n 2 (13.3) 1 (3.6) 0.525 Any postoperative complication, n 2 (13.3) 4 (14.3) 1.000 Final pathology, n (%) 0.133 – Accreta 7 (46.7) 5 (17.9) – Increta 2 (13.3) 6 (21.4) – Percreta 6 (40.0) 17 (60.7) Data are presented as mean ± SD, median (min–max), or n (%) as appropriate. Across PAS depth categories, baseline maternal characteristics, antenatal findings, transfusion requirements, hemoglobin change, ICU/NICU admission, Apgar scores, and postoperative complications were broadly comparable (global p > 0.05 for all). Operative time differed significantly among groups (Kruskal–Wallis p = 0.036): post-hoc testing showed longer procedures in percreta versus accreta (Bonferroni-adjusted Mann–Whitney p = 0.016), whereas percreta versus increta ( p = 0.136) and increta versus accreta ( p = 0.464) were not significant. These data are summarized in Table 3 . Table 3 Maternal, operative, and neonatal outcomes stratified by depth of placental invasion (accreta, increta, percreta). Variable Percreta (n = 23) Increta (n = 8) Accreta (n = 12) p-value Age, years 34 ± 5 37 ± 6 37 ± 7 0.384 Maternal height, cm 161 ± 5 162 ± 4 163 ± 7 0.777 Maternal weight, kg 75 ± 9 81 ± 11 81 ± 16 0.272 Discussion In this single-center PAS series (n = 43), more than half of the cases were percreta (53%), 35% delivered under emergency conditions, and 77% underwent cesarean hysterectomy (TAH). The median gestational age at delivery was ~34 weeks, and NICU admission occurred in 40%. When compared by delivery timing, most maternal metrics were comparable; the only notable difference was the more frequent use of preoperative double-J ureteral stents in the planned group, reflecting greater operative preparedness. In analyses by depth of invasion, only operative time (percreta vs accreta) remained significant after Bonferroni correction; neonatal outcomes did not vary across pathology strata. Our emergency delivery rate (35%) closely parallels the IS-PAS (International Society for Placenta Accreta Spectrum) multicenter database (33%). Morlando et al. reported that emergency births occurred at lower gestational ages (mean 34 vs 36 weeks) and were associated with higher ICU admission, yet did not show higher blood loss or transfusion compared with planned delivery when care was provided in experienced centers. In our cohort, the planned–emergency comparison likewise showed no significant differences in hemoglobin change or transfusion surrogates, supporting the view that—with established protocols and experienced teams—emergency delivery does not inevitably increase hemorrhagic morbidity (13). Diagnosis in our series was predominantly by ultrasound (93% overall); all planned cases had antenatal suspicion, whereas 20% of emergencies did not. A recent three-center cohort reported an “unsuspected” PAS rate of ~35%, with significantly higher 24-hour blood loss and transfusion in unsuspected cases; posterior placentation and the absence of risk factors for intrauterine adhesions were identified as key correlates of missed antenatal diagnosis. In our cohort, the emergency group contained fewer placenta previa cases (0% vs 100% in planned), consistent with the literature that absence of previa can hinder antenatal suspicion and predispose to emergency presentation (14). The high percreta proportion (53%) suggests tertiary referral bias and is comparable to severe-case series. Even within standardized, multidisciplinary pathways, percreta is associated with substantially higher severe maternal morbidity and hysterectomy rates than accreta/increta; in a large Paris series, severe morbidity was 86% in percreta versus 27% in accreta, with hysterectomy markedly more frequent in percreta (8). In our cohort, the overall TAH rate was 77%; by subgroup it was 91% (21/23) for percreta, 88% (7/8) for increta, and 42% (5/12) for accreta. Our policy of targeting delivery around 34 weeks yielded median Apgar scores of 7/8/8 at 1, 5, and 10 minutes and a 40% NICU admission rate. The IS-PAS analysis underscores that, when clinically feasible, deferring delivery beyond 36 weeks reduces major neonatal morbidity from ~25% at 34+1–36+0 weeks to ~19% after 36 weeks, which aligns with FIGO-endorsed strategies in stable cases under expert care. Moreover, depth of invasion does not consistently worsen neonatal outcomes once gestational age is accounted for; a classic comparative cohort found similar gestational age at birth, birthweight, NICU admission, and mortality between “deep” (increta/percreta) and “superficial” (accreta) invasion consistent with our lack of neonatal differences across pathology groups (6). Our antenatal detection rate was high (93%; 100% in planned, 80% in emergency cases), comparing favorably with reports from three academic centers where the “unsuspected” PAS rate was 35.4%. The fact that double-J stents were used only in antenatally detected planned cases (28.6%) illustrates how early diagnosis enables risk-reducing adjuncts. The literature consistently advocates management in tertiary, multidisciplinary centers and considers antenatal detection critical for optimizing outcomes. Finally, a five-year cohort from a resource-limited setting reported antenatal detection of 86.3% and demonstrated that team-based protocols can achieve results comparable to those in high-resource centers (11), supporting the reproducibility of a “high antenatal detection + multidisciplinary” model across contexts. In our cohort, the overall postoperative complication rate was 14% (6/43), comprising four bladder perforations (9.3%) and two ureteral injuries (4.7%). These figures are broadly consistent with contemporary PAS series. Large database analyses of cesarean hysterectomy for PAS report bladder injury rates of ~18–24% and ureteral injury rates of ~2–4%; our bladder perforation rate falls at the lower end of this range, whereas the ureteral injury rate is near the upper bound (15). Elective preoperative ureteral stenting used only in planned cases in our series has been associated in large datasets with fewer bladder injuries; this may partly account for our relatively low bladder injury rate and overall urologic profile despite a percreta-heavy case mix. Notably, these complication rates remain acceptable despite the high proportion of percreta cases, and no significant differences were observed between emergency and planned deliveries. Strengths of this study include consecutive case capture at a high-volume tertiary referral center, standardized data abstraction, and prespecified stratified analyses by delivery timing and depth of invasion. Limitations include the retrospective design and modest subgroup sizes; moreover, the referral case-mix with a high proportion of percreta may limit external generalizability, yet it provides clinically relevant insight into the most morbid end of the PAS spectrum. In addition, the statistical power of subgroup analyses, particularly for the increta group (n = 8), was limited, and these comparisons should therefore be interpreted with caution. In this single-center cohort, a >90% antenatal detection rate and a structured multidisciplinary pathway were linked to comparable hemorrhage-related maternal outcomes between emergency and planned deliveries. The main determinant of risk was surgical complexity, which increased with invasion depth, particularly in percreta. Importantly, urologic complications (bladder and ureter injuries) clustered in deeply invasive cases but were largely preventable when procedures were scheduled and surgical teams were adequately prepared. Neonatal outcomes were primarily influenced by gestational age, underscoring that, in stable patients managed at experienced centers, deferring delivery to later gestational weeks may optimize neonatal prognosis without compromising maternal safety. Abbreviations PAS placenta accreta spectrum BMI body mass index CS cesarean section USG ultrasonography TAH total abdominal hysterectomy ICU intensive care unit NICU neonatal intensive care unit RBC packed red blood cells DJ stent double-J ureteral stent Hb hemoglobin. Declarations Ethics approval and consent to participate: Ethics approval was obtained from the Kayseri City Hospital Non-Interventional Clinical Research Ethics Committee (decision no: 556, dated: 26.08.2025). Informed consent to participate was waived due to the retrospective design and the use of anonymized data Acknowledgments: The authors thank the surgical team and nursing staff of Kayseri City Hospital for their support during the study. We also appreciate the contributions of the ethics committee members for their guidance and approval of the research protocol. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest : none declared Competing interests: The authors declare that they have no competing interests. Acknowledgments: We gratefully acknowledge our colleagues at Kayseri City Hospital including the Departments of Obstetrics and Gynaecology, Anaesthesiology and Reanimation, Urology, Neonatology (NICU), Transfusion Medicine/Blood Bank, and Operating Room Nursing for their contributions to the PAS clinical pathway, data standardisation, and case coordination. All contributors provided permission to be acknowledged and received no compensation. No external financial or material support was received. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request, subject to institutional and ethical regulations. Author Contributions: Merve Genco: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Writing – original draft; Writing – review & editing; Visualization; Supervision; Project administration. Mehmet Genco: Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Writing – original draft; Writing – review & editing; Visualization; Supervision; Project administration. Hüseyin Aksoy: Methodology; Formal analysis; Writing – review & editing; Supervision. Harika Göçer: Investigation; Data curation; Writing – review & editing. 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Zhao J, Li Q, Liao E, Shi H, Luo X, Zhang L, Qi H, Zhang H, Li J. Incidence, risk factors and maternal outcomes of unsuspected placenta accreta spectrum disorders: a retrospective cohort study. BMC Pregnancy Childbirth. 2024;24(1):76. 10.1186/s12884-024-06254-z . PMID: 38262978; PMCID: PMC10804779. Matsuo K, Huang Y, Matsuzaki S, Vallejo A, Ouzounian JG, Roman LD, Khoury-Collado F, Friedman AM, Wright JD. Cesarean hysterectomy for placenta accreta spectrum: Surgeon specialty-specific assessment. Gynecol Oncol. 2024;186:85–93. doi: 10.1016/j.ygyno.2024.04.004. Epub 2024 Apr 11. PMID: 38603956. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9011421","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628470655,"identity":"93fcd5da-3809-43b3-93e0-99bca104de28","order_by":0,"name":"Merve Genco","email":"data:image/png;base64,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","orcid":"","institution":"Kayseri Devlet Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"Merve","middleName":"","lastName":"Genco","suffix":""},{"id":628470658,"identity":"a05d998a-27b6-4381-b57b-e953da6121d5","order_by":1,"name":"Mehmet Genco","email":"","orcid":"","institution":"Kayseri City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Genco","suffix":""},{"id":628470659,"identity":"ccc9cf2e-d6aa-42a2-8955-556769453c78","order_by":2,"name":"Hüseyin Aksoy","email":"","orcid":"","institution":"Kayseri City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hüseyin","middleName":"","lastName":"Aksoy","suffix":""},{"id":628470661,"identity":"63330428-c5c1-4064-9f97-a3c768daa122","order_by":3,"name":"Harika Göçer","email":"","orcid":"","institution":"Kayseri City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Harika","middleName":"","lastName":"Göçer","suffix":""},{"id":628470662,"identity":"fd5a4345-21a4-43f7-b028-14d16da4df89","order_by":4,"name":"Emrah Göçer","email":"","orcid":"","institution":"Kayseri City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Emrah","middleName":"","lastName":"Göçer","suffix":""},{"id":628470664,"identity":"3b7179f0-d35f-4ff6-98d5-308e76b5c50b","order_by":5,"name":"Koray Kaya","email":"","orcid":"","institution":"Kayseri City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Koray","middleName":"","lastName":"Kaya","suffix":""},{"id":628470666,"identity":"f41bea2c-d6a1-47b7-b2e2-54a20a1dd9e3","order_by":6,"name":"Beyza Aslım","email":"","orcid":"","institution":"Kayseri City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Beyza","middleName":"","lastName":"Aslım","suffix":""}],"badges":[],"createdAt":"2026-03-02 14:40:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9011421/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9011421/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109090407,"identity":"83ca7018-a369-4ede-96ec-34be04818e73","added_by":"auto","created_at":"2026-05-12 13:30:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":328280,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9011421/v1/46cb2939-a0b4-442b-85d4-3c9554edd100.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Management and Perinatal Outcomes in Placenta Accreta Spectrum: A Five-Year Single-Center Retrospective Cohort from Kayseri City Hospital","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePlacental invasion anomalies are currently classified under the Placenta Accreta Spectrum (PAS). They are characterized by insufficient development of the decidual layer (decidua basalis), allowing trophoblasts to invade the myometrium (accreta\u0026ndash;increta) and, in severe cases, traverse the uterine serosa to involve adjacent organs (percreta). PAS is among the leading causes of life-threatening obstetric hemorrhage (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe rapid global rise in cesarean delivery has markedly increased the frequency of PAS; between 1990 and 2014, the approximately threefold increase in cesarean rates has been associated with a significant rise in morbidity attributable to the accreta spectrum (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This trend is corroborated by large U.S. cohort studies reporting that PAS accounts for a growing share of cesarean-related complications (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In national, population-based studies, the prevalence of PAS has been reported as 0.017% in the United Kingdom and up to 0.034% in the Nordic countries (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe fundamental mechanism in PAS pathogenesis is absence or defect of the decidua basalis at the utero-placental interface, which facilitates trophoblastic invasion beyond normal limits (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The strongest risk factor is prior cesarean delivery: after two previous cesareans the risk increases by roughly eightfold, and with placenta previa plus a history of three or more cesareans the risk reaches 67% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Additional risk factors include placenta previa, prior uterine surgery, higher parity, and advanced maternal age. Morbidity is determined by the depth of invasion; in a multicenter study, severe maternal morbidity was approximately threefold higher in percreta than in accreta (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Massive transfusion, complex pelvic surgery, and peripartum hysterectomy are frequently required.\u003c/p\u003e \u003cp\u003eAntenatal diagnosis primarily by ultrasound (USG) and, when indicated, magnetic resonance imaging (MRI) reduces peripartum hemorrhage and the need for emergent hysterectomy (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Current FIGO guidance recommends planned delivery at 34\u0026ndash;36 weeks of gestation, a multidisciplinary team approach, and individualized conservative (leaving the placenta in situ) or radical (cesarean hysterectomy) strategies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Even in resource-limited settings, antenatal diagnosis and standardized surgical protocols have been shown to improve maternal and neonatal outcomes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTurkey has the highest cesarean rates among OECD (Organisation for Economic Co-operation and Development) countries. This high rate increases the population-level burden of obstetric complications such as PAS (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Protocols for the diagnosis and management of PAS vary substantially across the country: while high-volume referral centers can implement multidisciplinary care and planned surgery, access to antenatal diagnosis and systematic planning may be limited in resource-constrained provinces. Cases referred from surrounding provinces to tertiary centers such as Kayseri City Hospital increase the clinical load at these facilities, underscoring the importance of ensuring that experience with PAS management is adequately represented in national datasets. As most publications on PAS from Turkey are single-center with limited sample sizes, comprehensive series with detailed clinical outcomes remain scarce. This study aims to report maternal and neonatal outcomes of PAS surgeries performed at Kayseri City Hospital in detail, to compare them with the current international evidence, and to provide data-informed contributions to national health policy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis retrospective observational study included all consecutive women with a diagnosis of placenta accreta spectrum (PAS) managed at the Department of Obstetrics and Gynecology, Kayseri City Hospital, between 01/01/2021 and 01/08/2025 .\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003ewas obtained from the Kayseri City Hospital Non-Interventional Clinical Research Ethics Committee (decision no: 556, dated: 26.08.2025). Informed consent to participate was waived due to the retrospective design and the use of anonymized data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e \u003cp\u003e Ethical approval was obtained from the above ethics committee. Informed consent was waived due to the retrospective design and anonymized data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Publish:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e All procedures involving human participants complied with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Due to the retrospective nature of the study, informed consent was waived. Personal data were anonymized prior to analysis to maintain confidentiality.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eConsecutive cases with a diagnosis of placenta accreta spectrum (accreta/increta/percreta) who delivered at our institution were included if gestational age was \u0026ge;\u0026thinsp;24 weeks. To ensure comparability of neonatal outcomes, previable pregnancies (\u0026lt;\u0026thinsp;24 weeks) were excluded. In cases managed with hysterectomy, PAS was confirmed histopathologically; in those managed without hysterectomy or with a conservative approach, the diagnosis was established intraoperatively/clinically.\u003c/p\u003e \u003cp\u003eData were collected using a standardized case report form that captured demographic indicators (e.g., age) and risk factors (gravidity, prior cesarean delivery, myomectomy, antenatal diagnosis before the operation); operative characteristics (estimated blood loss, transfusion of blood products, duration of surgery, length of hospital stay, postoperative admission to the intensive care unit (ICU), and surgical complications); and neonatal outcomes, including Apgar scores.\u003c/p\u003e \u003cp\u003eFollowing pregnancy termination, the excised tissues were submitted for pathological examination, and the postoperative diagnosis was rendered by an experienced pathologist. All patients in this cohort were managed using a multidisciplinary team approach. After admission to the obstetrics and gynecology service, additional specialties were consulted as needed based on imaging or laboratory findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). A 95% confidence interval was applied, and statistical significance was defined as \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Categorical variables were summarized as frequencies (n) and percentages (%), while continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median (minimum\u0026ndash;maximum), as appropriate. The distribution of continuous variables was assessed using the Shapiro\u0026ndash;Wilk test and by evaluating skewness and kurtosis coefficients.\u003c/p\u003e \u003cp\u003eComparisons of categorical variables were carried out using the Chi-square test, and Fisher\u0026rsquo;s exact test was applied when Chi-square assumptions were not met. For comparisons of continuous variables between two independent groups, the independent samples \u003cem\u003et\u003c/em\u003e-test was used when normality assumptions were satisfied, whereas the Mann\u0026ndash;Whitney U test was applied otherwise. For comparisons among three independent groups, one-way ANOVA was used for normally distributed variables, while the Kruskal\u0026ndash;Wallis H test was employed for non-normally distributed data. When significant differences were observed in multiple group comparisons of non-normally distributed variables, the source of the difference was determined using the Bonferroni-adjusted Mann\u0026ndash;Whitney U test (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.017\u0026thinsp;=\u0026thinsp;0.05/3).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 43 PAS cases were evaluated; 15 were emergency and 28 were planned deliveries. By depth of invasion, the groups were: percreta 23 (53.5%), increta 8 (18.6%), and accreta 12 (27.9%).\u003c/p\u003e\n\u003cp\u003eThe mean maternal age was 35\u0026thinsp;\u0026plusmn;\u0026thinsp;6 years; mean height 162\u0026thinsp;\u0026plusmn;\u0026thinsp;6 cm, weight 78\u0026thinsp;\u0026plusmn;\u0026thinsp;12 kg, and BMI (body mass index\u003cstrong\u003e)\u003c/strong\u003e 29\u0026thinsp;\u0026plusmn;\u0026thinsp;5 kg/m\u0026sup2;. Median gravidity was 4 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), parity 3 (0\u0026ndash;6), and prior cesarean number 2 (0\u0026ndash;5). A history of myomectomy was present in 2/43 (4.7%) patients. The median gestational age at delivery was 34 (23\u0026ndash;39) weeks. Placenta previa was documented in 39/43 (90.7%) cases. PAS was diagnosed at a median of 27 (0\u0026ndash;39) weeks; diagnosis was established by ultrasound in 40/43 (93%), and preoperatively/intraoperatively in 3/43 (7%).\u003c/p\u003e\n\u003cp\u003eTAH (Total Abdominal Hysterectomy) was performed in 33/43 (76.7%) cases. Prophylactic double-J ureteral stents were used in 8/43 (18.6%). The median operative time was 1 hour 42 minutes (0.8\u0026ndash;4.0 h). ICU (Intensive Care Unit) admission was required in 13/43 (30.2%) patients. Pre- and postoperative hemoglobin values were 11\u0026thinsp;\u0026plusmn;\u0026thinsp;2 and 10\u0026thinsp;\u0026plusmn;\u0026thinsp;2 g/dL, respectively. Blood product replacement (red cell concentrates and cryoprecipitate) had a median of 2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) units for each component.\u003c/p\u003e\n\u003cp\u003eFor neonates, median length was 46 cm (26\u0026ndash;51) and birthweight 2450 g (510\u0026ndash;3580); NICU (Neonatal Intensive Care Unit) admission was required in 17/43 (39.5%). Maternal and/or neonatal death occurred in 3/43 (7.0%) one maternal and two neonatal deaths. Postoperative complications were recorded in 6/43 (14.0%) patients. These included 2 cases of ureteral injury and 4 cases of bladder perforation, all of which were recognized intraoperatively and repaired during the same surgical session. No patient required reoperation for these complications. Apgar scores at 1, 5, and 10 minutes were 7 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), 8 (0\u0026ndash;10), and 8 (0\u0026ndash;10), respectively.\u003c/p\u003e\n\u003cp\u003eThese data are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics and outcomes of the overall cohort (n\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eDelivery type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eEmergency 15 (34.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003ePlanned 28 (65.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003ePAS depth of invasion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003ePercreta 23 (53.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eIncreta 8 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eAccreta 12 (27.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e35\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBMI, kg/m\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e29\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e3 (0\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePrior cesarean, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (0\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePrior myomectomy,n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGestational age at delivery, weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e34 (23\u0026ndash;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBirth length, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e46 (26\u0026ndash;51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBirthweight, g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2450 (510\u0026ndash;3580)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003ePlacenta previa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003ePresent 39/43 (90.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eAbsent 3/43 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGestational week at PAS diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e27week (0\u0026ndash;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eDiagnosis method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eUltrasound 40 (93.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003ePre-op/Intra-op 3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eTAH performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes: 33 (76.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eNo:10 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eProphylactic double-J stent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes: 8 (18.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eNo: 35 (81.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOperative time, hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1.7 (0.8\u0026ndash;4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes: 13 (30.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eNo: 30 (69.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eNICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes: 17 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eNo: 26 (60.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePreoperative hemoglobin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePostoperative hemoglobin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRBC transfusion, units\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCryoprecipitate transfusion, units\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eMaternal and/or neonatal death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes: 3 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eNo: 39 (90.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003ePostoperative complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes: 6 (14.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eNo: 37 (86.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of emergency vs planned deliveries in PAS cohort.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eEmergency (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003ePlanned (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e38\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e34\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMaternal height, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e161\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e162\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMaternal weight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e74\u0026thinsp;\u0026plusmn;\u0026thinsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e79\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBMI, kg/m\u0026sup2;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e29\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.609\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5 (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e4 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e3 (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e3 (0\u0026ndash;6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePrior cesarean, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e3 (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e2 (0\u0026ndash;5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePrior myomectomy, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e2 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.289\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGestational age at delivery, weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e34w+3d (25.6\u0026ndash;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e34w+1d (23\u0026ndash;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBirth length, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e49 (32\u0026ndash;51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e46 (26\u0026ndash;49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBirthweight, g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2630 (800\u0026ndash;3170)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e2290 (510\u0026ndash;3580)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.460\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePlacenta previa present, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e28 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGestational week at PAS diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e31w (0\u0026ndash;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e27 (9.4\u0026ndash;38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDiagnosis by ultrasound, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e12 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e28 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.200\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTAH performed, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11 (73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e22 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.719\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eProphylactic double-J ureteral stent,n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e8 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.036\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOperative time, hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1.5 (0.8\u0026ndash;3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1.8 (1.0\u0026ndash;4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eICU admission, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e8 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNICU admission, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e7 (46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e10 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePreoperative hemoglobin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.889\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePostoperative hemoglobin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.535\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eRBC transfusion, units\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.805\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCryoprecipitate, units\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMaternal and/or neonatal death, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAny postoperative complication, n\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e4 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFinal pathology, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026ndash; Accreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e7 (46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e5 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026ndash; Increta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e6 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026ndash; Percreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e6 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e17 (60.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, median (min\u0026ndash;max), or n (%) as appropriate.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eAcross PAS depth categories, baseline maternal characteristics, antenatal findings, transfusion requirements, hemoglobin change, ICU/NICU admission, Apgar scores, and postoperative complications were broadly comparable (global \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all). Operative time differed significantly among groups (Kruskal\u0026ndash;Wallis \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036): post-hoc testing showed longer procedures in percreta versus accreta (Bonferroni-adjusted Mann\u0026ndash;Whitney \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.016), whereas percreta versus increta (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.136) and increta versus accreta (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.464) were not significant. These data are summarized in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMaternal, operative, and neonatal outcomes stratified by depth of placental invasion (accreta, increta, percreta).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003ePercreta (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eIncreta (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eAccreta (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e34\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e37\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c4\"\u003e\n \u003cp\u003e37\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e0.384\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMaternal height, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e161\u0026thinsp;\u0026plusmn;\u0026thinsp;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e162\u0026thinsp;\u0026plusmn;\u0026thinsp;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c4\"\u003e\n \u003cp\u003e163\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e0.777\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMaternal weight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e\n \u003cp\u003e75\u0026thinsp;\u0026plusmn;\u0026thinsp;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e\n \u003cp\u003e81\u0026thinsp;\u0026plusmn;\u0026thinsp;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\"±\" colname=\"c4\"\u003e\n \u003cp\u003e81\u0026thinsp;\u0026plusmn;\u0026thinsp;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\n \u003cp\u003e0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this single-center PAS series (n = 43), more than half of the cases were percreta (53%), 35% delivered under emergency conditions, and 77% underwent cesarean hysterectomy (TAH). The median gestational age at delivery was ~34 weeks, and NICU admission occurred in 40%. When compared by delivery timing, most maternal metrics were comparable; the only notable difference was the more frequent use of preoperative double-J ureteral stents in the planned group, reflecting greater operative preparedness. In analyses by depth of invasion, only operative time (percreta vs accreta) remained significant after Bonferroni correction; neonatal outcomes did not vary across pathology strata.\u003c/p\u003e\n\u003cp\u003eOur emergency delivery rate (35%) closely parallels the IS-PAS (International Society for Placenta Accreta Spectrum) multicenter database (33%). Morlando et al. reported that emergency births occurred at lower gestational ages (mean 34 vs 36 weeks) and were associated with higher ICU admission, yet did\u0026nbsp;not\u0026nbsp;show higher blood loss or transfusion compared with planned delivery when care was provided in experienced centers. In our cohort, the planned–emergency comparison likewise showed no significant differences in hemoglobin change or transfusion surrogates, supporting the view that—with established protocols and experienced teams—emergency delivery does not inevitably increase hemorrhagic morbidity (13).\u003c/p\u003e\n\u003cp\u003eDiagnosis in our series was predominantly by ultrasound (93% overall); all planned cases had antenatal suspicion, whereas 20% of emergencies did not. A recent three-center cohort reported an “unsuspected” PAS rate of ~35%, with significantly higher 24-hour blood loss and transfusion in unsuspected cases; posterior placentation and the absence of risk factors for intrauterine adhesions were identified as key correlates of missed antenatal diagnosis. In our cohort, the emergency group contained fewer placenta previa cases (0% vs 100% in planned), consistent with the literature that absence of previa can hinder antenatal suspicion and predispose to emergency presentation (14).\u003c/p\u003e\n\u003cp\u003eThe high percreta proportion (53%) suggests tertiary referral bias and is comparable to severe-case series. Even within standardized, multidisciplinary pathways, percreta is associated with substantially higher severe maternal morbidity and hysterectomy rates than accreta/increta; in a large Paris series, severe morbidity was 86% in percreta versus 27% in accreta, with hysterectomy markedly more frequent in percreta (8). In our cohort, the overall TAH rate was 77%; by subgroup it was 91% (21/23) for percreta, 88% (7/8) for increta, and 42% (5/12) for accreta.\u003c/p\u003e\n\u003cp\u003eOur policy of targeting delivery around 34 weeks yielded median Apgar scores of 7/8/8 at 1, 5, and 10 minutes and a 40% NICU admission rate. The IS-PAS analysis underscores that, when clinically feasible, deferring delivery beyond 36 weeks reduces major neonatal morbidity from ~25% at 34+1–36+0 weeks to ~19% after 36 weeks, which aligns with FIGO-endorsed strategies in stable cases under expert care. Moreover, depth of invasion does not consistently worsen neonatal outcomes once gestational age is accounted for; a classic comparative cohort found similar gestational age at birth, birthweight, NICU admission, and mortality between “deep” (increta/percreta) and “superficial” (accreta) invasion consistent with our lack of neonatal differences across pathology groups (6).\u003c/p\u003e\n\u003cp\u003eOur antenatal detection rate was high (93%; 100% in planned, 80% in emergency cases), comparing favorably with reports from three academic centers where the “unsuspected” PAS rate was 35.4%. The fact that double-J stents were used only in antenatally detected planned cases (28.6%) illustrates how early diagnosis enables risk-reducing adjuncts. The literature consistently advocates management in tertiary, multidisciplinary centers and considers antenatal detection critical for optimizing outcomes. Finally, a five-year cohort from a resource-limited setting reported antenatal detection of 86.3% and demonstrated that team-based protocols can achieve results comparable to those in high-resource centers (11), supporting the reproducibility of a “high antenatal detection + multidisciplinary” model across contexts.\u003c/p\u003e\n\u003cp\u003eIn our cohort, the overall postoperative complication rate was 14% (6/43), comprising four bladder perforations (9.3%) and two ureteral injuries (4.7%). These figures are broadly consistent with contemporary PAS series. Large database analyses of cesarean hysterectomy for PAS report bladder injury rates of ~18–24% and ureteral injury rates of ~2–4%; our bladder perforation rate falls at the lower end of this range, whereas the ureteral injury rate is near the upper bound (15). Elective preoperative ureteral stenting used only in planned cases in our series has been associated in large datasets with fewer bladder injuries; this may partly account for our relatively low bladder injury rate and overall urologic profile despite a percreta-heavy case mix. Notably, these complication rates remain acceptable despite the high proportion of percreta cases, and no significant differences were observed between emergency and planned deliveries.\u003c/p\u003e\n\u003cp\u003eStrengths\u0026nbsp;of this study include consecutive case capture at a high-volume tertiary referral center, standardized data abstraction, and prespecified stratified analyses by delivery timing and depth of invasion.\u0026nbsp;Limitations\u0026nbsp;include the retrospective design and modest subgroup sizes; moreover, the referral case-mix with a high proportion of percreta may limit external generalizability, yet it provides clinically relevant insight into the most morbid end of the PAS spectrum. In addition, the statistical power of subgroup analyses, particularly for the increta group (n = 8), was limited, and these comparisons should therefore be interpreted with caution.\u003c/p\u003e\n\u003cp\u003eIn this single-center cohort, a \u0026gt;90% antenatal detection rate and a structured multidisciplinary pathway were linked to comparable hemorrhage-related maternal outcomes between emergency and planned deliveries. The main determinant of risk was surgical complexity, which increased with invasion depth, particularly in percreta. Importantly, urologic complications (bladder and ureter injuries) clustered in deeply invasive cases but were largely preventable when procedures were scheduled and surgical teams were adequately prepared. Neonatal outcomes were primarily influenced by gestational age, underscoring that, in stable patients managed at experienced centers, deferring delivery to later gestational weeks may optimize neonatal prognosis without compromising maternal safety.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003ePAS\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eplacenta accreta spectrum\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eBMI\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003ebody mass index\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eCS\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003ecesarean section\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eUSG\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eultrasonography\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eTAH\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003etotal abdominal hysterectomy\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eICU\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eintensive care unit\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eNICU\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eneonatal intensive care unit\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eRBC\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003epacked red blood cells\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eDJ stent\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003edouble-J ureteral stent\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eHb\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003ehemoglobin.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the\u0026nbsp;Kayseri City Hospital Non-Interventional Clinical Research Ethics Committee\u0026nbsp;(decision no:\u0026nbsp;556, dated:\u0026nbsp;26.08.2025).\u0026nbsp;Informed consent to participate was waived\u0026nbsp;due to the retrospective design and the use of anonymized data\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors thank the surgical team and nursing staff of Kayseri City Hospital for their support during the study. We also appreciate the contributions of the ethics committee members for their guidance and approval of the research protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e:\u0026nbsp;none declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have\u0026nbsp;no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe gratefully acknowledge our colleagues at\u0026nbsp;Kayseri City Hospital including the Departments of Obstetrics and Gynaecology, Anaesthesiology and Reanimation, Urology, Neonatology (NICU), Transfusion Medicine/Blood Bank, and Operating Room Nursing for their contributions to the PAS clinical pathway, data standardisation, and case coordination. All contributors provided permission to be acknowledged and received no compensation. No external financial or material support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request, subject to institutional and ethical regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003eMerve Genco:\u003c/strong\u003e Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp; editing; Visualization; Supervision; Project administration.\u003cbr\u003e\u003cstrong\u003eMehmet Genco:\u003c/strong\u003e Conceptualization; Methodology; Investigation; Data curation; Formal analysis; Writing \u0026ndash; original draft; Writing \u0026ndash; review \u0026amp; editing; Visualization; Supervision; Project administration.\u003cbr\u003e\u003cstrong\u003eH\u0026uuml;seyin Aksoy:\u003c/strong\u003e Methodology; Formal analysis; Writing \u0026ndash; review \u0026amp; editing; Supervision.\u003cbr\u003e\u003cstrong\u003eHarika G\u0026ouml;\u0026ccedil;er:\u003c/strong\u003e Investigation; Data curation; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eEmrah G\u0026ouml;\u0026ccedil;er:\u003c/strong\u003e Investigation; Data curation; Writing \u0026ndash; review \u0026amp; editing.\u003cbr\u003e\u003cstrong\u003eKoray Kaya:\u003c/strong\u003e Data curation; Investigation.\u003cbr\u003e\u003cstrong\u003eBeyza Aslım:\u003c/strong\u003e Data curation; Investigation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJauniaux E, Jurkovic D. 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PMID: 38603956.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Placenta accreta spectrum, percreta, cesarean hysterectomy, antenatal diagnosis, NICU","lastPublishedDoi":"10.21203/rs.3.rs-9011421/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9011421/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePlacenta accreta spectrum (PAS) is a leading cause of life-threatening obstetric haemorrhage. Whether planned versus emergency delivery alters outcomes once care is centralised and protocolised remains uncertain.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAims\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo compare maternal and neonatal outcomes by delivery timing (emergency vs planned) and by depth of invasion (accreta, increta, percreta) in a single-centre cohort.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaterials and Methods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRetrospective observational study of consecutive PAS cases\u0026thinsp;\u0026ge;\u0026thinsp;24 weeks managed at a tertiary referral centre (2021\u0026ndash;2025). Antenatal diagnosis, operative metrics, transfusion surrogates, ICU/NICU admission, complications, and perinatal outcomes were abstracted from standardised records.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eForty-three patients: 15 (34.9%) emergency, 28 (65.1%) planned. Percreta 23 (53.5%), increta 8 (18.6%), accreta 12 (27.9%). Antenatal suspicion 93% overall (100% planned; 80% emergency). Hysterectomy in 33/43 (76.7%); prophylactic double-J stents 8/43 (18.6%), all planned. Maternal haemorrhage surrogates, ICU admission (30.2%), and maternal/neonatal death (7.0%; 1 maternal, 2 neonatal) were similar between groups (all p\u0026thinsp;\u0026ge;\u0026thinsp;0.525). NICU admission in 17/43 (39.5%), largely gestational-age related. Postoperative complications 6/43 (14.0%): 4 bladder and 2 ureteral injuries, all recognised intraoperatively and repaired without reoperation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn a multidisciplinary pathway with \u0026gt;\u0026thinsp;90% antenatal detection, maternal haemorrhage outcomes were similar for emergency and planned deliveries. Surgical risk rose with invasion depth not timing while urologic injuries clustered in deep invasion yet were manageable. Targeting later gestation in stable patients at experienced centres may improve neonatal outcomes without compromising maternal safety\u003c/p\u003e","manuscriptTitle":"Surgical Management and Perinatal Outcomes in Placenta Accreta Spectrum: A Five-Year Single-Center Retrospective Cohort from Kayseri City Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 12:58:28","doi":"10.21203/rs.3.rs-9011421/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba811ea3-963d-482f-8e46-6b9e7ad56e29","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-11T10:51:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T23:03:10+00:00","index":73,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-08T04:15:22+00:00","index":71,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-07T11:20:35+00:00","index":70,"fulltext":""},{"type":"reviewerAgreed","content":"159343651524933670501795895191829985718","date":"2026-05-06T06:38:00+00:00","index":69,"fulltext":""},{"type":"reviewerAgreed","content":"216530583351439174313795744264315271714","date":"2026-05-04T23:21:33+00:00","index":67,"fulltext":""},{"type":"reviewerAgreed","content":"167271950340006027587201947772253765144","date":"2026-05-04T11:53:30+00:00","index":66,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T12:46:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 12:58:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9011421","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9011421","identity":"rs-9011421","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}