Impact of a standardised diagnostic protocol on the management and outcome of patients at high-risk of placenta accreta spectrum

Impact of a standardised diagnostic protocol on the management and outcome of patients at high-risk of placenta accreta spectrum | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 14 November 2025 V1 Latest version Share on Impact of a standardised diagnostic protocol on the management and outcome of patients at high-risk of placenta accreta spectrum Authors : AHMED HUSSEIN 0000-0002-0003-2366 , Mohamed Thabet 0000-0003-0604-1420 , Rana Elbarmelgy 0000-0002-1474-3433 , Rasha Elbarmelgy , and Eric Jauniaux 0000-0003-0925-7737 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.176310561.19526524/v1 226 views 142 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To examine the impact of a standardised ultrasound-pathology diagnostic protocol on the management and outcome of patients presenting with a high risk of placenta accreta spectrum (PAS). Design: Time-to-event analysis. Setting: Cairo University Hospitals, Egypt. Population: Patients with a high probability of PAS managed by a specialist MDT between January 2015 and January 2025. Methods: This observational study examined and compared data obtained before (2015-2018; n=110) and after (2019-2025; n=227) the introduction of a standardised protocol for the MDT to correlate preoperative ultrasound images, intraoperative findings, and fresh macroscopic examination of surgical specimens. Main Outcomes Measures: Type of skin incision, peripartum hysterectomy (PH), bladder injury rates, and intraoperative blood loss. Results: The rates of midline vertical abdominal skin incision, PH, and bladder injuries decreased significantly, after 2019, from 100% to 65% ( P <.001); from 94.5% to 52% ( P <.001), and from 20% to 8% ( P <.002), respectively. The severity of blood loss and the number of units of packed red blood cells (PRBC) transfused peripartum increased significantly ( P <.001 and P <.002, respectively) between the two study periods. Yearly trends during the 2019-2025 period showed a significant decrease over time for all four parameters. Conclusions: Implementing a standardised diagnostic protocol that reports on detailed ultrasound, intraoperative, and macroscopic findings at delivery provides accurate epidemiological data on the prevalence and incidence of PAS, which is essential for healthcare provision and a reproducible management strategy for patients with PAS. It should also facilitate continuous education and capacity building for the MDT. Research article Impact of a standardised diagnostic protocol on the management and outcome of patients at high-risk of placenta accreta spectrum Ahmed M Hussein 1 | Mohamed M Thabet 1 | Rana M Elbarmelgy 1 | Rasha A Elbarmelgy 1 | Eric Jauniaux 2 1 Department of Obstetrics and Gynecology, Kasr Al Ainy School of Medicine, University of Cairo, Cairo, Egypt, | 2 EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London (UCL), London, UK. Funding : No funding was obtained for this study. Running title: Management and outcome of complex cesarean deliveries Correspondence: Eric Jauniaux. [email protected] Keywords : placenta previa accreta | complex caesarean section | placenta accreta spectrum | ultrasound imaging | multidisciplinary team | pathologic examination | cesarean hysterectomy | conservative surgical management. ABSTRACT Objective : To examine the impact of a standardised ultrasound-pathology diagnostic protocol on the management and outcome of patients presenting with a high risk of placenta accreta spectrum (PAS). Design : Time-to-event analysis. Setting: Cairo University Hospitals, Egypt. Population: Patients with a high probability of PAS managed by a specialist MDT between January 2015 and January 2025. Methods: This observational study examined and compared data obtained before (2015-2018; n=110) and after (2019-2025; n=227) the introduction of a standardised protocol for the MDT to correlate preoperative ultrasound images, intraoperative findings, and fresh macroscopic examination of surgical specimens. Main Outcomes Measures: Type of skin incision, peripartum hysterectomy (PH), bladder injury rates, and intraoperative blood loss. Results : The rates of midline vertical abdominal skin incision, PH, and bladder injuries decreased significantly, after 2019, from 100% to 65% ( P <.001); from 94.5% to 52% ( P <.001), and from 20% to 8% ( P <.002), respectively. The severity of blood loss and the number of units of packed red blood cells (PRBC) transfused peripartum increased significantly ( P <.001 and P <.002, respectively) between the two study periods. Yearly trends during the 2019-2025 period showed a significant decrease over time for all four parameters. Conclusions : Implementing a standardised diagnostic protocol that reports on detailed ultrasound, intraoperative, and macroscopic findings at delivery provides accurate epidemiological data on the prevalence and incidence of PAS, which is essential for healthcare provision and a reproducible management strategy for patients with PAS. It should also facilitate continuous education and capacity building for the MDT. 1 | Introduction The rapid rise in cesarean delivery (CD) rates worldwide has led to an increasing number of patients presenting with long-term complications associated with implantation and placentation in the scar area in subsequent pregnancies. 1 Major complications of scar placentation include placenta previa with and without placenta accreta spectrum (PAS) and major post-surgical remodeling of the lower uterine segment (LUS). 1,2 The incidence of these complications is directly associated with the number of prior CD 3,4 and indirectly with fertility rates in the corresponding population. 1 Patients presenting with clinical and imaging features indicating a high risk of complex CD, particularly those with a high probability of PAS, are at higher risk of life-threatening hemorrhage, peripartum hysterectomy, and injury to the bladder, bowel, or ureters. 5 Over the last decade, there has been mounting evidence indicating that maternal outcomes of these patients are improved when managed by a multidisciplinary team (MDT) in a specialist center. Data from these centres have shown that they are less likely to require emergency surgery, large-volume blood transfusions, and reoperation within 7 days of birth for bleeding complications, even in cases of unexpected PAS, compared with patients cared for by standard obstetric care without a specific protocol. 6-11 In high-income countries (HICs), most MDTs were developed in tertiary centers for high-risk obstetric management with maternal-fetal medicine specialists, surgeons with expertise in pelvic surgery (often gynecologic oncologists), anesthesiologists, neonatologists, interventional radiologists, and urologists as core members. The description and central role of experienced MDTs in the management of PAS have been reinforced by national and international guidelines. 13,14 This optimal management requires resource-intensive, patient-centred, and MDT care 15 , including a blood bank capable of delivering multiple blood products quickly; anesthesiologists with advanced expertise in the management of massive obstetric hemorrhage; interventional radiology procedures to provide the option of postoperative embolization for active bleeding; and access to an adult and neonatal intensive care unit (ICU), all with 24-hour coverage. 15,16 A few studies from low- and middle-income countries (LMICs) have also shown that patients with PAS, managed by an MDT using strict standardized protocols, require fewer units to be transfused, have lower cesarean hysterectomy (CHT) rates, and ICU admissions. 17-19 Many LMICs have faster-rising CD rates and higher fertility rates than HICs 1 , often resulting in a high volume of patients with complex CD, including PAS to manage. This situation, combined with limited access to expert prenatal imaging, with most cases of PAS diagnosed at delivery, and a lack of specialist surgical team, particularly outside tertiary centres, results in higher incidences of maternal morbidity and mortality than in HICs. 20,21 The present study aimed to evaluate the impact of standardized diagnostic protocol reporting on detailed ultrasound, intraoperative, and macroscopic findings at birth on the management and surgical outcomes of patients with a high probability of PAS. 2 | Methods 2.1 | Study population We conducted an observational time-to-event analysis study of a cohort of patients identified with a high probability of PAS managed by a specialist MDT between 1 st of January 2015, and 1 st of January 2025, at Cairo University Hospitals, Egypt. All patients included in the study presented with a singleton pregnancy, a history of at least one prior CD, and a low-lying placenta or placenta previa with markers of PAS on ultrasound examination and were referred for elective CD by the MDT at 32-37 weeks of gestation. All patients were managed according to local protocols, which included either peripartum hysterectomy (PH) or conservative management, specifically partial myometrial resection (PMR) and uterine anterior wall repair when sufficient myometrial tissue was available for reconstruction after dissection of the LUS 23 . Institutional Scientific and Research Ethical Committee approval (2018 RSEC 021001) was obtained before the start of this study, and all patients provided consent for the use of the photographic images obtained both before and after delivery. Clinical data were collected using a standard clinical audit protocol, and all data and pictures were fully anonymised for further analysis. Between 2015 and the end of 2018, all patients were managed by a surgical team of three specialists in obstetrics and gynecology, using a similar surgical technique 22 , assisted by residents in training for 3-6 months. The original MDT also included two senior anaesthetists, a resident in anaesthesiology and a neonatologist, together with a urologist and vascular surgeon on standby in the operating theatre. Provision was made for 6-8 units of packed red blood cells (PRBC) to be available for intraoperative transfusion, as well as for routine postoperative care in the ICU. Surgical specimens were sent to the general pathology department for histopathologic examination. The results of this examination were obtained 2-3 weeks after delivery. From January 2019, we introduced a new standardized prospective clinical protocol where the surgical team performed a preoperative transabdominal scan (TAS) and transvaginal scan (TVS) including a detailed evaluation of the anatomy of the LUS and the cervix, mapping of the utero- and intraplacental circulation as previously described 23,25,26 , lacunae score 27 , and placental location (low-lying or previa) 28 within 48h of the delivery. In all cases, the MDT also prospectively recorded (photos and video clips) the different phases of the surgical procedure and performed a gross histopathologic examination of fresh surgical specimens in the operating theatre. The diagnosis of PAS was confirmed when one or more placental lobule(s) could not be digitally separated from the uterine wall during the macroscopic examination of the fresh specimens. Samples were taken in all cases from the placenta-uterine interface of the abnormally attached cotyledons for histologic examination as previously described. 29 EJ independently reviewed the images and histological slides of all cases during that period. 2.2 | Outcomes and Exposure Data were recorded as follows: type of skin incision used (Midline or Pfannenstiel), type of surgical procedure (PH or conservative) and corresponding indication (primary PH; PH for hemostasis and PH due failure to repair the LUS), bladder injury, intraoperative estimated blood loss (EBL), calculated from the amount of blood in suction bottles and from weighing surgical gauzes, number of PRBC units transfused intraoperatively and immediately after; post-partum hemorrhage (PPH) within 24 hours of delivery and need for massive transfusion (> 10 units of PRBC within 24h including the surgical procedure). 2.3 | Statistical analysis The first analysis compared the differences in patient demographics, pregnancy measures, procedural variables, and patient outcomes between the two main study periods before and after the use of the standardized quality control protocol. Categorical variables were compared between groups using the Chi-square test, and continuous variables with the unpaired t-test if found to follow a normal distribution, and the Mann-Whitney test otherwise. The second set of analyses focused on the 2019-2025 period, examining trends over this time frame. Binary outcomes were analyzed using logistic regression, while continuous outcomes were analyzed using linear regression. Variables that did not follow a normal distribution were analyzed on the log scale to meet the statistical method’s assumptions. The trend over time is quantified by an odds ratio (OR) with corresponding confidence intervals (CI) from the logistic regression analysis, indicating the relative change in the odds of the outcome for a one-year increase in time. For these analyses, smaller categories were combined, where appropriate. SPSS V 28.0.1.1 (IBM Corp, Armonk, NY, USA) was used to analyse the data. A P -value <.05 was considered significant. 3 | Results Table 1 displays the main characteristics of the study groups managed by the MDT before 2019 (n= 110) and between 2019 and 2025 (n= 227). There was a significant (P<.005) decrease in the mean number of previous CDs in the group of patients managed after 2019. All patients in the 2015-2018 group were reported to have had PAS at birth by the pathologists, out of which 104 (94.6%) were reported as placenta percreta. In the 2019-2024 group, PAS was confirmed in 135 (59.5%) cases during the surgical procedure and macroscopic examination of hysterectomy or PMR specimens. The comparison of the findings at birth with the ultrasound features indicated that all patients with PAS confirmed at birth, except two (1.5%), were reported as having a high probability of PAS preoperatively. In the subgroup of patients described as presenting with a low probability of PAS at birth on the preoperative ultrasound (n= 92), there were two (2.2%) patients with a diagnosis of PAS at birth. Table 2 presents the main characteristics of patients by year of delivery for the 2019-2024 period. No differences were found in maternal age, parity, number of prior CD, or gestational age at delivery over that period. 3.1 | Comparison of surgical outcomes between study periods Table 3 displays the outcomes between the two time periods. Between 2015 and the end of 2018, all abdominal entries were performed using a midline vertical skin incision, which decreased significantly ( P < .001) to 65% of procedures and was replaced by a low transverse abdominal incision (Pfannenstiel) in the 2019-2024 period. In the period up to 2019, 104 (94.5%) out of 110 patients were managed by a PH, and the corresponding pathology reports confirmed PAS, including 98 (94.2%) cases reported as placenta percreta. The rate of PH fell significantly ( P <.001) to 52% during the 2019-2024 period, and the indication for PH changed significantly ( P <.001) between the two periods, with nine and 21 patients requiring a secondary hysterectomy for hemostasis and failure to reconstruct the LUS, respectively. The incidence of bladder injuries decreased significantly ( P <.002) between the study periods, from 20% up to 2019 to 8% during the 2019-2024 period. The PPH severity and the number of units of PRBC transfused during the surgical procedure and immediately after increased significantly ( P <.001 and P <.002, respectively) in the 2019-2024 period compared to the period before 2019. No differences were found between the two periods for the intraoperative blood loss (on a continuous scale) or the need for massive transfusion. One maternal death due to massive obstetric hemorrhage was recorded before 2019. 3.2 | Yearly trends in outcomes during the 2019-2024 period Significant differences over time (Supplementary Table 1) were observed for both the type of skin incision used ( P <0.01) and the type of surgical procedure performed ( P <0.01). The percentage of PH decreased over time, from 81% in 2019 to 14% in 2024. The OR of conservative surgery increased by 74% for every one year in time (Figure 1). A one-year increase in time was associated with a 2.5-fold increase in the odds of successful conservative surgery (Figure 2). The occurrence of a vertical incision also decreased over time, from 96% in 2019 to 18% in 2024. The amount of intraoperative blood loss and the number of blood units transfused decreased significantly over time ( P < .01 and P < .001, respectively). (Supplementary Table 2). There was also a 4% decrease in intraoperative blood loss per year (Figure 3) and a 9% decrease in the number of blood units transfused (Supplementary figure). 4 | Discussion 4.1 | Main Findings In this study, we have evaluated the role of a standardised diagnostic protocol for collecting and comparing preoperative ultrasound images, intraoperative findings, and macroscopic examination of surgical specimens at birth in patients with and without PAS. Our data indicate that this protocol enabled the MDT team to accurately identify preoperatively patients with a high probability of PAS and the ultrasound signs associated with higher surgical risks. The use of this protocol allowed for the development of surgical planning tailored to individual patients and contributed to changing local management strategies. Additionally, the diagnostic protocol enhanced our understanding of PAS pathophysiology, supported capacity building, and provided the background for continuous education for new staff members of the MDT. 4.2 | Clinical Implications Until recently, a cesarean hysterectomy has been the primary procedure recommended in the management of patients at high risk of PAS at birth. Palacios-Jaraquemada was the first to report, in 2022, a large cohort of patients diagnosed with PAS, with approximately 80% successfully managed with a conservative resection-reconstruction surgical technique. 30 Two recent systematic reviews and meta-analyses have strengthened the evidence supporting conservative management for PAS 31,32 , showing that it is associated with reduced surgical morbidity, including lower rates of ICU admission, lower rates of bladder injury, lower incidence of coagulopathy, lower mean EBL, and lower number of PRBC units transfused. Operative and postnatal complications, including massive bleeding and bladder injury, are expected to decrease with the expertise of the MDT, as observed in the present study (Supplementary Tables 1 and 2). One of the main limitations of studies on the outcomes of different surgical techniques for PAS, both conservative and radical, is the lack of detailed data on preoperative ultrasound imaging of the LUS, intraoperative findings at the different stages of the surgical procedure, and histopathologic confirmation of the diagnosis using criteria unchanged for almost a century. 2 These data are typically analysed retrospectively, which increases the likelihood of selection biases, particularly for cases that were not truly PAS, thereby limiting their interpretation and clinical application. Similarly, the data from the period up to 2019, before the use of a standardized diagnostic protocol, showed that around 94% of the cases were described as placenta “percreta” by the surgical team and the pathologists. We can now estimate that at least half of the cases managed during that period were cases of non-accreta placenta previa under a large uterine dehiscence 23,24 , and many could have probably been managed conservatively. Patients with placentation in the LUS and a history of CD have the highest risk of PAS at birth, and the risk increases with the number of prior CDs. 3,4 Ultrasound imaging has become essential in the prenatal screening of patients with a high probability of PAS at birth. 33-35 Our studies on the role of the preoperative ultrasound scan have shown that, in addition to identifying signs associated with PAS, allowing for differential diagnosis between patients with low and high probability of PAS, ultrasound imaging can accurately identify signs of major post-scarification remodelling of the LUS. 23,25,26,36,37 This provides essential information for the MDT for surgical planning and the patient’s consent regarding the operative risks and the need for PH. These data have been confirmed recently by other authors. 38,39 In the present study, the use of a new diagnostic protocol, which included detailed preoperative ultrasound findings correlated with intraoperative features, and fresh macroscopic examination of the hysterectomy or PMR specimens, provided new data for surgical planning. This resulted in an increase in the number of patients successfully managed conservatively after 2019 (Table 3). This approach was associated with an increase in the risk of moderate PPH compared to the period up to 2019 due to intraoperative bleeding during the PMR and reconstruction of the LUS and post-operative bleeding associated with uterine atony. The risk of intraoperative blood loss and the need for transfusion decreased significantly (P < .01 and P < .001, respectively) over time during the 2019-2024 period (Supplementary Table 2), likely due to the increased experience of the MDT in performing conservative surgical procedures. Similarly, the rate of bladder injury decreased over time. 4.3 | Research and Health Policy Implications LMIC countries, such as Egypt, with CD rates exceeding 50% and increasing, and fertility rates above 2.5, necessitate a rapid development of new MDTs, beyond tertiary academic units. Access to maternal-fetal medicine specialists, gynecology oncologists, interventional radiologists, obstetric anesthesiologists, and perinatal pathologists is limited or not available in most LMICs, particularly in state hospitals. Thus, the development of an MDT relies on training general obstetricians and gynecologists to perform complex CDs. 1,5 Our quality control protocol enabled us to start triaging the patients according to the level of surgical complexity and expertise required for the surgical procedure. 5,36 This allowed for the training of an increasing number of residents and identified those who would be able to lead an MDT for complex CD, including PAS, and to reduce the need for urologists and vascular surgeons in the MDT. By 2024, the three residents who joined the MDT in 2016 (RAE, RME & MMT) were able to perform 70% of the procedures as the lead surgeon with no increase in the operative complication rate. This approach should have also reduced the cost of the individual procedure by reducing the need for blood transfusion and admission to the ICU. Dannheim et al were the first to propose a new method for the histopathologic examination of hysterectomy from PAS, which includes gross examination of the fresh specimens. 39 Their study shows that this approach facilitates retrospective correlation with surgical and radiographic findings as well as standardized tissue sampling for potential research. We incorporated this method into our standardized quality control protocol and found that it is more efficient and cost-effective than standard histopathology examination, thereby improving the quality of the histologic sampling. It also provided accurate stratification of the size of uterine dehiscence, serosal and uteroplacental vascular changes, depth, and lateral extension of the accreta area, which are much more challenging to obtain when the surgical specimen has been fixed in formalin. This method became pivotal, in our study, in evaluating the use of ultrasound imaging in surgical planning from 2019. 23,25,26,36,37 Perinatal pathologists with expertise in placental pathology are not available in most LMICs. Histologic examination of samples from hysterectomy and PMR specimens is not essential in the management of PAS patients. 42 However, accurate sampling of the accreta areas allowed us to show that the abnormal attachment of part of the placental villous tissue is associated with thick fibrinoid deposition at the uteroplacental interface on microscopic examination 43 , distorting the Nitabuch membrane, and thus contributing to loss of parts of the physiological detachment site of the placenta from the uterine wall in PAS. These data have also shown that the villous tissue in PAS does not invade the uterine wall or the surrounding pelvic organs 24,42 , and that the main impact of accreta placentation in a CD scar is the uncontrolled migration of extravillous trophoblastic cells 44 and high-velocity flows entering the intervillous space from radial or arcuate arteries. 45 4.4 | Strengths and Limitations The strengths of our study include a large cohort of patients at high risk of PAS at birth managed by an MDT that extends over multiple years. Our sample size enabled us to evaluate the impact of a standardized diagnostic protocol on the development of an MDT in the management of complex CD in a limited-resource setting, which can be generalized to all healthcare models. The primary limitation of our study is the overall retrospective design. We were unable to review data on imaging, intraoperative findings, and histopathology from the period of 2015 to 2019, which may have led to the incorrect classification of many cases as PAS during that time. Another limitation is that the ongoing training of new staff after 2019 within the MDT may have masked improvements in some outcomes, such as operative time. 5 | Conclusions The use of a standardized diagnostic protocol that reports on detailed ultrasound, intraoperative, and macroscopic findings at birth provides accurate epidemiological data on the prevalence and incidence of PAS, which is essential for healthcare provision in both high- and low-resource settings. It should also facilitate continuous education and training opportunities for the next generation of obstetric surgeons. Author contributions AMH and EJ conceived and supervised the study. All authors were involved in the design and data collection of the study. EJ and AMH wrote the first draft of the manuscript. All authors contributed to the interpretation of the data, critically revised the article content, and agreed on the final manuscript prior to submission. The authors are grateful to the staff of the operating rooms of the Department of Obstetrics and Gynaecology, Cairo University Hospitals, Cairo, Egypt, for their continuous support during this time of this study; to Pr Mohamed Momtaz, Pr Tarek Abdelbar, Dr Ahmed Hosam, Dr Hesham Torad, and Dr Ahmed Samir for their support in the development of the MDT between 2015 and 2018 and to Mr. Paul Bassett, M.Sc. (Stats Consultancy Ltd., Bucks, UK), for his assistance with statistical analysis. Conflict of interest The authors declare that they have no conflict of interest . Data Availability Statement All data are available from the authors upon reasonable request. References 1. Jauniaux E, Bartels HC, Nieto-Calvache A, Hussein AM. Evolution of modern cesarean delivery: historical perspective and new challenges. 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Clin Obstet Gynecol. 2025 Jun 1;68(2):290-300. doi: 10.1097/GRF.0000000000000935. 22. Hussein AM, Kamel A, Raslan A, et al. Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt. Arch Gynecol Obstet. 2019 Mar;299(3):695-702. doi: 10.1007/s00404-018-5027-7. 23. Hussein AM, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Jauniaux E. Prospective evaluation of the impact of post-cesarean section uterine scarification in the perinatal diagnosis of placenta accreta spectrum. Ultrasound Obstet Gynecol 2022;59(4):474-482. doi: 10.1002/uog.23732. 24. Jauniaux E, Hecht JL, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Hussein AM. Searching for placenta percreta: a prospective cohort and systematic review of case reports. Am J Obstet Gynecol. 2022 Jun;226(6):837.e1-837.e13. doi: 10.1016/j.ajog.2021.12.030. 25. Hussein AM, Fox K, Bhide A, et al. The impact of preoperative ultrasound and intraoperative findings on surgical outcomes in patients at high risk of placenta accreta spectrum. BJOG 2023;62(1):137-142. doi: 10.1002/uog.26196. 26. Jauniaux E, Hussein AM, Thabet MM, Elbarmelgy RM, Elbarmelgy RA, Jurkovic D. The role of transvaginal ultrasound in the third-trimester evaluation of patients at high risk of placenta accreta spectrum at birth. Am J Obstet Gynecol. 2023 Oct;229(4):445.e1-445.e11. doi: 10.1016/j.ajog.2023.05.004. 27. Finberg HJ, Williams JW. Placenta accreta: prospective sonographic diagnosis in patients with placenta previa and prior cesarean section. J Ultrasound Med 1992;11(7):333-43. doi: 10.7863/jum.1992.11.7.333. 28. Reddy UM, Abuhamad AZ, Levine D, Saade GR; Fetal Imaging Workshop Invited Participants. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. J Ultrasound Med . 2014;33(5):745-57. doi: 10.7863/ultra.33.5.745. 29. Jauniaux E, Hussein AM, Zosmer N, Elbarmelgy RM, Elbarmelgy RA, Shaikh H, Burton GJ. A new methodologic approach for clinico-pathologic correlations in invasive placenta previa accreta. Am J Obstet Gynecol 2020;222(4):379.e1-379.e11. doi: 10.1016/j.ajog.2019.11.1246. 30. Palacios-Jaraquemada JM, Fiorillo A, Hamer J, Martínez M, Bruno C. Placenta accreta spectrum: a hysterectomy can be prevented in almost 80% of cases using a resective-reconstructive technique. J Matern Fetal Neonatal Med. 2022 Jan;35(2):275-282. doi: 10.1080/14767058.2020.1716715. 31. Futterman ID, Gomes C, Sher O, et al. Surgical Morbidity following Planned Hysterectomy versus Conservative Management for Placenta Accreta Spectrum: A Systematic Review and Meta-analysis. Am J Perinatol. 2025 Sep;42(12):1511-1525. doi: 10.1055/a-2491-4328. 32. Hessami K, Kamepalli S, Lombaard HA, et al. Conservative management of placenta accreta spectrum is associated with improved surgical outcomes compared to cesarean hysterectomy: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025 May;232(5):432-452.e3. doi: 10.1016/j.ajog.2025.01.030. 33. Jauniaux E, Bhide A. Prenatal ultrasound diagnosis and outcome of placenta previa accreta after cesarean delivery: a systematic review and meta-analysis. Am J Obstet Gynecol 2017;217(1):27-36. doi: 10.1016/j.ajog.2017.02.050. 34. Shainker SA, Coleman B, Timor-Tritsch IE, et al. 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Hysterectomy for placenta accreta; methods for gross and microscopic pathology examination. Arch Gynecol Obstet. 2016 May;293(5):951-8. doi: 10.1007/s00404-015-4006-5. 42. Hussein AM, Fox K, Bhide A, Jauniaux E. Confirming the diagnosis of placenta accreta at birth: Intraoperative and macroscopic findings are essential but not histology. BJOG. 2023 Sep;130(10):1290-1292. doi: 10.1111/1471-0528.17507. 43. Jauniaux E, Hussein AM, Elbarmelgy RM, Elbarmelgy RA, Burton GJ. Failure of placental detachment in accreta placentation is associated with excessive fibrinoid deposition at the utero-placental interface. Am J Obstet Gynecol. 2022 Feb;226(2):243.e1-243.e10. doi: 10.1016/j.ajog.2021.08.026. 44. Allen A, Jones CJP, Jauniaux E, Hussein A, Aplin JD. Patterns of trophoblast migration in deep uterine arteries in accreta placentation. Placenta. 2025 Aug;168:135-143. doi: 10.1016/j.placenta.2025.06.014. 45. Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol. 2022 Sep;227(3):384-391. doi: 10.1016/j.ajog.2022.02.038. Table 1: Patient characteristics by period. Maternal age (years) 32.1;4.0 32.4;4.9 .66 Parity 3.2;1.1 3.2;1.3 .79 Prior CD 3.2;1.1 2.8;1.2 .005 Gestational age at delivery (weeks) 36.1;0.9 36.4;1.1 .07 CD= Cesarean delivery. Results are displayed as Mean; SD Table 2 . Patient characteristics by year during the 2019-2024. Maternal age (years) 31.6;4.7 30.3;3.2 33.2;5.0 34.0;5.0 33.4;5.5 32.4;5.1 0.3 (0.0, 0.7) .05 Parity 3.4;1.4 2.5;0.8 3.1;1.8 3.2;0.9 3.4;1.7 3.1;1.2 0.0 (-0.1, 0.1) .88 Prior CD 3.1;1.3 2.5;0.8 2.7;1.1 2.8;1.0 2.8;1.4 2.8;1.2 0.0 (-0.1, 0.0) .43 Gestational age at delivery (weeks) 36.1;1.6 36.3;0.7 36.4;0.8 36.5;0.8 36.7;0.6 36.3;1.1 0.1 (0.0, 0.1) .08 CD= Cesarean delivery. Data are displayed as Mean; SD Table 3. Surgical outcomes by study period Skin incision Midline 110 (100%) 147 (65%) <.001 Pfannenstiel 0 80 (35%) Type of surgery Conservative (PMR) 6 (5%) 109 (48%) <.001 PH 104 (95%) 118 (52%) Indication for PH Primary 110 (100%) 89 (75%) <.001 Haemostasis 0 9 (8%) Failure to reconstruct LUS 0 21 (18%) Bladder injury No 88 (80%) 208 (92%) .002 Yes 22 (20%) 19 (8%) Intraoperative blood loss (mL) 1800 [1200, 2600] 1800 [1400, 2300] .69 PPH severity Minor (500-1000 ml) 16 (15%) 6 (3%) 2000 ml) 50 (45%) 92 (40%) Peripartum PRBC units transfused (*) 2 [1;3] 3 [2;6] .002 Massive transfusion No 106 (94%) 205 (90%) .41 Yes 4 (6%) 22 (10%) Data are presented as percentage (%) or median [inter-quartile range] (*) PRBC= Packed red blood cells; PPH= Post-partum hemorrhage; LUS Lower uterine segment; PMR= Partial myometrial resection; PH= peripartum hysterectomy. Figure legends Figure 1: Type of surgery procedure by year. Figure 2: Type of skin incision by year. Figure 3: Intraoperative blood loss by year. Supplementary Figure: Units of blood transfused by year. Information & Authors Information Version history V1 Version 1 14 November 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords delivery: caesarean section diagnostic studies fetal medicine: perinatal diagnosis—ultrasound imaging placental pathology Authors Affiliations AHMED HUSSEIN 0000-0002-0003-2366 Cairo University Obstetrics and Gynecology Department View all articles by this author Mohamed Thabet 0000-0003-0604-1420 Cairo University Obstetrics and Gynecology Department View all articles by this author Rana Elbarmelgy 0000-0002-1474-3433 Cairo University Obstetrics and Gynecology Department View all articles by this author Rasha Elbarmelgy Cairo University Obstetrics and Gynecology Department View all articles by this author Eric Jauniaux 0000-0003-0925-7737 [email protected] University College London Elizabeth Garrett Anderson Institute for Women's Health View all articles by this author Metrics & Citations Metrics Article Usage 226 views 142 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation AHMED HUSSEIN, Mohamed Thabet, Rana Elbarmelgy, et al. Impact of a standardised diagnostic protocol on the management and outcome of patients at high-risk of placenta accreta spectrum. Authorea . 14 November 2025. DOI: https://doi.org/10.22541/au.176310561.19526524/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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