The Quintessential High-Risk Triad: Advanced Management Strategies for Placenta Accreta Spectrum in Patients with Advanced Maternal Age and IVF Conception

The Quintessential High-Risk Triad: Advanced Management Strategies for Placenta Accreta Spectrum in Patients with Advanced Maternal Age and IVF Conception | 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 Case Report The Quintessential High-Risk Triad: Advanced Management Strategies for Placenta Accreta Spectrum in Patients with Advanced Maternal Age and IVF Conception Shanza Waseem, Siyuan Zeng, Jun Zhan, Liujie Han, Hu Zhao, Xue Xiao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8663115/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 30 You are reading this latest preprint version Abstract Background: The convergence of Advanced Maternal Age (AMA ≥35), In Vitro Fertilization (IVF) conception, and Placenta Accreta Spectrum (PAS) disorders represents a clinical nexus of extreme obstetric risk, characterized by a high probability of massive peripartum hemorrhage (MPH). This triad necessitates a paradigm shift from reactive to proactive, protocol-driven management. Case presentation: A 54-year-old G4P2 with an IVF-conceived twin pregnancy and two prior cesarean deliveries presented at 34 1/7 weeks with catastrophic hemorrhage. Prenatal MRI confirmed placenta percreta. An emergency classical cesarean hysterectomy with partial cystectomy was performed by a multidisciplinary team employing a comprehensive hemostatic strategy including prophylactic arterial balloon occlusion, tranexamic acid, intraoperative cell salvage, and a massive transfusion protocol. Estimated blood loss was 4,500 mL. Both neonates required NICU admission but were discharged in stable condition. Conclusions: This case exemplifies the synergistic pathophysiology and amplified morbidity of the AMA/IVF/PAS triad. Effective management mandates: 1) Aggressive prenatal diagnosis with early MRI; 2) Mandatory delivery at a Level IV center with a pre-assembled, multidisciplinary team; and 3) Implementation of a proactive Patient Blood Management plan. We propose a structured clinical pathway and standardized referral algorithm to optimize outcomes for this uniquely high-risk population. Advanced Maternal Age In Vitro Fertilization Placenta Accreta Spectrum Multidisciplinary Team Care Patient Blood Management Peripartum Hemorrhage Figures Figure 1 Figure 2 Figure 3 Background The rising incidence of Placenta Accreta Spectrum (PAS), now estimated at approximately 1 in 533 deliveries, has emerged as a critical challenge in modern obstetrics, driven primarily by two powerful demographic trends: the increasing prevalence of childbearing at AMA and the growing utilization of IVF [ 1 – 3 ]. Advancing maternal age alone is a significant risk factor, conferring an annual increase in risk with an odds ratio of 1.13 (95% CI 1.089–1.194, P < 0.0001) for each additional year of maternal age [ 1 ]. Concurrently, IVF conception serves as an established and independent risk factor for PAS, substantially elevating risk above that of spontaneously conceived pregnancies [ 2 , 3 ]. PAS encompasses a dangerous pathological spectrum of abnormal placental adherence, ranging from accreta (adhesion to myometrium) to increta (myometrial invasion) and percreta (penetration to adjacent organs). These conditions are strongly associated with catastrophic peripartum hemorrhage, unplanned hysterectomy, and severe maternal morbidity, necessitating comprehensive prenatal surveillance and coordinated, multidisciplinary management to optimize outcomes [ 2 , 3 ]. When AMA, IVF conception, and the cornerstone risk factor of a prior uterine scar converge, they create what we define as the quintessential high-risk triad . The pathophysiological risk is not merely additive but truly synergistic, as visually conceptualized in Fig. 1 . Each element compounds the others' effects: a prior hysterotomy scar provides the anatomical locus of defective decidua basalis, creating the substrate for invasion [ 4 , 5 , 6 ]; IVF is associated with fundamental disruptions in endometrial decidualization, adhesion molecule expression, and placental development from the earliest stages of implantation [ 7 , 8 ]; and AMA introduces systemic vascular endothelial dysfunction and local uterine changes, including structural pathology and impaired receptivity, that create a permissive environment for abnormal placentation [ 9 ]. The convergence of these three pathways facilitates the deep, uninhibited trophoblastic invasion that defines PAS. This article presents a critical analysis of a paradigmatic case of catastrophic hemorrhage in a patient embodying this high-risk triad. We deconstruct the clinical and surgical management challenges and synthesize a comprehensive body of contemporary evidence organized into seven thematic literature review tables. Based on this synthesis, we propose a structured, proactive, and evidence-based framework for the optimal care of this escalating, extreme-risk obstetric population. Case presentation A 54-year-old gravida 4, para 2 presented via emergency air transport at 34 + 1 weeks gestation with acute, painless vaginal hemorrhage exceeding 1,000 mL. Her dichorionic diamniotic twin pregnancy resulted from IVF with donor oocytes via a single Frozen Embryo Transfer (FET) cycle after prolonged infertility. Her obstetric history included two prior low transverse cesarean deliveries. Notably, her gynecologic history was significant for multiple diagnostic dilatation and curettage (D&C) procedures performed for abnormal uterine bleeding and infertility workup prior to her successful IVF conception. Prenatal Course and Diagnostic Evaluation Antenatal care included low-dose aspirin (100 mg daily) and prophylactic enoxaparin (4000 IU) for thromboprophylaxis. Serial ultrasounds confirmed a complete placenta previa overlying the prior uterine scar. A dedicated PAS ultrasound at 28 weeks revealed key sonographic features: loss of the retroplacental clear zone, multiple large placental lacunae, and myometrial thinning to less than 1 mm at the bladder interface. A subsequent MRI at 32 weeks confirmed the diagnosis of placenta percreta with invasion into the posterior bladder wall ( Fig. 2 ). Concurrent fetal ultrasound findings included an isolated short femur length (< 10th percentile) and polyhydramnios. A formal multidisciplinary team consultation at 30 weeks established a plan for scheduled delivery at 34 weeks and 3 days of gestation. However, the patient presented with an emergency two days prior to the planned admission. Acute Presentation and Multidisciplinary Response On arrival, the patient was tachycardic and hypotensive. The institutional "Code Crimson" protocol for suspected PAS was activated. Under general anesthesia, bilateral common iliac artery balloon occlusion catheters were placed prophylactically by interventional radiology. A midline vertical laparotomy confirmed extensive placenta percreta with invasion into the posterior bladder wall and dense adhesive disease involving the anterior abdominal wall and omentum. A classical uterine incision was made to deliver both viable neonates. Given the extent of invasion and hemodynamic instability, the multidisciplinary team proceeded with a classical cesarean hysterectomy and partial cystectomy. Hemostatic Management and Outcomes A multimodal hemostatic strategy was employed: tranexamic acid (1g IV) was administered at cord clamping along with carbetocin (100µg) and methylergometrine (0.2mg IM); intermittent arterial balloon occlusion was utilized for temporary vascular control; intraoperative cell salvage with a leukocyte depletion filter was initiated; and resuscitation was guided by a massive transfusion protocol. The patient's estimated blood loss was 4,500 mL, requiring transfusion of 1.5 units of leukocyte-reduced packed red blood cells and 600 mL of fresh frozen plasma. The patient was extubated 8 hours postoperatively, transferred from the ICU on postoperative day 2, and discharged home on postoperative day 10 following treatment for a superficial surgical site infection. Neonatal Outcomes Both neonates required NICU admission. The first neonate (2050g) had Apgar scores of 9-9-10 but developed respiratory distress, pathological jaundice (peak total bilirubin 104.0 µmol/L), and was found to have a possible left ventricular ependymal cyst on cranial ultrasound, necessitating long-term neurological follow-up. Both infants were discharged in stable condition after 10 days with multidisciplinary follow-up plans. Discussion This case crystallizes the extreme challenges posed by the AMA/IVF/PAS triad. The management journey, from diagnosis to recovery, underscores critical areas for systems-based improvement informed by a comprehensive evidence base. Synergistic Pathophysiology and Risk Stratification The patient's profile represents a convergence of risk factors with documented multiplicative effects, as visually synthesized in Fig. 1 . As summarized in Table 1 , contemporary evidence demonstrates a powerful synergistic interaction [ 10 – 43 ]. IVF increases the risk for PAS approximately five-fold (OR 5.03, 95% CI: 3.34, 7.56) [ 27 ]. This risk is profoundly amplified by a history of prior uterine surgery. Specifically, hysteroscopic adhesiolysis is associated with a 7.72-fold increase in risk (OR 7.72, 95% CI: 4.10-14.53), while endometrial ablation demonstrates a staggering 20-fold elevation (OR 20.26, 95% CI: 17.15–23.93) [ 44 ]. Table 1 Epidemiology and Pathophysiology of the High-Risk Triad: Advanced Maternal Age, IVF, and Placenta Accreta Spectrum Author, Year Study Type Population Primary Finding Clinical Implication Quality Level Historical & Foundational Studies (1969–2009) Effer, 1969 Retrospective cohort High-risk pregnancies Severe pre-eclampsia, IUGR with placental insufficiency, and irreversible premature labor warrant intensive care. Establishes early framework for identifying high-risk pregnancies requiring specialized management. Level III Frydman et al., 1986 Retrospective cohort 142 IVF pregnancies vs controls (1981-84) IVF pregnancies had significantly higher rates of hypertension (16.5% vs 8.5%), C-section (46.8% vs 15.5%), and breech presentation (13.9% vs 4.3%). IVF pregnancies are high-risk, requiring enhanced obstetric monitoring from the outset. Level III Fiedler et al., 1990 Retrospective cohort 246 IVF pregnancies Increased incidence of EPH-gestosis, placental insufficiency, IUFD, abruption, and prematurity in IVF pregnancies. Confirms IVF as a significant risk factor for a range of pregnancy complications. Low-Moderate Davis & Rosenwaks, 1992 Review IVF patients Reviews rapid advancements in ART techniques like micromanipulation and ovarian stimulation. Highlights the need for ongoing evaluation of evolving IVF practices. Expert Opinion Ishikawa, 1995 Retrospective analysis 9,667 IVF cycles in Japan IVF pregnancy rate was 12.7% per retrieval cycle in 1991. Early ART had low success rates, indicating need for protocol improvements. Level III Liao et al., 1997 Clinical audit 185 IVF pregnancies (1990 vs 1993) Policy change to transfer max 2–3 embryos reduced multiple pregnancy rates and NICU costs 9-fold. Embryo transfer policy directly impacts perinatal outcomes and healthcare costs. Level III Whelan & Vlahos, 2000 Literature Review Women at risk for OHSS OHSS remains an elusive, potentially critical iatrogenic complication of ovarian stimulation. Physicians must understand OHSS risk factors, prevention, and staging. Expert Opinion Wang et al., 2009 Retrospective cohort 210 IVF vs natural conception mothers (2001-02) IVF had higher rates of multiples, hypertension, C-section, preterm birth, LBW, and malformations. IVF significantly increases obstetric risks, largely mediated by multiple births. Level III Modern Era Studies (2014–2020) Ciancimino et al., 2014 Retrospective case-control 1,347 pregnant women (210 AMA ≥ 35) AMA associated with 12.8x risk of spontaneous abortion, 69.8x risk of preterm delivery, and 3.9x risk of congenital malformations. AMA is a significant independent risk factor requiring enhanced surveillance and counseling. Level III El Gelany et al., 2019 Prospective cohort 102 women with PAS PAS incidence 0.91%; 82% had ≥ 2 prior C-sections. Mean age 32.4 years. Maternal age > 32, ≥2 C-sections, multiparity, and previa are key PAS risk factors. Level II Kyozuka et al., 2019 Retrospective cohort 90,554 Japanese births (2011-14) ART increased PAS risk 6.78-fold; placenta previa increased risk 12.86-fold. ART and placenta previa are major, independent risk factors requiring enhanced surveillance. High Morlando & Collins, 2020 Review PAS cases worldwide PAS incidence rising rapidly with increasing C-section rates; condition is heterogeneous with high morbidity/mortality. Need for standardized approach to ultrasound, clinical, and pathologic diagnosis. Moderate Recent Studies (2021–2025) Donovan & Shainker, 2021 Review PAS patients PAS incidence rising due to increased C-sections and ART. Planned delivery at 34–35 weeks optimizes outcomes. Multidisciplinary PAS teams are standard; antenatal diagnosis improves outcomes. High Einerson & Weiniger, 2021 Review PAS patients in developed world PAS incidence increased from ~ 0.03 (1950s) to 0.79–3.11 per 1000 pregnancies; leading cause of peripartum hysterectomy in US. Anesthesiologists play a vital role in managing PAS through systematic preparation for massive hemorrhage. High Liu et al., 2021 Review PAS patients PAS prevalence has increased over past decades due to abnormal placental implantation. Need for evidence-based management protocols across all phases of care. Moderate Shi et al., 2021 Systematic Review & Meta-analysis Women ≥ 35 undergoing IVF/ICSI PGT-A with comprehensive chromosomal screening increased live birth rate by 30% (RR = 1.30). PGT-A improves outcomes in AMA patients; blastocyst biopsy is superior. High Cui et al., 2021 Cohort study 764 children (382 ART, 382 natural), age 6–10 ART children had higher blood pressure and reduced left ventricular ejection fraction. ART conception is associated with early cardiovascular dysfunction, necessitating long-term monitoring. High Jenabi et al., 2022 Umbrella review / Meta-analysis 419,460 abruption cases from 15 meta-analyses AMA (OR 1.44) and ART use (OR 1.87) are significant risk factors for placental abruption (suggestive evidence, Class III). Prior cesarean also a key risk factor (RR 1.38). The AMA/IVF risk profile extends beyond PAS to include placental abruption, necessitating broadened surveillance for placental disorders. Low to Critically Low Enste et al., 2022 Two-part review PAS patients PAS associated with high maternal morbidity/mortality due to coagulopathies and peripartum hemorrhage. Anesthesiologists must prepare for massive transfusion; multidisciplinary teams in specialized centers are essential. High Guo et al., 2022 Retrospective cohort 14,583 women with C-sections (2015-20) Multiple gestation associated with higher PAS risk (aOR = 1.63), despite lower rates of classic risk factors (prior C-section, previa). PAS screening protocols are needed for multiple gestations, even with different risk profiles. High Lv et al., 2023 Retrospective cohort 131 pregnant women with placenta previa Low fibrinogen increased PPH risk; high D-dimer increased low Apgar score risk. Preoperative biomarkers can identify high-risk placenta previa patients for enhanced monitoring. Moderate Rodrigues et al., 2023 Systematic Review AMA vs non-AMA pregnancies Evidence supports a lack of association between AMA and neonatal morbidity; association found only with older age thresholds (≥ 40/45). Current evidence does not support AMA alone as a cause of neonatal morbidity; age threshold matters. Moderate Samare-Najaf et al., 2023 Review Reproductive disorder patients Autophagy disruption is implicated in multiple infertility-related conditions (e.g., POI, PCOS, endometriosis). Understanding autophagy pathways may guide future interventions for infertility complications. Moderate Kobayashi et al., 2024 Literature Review FET vs fresh ET cycles FET cycles associated with higher incidence of PAS, preeclampsia, and pregnancy-induced hypertension vs fresh ET. Freezing/thawing affects cellular pathways (proliferation, invasion, mitochondrial function), influencing PAS risk. High / Moderate Lizárraga-Verdugo et al., 2024 Narrative Review PAS patients Describes PAS spectrum (accreta, increta, percreta) and strong association with prior uterine surgery. Early diagnosis is critical due to rising global C-section rates; interdisciplinary care is needed. Moderate Modest et al., 2024 International Multicenter Retrospective 692 PAS patients (44 IVF, 648 non-IVF) IVF-associated PAS had lower prior cesarean rate (70.5% vs 91%) but similar previa prevalence, making antenatal detection more challenging. IVF-associated PAS may have a different risk profile than traditional PAS. Moderate Papathanasiou et al., 2024 Review Medically complex IVF patients Increasing number of women with underlying health conditions seek IVF, necessitating a comprehensive risk framework (GRASP). Need for systematic risk assessment and multidisciplinary care coordination for complex IVF patients. Moderate Bentov & Schenker, 2025 Review Global IVF population IVF accounts for 2–5% of global births, with more older women and medically complex patients seeking treatment. Expanding, complex patient demographics reshape the clinical and public health risk profile of IVF. High Bonanni et al., 2025 Systematic Review PAS management guidelines (14 guidelines) Poor consensus on cesarean hysterectomy (38.5% insufficient evidence) and conservative techniques (33.3% insufficient evidence). Urgent need for standardized PAS management protocols and further research. Moderate Ganer Herman et al., 2025 Systematic Review & Meta-analysis AMA patients undergoing IVF (151 studies) Significant increase in AMA patients seeking IVF over past decades. Rising trend requires adapted, evidence-based treatment protocols for the older reproductive population. High Kaur et al., 2025 Retrospective cohort 9,088 deliveries with 85 PAS cases PAS incidence 0.94%; IVF was a significant risk factor (7.1% of cases, p < 0.05). IVF is a significant risk factor for PAS, requiring enhanced surveillance and early identification. Level III Lee & Kim, 2025 Review Global PAS cases PAS incidence increasing globally due to rising C-section rates, uterine surgeries, and ART. Early risk identification, prenatal screening, and referral to specialized centers are essential. High Leiva et al., 2025 Review ART patients with viral infections Viral pathogens significantly impact reproductive systems and fertility outcomes. Advanced screening protocols are essential to minimize transmission risks in ART. High Li et al., 2025 Retrospective cohort 20,882 AMA singleton pregnancies (≥ 35) IVF-ET increased placenta accreta risk 2.52-fold and placental abnormality risk 1.87-fold. AMA women undergoing IVF require specialized placental monitoring and delivery planning. High Abbreviations: AI = Artificial Intelligence; ACOG = American College of Obstetricians and Gynecologists; AMA = Advanced Maternal Age; AUC = Area Under the Curve; CT = Computed Tomography; ET = Embryo Transfer; FISH = Fluorescence In Situ Hybridization; IVF = In Vitro Fertilization; MRI = Magnetic Resonance Imaging; PAS = Placenta Accreta Spectrum; PGT-A = Preimplantation Genetic Testing for Aneuploidies; PPV = Positive Predictive Value; RR = Relative Risk; SAR/ESUR = Society of Abdominal Radiology/European Society of Urogenital Radiology; Sens = Sensitivity; Spec = Specificity; US = Ultrasound. AMA is an independent, compounding risk factor within this triad. Among women diagnosed with PAS, AMA is independently associated with a three-fold increased risk of requiring hysterectomy (OR 3.0, p = 0.045) [ 45 ]. As illustrated in Fig. 1 , the convergence of AMA, IVF, and a prior uterine scar creates a synergistic "perfect storm." The interacting pathways of vascular/uterine senescence, impaired decidualization, and anatomical decidual deficiency overwhelm normal implantation defenses, facilitating deep trophoblastic invasion. Consequently, identification of this triad mandates automatic classification as "highest possible risk," triggering intensive surveillance and preemptive, multidisciplinary management. 2. The Imperative of Precision Diagnosis and Protocolized Care Effective management begins with precision in prenatal diagnosis . As detailed in Table 2 , a low threshold for advanced imaging is mandatory [ 25 , 46 – 72 ]. Ultrasound findings of placenta previa over a prior scar in an AMA/IVF patient should automatically trigger MRI evaluation, which offers superior anatomical detail for assessing invasion depth critical data for surgical planning. The available evidence demonstrates that MRI achieves high diagnostic accuracy for PAS, with reported sensitivity of 96.08% and specificity of 87.50%, with the dark intra-placental band being the most sensitive MRI sign [ 73 ]. However, this diagnostic accuracy is significantly compromised in the specific population of IVF-conceived pregnancies. Studies show the MRI sensitivity for antenatal PAS diagnosis plummets to only 22.2% in IVF patients compared to 94.7% in spontaneous conceptions, underscoring a unique diagnostic challenge and the need for heightened vigilance and expertise in this subgroup [ 74 ]. Table 2 Prenatal Diagnosis and Imaging Modalities for Placenta Accreta Spectrum with Emphasis on Diagnostic Accuracy and Clinical Application in High-Risk Pregnancies Author, Year Imaging Modality / Focus Diagnostic Criteria / Study Focus Sensitivity/Specificity / Key Metric Key Contribution ACOG Category / Level Historical & Foundational Studies Coakley, 2001 MRI Superior soft-tissue contrast for fetal assessment. Not specified Established MRI's advantages (larger field of view, precise volumetric measurements) over ultrasound in specific contexts. Level III Constantine & McCormack, 1991 Mid-trimester ultrasound (16–18 weeks) Formal anomaly screening. 45% sensitivity before 20 weeks vs 30% at booking scan. Demonstrated that earlier, systematic anomaly scanning improves detection rates. Not Specified Modern Imaging Modalities & Protocols ACOG Committee, 2017 Multi-modal (X-ray, US, CT, MRI, Nuclear Medicine) Risk-benefit assessment framework for diagnostic imaging. Not specified Guidelines for safe diagnostic imaging during pregnancy and lactation, emphasizing coordination to minimize fetal radiation exposure. Committee Opinion / Level III Ball, 2004 First-trimester screening Aneuploidy detection. Comparable or superior to second-trimester screening. Established first-trimester screening as an effective early tool for aneuploidy detection. Clinical Review Copel et al., 2017 X-ray, Ultrasonography, CT, Nuclear Medicine, MRI Risk-benefit assessment for radiation exposure. Not specified Provided specific guidelines for safe diagnostic imaging during pregnancy and lactation. Committee Opinion PAS - General Imaging Araujo Júnior et al., 2023 2D/3D Ultrasound, MRI Placental lacunae, bladder-uterine interface disruption, turbulent flow, bridging vessels. Not specified Comprehensive review of major prenatal imaging features across multiple modalities for PAS. Level III / II-3 Badr et al., 2020 Prenatal ultrasound Uterine body PAS identification. Only 3% diagnosed pre-symptomatically. Highlighted the diagnostic challenges of uterine body PAS, with 97% missed pre-symptomatically. Research Study Chen et al., 2025 Ultrasound (primary), MRI (supplementary) Standard ultrasound criteria; MRI for complex cases. Ultrasound accuracy is operator-dependent. MRI provides superior anatomical detail for invasion depth/location, especially in complex or posterior placentas. Level III Conturie et al., 2022 Ultrasound (preferred), MRI (adjunct) Consensus guideline markers for PAS. Ultrasound highly accurate when performed by experts. Ultrasound is the preferred modality; MRI is an adjunct and not routinely recommended. Level III PAS - Ultrasound Diagnostic Performance Adu-Bredu et al., 2024 3D Volume Rendering Ultrasound with 2D Doppler 3D loss of clear zone, bridging vessels on Doppler. 3D clear zone loss: Sens 89.3%, Spec 92.9%. Bridging vessels: Sens 91.1%, Spec 78.6%. Advanced 3D ultrasound techniques show superior performance for differentiating PAS from simple scar dehiscence. Level II-2 Gao et al., 2021 Ultrasound Scoring system: Lacunae ≥ 3, bladder wall interruption, placental bulge. 82.6% sensitivity, 81.8% specificity. AUC 0.925. Developed a comprehensive scoring system combining maternal characteristics and ultrasound features for PAS prediction. Level II Maged et al., 2023 2D/3D Ultrasound Meta-analysis of criteria: loss of retroplacental zone, myometrial thinning, lacunae, bridging vessels, bladder wall interruption, uterovesical hypervascularity. Overall: Sens 87.0%, Spec 86.3%. Individual criteria ranged from 45.5%-78.5% Sens and 80.9%-99.4% Spec. Comprehensive meta-analysis of 54 studies (5,307 women) establishing the diagnostic accuracy of individual ultrasound signs. Level I Nieto-Calvache et al., 2022 Prenatal ultrasound Standard PAS imaging criteria. False-positive: 28.9% at referral centers, 68.5% at referring hospitals. False-negative: 2.1%. Demonstrated significantly improved diagnostic accuracy (reduced false positives) at specialized referral centers. Level III / II-2 Vimercati et al., 2024 Transabdominal/Transvaginal Ultrasound Retroplacental myometrial thinning (< 1 mm), vascular lacunae, "riddled cervix" sign. Not specified Identified specific ultrasound markers for PAS risk stratification and prediction of surgical complications. Level III PAS - MRI Diagnostic Performance AbdelAziz et al., 2025 MRI Meta-analysis of 8 criteria: dark bands, heterogeneous placenta, indistinct myometrium, loss of dark zone, myometrial thinning, placental bulge, bladder wall interruption, abnormal vasculature. Overall: Sens 86.7%, Spec 86.0%. Individual criteria: Sens 38.4%-82.8%, Spec 59.3%-98.5%. Highest Spec: indistinct myometrium (98.4%). Comprehensive meta-analysis of 40 studies (3,664 women) confirming MRI's high diagnostic accuracy for PAS. Level I De Oliveira Carniello et al., 2022 Ultrasound vs. MRI Risk factor assessment in women with PAS. US: Sens 83.3%, Spec 83.4%. MRI: Sens 83.8%, Spec 83.1%. Meta-analysis of 17 studies (1,301 women) found no statistically significant difference in diagnostic performance between US and MRI. Level I Do et al., 2024 MRI Greatest dimension of invasion measurement. 96% sensitivity at 2.5 cm cutoff for predicting need for hysterectomy. MRI had higher specificity and PPV than ultrasound for predicting PAS cases requiring hysterectomy. Level III Jha et al., 2020 (SAR/ESUR Consensus) MRI Seven consensus features: dark T2 bands, uterine bulge, loss of T2 line, myometrial thinning, bladder interruption, exophytic mass, abnormal vasculature. 80% expert consensus achieved. Established a standardized MRI protocol and reporting system for PAS diagnosis. Level III Li et al., 2025 Ultrasound vs. MRI (Meta-analysis) Best US feature: Intraplacental lacunae. Best MRI feature: Placental bulge. US lacunae: Sens 87%, Spec 83%. MRI bulge: Sens 87%, Spec 84% (AUC 0.89). Meta-analysis of 1,989 women showed equivalent overall diagnostic accuracy between US and MRI. Level I PAS - Advanced & Integrated Imaging Techniques D'Antonio et al., 2022 Integrated First & Third-Trimester Ultrasound Multiple risk factor assessment, early identification criteria. Not specified Proposed an integration approach for predicting PAS development and severity, showing increased literature interest. Level III Dar et al., 2024 First-trimester ultrasound Cervico-isthmical complex assessment, cesarean scar evaluation. Not specified Focused on early PAS detection strategies in the first trimester for optimal delivery planning. Level III Huang et al., 2024 MRI-based Radiomics Radiomic features extracted from MRI with histopathology reference. Sens 87% (76%-93%), Spec 92% (89%-94%). AUC 0.93. First meta-analysis demonstrating high diagnostic accuracy of MRI radiomics; automated segmentation was superior to manual. Level I Robinson et al., 2018 Fetal MRI (Technical Advances) 3.0T imaging, 3D T2-weighted MRI, susceptibility-weighted imaging, diffusion tensor imaging. Not specified Reviewed technical advances (2011–2016) in fetal neuroimaging, including motion compensation. Level III Zhong et al., 2025 MRI + Clinical Factors Nomogram Age, previa, T2 dark band, placental/uterine bulge, loss of T2 interface, myometrial thinning, abnormal vessels. AUC > 0.8 (ROC analysis). Developed and validated a nomogram combining MRI and clinical factors with high diagnostic accuracy for PAS. Level II-2 Imaging in IVF & AMA Populations Matsuzaki et al., 2021 Ultrasound Standard PAS criteria. Antenatal diagnosis rate: 22.2% in IVF-ET pregnancies vs. 94.7% in spontaneous conception. Highlighted the significantly reduced antenatal PAS diagnosis rates in IVF pregnancies, indicating a diagnostic challenge. Level II-2 Shi et al., 2021 Preimplantation Genetic Testing for Aneuploidy (PGT-A) Blastocyst biopsy with comprehensive chromosomal screening vs. FISH. Live birth rate RR = 1.30 (95% CI 1.03–1.65) for comprehensive screening. PGT-A with comprehensive screening improves live birth rates by 30% in AMA (≥ 35) patients compared to older FISH techniques. Level I Other Relevant Imaging Topics Skelton et al., 2022 Antenatal Imaging (General) Qualitative assessment of parent-centered imaging experience. Not applicable (qualitative study). Identified six key themes for optimizing parent experience and prenatal attachment during imaging procedures. Level III Umans et al., 2024 AI-enhanced Ultrasonography First-trimester screening for various risks. Variable performance metrics across 27 studies. Systematic review of AI algorithms for early pregnancy risk stratification, showing promise but variable results. Level III Abbreviations: AI = Artificial Intelligence; ACOG = American College of Obstetricians and Gynecologists; AMA = Advanced Maternal Age; AUC = Area Under the Curve; CT = Computed Tomography; ET = Embryo Transfer; FISH = Fluorescence In Situ Hybridization; IVF = In Vitro Fertilization; MRI = Magnetic Resonance Imaging; PAS = Placenta Accreta Spectrum; PGT-A = Preimplantation Genetic Testing for Aneuploidies; PPV = Positive Predictive Value; RR = Relative Risk; SAR/ESUR = Society of Abdominal Radiology/European Society of Urogenital Radiology; Sens = Sensitivity; Spec = Specificity; US = Ultrasound. Reactive management yields poor outcomes. The standard of care must be planned delivery at a center with immediately available resources and a dedicated, rehearsed team. The composition and impact of such teams are outlined in Table 3 . Our institution's protocol ensures simultaneous activation of all necessary personnel [ 22 , 38 – 40 , 75 – 91 ]. The preoperative "huddle" is non-negotiable for determining the surgical approach whether primary hysterectomy or a uterine-conserving strategy based on imaging and patient consent, not during emergent hemorrhage. Table 3 Composition, Timing, and Impact of Multidisciplinary Care Teams in the Management of High-Risk Obstetric Conditions Author, Year Team Components Delivery Timing / Focus Outcome Metrics Recommendation Strength Implementation Level Historical & Foundational Studies Writer, 1986 Obstetric anesthetist as irreplaceable team member, Multidisciplinary perinatal care teams Not specified Declining perinatal morbidity and mortality rates Strong - understanding pathophysiology is essential for all team members Tertiary perinatal centers Frydman et al., 2004 Quality management team with coordinated in-series organization Not specified (IVF process focus) Clinical pregnancy rate: 41% (IVF), 38.5% (ICSI); Implantation rate: 20% (IVF), 23.5% (ICSI) Strong evidence (P < 0.01) for structured team approach Implemented in 408 consecutive IVF/ICSI cases Maserati et al., 2010 Comprehensive multispecialty interdisciplinary team Throughout treatment continuum No significant differences in maternal/neonatal outcomes between high-risk publicly funded vs private groups (n = 600 each) Strong - effective model for underserved populations Public health program implementation Lataifeh et al., 2010 Multidisciplinary ICU team Postpartum (95.3% of admissions) Maternal mortality: 6.9%; Mechanical ventilation: 18.6%; Blood transfusion: 48.8% Strong - essential for managing hypertensive disorders and hemorrhage Tertiary care center Modern Multidisciplinary Models (2019–2025) Berhan & Urgie, 2020 Multidisciplinary team approach for PAS Antenatal diagnosis and center of excellence management Success in expectant management, reduced emergency hysterectomy rates Strongly recommended Center of excellence hospitals, high and middle-income countries Berardi et al., 2020 Multidisciplinary tumor boards (adaptable framework for complex care) Throughout treatment continuum Adherence to clinical guidelines, treatment outcomes, decision-making improvement Moderate - benefits documented but limitations noted (costs, legal responsibility, geographic barriers) Variable implementation Shao et al., 2019 Conferences and clinics format, all relevant disciplines Not specified for obstetric cases Patient, provider, and system-level outcomes Heterogeneous evidence base across 191 studies Varied implementation contexts Campbell et al., 2022 IVF laboratory teams: clinical laboratory scientists, embryologists, nursing, administrative, laboratory, clinical staff Throughout fertility treatment cycle Not specified (descriptive study) Moderate - descriptive guidance for team structure Large IVF clinics Chandraharan et al., 2021 Fetal medicine specialists, complex pelvic surgeons, obstetric anesthetists, hematology, interventional radiology, midwifery, neonatology, HDU/ICU teams Antenatal diagnosis by specialized teams Improved maternal and perinatal outcomes through continuous audit Strong - specialized expertise required Regional referral centers with established MDT pathways Jauniaux et al., 2021 Multidisciplinary team with expertise in complex pelvic surgery, comprehensive blood products access, adult and neonatal intensive care Multi-modal ultrasound imaging for high-risk evaluation Safe outcomes for mothers and newborns Strong recommendations from RCOG, ACOG, SMFM, FIGO, SOGC guidelines Requires full logistic support structures American Heart Association et al., 2022 Obstetrics, maternal-fetal medicine, neonatology, pediatrics, gynecology, genetics PPCM with LVEF < 30%: anticoagulation until 6–8 weeks postpartum; Preconception management with repeat echo ~ 3 months post-medication adjustment LVEF recovery in PPCM, breastfeeding safety metrics, neonatal medication safety, cardiovascular risk assessment Strong - evidence-based guidelines with specific LVEF thresholds and timing Specialized cardiac-obstetric units; requires personalized counseling Sandlin et al., 2022 (Study Period: 2016–2020) Dedicated multidisciplinary PAS care team Planned coordinated delivery 1-min APGAR: 6 vs 2 (p = 0.0035); 5-min APGAR: 7 vs 6 (p = 0.0301); Intraop PRBC: 3.26 vs 6.52 units; Total PRBC: 3.51 vs 9.93 units; Cryoprecipitate: 0.08 vs 0.77 units Strong - significant improvement in maternal and neonatal outcomes University medical center in a rural state Sylvester-Armstrong et al., 2022 Standardized multidisciplinary PAS protocol team Not specified (T2 period implementation) 70% reduction in composite maternal morbidity; Blood loss: 1,100 vs 2,000 mL median; 68% less blood product transfusion; PRBC units: 0 vs 2 median Strong - protocol was an independent predictor of improved outcomes 58% protocol implementation rate at a single institution Einerson et al., 2023 Experienced multidisciplinary PAS team Planned and coordinated delivery Optimized maternal and infant outcomes Consensus recommendation from the Pan-American Society Guidelines for PAS management Haftel & Carlson, 2024 (StatPearls) Obstetricians, maternal-fetal specialists, anesthesiologists, labor/delivery nurses, neonatologists, intensivists, hematologists, perfusionists, respiratory therapists, NICU nurses Emergency response for cardiovascular collapse and coagulopathy (e.g., AFE) Maternal and infant survival outcomes Strong - crucial for optimizing outcomes in acute emergencies High-acuity hospital setting required Ng et al., 2025 Maternal-fetal medicine specialists, neonatologists, anesthesiologists, relevant subspecialties Not specified (High-Risk Consult focus) 1.5% of pregnancies required HRC consultation; Fetal anomaly cases increased from 1.6% to 14.5%; PROM decreased from 17.6% to 9.6%; Preeclampsia decreased from 10% to 4.8% Strong - consistent 1.5% consultation rate across epochs indicates need Tertiary center implementation Sokou et al., 2025 Multidisciplinary team with early risk identification, continuous monitoring, individualized interventions Not specified (preventive framework) Reduced preterm birth, fetal growth restriction, low birth weight, congenital anomalies Strong - emphasizes necessity of an integrative preventive framework Global health system level Kaur et al., 2025 Risk stratification teams for early PAS identification Early detection protocols PAS incidence 0.94%, maternal morbidity reduction Evidence-based model development recommended Resource-limited settings with structured referral pathways Ganer Herman et al., 2025 IVF specialists, reproductive endocrinologists Pre-conception through delivery (AMA patient management) Live birth rates, clinical pregnancy rates, multiple pregnancy rates Variable/Weak - no clear advantage found for routine specific strategies in AMA patients Limited evidence for specific interventions across 151 studies Bonanni et al., 2025 Obstetrics, maternal-fetal medicine, surgical and medical specialties Antenatal management with specialized expertise Clinical outcomes optimization, risk mitigation; Evidence Gaps: Poor consensus in cesarean hysterectomy (38.5% insufficient evidence), conservative techniques (33.3% insufficient) High agreement for specialized expertise (100%), antenatal management (88.9%) Standardized protocols required; highlights significant evidence gaps Donovan & Zuckerwise, 2025 Team-based, patient-centered, multidisciplinary care (specific disciplines not detailed) From time of diagnosis through delivery and postpartum Maternal hemorrhage reduction, surgical morbidity outcomes, patient experience Strong evidence for team-based, patient-centered care Expert opinion guidance Abbreviations: ACOG = American College of Obstetricians and Gynecologists; AFE = Amniotic Fluid Embolism; AMA = Advanced Maternal Age; FIGO = International Federation of Gynecology and Obstetrics; HDU = High Dependency Unit; HRC = High-Risk Consult; ICSI = Intracytoplasmic Sperm Injection; ICU = Intensive Care Unit; IVF = In Vitro Fertilization; LVEF = Left Ventricular Ejection Fraction; MDT = Multidisciplinary Team; NICU = Neonatal Intensive Care Unit; PAS = Placenta Accreta Spectrum; PPCM = Peripartum Cardiomyopathy; PROM = Premature Rupture of Membranes; PRBC = Packed Red Blood Cells; RCOG = Royal College of Obstetricians and Gynaecologists; SMFM = Society for Maternal-Fetal Medicine; SOGC = Society of Obstetricians and Gynaecologists of Canada. The available evidence robustly supports this protocolized approach. Implementation of a dedicated multidisciplinary PAS program has been shown to significantly improve outcomes, reducing ICU admissions from 53.7% to 19.2% and decreasing the rate of transfusion from 85.4% to 53.9% [ 92 ]. Furthermore, structured protocols dramatically increase antenatal PAS detection rates, from 23.5% to 90.9%, and improve adherence to comprehensive care bundles from 0% to 40.9% [ 93 ]. This underscores that a systematic, team-based framework is essential for translating diagnostic accuracy into optimized clinical results. 3. Evolution of Proactive Hemostatic Strategies A formal, proactive Patient Blood Management (PBM) program is essential for managing high-risk obstetric hemorrhage. As synthesized in Table 4 , evidence strongly supports the systematic use of tranexamic acid and intraoperative cell salvage, while the role of prophylactic arterial balloon occlusion remains nuanced and case-specific [ 2 , 28 , 40 , 59 , 94 – 119 ]. Implementing such comprehensive PBM protocols significantly reduces transfusion requirements, decreasing red blood cell use by 19.5% and plasma by 33% [ 120 , 121 ]. These protocols also lower the proportion of patients requiring any transfusion from 13% to 3% and reduce the rate of post-discharge anemia from 25% to 14% [ 120 ]. Table 4 Surgical and Hemostatic Strategies for Major Obstetric Hemorrhage and Placenta Accreta Spectrum: Techniques, Outcomes, and Recommendations Author, Year Intervention Blood Loss Reduction / Key Metric Transfusion Reduction / Other Benefit Complication Rate / Outcome Current Recommendation Historical & Early Studies (2001–2006) Pahlavan et al., 2001 Sequential hemostatic interventions aims to reduce morbidity Not specified Reduced morbidity with timely intervention Focus on uterine preservation and fertility conservation d'Ercole et al., 2004 Conservative arterial ligations; Uterine compression sutures; Hysterectomy (total/subtotal) Not quantified Not specified Preserves reproductive future; Conservative option preserving fertility; Radical option Essential familiarity required; Use before radical options; Reserved for when conservative measures fail Ojala et al., 2005 Arterial embolization for PPH Successful management of blood loss (3.2-15L range) Not specified Complication rate: 13.6% (3/22: thrombosis, vaginal necrosis, paresthesia) Primary procedure for persistent bleeding; prophylactic balloon catheterization is safe/effective Skupski et al., 2006 Multidisciplinary rapid response team with early diagnosis No significant difference in EBL between periods Not specified Mortality due to hemorrhage significantly improved (p = 0.036) Systemic patient safety approaches recommended for high-risk obstetric hemorrhage Modern Perioperative & Pharmacologic Strategies (2013–2025) Costa et al., 2013 Tranexamic acid (local hemostatic) Effective Not specified Hemorrhage in 4.4% (171/3891) of cases Main local hemostatic measure in anticoagulated patients Collis & Collins, 2015 Tranexamic acid (systemic); Fibrinogen concentrate Not quantified Reduces FFP over-transfusion; Not specified Not specified Therapeutic option for coagulopathy; Alternative therapeutic option Ito et al., 2018 Fibrin sealant in gynecologic surgery; Thrombin-gelatin matrix Decreased EBL vs. bipolar energy; Not specified Not specified; Not specified No significant difference vs. bipolar energy; Less ovarian function damage vs. bipolar energy Recommended for reducing operative time and blood loss; Consider for ovarian tissue preservation Shah et al., 2020 Preoperative anticoagulant management; Intraoperative cell salvage; Tranexamic acid (systemic) Not specified; Effective when > 500ml loss anticipated; Effective Not specified; Not specified; Not specified Not specified; Not specified; Safe Stop direct-acting anticoagulants 48h before surgery; Recommended for anticipated blood loss > 500ml; Routine use when high blood loss anticipated ACOG Committee, 2020 Topical hemostatic agents Limited data available Not specified Not specified Use based on extrapolated evidence from non-obstetric surgeries Connell et al., 2021 Desmopressin challenge-guided therapy Not specified Not specified 94% surgical efficacy (95% CI: 81%-98%) Use challenge results to determine surgical prophylaxis in von Willebrand disease Enste et al., 2022 Massive transfusion protocols; Point-of-care hemostatic diagnostics; Novel hemostatic agents; Multidisciplinary PAS centers of excellence Not specified; Not quantified; Not quantified; Not quantified Improved transfusion management; Not specified; Not specified; Not specified High morbidity/mortality rates without protocol; Not specified; Not specified; Reduced maternal morbidity/mortality Essential preparation for PAS cases; Implement for real-time assessment; Consider for massive hemorrhage; Establish standardized care teams Khoury-Collado et al., 2023 Cesarean hysterectomy Not quantified Not reported Not quantified Requires multidisciplinary team and careful surgical techniques Cassardo et al., 2024 Uterine balloon tamponade; Balloon fixation techniques Effective for refractory hemorrhage; Prevents displacement Not specified; Not specified Balloon displacement risk; Variable by technique Second-line strategy for uterine atony; Choose approach based on clinical scenario Habek et al., 2024 Compression hemostatic sutures; Lower uterine segment sutures Controlled bleeding > 1000 mL; Effective hemostasis Reduced to 440–880 mL transfusion; 440–880 mL blood products No hysterectomy required; Preserved fertility in 3 patients Successful in 10/12 cases; Simple technique with fast learning curve Liu et al., 2024 Bakri balloon + B-Lynch sutures; Bakri balloon + modified Hayman suture Significant reduction vs. baseline; Greater reduction than B-Lynch Not specified; Not specified Not specified; Lower adverse events vs. B-Lynch Effective for PIH patients with persistent bleeding; Preferred over B-Lynch for better outcomes Vimercati et al., 2024 Prenatal ultrasound risk stratification Not specified Not specified Reduced surgical complications with early detection Integrate specific markers (myometrial thinning <1mm, vascular lacunae, "riddled cervix" sign) into protocols Gilner & Deshmukh, 2025 Preoperative anemia management; Intraoperative cell salvage; Tranexamic acid administration; Neuraxial anesthesia; Hysterotomy site selection; Routine cystoscopy ± ureteral stents; Endovascular balloon occlusion; Multivessel arterial embolization Not quantified; Not quantified; Reduces excessive bleeding; Not quantified; Not quantified; Not quantified; Not quantified; Not quantified Clear benefit demonstrated; Reduces transfusion requirements; Not specified; Not specified; Not specified; Not specified; Not specified; Not specified Not specified; Decreases morbidity; Not specified; Not specified; Reduces morbidity; Not specified; Experimental status; Experimental status Strongly recommended evidence-based preparation; Standard preparation for PAS delivery; Administer if excessive bleeding occurs; Maintain until delivery; Place well away from placental margin; Experimental - requires further research; Requires further research; Under investigation Modern Surgical & Interventional Techniques (2017–2025) Barinov et al., 2017 (Study: 2010–2015) Combined: TEG-guided coag management + balloon tamponade + early surgery Mean loss 1836ml vs. 2502ml (p = 0.04); 16.2% vs. 27.6% had > 2000ml loss (p = 0.03) Not specified Hysterectomy rate 4.44% vs. 31.03% (p = 0.02) Powerful fertility-sparing tool for life-threatening hemorrhage Fu et al., 2018 (Study: 2011–2015) Transarterial Embolization (TAE) Not quantified Not quantified 15.2% clinical failure rate; monitor post-TAE shock index > 0.8 as failure predictor Clinically successful in 84.8% of PPH cases Smith et al., 2022 Reloadable articulating stapler device 1,809 ± 868 mL vs. 2,500-5,000 mL traditional 3 ± 1 units intraop, 1 ± 0.5 units postop 27.8% urological injury Recommended for rapid hemostasis in peripartum hysterectomy Pinto et al., 2025 Myometrial resection (conservative); Other conservative surgery; Overall conservative surgery Mean EBL: 1801.28 mL; Mean EBL: 1753.85 mL; Not specified Not reported; Not reported; Not reported Hysterectomy rate: 5%; Hysterectomy rate: 5%; Overall hysterectomy: 11.2%; Urologic complications: 8.8% Feasible in high percentage of PAS patients; Similar outcomes to myometrial resection; Uterine-sparing surgery feasible when appropriate Brown et al., 2025 Abdominopelvic packing Not quantified Not specified Lifesaving in catastrophic hemorrhage Critical tool for refractory coagulopathy Bui et al., 2025 Rectangular-shaped hemostatic sutures Mean blood loss 761.54 ± 614.12 mL Not specified 7.7% (1/13 cases with complications) Simple, safe, cost-effective for PAS management Knapp et al., 2025 Passive hemostatic agents; Active hemostatic agents; Combined active/passive agents Lowest EBL: 301.5 ± 295.78 mL; EBL: 390.7 ± 1004.81 mL; Highest EBL: 521.3 ± 1456.83 mL Not specified; Not specified; Not specified Not specified; Not specified; Longer operative times, extended ICU stays, higher mortality Preferred for routine hemostasis; Consider for targeted bleeding control; Not recommended due to increased complications Specific Population & Timing Strategies (2025) Sinha et al., 2025 Planned vs. Emergency PAS Surgery Emergency: mean 1822 ml EBL (600–3600 ml range); 1918ml higher (β coefficient, p = 0.001) Not specified Emergency surgery significantly associated with higher complications (p = 0.0002) Early antenatal diagnosis and planned surgeries mandatory He et al., 2025 AMA-specific hemorrhage management AMA group had significantly greater intraoperative blood loss vs. younger women Not specified Higher discordant twin growth rates in AMA (P < 0.05) Targeted hemorrhage protocols needed for AMA populations Kaur et al., 2025 Risk stratification model (incl. IVF) Not specified Not specified 88.2% prior cesarean risk factor; 7.1% IVF association (p < 0.05) Early identification for structured referral; include IVF in risk evaluation Suppan et al., 2025 (citing 2022 guidelines) Tranexamic Acid (systematic administration); Intrauterine Vacuum Tamponade; Chitin-based Hemostatic Dressings Not quantified; Enhanced myometrial contraction; Active even with coagulopathy Sequential individualized strategy; Not quantified; Not quantified Not specified; Not specified; Requires clinical trial confirmation Systematic administration recommended; Effective alternative to invasive procedures; Promising but needs controlled studies Donovan & Zuckerwise, 2025 Team-based, patient-centered care Not quantified Not specified Reduces surgical morbidity Strong evidence for multidisciplinary approach Abbreviations: ACOG = American College of Obstetricians and Gynecologists; AFE = Amniotic Fluid Embolism; AMA = Advanced Maternal Age; FIGO = International Federation of Gynecology and Obstetrics; HDU = High Dependency Unit; HRC = High-Risk Consult; ICSI = Intracytoplasmic Sperm Injection; ICU = Intensive Care Unit; IVF = In Vitro Fertilization; LVEF = Left Ventricular Ejection Fraction; MDT = Multidisciplinary Team; NICU = Neonatal Intensive Care Unit; PAS = Placenta Accreta Spectrum; PPCM = Peripartum Cardiomyopathy; PROM = Premature Rupture of Membranes; PRBC = Packed Red Blood Cells; RCOG = Royal College of Obstetricians and Gynaecologists; SMFM = Society for Maternal-Fetal Medicine; SOGC = Society of Obstetricians and Gynaecologists of Canada. The surgical management of PAS is evolving, as detailed in Table 5 . This table highlights that the high-risk triad profile is associated with more invasive phenotypes, often necessitating modified protocols including planned delivery at 34–35 weeks gestation [ 3 , 39 , 40 , 59 , 76 , 84 , 87 , 117 , 119 , 122 – 133 ]. While the standard of care remains planned cesarean hysterectomy with the placenta left in situ to mitigate catastrophic hemorrhage risk [ 134 , 135 ], emerging uterine-preserving techniques show promise. One novel approach, involving meticulous ligation of perforating and superficial uterine vessels, successfully enabled uterine-sparing surgery in a series of patients without major morbidity [ 134 ]. Table 5 Management of the High-Risk Obstetric Triad (AMA, IVF, PAS): Special Considerations and Management Modifications Author, Year Specific Population Unique Risks Management Modifications Outcome Data Evidence Level Historical & Foundational Studies (1992–2004) Seoud et al., 1992 IVF multiple pregnancies (n = 134; twins = 115, triplets = 15, quadruplets = 4) Abortion rates: 30.3% twins, 42% triplets, 20% quadruplets; Premature labor: 41.5%, 92.3%, 75%; PIH: 17.0%, 38.6%, 50%; GDM: 3.1%, 38.5%, 25% Enhanced antenatal monitoring for multiple gestations; NICU preparedness protocols Mean GA: 35.5 ± 3.7, 31.8 ± 2.7, 31.0 ± 1.7 weeks; NICU admission: 22.7%, 64.1%, 75%; Perinatal mortality: 38.5, 0.0, 0.0 per 1000 live births Level III Peterson et al., 2004 IVF patients with high-order multiple pregnancy risk High-order multiple pregnancy rates: 11.8% for DE-IVF, 9.1% for all IVF; Age < 35, donor egg cycles, and embryo scores as risk factors Clinic-specific risk counseling; Individualized embryo transfer protocols during informed consent HMP reduction: 90.9% for DE-IVF (11.8% to 1%) and 53.8% for all IVF (9.1% to 4.2%); No decrease in clinical pregnancy or delivery rates Level III Frydman et al., 2004 IVF/ICSI patients (n = 408 couples) Suboptimal pregnancy rates in assisted reproduction; Multiple pregnancy risks Quality management system implementation; Switch from non-stop to intermittent activity protocols IVF pregnancy rate increased from 28.9%/25.2% to 41%; ICSI rate from 23%/26% to 38.5%; Implantation rate improved from 14.8%/13.4% to 20% (IVF) and 12.1%/12.9% to 23.5% (ICSI) Level III Modern Triad-Specific Considerations (2021–2025) Jauniaux et al., 2021 High-risk PAS patients with prior uterine surgery and anterior low-lying placenta/placenta previa Invasive placentation forms impacting maternal health globally; Increasing PAS prevalence Multi-modal ultrasound imaging; Multidisciplinary team-based care with full logistic support; Immediate access to comprehensive blood products, adult and neonatal ICU Maximized safe outcomes for mothers and newborns through structured care protocols Level I (Guidelines) Sylvester-Armstrong et al., 2022 PAS patients managed via standardized multidisciplinary protocol (n = 36) vs historic controls (n = 39) Composite maternal morbidity, surgical complications, massive blood loss Standardized multidisciplinary protocol implementation (58% adherence); Enhanced blood product management; Systematic ICU protocols 70% reduction in composite maternal morbidity (95% CI: 0.11–0.82); Median blood loss decreased from 2,000 to 1,100 mL; 68% reduction in transfusion requirements (95% CI: 0.12–0.81) Level II Xin et al., 2022 PAS with cervical implantation (n = 166) Cervical width abnormalities, abundant cervical blood flow, bladder line interruption AI-based early warning model; Risk factor screening via logistic regression Worse maternal outcomes in cervical implantation group vs lower uterine implantation Level III Birendra & Jigyasa, 2023 PAS pregnancies (n = 32), mean age 31 years 50% had placenta previa, 75% previous cesareans Multidisciplinary approach; Early antenatal detection Hysterectomy rate 87.5%; 2 maternal deaths; Better perinatal outcomes with antenatal detection Level III Machado-Gédéon et al., 2023 AMA patients (44–54 years) 40% increased IUFD (ages 46–49); 4-fold maternal mortality risk; 17% increased SGA risk (ages 44–45) Enhanced maternal monitoring protocols Higher maternal mortality and IUFD rates in extreme AMA groups Level III Kim et al., 2023 AMA with IVF cycles (n = 1,368 patients; 520 PGT-A vs 848 non-PGT-A cycles) Higher aneuploidy risk; Early pregnancy loss 34.3% in AMA without PGT-A PGT-A protocols; Careful candidate selection for high-risk populations PGT-A improved implantation rates (39.3% vs 16.2%); Live birth rates (42.0% vs 21.8%); Reduced pregnancy loss (16.7% vs 34.3%) Level III Moini et al., 2024 High-risk AMA/IVF patients with RIF, RPL, SMF (n = 1,368 cycles) Recurrent implantation failure; Pregnancy loss rates up to 50% in RPL group PGT-A implementation; Targeted selection criteria for high-risk candidates Significant improvements across groups: RIF (47.0% vs 28.6% LBR); RPL (49.1% vs 24.2% LBR); Reduced loss rates Level III Vimercati et al., 2024 High-risk patients with placenta previa and suspected PAS (n = 102) Retroplacental myometrial thinning (< 1mm), vascular lacunae, "Riddled cervix" sign indicating extensive cervical/parametrial involvement Specialized ultrasound assessment protocols; Risk stratification based on sonographic markers; Surgical planning guided by ultrasound features Patients with "riddled cervix" sign had worst surgical outcomes; Key ultrasound features significantly associated with PAS and surgical complications Level III Zarudskaya et al., 2024 High-risk population with anterior placenta previa/low-lying placenta and prior cesarean deliveries Increased mean PAI total score in PAS cases compared to non-PAS cases Multiparametric PAI score assessment for prenatal PAS prediction with high sensitivity and specificity 1,044 cases analyzed across 11 studies; Consistent diagnostic tool performance Level I (Systematic Review) Li et al., 2025 AMA women (≥ 35 years) with IVF-ET singleton pregnancies (n = 20,882) Placental abnormalities (aRR = 1.87); Placenta accreta (aRR = 2.52); Placenta previa (aRR = 1.68); PPH (aRR = 2.03); Preeclampsia (aRR = 1.52); GDM (aRR = 1.30) Enhanced placental surveillance protocols; Multidisciplinary team approach; Prophylactic hemorrhage management; CS rate optimization CS mediated 21.47% of PPH risk and 26.15% of neonatal jaundice risk in IVF-ET pregnancies Level II Ganer Herman et al., 2025 AMA patients (> 35 years) undergoing IVF treatments (n = 151 studies reviewed) No clear advantage to specific stimulation protocols; Assisted hatching shows decreased live birth rates; Multiple embryo transfer increases multiple pregnancy risk Avoid routine ICSI; Avoid routine assisted hatching; Consider single embryo transfer to reduce multiple pregnancy complications; Standard FSH protocols without LH addition Assisted hatching associated with decreased live birth rates; Multiple embryo transfer increases live birth rates but with higher multiple pregnancy rates; PGT-A shows similar live birth rates as no testing Level I (Systematic Review) Kaur et al., 2025 PAS cases with multiple risk factors including IVF (n = 85 cases from 9,088 deliveries) IVF as significant PAS risk factor (7.1%, p < 0.05); Combined with multiparity (82.4%) and prior cesareans (88.2%) creates highest risk profile Region-specific weighted scoring system for early PAS identification; Structured referral pathways; Multidisciplinary team approach for resource-limited settings PAS incidence 0.94%; Placenta accreta 35.3%, increta 34.1%, percreta 30.6%; Early detection model developed Level III He et al., 2025 AMA nulliparous women (≥ 35 years) with IVF-conceived DCDA twins (n = 47 matched with 94 YMA controls) Discordant twin growth (significantly higher, p < 0.05); Greater intraoperative blood loss during cesarean delivery Targeted prenatal surveillance for twin growth trajectories; Enhanced intraoperative hemorrhage management protocols; Tailored clinical protocols for high-risk demographic No significant differences in PTB, LBW, placental complications, GDM, hypertensive disorders, or PPH compared to younger counterparts Level II Deng et al., 2025 AMA primiparas with ART (n = 2,329) Preeclampsia risk (aOR 1.89); Cesarean delivery (aOR 2.31); Preterm birth (aOR 1.55) Targeted antenatal surveillance; Individualized management protocols NICU admission increased 2.38-fold; No difference in GDM (33.18% vs 31.31%) Level III Hu et al., 2025 IVF/ICSI patients with PAS across 974 cesarean deliveries IVF/ICSI increases PPH risk 9.20-fold (95% CI: 2.68–9.22); Red cell transfusion ≥4U risk 3.71-fold (95% CI: 1.21–11.33) Enhanced prenatal management protocols; Adequate blood product reserves during delivery; Specialized hemorrhage control strategies No increased depth of placental implantation but higher bleeding complications requiring transfusion Level III Chamani et al., 2025 IVF patients undergoing preimplantation genetic testing (PGT) PPROM rates higher with PGT (OR 1.29, 95% CI 1.04–1.60, p = 0.02); Lower BMI in PGT patients Enhanced monitoring protocols for PPROM risk in PGT-IVF pregnancies No increased PAS risk with embryo biopsy (OR 0.78, 95% CI 0.22–2.76) Level II (Systematic Review) Donovan & Zuckerwise, 2025 PAS patients requiring multidisciplinary care Significant maternal hemorrhage and surgical morbidity risks with increasing PAS incidence Team-based, patient-centered, multidisciplinary care approach; Evidence-based management from diagnosis through postpartum care Emphasis on optimizing patient outcomes and experience through coordinated care Level V (Expert Opinion) Su et al., 2024 (ASCO Guideline) Cancer survivors requiring fertility preservation with subsequent AMA pregnancies Reduced live birth rates: Oocyte cryopreservation 26–32%; Embryo cryopreservation 35–41% Optimized IVF protocols for preserved gametes; Enhanced prenatal monitoring for high-risk pregnancies Live birth rates significantly lower than fresh cycles requiring modified expectations Level II (Guideline) Abbreviations : aOR: adjusted odds ratio; aRR: adjusted relative risk; AI: artificial intelligence; AMA: advanced maternal age; ART: assisted reproductive technology; BMI: body mass index; CI: confidence interval; CS: cesarean section; DCDA: dichorionic diamniotic; DE-IVF: donor egg in vitro fertilization; ET: embryo transfer; FSH: follicle-stimulating hormone; GA: gestational age; GDM: gestational diabetes mellitus; HMP: high-order multiple pregnancy; ICSI: intracytoplasmic sperm injection; ICU: intensive care unit; IUFD: intrauterine fetal demise; IVF: in vitro fertilization; LBR: live birth rate; LH: luteinizing hormone; NICU: neonatal intensive care unit; OR: odds ratio; PAI: placental accreta index; PAS: placenta accreta spectrum; PGT-A: preimplantation genetic testing for aneuploidy; PHI: pregnancy-induced hypertension; PPH: postpartum hemorrhage; PPROM: preterm premature rupture of membranes; PTB: preterm birth; RIF: recurrent implantation failure; RPL: recurrent pregnancy loss; SGA: small for gestational age; SMF: severe male factor. As quantified in Table 6 , PAS incurs a substantial economic burden due to significantly higher transfusion volumes and ICU utilization [ 3 , 18 , 39 , 40 , 129 – 133 , 136 – 144 ]. This underscores the cost-effectiveness of preventative strategies. Prenatal diagnosis is a critical component, as it is associated with a significant reduction in transfused red blood cell units (mean difference: -1.96 units) and intraoperative blood loss (mean difference: -0.65) [ 144 ]. Therefore, early identification through advanced imaging, such as the placenta percreta demonstrated in Fig. 2 , followed by the proactive implementation of structured PBM and multidisciplinary care at high-level facilities, is paramount to optimizing outcomes and containing costs. Table 6 Outcomes & Economics of the High-Risk Obstetric Triad (AMA, IVF, PAS) Author, Year Study Focus Maternal Morbidity Neonatal Outcomes Cost Analysis Quality of Life Historical & Foundational Studies (1991–2002) Seoud et al., 1991 IVF multiple pregnancy outcomes (triplets/quadruplets) First trimester bleeding: 53.3% (triplets), 80% (quadruplets); Premature labor: 92.3% (triplets), 67% (quadruplets); PIH: 28.6% (triplets), 67% (quadruplets); GDM: 38.5% (triplets), 33% (quadruplets) Mean GA: 31.8 ± 2.7 wk (triplets), 30.3 ± 0.6 wk (quadruplets); Mean BW: 1663 ± 423g (triplets), 1232 ± 181g (quadruplets); Perinatal mortality: 2.2% (triplets), 0% (quadruplets) Hospitalization: 22.9 ± 19.4 days (triplets), 56.0 ± 30.5 days (quadruplets); Neonatal stay: 28.1 ± 16.2 days (triplets), 69.6 ± 15.5 days (quadruplets) Not assessed Schieve et al., 1998 IVF pregnancy outcomes in Central New York population Significantly increased risk of PROM and preterm delivery in IVF pregnancies Higher rates of preterm delivery associated with IVF Regional perinatal data system utilized across all 23 hospitals in 14-county region Not assessed Garceau et al., 2002 Economic evaluation of assisted reproductive techniques (57 studies) Not specifically assessed Not specifically assessed IUI more cost-effective than IVF; vasectomy reversal more cost-effective than ICSI; poor prognosis factors decrease cost-effectiveness Not assessed Modern Outcomes Research (2014–2025) Ciancimino et al., 2014 AMA outcomes (> 35 years) vs controls Spontaneous abortion (OR 12.82); Preterm delivery (OR 69.84); Cesarean section (OR 2.33) Congenital malformations (OR 3.94); No significant differences in Apgar scores or NICU admissions Not reported Not reported Badeghiesh et al., 2023 IVF pregnancies vs spontaneous conception in AMA (38–43 years) Hypertensive disorders (aOR = 1.31); GDM (aOR = 1.26); Preterm delivery (aOR = 1.45); Cesarean section (aOR = 1.84); PPH (aOR = 1.68); Maternal infection (aOR = 1.90) Comparable neonatal outcomes between groups Not assessed Not assessed Violette et al., 2023 (Data: 2012–2015) ART and abnormal placentation PAS: 2.8 vs 1.0 per 1000 deliveries (aOR 2.06); Placenta previa: 24.5 vs 8.6 per 1000 (aOR 2.98); Vasa previa: 2.3 vs < 0.3 per 1000 (aOR 11.3) Not reported Not reported Not reported Deng et al., 2025 (Data: 2016–2020) ART outcomes in AMA primiparous women (≥ 35 years) Preeclampsia (aOR 1.89); Cesarean delivery (aOR 2.31); Preterm birth (aOR 1.55); No significant differences in GDM (33.18% vs 31.31%) or placental abruption (0.95% vs 1.42%) NICU admission (aOR 2.38); Higher neonatal morbidity rates Not reported Not reported Li et al., 2025 (Data: 2016–2020) IVF-ET outcomes in AMA women (≥ 35 years) vs spontaneous conception Placental abnormalities (aRR = 1.87); Placenta accreta (aRR = 2.52); Placenta previa (aRR = 1.68); GDM (aRR = 1.30); Preeclampsia (aRR = 1.52); PPH (aRR = 2.03); Cesarean section (aRR = 1.19) Neonatal asphyxia (aRR = 2.45); Respiratory distress (aRR = 1.61); Neonatal jaundice (aRR = 1.36); Preterm birth (aRR = 1.31) Not reported Not reported Hamada et al., 2025 Perinatal outcomes in very AMA (≥ 45 years) at full term Intrapartum CD rates: AMA 17.0%, moderate AMA 27.1%, very AMA 35.3%; Higher blood loss in moderate AMA group No significant differences in BW, Apgar scores, UA pH, respiratory support needs, or NICU admission within 24h across age groups Not assessed Not assessed Hu et al., 2025 IVF/ICSI impact on PAS severity and pregnancy complications Postpartum hemorrhage (OR = 9.20); Red cell transfusion ≥4U (OR = 3.71); No increased PAS grading severity (OR = 0.76) Not specifically assessed Not assessed Not assessed Kaur et al., 2025 PAS incidence and risk factors PAS incidence 0.94%; IVF as significant risk factor (7.1%, p < 0.05); Multiparity (82.4%), prior C-sections (88.2%), placenta previa (70.6%) Not specifically assessed Not assessed Not assessed Chamani et al., 2025 Systematic review of PGT embryo biopsy effects on placental implantation (8 studies) No increased PAS risk with PGT (OR 0.78, 95% CI 0.22–2.76); PPROM rates 29% higher (OR 1.29, 95% CI 1.04–1.60) Not assessed Not assessed Not assessed Ganer Herman et al., 2025 Systematic review of IVF interventions in AMA patients (151 studies) Multiple embryo transfer increases multiple pregnancies Similar live birth rates with PGT-A vs no testing; Assisted hatching decreases live birth rates Cost-effectiveness not routinely assessed across interventions Not assessed Si et al., 2024 Economic evaluation of ART treatments (12 studies) Not specifically assessed Live birth rate used as outcome indicator in 50% of studies Direct non-medical and indirect costs included in only 2 studies; Cost-effectiveness thresholds needed Not assessed Wada et al., 2025 ART accessibility post-insurance coverage Not specified Not specified 4.0% increase in ART patients; 22.9% increase in 25–34 age group; Improved rural access Not assessed Zarudskaya et al., 2024 Systematic review of PAI score for PAS prediction (1,044 cases) Women with PAS had increased mean PAI total scores compared to those without PAS Not assessed Not assessed Not assessed Su et al., 2024 (ASCO Guideline) Reproductive and safety outcomes after oncofertility treatments Not specifically assessed Not specifically assessed Not assessed Not assessed Abbreviations : aOR: adjusted odds ratio; aRR: adjusted relative risk; AMA: advanced maternal age; ART: assisted reproductive technology; BW: birth weight; CD: cesarean delivery; CI: confidence interval; ET: embryo transfer; GA: gestational age; GDM: gestational diabetes mellitus; ICSI: intracytoplasmic sperm injection; IUI: intrauterine insemination; IVF: in vitro fertilization; NICU: neonatal intensive care unit; OR: odds ratio; PAI: placental accreta index; PAS: placenta accreta spectrum; PGT: preimplantation genetic testing; PHI: pregnancy-induced hypertension; PPH: postpartum hemorrhage; PPROM: preterm premature rupture of membranes; PROM: premature rupture of membranes; UA pH: umbilical artery pH. 4. Future Directions: Integrating Innovation The field of PAS management must embrace technological innovation to further de-risk patient care, as the condition's increasing prevalence now affects 1 in 2500 pregnancies [ 145 ]. Table 7 catalogs promising advances, from AI-enhanced diagnostic imaging and embryo selection to novel hemostatic agents [ 37 , 40 , 130 , 131 , 146 – 164 ]. The integration of such technologies, guided by structured frameworks like the one proposed in Fig. 3 , holds the potential to revolutionize early detection, surgical planning, and personalized care pathways. Table 7 Emerging Technologies and Future Directions in Managing the High-Risk Obstetric Triad (AMA/IVF/PAS) Author, Year Technology/Approach Stage of Development Proposed Mechanism Preliminary Results Potential Application Historical & Early Development (1990–2007) Kim, 1990 GIFT/ZIFT Procedures; Micromanipulation Technologies Clinical implementation; Clinical development Enhanced gamete/zygote transfer techniques; Direct gamete manipulation for fertilization Pregnancy rates comparable to natural fecundity; Improved understanding of human fertilization Alternative to IVF for AMA patients; Enhanced IVF outcomes in complex cases Moghissi & Leach, 1992 Enhanced IVF protocols Clinical refinement Improved pharmacologic agents and surgical preservation Sustained research led to IVF refinement AMA patients requiring ART Fauser et al., 2002 Alternative stimulation protocols Clinical investigation Novel gonadotropin formulations and protocols Reduced side effects with maintained efficacy Safer stimulation protocols for high-risk AMA patients Marzal et al., 2012 Anti-Müllerian Hormone Markers; Comparative Genomic Hybridization PGS Clinical validation; Technology development OHSS risk prediction through hormonal assessment; Enhanced chromosomal screening accuracy Effective OHSS prevention strategies; Superior embryo selection protocols Risk stratification in AMA-IVF cases; Genetic risk reduction in AMA pregnancies Modern Technologies (2010–2015) Swain & Smith, 2011 Microfluidic embryo culture Research development Dynamic culture with controlled fluid flow Promising early results Improved embryo quality in high-risk cases Meseguer et al., 2012 Microfluidic sperm selection; Integrated IVF lab-on-a-chip Research development; Conceptual design Viability-based sperm selection through narrow channels; Fully automated processing from gametes to embryo Enhanced sperm quality assessment; Theoretical perfect embryo selection Improved outcomes for AMA-IVF patients; Complete ART automation Datta et al., 2015 Time-lapse Embryo Monitoring; Preimplantation Genetic Screening; Advanced Sperm Selection Procedures; Embryo-Glue Transfer Medium Clinical implementation; Clinical practice; Clinical validation; Clinical trials Continuous embryo development tracking without incubator disruption; Chromosomal abnormality detection in embryos pre-transfer; Enhanced sperm quality assessment and selection techniques; Hyaluronic acid-enriched medium mimicking natural environment Improved embryo selection accuracy; Reduced miscarriage rates and improved live birth rates; Improved fertilization and embryo quality; Enhanced embryo adhesion and implantation Enhanced IVF outcomes in AMA patients through better embryo assessment; Critical for AMA patients with increased aneuploidy risk; Optimized outcomes for male factor infertility in AMA/IVF cases; Supportive therapy for high-risk obstetric cases Advanced AI & Machine Learning Applications (2020–2025) Pedrosa et al., 2020 Microfluidic Sperm Selection Devices; AI-Based Sperm Selection Systems Clinical Development; Early Clinical Testing Non-invasive sperm sorting based on motility and morphology patterns; Machine learning algorithms for automated sperm evaluation Enhanced sperm quality identification for IVF procedures; Objective, reproducible sperm quality assessment AMA/IVF outcomes optimization through superior gamete selection; Standardized ART protocols for AMA patients Burgaud et al., 2023 Advanced Embryo Culture Models; Blastoid Generation Technology Research phase; Development phase Enhanced understanding of human embryonic development through improved culture conditions; Creation of embryo-like structures for developmental studies Potential to reduce 75% IVF cycle failure rate; Establishing new knowledge base for ART improvement Improved IVF success rates for AMA patients; Enhanced embryo selection in high-risk pregnancies Abdullah et al., 2023 AI-Integrated IVF Automation Clinical Development Artificial intelligence integration across patient treatment pathway, gamete/embryo selection, and endometrial evaluation Promises personalization and partial automation of IVF processes Reducing labor-intensive procedures, improving accessibility and affordability for AMA-IVF patients Hew et al., 2024 AI-Enhanced IVF Quality Control Clinical Implementation Neural networks and deep learning for automated embryo/sperm selection Increased accuracy, consistency, and operational efficiency in IVF laboratories Standardizing processes, improving patient outcomes, reducing human error in AMA-IVF cases Danaei et al., 2025 nnU-Net Deep Learning Model; DenseNet-PAS Algorithm; Radiomics-Clinical Integration Clinical validation; Clinical validation; Research phase Automated segmentation and classification of PAS using MRI/ultrasound imaging; Integration of quantitative imaging features with clinical data for PAS prediction; Combines quantitative imaging biomarkers with demographic and obstetric factors Superior performance over traditional diagnostic methods with high AUC scores; Demonstrated superior performance in PAS classification; Improved prediction of surgical morbidity Early PAS detection and risk stratification in high-risk pregnancies; Enhanced diagnostic accuracy and optimized surgical planning; Comprehensive risk assessment for AMA/IVF patients with PAS Lee, 2025 Fluorescence Lifetime Imaging Microscopy; AI-Powered Smartphone Ultrasound Clinical research; Pilot studies Real-time metabolic assessment via NAD(P)H and flavine adenine dinucleotide quantification; Automated follicle segmentation using smartphone-compatible devices Metabolic signatures correlate with developmental competence; Supports self-assessment of ovarian follicles Non-invasive embryo quality evaluation beyond morphological criteria; Improved ovarian stimulation tracking in AMA patients Qaderi et al., 2025 Gradient Boosting Trees for NOA; Random Forests for IVF Prediction Clinical validation; Clinical application Machine learning prediction of sperm retrieval success; Multi-parameter success prediction modeling AUC 0.807, 91% sensitivity (119 patients); AUC 84.23% (486 patients) Enhanced male factor assessment in AMA/IVF cases; Personalized treatment protocols for high-risk triad patients Li et al., 2025 IPTW-Adjusted Risk Modeling; Mediation Analysis Framework Clinical validation; Research implementation Stabilized inverse probability treatment weighting for IVF-AMA outcomes; Quantifying cesarean section's mediating role in adverse outcomes Placenta accreta risk 2.52-fold increased; PPH risk 2.03-fold increased; CS explains 21.47% of PPH risk and 26.15% of neonatal jaundice risk Precision risk stratification for AMA-IVF patients with PAS susceptibility; Targeted intervention strategies to reduce cascade complications in high-risk obstetric triad Giaxi et al., 2025 AI/ML Diagnostic Systems; ML-Based Perinatal Outcome Prediction Rapid clinical adoption; Clinical implementation 3D/4D ultrasound and MRI-based automated diagnosis; Integrated risk modeling for mortality, hemorrhage, and neonatal complications High accuracy achieved across pregnancy risk assessment domains; Significant improvements in PPH and neonatal respiratory distress prediction Real-time PAS detection and preeclampsia prediction in AMA-IVF populations; Comprehensive outcome forecasting for high-risk obstetric triad management Racowsky et al., 2025 Laboratory Automation Systems; Multimodal AI Embryo Selection Experimental validation; Clinical integration Precision-controlled dish preparation, denudation, and micromanipulation; High-resolution imaging combined with metabolic and proteomic profiling Equal or superior precision compared to skilled human operators; Superior consistency in embryo evaluation and accelerated training Standardized embryo handling for high-risk AMA-IVF cases; Comprehensive embryo assessment for PAS-risk AMA patients Alikani et al., 2025 AI-Integrated Quality Management Development phase Data-driven benchmarks and automated processes for standardization Better predictable outcomes in IVF laboratories Standardized care protocols for high-risk obstetric populations Petrogiannis et al., 2025 Platelet-Rich Plasma Treatment (PRP); Mitochondrial Replacement Therapy (MRT) Clinical investigation; Research development Ovarian rejuvenation through growth factor delivery; Oocyte competence enhancement through mitochondrial function Improved ovarian function in poor-prognosis patients; Improved oocyte quality in aging patients AMA ovarian reserve enhancement; AMA oocyte quality restoration Kaur et al., 2025 PAS Risk Stratification Model Clinical validation Region-specific weighted scoring integrating clinical predictors 0.94% PAS incidence; IVF risk factor (7.1%, p < 0.05) Early identification and structured referral pathways for high-risk obstetric cases Hu et al., 2025 Enhanced Blood Management Protocols Clinical implementation Targeted hemorrhage prevention in IVF/ICSI-PAS patients 9.20-fold increased PPH risk; 3.71-fold increased transfusion need ≥4U Optimized blood product reserves and prenatal management for IVF-conceived PAS patients Bentov & Schenker, 2025 Advanced Patient Stratification Systems Clinical integration Risk profiling for complex medical conditions Better outcomes in medically complex patients Personalized AMA-IVF-PAS management ACOG Committee, 2020 Real-world Data Collection Systems Implementation phase Longitudinal safety and efficacy monitoring Improved device evaluation Evidence-based technology adoption in obstetric care Abbreviations : AI: artificial intelligence; AMA: advanced maternal age; ART: assisted reproductive technology; AUC: area under the curve; CS: cesarean section; GIFT: gamete intrafallopian transfer; ICSI: intracytoplasmic sperm injection; IPTW: inverse probability of treatment weighting; IVF: in vitro fertilization; ML: machine learning; MRI: magnetic resonance imaging; MRT: mitochondrial replacement therapy; NAD(P)H: nicotinamide adenine dinucleotide phosphate; NOA: non-obstructive azoospermia; OHSS: ovarian hyperstimulation syndrome; PAS: placenta accreta spectrum; PGT: preimplantation genetic testing; PGS: preimplantation genetic screening; PPH: postpartum hemorrhage; PRP: platelet-rich plasma; ZIFT: zygote intrafallopian transfer. While the available literature demonstrates successful implementation of conservative management strategies including uterine artery embolization combined with methotrexate therapy to reduce morbidity and mortality in carefully selected cases [ 165 ], and innovative surgical techniques to control hemorrhage while avoiding hysterectomy [ 166 , 167 ] the adoption of emerging technologies can build upon these foundations. Together, these integrated innovations aim to further reduce the substantial risks associated with this high-morbidity obstetric condition. Recommendations Based on our case analysis and evidence synthesis, we propose a structured approach with the following recommendations, which align with current best practices for PAS management [ 168 ]: first, implement Universal Screening & Referral , mandating PAS ultrasound at 18–20 weeks for patients with advanced maternal age and IVF pregnancy with a prior uterine scar, triggering immediate referral to a regional PAS center of excellence; second, ensure Centralized, Protocolized Care exclusively at designated Level IV centers with 24/7 multidisciplinary availability, governed by institutional checklists for preoperative planning; third, adopt a Proactive Hemostasis Bundle as part of comprehensive patient blood management (PBM), including preoperative anemia correction, routine intraoperative cell salvage, tranexamic acid, and goal-directed transfusion therapy, incorporating novel diagnostics and pharmaceuticals regarding hemostasis [ 168 ]; and fourth, establish Specialized Registries & Research to specifically track outcomes for this subpopulation to generate higher-quality evidence, addressing current data heterogeneity, while prioritizing cost-effectiveness analyses and the integration of emerging technologies [ 168 ]. Conclusions The patient with Advanced Maternal Age, IVF conception, and suspected Placenta Accreta Spectrum represents one of the most formidable challenges in contemporary obstetrics. This triad creates a synergistic risk profile that demands the highest level of coordinated, preemptive care. By recognizing its unique pathophysiology, implementing rigid management protocols centered on multidisciplinary expertise and comprehensive hemorrhage control, and developing standardized referral pathways, we can strive to improve outcomes for these highest-risk pregnancies. This represents an urgent priority for global maternal healthcare systems. Abbreviations AMA Advanced Maternal Age IVF In Vitro Fertilization PAS Placenta Accreta Spectrum MPH Massive Peripartum Hemorrhage MRI Magnetic Resonance Imaging PBM Patient Blood Management ICU Intensive Care Unit NICU Neonatal Intensive Care Unit FET Frozen Embryo Transfer D&C Dilatation and Curettage PGT-A Preimplantation Genetic Testing for Aneuploidies. Declarations Ethics approval and consent to participate Written informed consent was obtained from the patient for publication of this case report and the accompanying de-identified medical images. This case report was conducted in accordance with the Declaration of Helsinki. As this was a retrospective analysis of a single clinical case for educational purposes, formal IRB approval was not required per the policies of West China Second University Hospital, Sichuan University. The patient consent form explicitly permits publication of de-identified clinical data and images. Consent for publication The patient has provided written informed consent for publication of this case report and accompanying images. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests: The authors declare that they have no competing interests. Funding: 1. National Key Research and Development Program of China (2022YFC3600304) National Key Research and Development Program of China (2022YFC2704700) Cadre Health Care Committee of Sichuan Province, China (2023-1701) Principal Investigator Foundation of Tianfu Jincheng Laboratory (TFJCPI20250037) Authors' contributions: S.W: Conceptualization, Writing – Original Draft, Investigation, Project administration. S.Z: Methodology, Formal Analysis, Data Curation, Writing – Review & Editing. J.Z: Investigation, Validation, Writing – Review & Editing. L.H: Investigation, Resources, Writing – Review & Editing. 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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-8663115","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":595230255,"identity":"2bfef55d-0ca5-4617-8c4a-db9d2d33d0a2","order_by":0,"name":"Shanza Waseem","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Shanza","middleName":"","lastName":"Waseem","suffix":""},{"id":595230256,"identity":"682145f9-3102-410a-8bb0-daa9cee1a75a","order_by":1,"name":"Siyuan Zeng","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Siyuan","middleName":"","lastName":"Zeng","suffix":""},{"id":595230257,"identity":"3d70d77c-3eed-4753-9995-f726a257d32f","order_by":2,"name":"Jun Zhan","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Zhan","suffix":""},{"id":595230258,"identity":"6adc680f-dc6b-4f5c-8971-634f05ac22e7","order_by":3,"name":"Liujie Han","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Liujie","middleName":"","lastName":"Han","suffix":""},{"id":595230259,"identity":"14f6f272-89ce-48ea-b779-04247abe4790","order_by":4,"name":"Hu Zhao","email":"","orcid":"","institution":"Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Hu","middleName":"","lastName":"Zhao","suffix":""},{"id":595230261,"identity":"a32d0c2a-f927-433b-b7ce-78d16ce1779d","order_by":5,"name":"Xue Xiao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDACZgglw8DeAGYwNhCrhYeB5wCxWhhgWiQSiNRicJz54WPeNhse/pnPH37mYbCR3XCA+dkDfFokm9mMDWe2pfFI3M4xluZhSDPecIDN3ACfFn5mBjOJj22HeRhu57Ax8zAcTtxwgIdNAp8WNmb2bxKJbf955G8efwbU8p+wFn5mHpAtB3gMbjCYAbUcIKxFspmn2HDGuWQewzM5xpJzDJKNZx5mM8OrxeD88Y2Pecrs5OSOH3/44U2FnWzf8eZneLWgm8AAj9xRMApGwSgYBRQAAPR6P4MdCNaUAAAAAElFTkSuQmCC","orcid":"","institution":"Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Xue","middleName":"","lastName":"Xiao","suffix":""}],"badges":[],"createdAt":"2026-01-21 19:38:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8663115/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8663115/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103347283,"identity":"a4ba662c-be11-4527-b4a4-d915d9bad41c","added_by":"auto","created_at":"2026-02-24 16:25:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1300101,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePathophysiological Synergy in the High-Risk Triad: AMA, IVF, and Prior Uterine Scar.\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e\u003cbr\u003e\nThis diagram illustrates the non-additive convergence of three distinct pathological pathways leading to PAS. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eAdvanced Maternal Age\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e contributes vascular senescence and accumulated uterine pathology. \u003c/em\u003e\u003cem\u003e\u003cstrong\u003eIn Vitro Fertilization\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e introduces impaired decidualization and aberrant placentation. A \u003c/em\u003e\u003cem\u003e\u003cstrong\u003ePrior Uterine Scar\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e provides an anatomical site of deficient decidua basalis. Their interaction overwhelms the normal physiological barriers to implantation, facilitating the deep trophoblastic invasion characteristic of PAS. This synergy defines the extreme-risk obstetric profile that demands pre-emptive, protocol-driven, and multidisciplinary care. AMA = Advanced Maternal Age; IVF = In Vitro Fertilization; PAS = Placenta Accreta Spectrum.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"FIGURE1.png","url":"https://assets-eu.researchsquare.com/files/rs-8663115/v1/4b533a9cb94560eada98aa26.png"},{"id":103347301,"identity":"11683a06-0a06-4642-85f2-af8ce4497a3c","added_by":"auto","created_at":"2026-02-24 16:26:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":19427406,"visible":true,"origin":"","legend":"\u003cp\u003eMRI Confirmation of Placenta Percreta. \u003cem\u003eSagittal T2-weighted magnetic resonance images at 32 weeks' gestation demonstrating definitive signs of placental invasion. A: Key imaging features include (a) marked thinning of the myometrium with only the serosal layer remaining, (b) prominent intraplacental vascular channels, and (c) a T2-hypointense band, a specific indicator of placental invasion (asterisk). B: A similar view shows (d) a corresponding area of extreme myometrial thinning, confirming the invasive front, and (e) the cervical canal. These findings correlate with the diagnosis of placenta percreta with posterior bladder wall invasion.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"FIGURE2.png","url":"https://assets-eu.researchsquare.com/files/rs-8663115/v1/ee7dab48e5f634cf77a83c56.png"},{"id":103347325,"identity":"0905ed86-d938-41fa-a571-f353cdd76d29","added_by":"auto","created_at":"2026-02-24 16:26:09","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1341417,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eProposed Clinical Management Pathway for the High-Risk Triad.\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e This algorithm outlines a standardized, stepwise approach from the initial identification of risk factors (AMA, IVF, prior uterine scar) through long-term follow-up. Key steps include: (1) Mandatory dedicated PAS ultrasound at 18-20 weeks; (2) Immediate referral to a Level IV center upon identification of any ultrasound markers; (3) Confirmatory MRI and formal multidisciplinary team planning; (4) Planned delivery at 34-35 weeks with a comprehensive hemostatic bundle; and (5) Structured postoperative surveillance. Red diamonds indicate critical decision points requiring multidisciplinary input.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"FIGURE3.png","url":"https://assets-eu.researchsquare.com/files/rs-8663115/v1/0f97bd5a470c28e5387ff75f.png"},{"id":103347501,"identity":"331a6b13-1aa1-4cdf-ad4e-c2fe90e4e9ce","added_by":"auto","created_at":"2026-02-24 16:26:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":69372087,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8663115/v1/9dc120d7-9a5f-464b-bc1b-859e248edf0a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Quintessential High-Risk Triad: Advanced Management Strategies for Placenta Accreta Spectrum in Patients with Advanced Maternal Age and IVF Conception","fulltext":[{"header":"Background","content":"\u003cp\u003eThe rising incidence of Placenta Accreta Spectrum (PAS), now estimated at approximately 1 in 533 deliveries, has emerged as a critical challenge in modern obstetrics, driven primarily by two powerful demographic trends: the increasing prevalence of childbearing at AMA and the growing utilization of IVF [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Advancing maternal age alone is a significant risk factor, conferring an annual increase in risk with an odds ratio of 1.13 (95% CI 1.089\u0026ndash;1.194, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) for each additional year of maternal age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Concurrently, IVF conception serves as an established and independent risk factor for PAS, substantially elevating risk above that of spontaneously conceived pregnancies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePAS encompasses a dangerous pathological spectrum of abnormal placental adherence, ranging from \u003cb\u003eaccreta\u003c/b\u003e (adhesion to myometrium) to \u003cb\u003eincreta\u003c/b\u003e (myometrial invasion) and \u003cb\u003epercreta\u003c/b\u003e (penetration to adjacent organs). These conditions are strongly associated with catastrophic peripartum hemorrhage, unplanned hysterectomy, and severe maternal morbidity, necessitating comprehensive prenatal surveillance and coordinated, multidisciplinary management to optimize outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen AMA, IVF conception, and the cornerstone risk factor of a prior uterine scar converge, they create what we define as \u003cb\u003ethe quintessential high-risk triad\u003c/b\u003e. The pathophysiological risk is not merely additive but truly synergistic, as visually conceptualized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Each element compounds the others' effects: a prior hysterotomy scar provides the anatomical locus of defective decidua basalis, creating the substrate for invasion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]; IVF is associated with fundamental disruptions in endometrial decidualization, adhesion molecule expression, and placental development from the earliest stages of implantation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; and AMA introduces systemic vascular endothelial dysfunction and local uterine changes, including structural pathology and impaired receptivity, that create a permissive environment for abnormal placentation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The convergence of these three pathways facilitates the deep, uninhibited trophoblastic invasion that defines PAS.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis article presents a critical analysis of a paradigmatic case of catastrophic hemorrhage in a patient embodying this high-risk triad. We deconstruct the clinical and surgical management challenges and synthesize a comprehensive body of contemporary evidence organized into seven thematic literature review tables. Based on this synthesis, we propose a structured, proactive, and evidence-based framework for the optimal care of this escalating, extreme-risk obstetric population.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 54-year-old gravida 4, para 2 presented via emergency air transport at 34\u0026thinsp;+\u0026thinsp;1 weeks gestation with acute, painless vaginal hemorrhage exceeding 1,000 mL. Her dichorionic diamniotic twin pregnancy resulted from IVF with donor oocytes via a single Frozen Embryo Transfer (FET) cycle after prolonged infertility. Her obstetric history included two prior low transverse cesarean deliveries. Notably, her gynecologic history was significant for multiple diagnostic dilatation and curettage (D\u0026amp;C) procedures performed for abnormal uterine bleeding and infertility workup prior to her successful IVF conception.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePrenatal Course and Diagnostic Evaluation\u003c/h2\u003e \u003cp\u003eAntenatal care included low-dose aspirin (100 mg daily) and prophylactic enoxaparin (4000 IU) for thromboprophylaxis. Serial ultrasounds confirmed a complete placenta previa overlying the prior uterine scar. A dedicated PAS ultrasound at 28 weeks revealed key sonographic features: loss of the retroplacental clear zone, multiple large placental lacunae, and myometrial thinning to less than 1 mm at the bladder interface. A subsequent MRI at 32 weeks confirmed the diagnosis of placenta percreta with invasion into the posterior bladder wall \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eConcurrent fetal ultrasound findings included an isolated short femur length (\u0026lt;\u0026thinsp;10th percentile) and polyhydramnios. A formal multidisciplinary team consultation at 30 weeks established a plan for scheduled delivery at 34 weeks and 3 days of gestation. However, the patient presented with an emergency two days prior to the planned admission.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAcute Presentation and Multidisciplinary Response\u003c/h3\u003e\n\u003cp\u003eOn arrival, the patient was tachycardic and hypotensive. The institutional \"Code Crimson\" protocol for suspected PAS was activated. Under general anesthesia, bilateral common iliac artery balloon occlusion catheters were placed prophylactically by interventional radiology. A midline vertical laparotomy confirmed extensive placenta percreta with invasion into the posterior bladder wall and dense adhesive disease involving the anterior abdominal wall and omentum. A classical uterine incision was made to deliver both viable neonates. Given the extent of invasion and hemodynamic instability, the multidisciplinary team proceeded with a classical cesarean hysterectomy and partial cystectomy.\u003c/p\u003e\n\u003ch3\u003eHemostatic Management and Outcomes\u003c/h3\u003e\n\u003cp\u003eA multimodal hemostatic strategy was employed: tranexamic acid (1g IV) was administered at cord clamping along with carbetocin (100\u0026micro;g) and methylergometrine (0.2mg IM); intermittent arterial balloon occlusion was utilized for temporary vascular control; intraoperative cell salvage with a leukocyte depletion filter was initiated; and resuscitation was guided by a massive transfusion protocol. The patient's estimated blood loss was 4,500 mL, requiring transfusion of 1.5 units of leukocyte-reduced packed red blood cells and 600 mL of fresh frozen plasma. The patient was extubated 8 hours postoperatively, transferred from the ICU on postoperative day 2, and discharged home on postoperative day 10 following treatment for a superficial surgical site infection.\u003c/p\u003e\n\u003ch3\u003eNeonatal Outcomes\u003c/h3\u003e\n\u003cp\u003eBoth neonates required NICU admission. The first neonate (2050g) had Apgar scores of 9-9-10 but developed respiratory distress, pathological jaundice (peak total bilirubin 104.0 \u0026micro;mol/L), and was found to have a possible left ventricular ependymal cyst on cranial ultrasound, necessitating long-term neurological follow-up. Both infants were discharged in stable condition after 10 days with multidisciplinary follow-up plans.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case crystallizes the extreme challenges posed by the AMA/IVF/PAS triad. The management journey, from diagnosis to recovery, underscores critical areas for systems-based improvement informed by a comprehensive evidence base.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSynergistic Pathophysiology and Risk Stratification\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe patient's profile represents a convergence of risk factors with documented multiplicative effects, as visually synthesized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. As summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, contemporary evidence demonstrates a powerful synergistic interaction [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. IVF increases the risk for PAS approximately five-fold (OR 5.03, 95% CI: 3.34, 7.56) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This risk is profoundly amplified by a history of prior uterine surgery. Specifically, hysteroscopic adhesiolysis is associated with a 7.72-fold increase in risk (OR 7.72, 95% CI: 4.10-14.53), while endometrial ablation demonstrates a staggering 20-fold elevation (OR 20.26, 95% CI: 17.15\u0026ndash;23.93) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEpidemiology and Pathophysiology of the High-Risk Triad: Advanced Maternal Age, IVF, and Placenta Accreta Spectrum\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Finding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical Implication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQuality Level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistorical \u0026amp; Foundational Studies (1969\u0026ndash;2009)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffer, 1969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh-risk pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSevere pre-eclampsia, IUGR with placental insufficiency, and irreversible premature labor warrant intensive care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstablishes early framework for identifying high-risk pregnancies requiring specialized management.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrydman et al., 1986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e142 IVF pregnancies vs controls (1981-84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVF pregnancies had significantly higher rates of hypertension (16.5% vs 8.5%), C-section (46.8% vs 15.5%), and breech presentation (13.9% vs 4.3%).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIVF pregnancies are high-risk, requiring enhanced obstetric monitoring from the outset.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFiedler et al., 1990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e246 IVF pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncreased incidence of EPH-gestosis, placental insufficiency, IUFD, abruption, and prematurity in IVF pregnancies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConfirms IVF as a significant risk factor for a range of pregnancy complications.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow-Moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDavis \u0026amp; Rosenwaks, 1992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIVF patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReviews rapid advancements in ART techniques like micromanipulation and ovarian stimulation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHighlights the need for ongoing evaluation of evolving IVF practices.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExpert Opinion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIshikawa, 1995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,667 IVF cycles in Japan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVF pregnancy rate was 12.7% per retrieval cycle in 1991.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEarly ART had low success rates, indicating need for protocol improvements.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiao et al., 1997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical audit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185 IVF pregnancies (1990 vs 1993)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePolicy change to transfer max 2\u0026ndash;3 embryos reduced multiple pregnancy rates and NICU costs 9-fold.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEmbryo transfer policy directly impacts perinatal outcomes and healthcare costs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhelan \u0026amp; Vlahos, 2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiterature Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen at risk for OHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOHSS remains an elusive, potentially critical iatrogenic complication of ovarian stimulation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhysicians must understand OHSS risk factors, prevention, and staging.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExpert Opinion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWang et al., 2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210 IVF vs natural conception mothers (2001-02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVF had higher rates of multiples, hypertension, C-section, preterm birth, LBW, and malformations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIVF significantly increases obstetric risks, largely mediated by multiple births.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Era Studies (2014\u0026ndash;2020)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiancimino et al., 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective case-control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,347 pregnant women (210 AMA\u0026thinsp;\u0026ge;\u0026thinsp;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAMA associated with 12.8x risk of spontaneous abortion, 69.8x risk of preterm delivery, and 3.9x risk of congenital malformations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAMA is a significant independent risk factor requiring enhanced surveillance and counseling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEl Gelany et al., 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 women with PAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS incidence 0.91%; 82% had\u0026thinsp;\u0026ge;\u0026thinsp;2 prior C-sections. Mean age 32.4 years.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaternal age\u0026thinsp;\u0026gt;\u0026thinsp;32, \u0026ge;2 C-sections, multiparity, and previa are key PAS risk factors.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKyozuka et al., 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90,554 Japanese births (2011-14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eART increased PAS risk 6.78-fold; placenta previa increased risk 12.86-fold.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eART and placenta previa are major, independent risk factors requiring enhanced surveillance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMorlando \u0026amp; Collins, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS cases worldwide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS incidence rising rapidly with increasing C-section rates; condition is heterogeneous with high morbidity/mortality.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeed for standardized approach to ultrasound, clinical, and pathologic diagnosis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecent Studies (2021\u0026ndash;2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDonovan \u0026amp; Shainker, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS incidence rising due to increased C-sections and ART. Planned delivery at 34\u0026ndash;35 weeks optimizes outcomes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMultidisciplinary PAS teams are standard; antenatal diagnosis improves outcomes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEinerson \u0026amp; Weiniger, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS patients in developed world\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS incidence increased from ~\u0026thinsp;0.03 (1950s) to 0.79\u0026ndash;3.11 per 1000 pregnancies; leading cause of peripartum hysterectomy in US.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnesthesiologists play a vital role in managing PAS through systematic preparation for massive hemorrhage.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiu et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS prevalence has increased over past decades due to abnormal placental implantation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeed for evidence-based management protocols across all phases of care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShi et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic Review \u0026amp; Meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen\u0026thinsp;\u0026ge;\u0026thinsp;35 undergoing IVF/ICSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePGT-A with comprehensive chromosomal screening increased live birth rate by 30% (RR\u0026thinsp;=\u0026thinsp;1.30).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePGT-A improves outcomes in AMA patients; blastocyst biopsy is superior.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCui et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCohort study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e764 children (382 ART, 382 natural), age 6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eART children had higher blood pressure and reduced left ventricular ejection fraction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eART conception is associated with early cardiovascular dysfunction, necessitating long-term monitoring.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJenabi et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUmbrella review / Meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e419,460 abruption cases from 15 meta-analyses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAMA (OR 1.44) and ART use (OR 1.87) are significant risk factors for placental abruption (suggestive evidence, Class III). Prior cesarean also a key risk factor (RR 1.38).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe AMA/IVF risk profile extends beyond PAS to include placental abruption, necessitating broadened surveillance for placental disorders.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow to Critically Low\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnste et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTwo-part review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS associated with high maternal morbidity/mortality due to coagulopathies and peripartum hemorrhage.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnesthesiologists must prepare for massive transfusion; multidisciplinary teams in specialized centers are essential.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuo et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14,583 women with C-sections (2015-20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple gestation associated with higher PAS risk (aOR\u0026thinsp;=\u0026thinsp;1.63), despite lower rates of classic risk factors (prior C-section, previa).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePAS screening protocols are needed for multiple gestations, even with different risk profiles.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLv et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131 pregnant women with placenta previa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow fibrinogen increased PPH risk; high D-dimer increased low Apgar score risk.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreoperative biomarkers can identify high-risk placenta previa patients for enhanced monitoring.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRodrigues et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMA vs non-AMA pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEvidence supports a lack of association between AMA and neonatal morbidity; association found only with older age thresholds (\u0026ge;\u0026thinsp;40/45).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCurrent evidence does not support AMA alone as a cause of neonatal morbidity; age threshold matters.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSamare-Najaf et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReproductive disorder patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAutophagy disruption is implicated in multiple infertility-related conditions (e.g., POI, PCOS, endometriosis).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnderstanding autophagy pathways may guide future interventions for infertility complications.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKobayashi et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLiterature Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFET vs fresh ET cycles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFET cycles associated with higher incidence of PAS, preeclampsia, and pregnancy-induced hypertension vs fresh ET.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFreezing/thawing affects cellular pathways (proliferation, invasion, mitochondrial function), influencing PAS risk.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh / Moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiz\u0026aacute;rraga-Verdugo et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNarrative Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDescribes PAS spectrum (accreta, increta, percreta) and strong association with prior uterine surgery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEarly diagnosis is critical due to rising global C-section rates; interdisciplinary care is needed.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModest et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternational Multicenter Retrospective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e692 PAS patients (44 IVF, 648 non-IVF)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVF-associated PAS had lower prior cesarean rate (70.5% vs 91%) but similar previa prevalence, making antenatal detection more challenging.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIVF-associated PAS may have a different risk profile than traditional PAS.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePapathanasiou et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedically complex IVF patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncreasing number of women with underlying health conditions seek IVF, necessitating a comprehensive risk framework (GRASP).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeed for systematic risk assessment and multidisciplinary care coordination for complex IVF patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBentov \u0026amp; Schenker, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGlobal IVF population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVF accounts for 2\u0026ndash;5% of global births, with more older women and medically complex patients seeking treatment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExpanding, complex patient demographics reshape the clinical and public health risk profile of IVF.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBonanni et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic Review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS management guidelines (14 guidelines)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePoor consensus on cesarean hysterectomy (38.5% insufficient evidence) and conservative techniques (33.3% insufficient evidence).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrgent need for standardized PAS management protocols and further research.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGaner Herman et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic Review \u0026amp; Meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMA patients undergoing IVF (151 studies)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant increase in AMA patients seeking IVF over past decades.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRising trend requires adapted, evidence-based treatment protocols for the older reproductive population.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaur et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,088 deliveries with 85 PAS cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS incidence 0.94%; IVF was a significant risk factor (7.1% of cases, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIVF is a significant risk factor for PAS, requiring enhanced surveillance and early identification.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLee \u0026amp; Kim, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGlobal PAS cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS incidence increasing globally due to rising C-section rates, uterine surgeries, and ART.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEarly risk identification, prenatal screening, and referral to specialized centers are essential.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeiva et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eART patients with viral infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eViral pathogens significantly impact reproductive systems and fertility outcomes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdvanced screening protocols are essential to minimize transmission risks in ART.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20,882 AMA singleton pregnancies (\u0026ge;\u0026thinsp;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIVF-ET increased placenta accreta risk 2.52-fold and placental abnormality risk 1.87-fold.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAMA women undergoing IVF require specialized placental monitoring and delivery planning.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eAI = Artificial Intelligence; ACOG = American College of Obstetricians and Gynecologists; AMA = Advanced Maternal Age; AUC = Area Under the Curve; CT = Computed Tomography; ET = Embryo Transfer; FISH = Fluorescence In Situ Hybridization; IVF = In Vitro Fertilization; MRI = Magnetic Resonance Imaging; PAS = Placenta Accreta Spectrum; PGT-A = Preimplantation Genetic Testing for Aneuploidies; PPV = Positive Predictive Value; RR = Relative Risk; SAR/ESUR = Society of Abdominal Radiology/European Society of Urogenital Radiology; Sens = Sensitivity; Spec = Specificity; US = Ultrasound.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAMA is an independent, compounding risk factor within this triad. Among women diagnosed with PAS, AMA is independently associated with a three-fold increased risk of requiring hysterectomy (OR 3.0, p\u0026thinsp;=\u0026thinsp;0.045) [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the convergence of AMA, IVF, and a prior uterine scar creates a synergistic \"perfect storm.\" The interacting pathways of vascular/uterine senescence, impaired decidualization, and anatomical decidual deficiency overwhelm normal implantation defenses, facilitating deep trophoblastic invasion. Consequently, identification of this triad mandates automatic classification as \"highest possible risk,\" triggering intensive surveillance and preemptive, multidisciplinary management.\u003c/p\u003e \u003cp\u003e \u003cb\u003e2. The Imperative of Precision Diagnosis and Protocolized Care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEffective management begins with \u003cb\u003eprecision in prenatal diagnosis\u003c/b\u003e. As detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, a low threshold for advanced imaging is mandatory [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47 CR48 CR49 CR50 CR51 CR52 CR53 CR54 CR55 CR56 CR57 CR58 CR59 CR60 CR61 CR62 CR63 CR64 CR65 CR66 CR67 CR68 CR69 CR70 CR71\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Ultrasound findings of placenta previa over a prior scar in an AMA/IVF patient should automatically trigger MRI evaluation, which offers superior anatomical detail for assessing invasion depth critical data for surgical planning. The available evidence demonstrates that MRI achieves high diagnostic accuracy for PAS, with reported sensitivity of 96.08% and specificity of 87.50%, with the dark intra-placental band being the most sensitive MRI sign [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. However, this diagnostic accuracy is significantly compromised in the specific population of IVF-conceived pregnancies. Studies show the MRI sensitivity for antenatal PAS diagnosis plummets to only 22.2% in IVF patients compared to 94.7% in spontaneous conceptions, underscoring a unique diagnostic challenge and the need for heightened vigilance and expertise in this subgroup [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrenatal Diagnosis and Imaging Modalities for Placenta Accreta Spectrum with Emphasis on Diagnostic Accuracy and Clinical Application in High-Risk Pregnancies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImaging Modality / Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiagnostic Criteria / Study Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSensitivity/Specificity / Key Metric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKey Contribution\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eACOG Category / Level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistorical \u0026amp; Foundational Studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoakley, 2001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuperior soft-tissue contrast for fetal assessment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstablished MRI's advantages (larger field of view, precise volumetric measurements) over ultrasound in specific contexts.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstantine \u0026amp; McCormack, 1991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMid-trimester ultrasound (16\u0026ndash;18 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFormal anomaly screening.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45% sensitivity before 20 weeks vs 30% at booking scan.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDemonstrated that earlier, systematic anomaly scanning improves detection rates.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot Specified\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Imaging Modalities \u0026amp; Protocols\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACOG Committee, 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMulti-modal (X-ray, US, CT, MRI, Nuclear Medicine)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRisk-benefit assessment framework for diagnostic imaging.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGuidelines for safe diagnostic imaging during pregnancy and lactation, emphasizing coordination to minimize fetal radiation exposure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCommittee Opinion / Level III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBall, 2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst-trimester screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAneuploidy detection.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComparable or superior to second-trimester screening.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstablished first-trimester screening as an effective early tool for aneuploidy detection.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClinical Review\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCopel et al., 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eX-ray, Ultrasonography, CT, Nuclear Medicine, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRisk-benefit assessment for radiation exposure.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProvided specific guidelines for safe diagnostic imaging during pregnancy and lactation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCommittee Opinion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePAS - General Imaging\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAraujo J\u0026uacute;nior et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D/3D Ultrasound, MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlacental lacunae, bladder-uterine interface disruption, turbulent flow, bridging vessels.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComprehensive review of major prenatal imaging features across multiple modalities for PAS.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III / II-3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBadr et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrenatal ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUterine body PAS identification.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnly 3% diagnosed pre-symptomatically.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHighlighted the diagnostic challenges of uterine body PAS, with 97% missed pre-symptomatically.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eResearch Study\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChen et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound (primary), MRI (supplementary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard ultrasound criteria; MRI for complex cases.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUltrasound accuracy is operator-dependent.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI provides superior anatomical detail for invasion depth/location, especially in complex or posterior placentas.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConturie et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound (preferred), MRI (adjunct)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsensus guideline markers for PAS.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUltrasound highly accurate when performed by experts.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUltrasound is the preferred modality; MRI is an adjunct and not routinely recommended.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePAS - Ultrasound Diagnostic Performance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdu-Bredu et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D Volume Rendering Ultrasound with 2D Doppler\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D loss of clear zone, bridging vessels on Doppler.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D clear zone loss: Sens 89.3%, Spec 92.9%. Bridging vessels: Sens 91.1%, Spec 78.6%.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdvanced 3D ultrasound techniques show superior performance for differentiating PAS from simple scar dehiscence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II-2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGao et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eScoring system: Lacunae\u0026thinsp;\u0026ge;\u0026thinsp;3, bladder wall interruption, placental bulge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.6% sensitivity, 81.8% specificity. AUC 0.925.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDeveloped a comprehensive scoring system combining maternal characteristics and ultrasound features for PAS prediction.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaged et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2D/3D Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeta-analysis of criteria: loss of retroplacental zone, myometrial thinning, lacunae, bridging vessels, bladder wall interruption, uterovesical hypervascularity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverall: Sens 87.0%, Spec 86.3%. Individual criteria ranged from 45.5%-78.5% Sens and 80.9%-99.4% Spec.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComprehensive meta-analysis of 54 studies (5,307 women) establishing the diagnostic accuracy of individual ultrasound signs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNieto-Calvache et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrenatal ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard PAS imaging criteria.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFalse-positive: 28.9% at referral centers, 68.5% at referring hospitals. False-negative: 2.1%.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDemonstrated significantly improved diagnostic accuracy (reduced false positives) at specialized referral centers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III / II-2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVimercati et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransabdominal/Transvaginal Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetroplacental myometrial thinning (\u0026lt;\u0026thinsp;1 mm), vascular lacunae, \"riddled cervix\" sign.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIdentified specific ultrasound markers for PAS risk stratification and prediction of surgical complications.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePAS - MRI Diagnostic Performance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdelAziz et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeta-analysis of 8 criteria: dark bands, heterogeneous placenta, indistinct myometrium, loss of dark zone, myometrial thinning, placental bulge, bladder wall interruption, abnormal vasculature.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverall: Sens 86.7%, Spec 86.0%. Individual criteria: Sens 38.4%-82.8%, Spec 59.3%-98.5%. Highest Spec: indistinct myometrium (98.4%).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComprehensive meta-analysis of 40 studies (3,664 women) confirming MRI's high diagnostic accuracy for PAS.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDe Oliveira Carniello et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound vs. MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRisk factor assessment in women with PAS.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUS: Sens 83.3%, Spec 83.4%. MRI: Sens 83.8%, Spec 83.1%.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMeta-analysis of 17 studies (1,301 women) found no statistically significant difference in diagnostic performance between US and MRI.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGreatest dimension of invasion measurement.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96% sensitivity at 2.5 cm cutoff for predicting need for hysterectomy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMRI had higher specificity and PPV than ultrasound for predicting PAS cases requiring hysterectomy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJha et al., 2020 (SAR/ESUR Consensus)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSeven consensus features: dark T2 bands, uterine bulge, loss of T2 line, myometrial thinning, bladder interruption, exophytic mass, abnormal vasculature.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80% expert consensus achieved.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstablished a standardized MRI protocol and reporting system for PAS diagnosis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound vs. MRI (Meta-analysis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBest US feature: Intraplacental lacunae. Best MRI feature: Placental bulge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUS lacunae: Sens 87%, Spec 83%. MRI bulge: Sens 87%, Spec 84% (AUC 0.89).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMeta-analysis of 1,989 women showed equivalent overall diagnostic accuracy between US and MRI.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePAS - Advanced \u0026amp; Integrated Imaging Techniques\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD'Antonio et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegrated First \u0026amp; Third-Trimester Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultiple risk factor assessment, early identification criteria.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProposed an integration approach for predicting PAS development and severity, showing increased literature interest.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDar et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst-trimester ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCervico-isthmical complex assessment, cesarean scar evaluation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFocused on early PAS detection strategies in the first trimester for optimal delivery planning.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHuang et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI-based Radiomics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRadiomic features extracted from MRI with histopathology reference.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSens 87% (76%-93%), Spec 92% (89%-94%). AUC 0.93.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFirst meta-analysis demonstrating high diagnostic accuracy of MRI radiomics; automated segmentation was superior to manual.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobinson et al., 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFetal MRI (Technical Advances)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0T imaging, 3D T2-weighted MRI, susceptibility-weighted imaging, diffusion tensor imaging.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReviewed technical advances (2011\u0026ndash;2016) in fetal neuroimaging, including motion compensation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZhong et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI\u0026thinsp;+\u0026thinsp;Clinical Factors Nomogram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge, previa, T2 dark band, placental/uterine bulge, loss of T2 interface, myometrial thinning, abnormal vessels.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAUC\u0026thinsp;\u0026gt;\u0026thinsp;0.8 (ROC analysis).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDeveloped and validated a nomogram combining MRI and clinical factors with high diagnostic accuracy for PAS.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II-2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImaging in IVF \u0026amp; AMA Populations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMatsuzaki et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard PAS criteria.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAntenatal diagnosis rate: 22.2% in IVF-ET pregnancies vs. 94.7% in spontaneous conception.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHighlighted the significantly reduced antenatal PAS diagnosis rates in IVF pregnancies, indicating a diagnostic challenge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II-2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShi et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreimplantation Genetic Testing for Aneuploidy (PGT-A)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlastocyst biopsy with comprehensive chromosomal screening vs. FISH.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLive birth rate RR\u0026thinsp;=\u0026thinsp;1.30 (95% CI 1.03\u0026ndash;1.65) for comprehensive screening.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePGT-A with comprehensive screening improves live birth rates by 30% in AMA (\u0026ge;\u0026thinsp;35) patients compared to older FISH techniques.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther Relevant Imaging Topics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkelton et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAntenatal Imaging (General)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative assessment of parent-centered imaging experience.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot applicable (qualitative study).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIdentified six key themes for optimizing parent experience and prenatal attachment during imaging procedures.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUmans et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAI-enhanced Ultrasonography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFirst-trimester screening for various risks.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVariable performance metrics across 27 studies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSystematic review of AI algorithms for early pregnancy risk stratification, showing promise but variable results.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eAI = Artificial Intelligence; ACOG = American College of Obstetricians and Gynecologists; AMA = Advanced Maternal Age; AUC = Area Under the Curve; CT = Computed Tomography; ET = Embryo Transfer; FISH = Fluorescence In Situ Hybridization; IVF = In Vitro Fertilization; MRI = Magnetic Resonance Imaging; PAS = Placenta Accreta Spectrum; PGT-A = Preimplantation Genetic Testing for Aneuploidies; PPV = Positive Predictive Value; RR = Relative Risk; SAR/ESUR = Society of Abdominal Radiology/European Society of Urogenital Radiology; Sens = Sensitivity; Spec = Specificity; US = Ultrasound.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eReactive management yields poor outcomes. The standard of care must be planned delivery at a center with immediately available resources and a dedicated, rehearsed team. \u003cb\u003eThe composition and impact of such teams are outlined in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Our institution's protocol ensures simultaneous activation of all necessary personnel [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan additionalcitationids=\"CR76 CR77 CR78 CR79 CR80 CR81 CR82 CR83 CR84 CR85 CR86 CR87 CR88 CR89 CR90\" citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]. The preoperative \"huddle\" is non-negotiable for determining the surgical approach whether primary hysterectomy or a uterine-conserving strategy based on imaging and patient consent, not during emergent hemorrhage.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComposition, Timing, and Impact of Multidisciplinary Care Teams in the Management of High-Risk Obstetric Conditions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeam Components\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDelivery Timing / Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOutcome Metrics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRecommendation Strength\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImplementation Level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistorical \u0026amp; Foundational Studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWriter, 1986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetric anesthetist as irreplaceable team member, Multidisciplinary perinatal care teams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDeclining perinatal morbidity and mortality rates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - understanding pathophysiology is essential for all team members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTertiary perinatal centers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrydman et al., 2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuality management team with coordinated in-series organization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified (IVF process focus)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical pregnancy rate: 41% (IVF), 38.5% (ICSI); Implantation rate: 20% (IVF), 23.5% (ICSI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong evidence (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) for structured team approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImplemented in 408 consecutive IVF/ICSI cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaserati et al., 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive multispecialty interdisciplinary team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThroughout treatment continuum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo significant differences in maternal/neonatal outcomes between high-risk publicly funded vs private groups (n\u0026thinsp;=\u0026thinsp;600 each)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - effective model for underserved populations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePublic health program implementation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLataifeh et al., 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultidisciplinary ICU team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostpartum (95.3% of admissions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaternal mortality: 6.9%; Mechanical ventilation: 18.6%; Blood transfusion: 48.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - essential for managing hypertensive disorders and hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTertiary care center\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Multidisciplinary Models (2019\u0026ndash;2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerhan \u0026amp; Urgie, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultidisciplinary team approach for PAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAntenatal diagnosis and center of excellence management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSuccess in expectant management, reduced emergency hysterectomy rates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrongly recommended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCenter of excellence hospitals, high and middle-income countries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBerardi et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultidisciplinary tumor boards (adaptable framework for complex care)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThroughout treatment continuum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdherence to clinical guidelines, treatment outcomes, decision-making improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate - benefits documented but limitations noted (costs, legal responsibility, geographic barriers)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVariable implementation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShao et al., 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConferences and clinics format, all relevant disciplines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified for obstetric cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePatient, provider, and system-level outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHeterogeneous evidence base across 191 studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVaried implementation contexts\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCampbell et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF laboratory teams: clinical laboratory scientists, embryologists, nursing, administrative, laboratory, clinical staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThroughout fertility treatment cycle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified (descriptive study)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate - descriptive guidance for team structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLarge IVF clinics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChandraharan et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFetal medicine specialists, complex pelvic surgeons, obstetric anesthetists, hematology, interventional radiology, midwifery, neonatology, HDU/ICU teams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAntenatal diagnosis by specialized teams\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImproved maternal and perinatal outcomes through continuous audit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - specialized expertise required\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRegional referral centers with established MDT pathways\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJauniaux et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultidisciplinary team with expertise in complex pelvic surgery, comprehensive blood products access, adult and neonatal intensive care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti-modal ultrasound imaging for high-risk evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSafe outcomes for mothers and newborns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong recommendations from RCOG, ACOG, SMFM, FIGO, SOGC guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRequires full logistic support structures\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmerican Heart Association et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetrics, maternal-fetal medicine, neonatology, pediatrics, gynecology, genetics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPCM with LVEF\u0026thinsp;\u0026lt;\u0026thinsp;30%: anticoagulation until 6\u0026ndash;8 weeks postpartum; Preconception management with repeat echo\u0026thinsp;~\u0026thinsp;3 months post-medication adjustment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLVEF recovery in PPCM, breastfeeding safety metrics, neonatal medication safety, cardiovascular risk assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - evidence-based guidelines with specific LVEF thresholds and timing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecialized cardiac-obstetric units; requires personalized counseling\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSandlin et al., 2022 (Study Period: 2016\u0026ndash;2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDedicated multidisciplinary PAS care team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlanned coordinated delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1-min APGAR: 6 vs 2 (p\u0026thinsp;=\u0026thinsp;0.0035); 5-min APGAR: 7 vs 6 (p\u0026thinsp;=\u0026thinsp;0.0301); Intraop PRBC: 3.26 vs 6.52 units; Total PRBC: 3.51 vs 9.93 units; Cryoprecipitate: 0.08 vs 0.77 units\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - significant improvement in maternal and neonatal outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUniversity medical center in a rural state\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSylvester-Armstrong et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStandardized multidisciplinary PAS protocol team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified (T2 period implementation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70% reduction in composite maternal morbidity; Blood loss: 1,100 vs 2,000 mL median; 68% less blood product transfusion; PRBC units: 0 vs 2 median\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - protocol was an independent predictor of improved outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58% protocol implementation rate at a single institution\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEinerson et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperienced multidisciplinary PAS team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlanned and coordinated delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimized maternal and infant outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConsensus recommendation from the Pan-American Society\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGuidelines for PAS management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaftel \u0026amp; Carlson, 2024 (StatPearls)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetricians, maternal-fetal specialists, anesthesiologists, labor/delivery nurses, neonatologists, intensivists, hematologists, perfusionists, respiratory therapists, NICU nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency response for cardiovascular collapse and coagulopathy (e.g., AFE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaternal and infant survival outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - crucial for optimizing outcomes in acute emergencies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh-acuity hospital setting required\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNg et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaternal-fetal medicine specialists, neonatologists, anesthesiologists, relevant subspecialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified (High-Risk Consult focus)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5% of pregnancies required HRC consultation; Fetal anomaly cases increased from 1.6% to 14.5%; PROM decreased from 17.6% to 9.6%; Preeclampsia decreased from 10% to 4.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - consistent 1.5% consultation rate across epochs indicates need\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTertiary center implementation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSokou et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultidisciplinary team with early risk identification, continuous monitoring, individualized interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified (preventive framework)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduced preterm birth, fetal growth restriction, low birth weight, congenital anomalies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong - emphasizes necessity of an integrative preventive framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlobal health system level\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaur et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk stratification teams for early PAS identification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEarly detection protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePAS incidence 0.94%, maternal morbidity reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEvidence-based model development recommended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eResource-limited settings with structured referral pathways\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGaner Herman et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF specialists, reproductive endocrinologists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-conception through delivery (AMA patient management)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLive birth rates, clinical pregnancy rates, multiple pregnancy rates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVariable/Weak - no clear advantage found for routine specific strategies in AMA patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLimited evidence for specific interventions across 151 studies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBonanni et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstetrics, maternal-fetal medicine, surgical and medical specialties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAntenatal management with specialized expertise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinical outcomes optimization, risk mitigation; Evidence Gaps: Poor consensus in cesarean hysterectomy (38.5% insufficient evidence), conservative techniques (33.3% insufficient)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh agreement for specialized expertise (100%), antenatal management (88.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandardized protocols required; highlights significant evidence gaps\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDonovan \u0026amp; Zuckerwise, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeam-based, patient-centered, multidisciplinary care (specific disciplines not detailed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrom time of diagnosis through delivery and postpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMaternal hemorrhage reduction, surgical morbidity outcomes, patient experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong evidence for team-based, patient-centered care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExpert opinion guidance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eACOG = American College of Obstetricians and Gynecologists; AFE = Amniotic Fluid Embolism; AMA = Advanced Maternal Age; FIGO = International Federation of Gynecology and Obstetrics; HDU = High Dependency Unit; HRC = High-Risk Consult; ICSI = Intracytoplasmic Sperm Injection; ICU = Intensive Care Unit; IVF = In Vitro Fertilization; LVEF = Left Ventricular Ejection Fraction; MDT = Multidisciplinary Team; NICU = Neonatal Intensive Care Unit; PAS = Placenta Accreta Spectrum; PPCM = Peripartum Cardiomyopathy; PROM = Premature Rupture of Membranes; PRBC = Packed Red Blood Cells; RCOG = Royal College of Obstetricians and Gynaecologists; SMFM = Society for Maternal-Fetal Medicine; SOGC = Society of Obstetricians and Gynaecologists of Canada.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe available evidence robustly supports this protocolized approach. Implementation of a dedicated multidisciplinary PAS program has been shown to significantly improve outcomes, reducing ICU admissions from 53.7% to 19.2% and decreasing the rate of transfusion from 85.4% to 53.9% [\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e]. Furthermore, structured protocols dramatically increase antenatal PAS detection rates, from 23.5% to 90.9%, and improve adherence to comprehensive care bundles from 0% to 40.9% [\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e]. This underscores that a systematic, team-based framework is essential for translating diagnostic accuracy into optimized clinical results.\u003c/p\u003e \u003cp\u003e \u003cb\u003e3. Evolution of Proactive Hemostatic Strategies\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA formal, proactive Patient Blood Management (PBM) program is essential for managing high-risk obstetric hemorrhage. \u003cb\u003eAs synthesized in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, evidence strongly supports the systematic use of tranexamic acid and intraoperative cell salvage, while the role of prophylactic arterial balloon occlusion remains nuanced and case-specific [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan additionalcitationids=\"CR95 CR96 CR97 CR98 CR99 CR100 CR101 CR102 CR103 CR104 CR105 CR106 CR107 CR108 CR109 CR110 CR111 CR112 CR113 CR114 CR115 CR116 CR117 CR118\" citationid=\"CR94\" class=\"CitationRef\"\u003e94\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e]. Implementing such comprehensive PBM protocols significantly reduces transfusion requirements, decreasing red blood cell use by 19.5% and plasma by 33% [\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e, \u003cspan citationid=\"CR121\" class=\"CitationRef\"\u003e121\u003c/span\u003e]. These protocols also lower the proportion of patients requiring any transfusion from 13% to 3% and reduce the rate of post-discharge anemia from 25% to 14% [\u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e120\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical and Hemostatic Strategies for Major Obstetric Hemorrhage and Placenta Accreta Spectrum: Techniques, Outcomes, and Recommendations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlood Loss Reduction / Key Metric\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTransfusion Reduction / Other Benefit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComplication Rate / Outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCurrent Recommendation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistorical \u0026amp; Early Studies (2001\u0026ndash;2006)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePahlavan et al., 2001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSequential hemostatic interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaims to reduce morbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduced morbidity with timely intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFocus on uterine preservation and fertility conservation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed'Ercole et al., 2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConservative arterial ligations; Uterine compression sutures; Hysterectomy (total/subtotal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreserves reproductive future; Conservative option preserving fertility; Radical option\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEssential familiarity required; Use before radical options; Reserved for when conservative measures fail\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOjala et al., 2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArterial embolization for PPH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuccessful management of blood loss (3.2-15L range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComplication rate: 13.6% (3/22: thrombosis, vaginal necrosis, paresthesia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePrimary procedure for persistent bleeding; prophylactic balloon catheterization is safe/effective\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkupski et al., 2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultidisciplinary rapid response team with early diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo significant difference in EBL between periods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMortality due to hemorrhage significantly improved (p\u0026thinsp;=\u0026thinsp;0.036)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystemic patient safety approaches recommended for high-risk obstetric hemorrhage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Perioperative \u0026amp; Pharmacologic Strategies (2013\u0026ndash;2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCosta et al., 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTranexamic acid (local hemostatic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHemorrhage in 4.4% (171/3891) of cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMain local hemostatic measure in anticoagulated patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollis \u0026amp; Collins, 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTranexamic acid (systemic); Fibrinogen concentrate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduces FFP over-transfusion; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTherapeutic option for coagulopathy; Alternative therapeutic option\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIto et al., 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFibrin sealant in gynecologic surgery; Thrombin-gelatin matrix\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDecreased EBL vs. bipolar energy; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo significant difference vs. bipolar energy; Less ovarian function damage vs. bipolar energy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRecommended for reducing operative time and blood loss; Consider for ovarian tissue preservation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShah et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative anticoagulant management; Intraoperative cell salvage; Tranexamic acid (systemic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified; Effective when \u0026gt;\u0026thinsp;500ml loss anticipated; Effective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified; Not specified; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified; Not specified; Safe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStop direct-acting anticoagulants 48h before surgery; Recommended for anticipated blood loss \u0026gt;\u0026thinsp;500ml; Routine use when high blood loss anticipated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACOG Committee, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTopical hemostatic agents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited data available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUse based on extrapolated evidence from non-obstetric surgeries\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConnell et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesmopressin challenge-guided therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94% surgical efficacy (95% CI: 81%-98%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUse challenge results to determine surgical prophylaxis in von Willebrand disease\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnste et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMassive transfusion protocols; Point-of-care hemostatic diagnostics; Novel hemostatic agents; Multidisciplinary PAS centers of excellence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified; Not quantified; Not quantified; Not quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImproved transfusion management; Not specified; Not specified; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh morbidity/mortality rates without protocol; Not specified; Not specified; Reduced maternal morbidity/mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEssential preparation for PAS cases; Implement for real-time assessment; Consider for massive hemorrhage; Establish standardized care teams\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhoury-Collado et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCesarean hysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRequires multidisciplinary team and careful surgical techniques\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCassardo et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUterine balloon tamponade; Balloon fixation techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEffective for refractory hemorrhage; Prevents displacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBalloon displacement risk; Variable by technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSecond-line strategy for uterine atony; Choose approach based on clinical scenario\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHabek et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompression hemostatic sutures; Lower uterine segment sutures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControlled bleeding\u0026thinsp;\u0026gt;\u0026thinsp;1000 mL; Effective hemostasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReduced to 440\u0026ndash;880 mL transfusion; 440\u0026ndash;880 mL blood products\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo hysterectomy required; Preserved fertility in 3 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSuccessful in 10/12 cases; Simple technique with fast learning curve\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiu et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBakri balloon\u0026thinsp;+\u0026thinsp;B-Lynch sutures; Bakri balloon\u0026thinsp;+\u0026thinsp;modified Hayman suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificant reduction vs. baseline; Greater reduction than B-Lynch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified; Lower adverse events vs. B-Lynch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEffective for PIH patients with persistent bleeding; Preferred over B-Lynch for better outcomes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVimercati et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrenatal ultrasound risk stratification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduced surgical complications with early detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntegrate specific markers (myometrial thinning \u0026lt;1mm, vascular lacunae, \"riddled cervix\" sign) into protocols\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGilner \u0026amp; Deshmukh, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative anemia management; Intraoperative cell salvage; Tranexamic acid administration; Neuraxial anesthesia; Hysterotomy site selection; Routine cystoscopy\u0026thinsp;\u0026plusmn;\u0026thinsp;ureteral stents; Endovascular balloon occlusion; Multivessel arterial embolization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified; Not quantified; Reduces excessive bleeding; Not quantified; Not quantified; Not quantified; Not quantified; Not quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClear benefit demonstrated; Reduces transfusion requirements; Not specified; Not specified; Not specified; Not specified; Not specified; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified; Decreases morbidity; Not specified; Not specified; Reduces morbidity; Not specified; Experimental status; Experimental status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStrongly recommended evidence-based preparation; Standard preparation for PAS delivery; Administer if excessive bleeding occurs; Maintain until delivery; Place well away from placental margin; Experimental - requires further research; Requires further research; Under investigation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Surgical \u0026amp; Interventional Techniques (2017\u0026ndash;2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarinov et al., 2017 (Study: 2010\u0026ndash;2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined: TEG-guided coag management\u0026thinsp;+\u0026thinsp;balloon tamponade\u0026thinsp;+\u0026thinsp;early surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean loss 1836ml vs. 2502ml (p\u0026thinsp;=\u0026thinsp;0.04); 16.2% vs. 27.6% had \u0026gt;\u0026thinsp;2000ml loss (p\u0026thinsp;=\u0026thinsp;0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHysterectomy rate 4.44% vs. 31.03% (p\u0026thinsp;=\u0026thinsp;0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePowerful fertility-sparing tool for life-threatening hemorrhage\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFu et al., 2018 (Study: 2011\u0026ndash;2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransarterial Embolization (TAE)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.2% clinical failure rate; monitor post-TAE shock index\u0026thinsp;\u0026gt;\u0026thinsp;0.8 as failure predictor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClinically successful in 84.8% of PPH cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmith et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReloadable articulating stapler device\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,809\u0026thinsp;\u0026plusmn;\u0026thinsp;868 mL vs. 2,500-5,000 mL traditional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026thinsp;\u0026plusmn;\u0026thinsp;1 units intraop, 1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 units postop\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27.8% urological injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRecommended for rapid hemostasis in peripartum hysterectomy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePinto et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyometrial resection (conservative); Other conservative surgery; Overall conservative surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean EBL: 1801.28 mL; Mean EBL: 1753.85 mL; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot reported; Not reported; Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHysterectomy rate: 5%; Hysterectomy rate: 5%; Overall hysterectomy: 11.2%; Urologic complications: 8.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFeasible in high percentage of PAS patients; Similar outcomes to myometrial resection; Uterine-sparing surgery feasible when appropriate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrown et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbdominopelvic packing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLifesaving in catastrophic hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCritical tool for refractory coagulopathy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBui et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRectangular-shaped hemostatic sutures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean blood loss 761.54\u0026thinsp;\u0026plusmn;\u0026thinsp;614.12 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.7% (1/13 cases with complications)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSimple, safe, cost-effective for PAS management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnapp et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePassive hemostatic agents; Active hemostatic agents; Combined active/passive agents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLowest EBL: 301.5\u0026thinsp;\u0026plusmn;\u0026thinsp;295.78 mL; EBL: 390.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1004.81 mL; Highest EBL: 521.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1456.83 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified; Not specified; Not specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified; Not specified; Longer operative times, extended ICU stays, higher mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePreferred for routine hemostasis; Consider for targeted bleeding control; Not recommended due to increased complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecific Population \u0026amp; Timing Strategies (2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinha et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlanned vs. Emergency PAS Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmergency: mean 1822 ml EBL (600\u0026ndash;3600 ml range); 1918ml higher (β coefficient, p\u0026thinsp;=\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEmergency surgery significantly associated with higher complications (p\u0026thinsp;=\u0026thinsp;0.0002)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEarly antenatal diagnosis and planned surgeries mandatory\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHe et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA-specific hemorrhage management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMA group had significantly greater intraoperative blood loss vs. younger women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher discordant twin growth rates in AMA (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTargeted hemorrhage protocols needed for AMA populations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaur et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk stratification model (incl. IVF)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.2% prior cesarean risk factor; 7.1% IVF association (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEarly identification for structured referral; include IVF in risk evaluation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuppan et al., 2025 (citing 2022 guidelines)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTranexamic Acid (systematic administration); Intrauterine Vacuum Tamponade; Chitin-based Hemostatic Dressings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified; Enhanced myometrial contraction; Active even with coagulopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSequential individualized strategy; Not quantified; Not quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot specified; Not specified; Requires clinical trial confirmation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSystematic administration recommended; Effective alternative to invasive procedures; Promising but needs controlled studies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDonovan \u0026amp; Zuckerwise, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeam-based, patient-centered care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot quantified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduces surgical morbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStrong evidence for multidisciplinary approach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eACOG = American College of Obstetricians and Gynecologists; AFE = Amniotic Fluid Embolism; AMA = Advanced Maternal Age; FIGO = International Federation of Gynecology and Obstetrics; HDU = High Dependency Unit; HRC = High-Risk Consult; ICSI = Intracytoplasmic Sperm Injection; ICU = Intensive Care Unit; IVF = In Vitro Fertilization; LVEF = Left Ventricular Ejection Fraction; MDT = Multidisciplinary Team; NICU = Neonatal Intensive Care Unit; PAS = Placenta Accreta Spectrum; PPCM = Peripartum Cardiomyopathy; PROM = Premature Rupture of Membranes; PRBC = Packed Red Blood Cells; RCOG = Royal College of Obstetricians and Gynaecologists; SMFM = Society for Maternal-Fetal Medicine; SOGC = Society of Obstetricians and Gynaecologists of Canada.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe surgical management of PAS is evolving, \u003cb\u003eas detailed in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. This table highlights that the high-risk triad profile is associated with more invasive phenotypes, often necessitating modified protocols including planned delivery at 34\u0026ndash;35 weeks gestation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR117\" class=\"CitationRef\"\u003e117\u003c/span\u003e, \u003cspan citationid=\"CR119\" class=\"CitationRef\"\u003e119\u003c/span\u003e, \u003cspan additionalcitationids=\"CR123 CR124 CR125 CR126 CR127 CR128 CR129 CR130 CR131 CR132\" citationid=\"CR122\" class=\"CitationRef\"\u003e122\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e]. While the standard of care remains planned cesarean hysterectomy with the placenta left in situ to mitigate catastrophic hemorrhage risk [\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e, \u003cspan citationid=\"CR135\" class=\"CitationRef\"\u003e135\u003c/span\u003e], emerging uterine-preserving techniques show promise. One novel approach, involving meticulous ligation of perforating and superficial uterine vessels, successfully enabled uterine-sparing surgery in a series of patients without major morbidity [\u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e134\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eManagement of the High-Risk Obstetric Triad (AMA, IVF, PAS): Special Considerations and Management Modifications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecific Population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnique Risks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eManagement Modifications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOutcome Data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvidence Level\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistorical \u0026amp; Foundational Studies (1992\u0026ndash;2004)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeoud et al., 1992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF multiple pregnancies (n\u0026thinsp;=\u0026thinsp;134; twins\u0026thinsp;=\u0026thinsp;115, triplets\u0026thinsp;=\u0026thinsp;15, quadruplets\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbortion rates: 30.3% twins, 42% triplets, 20% quadruplets; Premature labor: 41.5%, 92.3%, 75%; PIH: 17.0%, 38.6%, 50%; GDM: 3.1%, 38.5%, 25%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced antenatal monitoring for multiple gestations; NICU preparedness protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean GA: 35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7, 31.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7, 31.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 weeks; NICU admission: 22.7%, 64.1%, 75%; Perinatal mortality: 38.5, 0.0, 0.0 per 1000 live births\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeterson et al., 2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF patients with high-order multiple pregnancy risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh-order multiple pregnancy rates: 11.8% for DE-IVF, 9.1% for all IVF; Age\u0026thinsp;\u0026lt;\u0026thinsp;35, donor egg cycles, and embryo scores as risk factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic-specific risk counseling; Individualized embryo transfer protocols during informed consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHMP reduction: 90.9% for DE-IVF (11.8% to 1%) and 53.8% for all IVF (9.1% to 4.2%); No decrease in clinical pregnancy or delivery rates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrydman et al., 2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF/ICSI patients (n\u0026thinsp;=\u0026thinsp;408 couples)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuboptimal pregnancy rates in assisted reproduction; Multiple pregnancy risks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuality management system implementation; Switch from non-stop to intermittent activity protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIVF pregnancy rate increased from 28.9%/25.2% to 41%; ICSI rate from 23%/26% to 38.5%; Implantation rate improved from 14.8%/13.4% to 20% (IVF) and 12.1%/12.9% to 23.5% (ICSI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Triad-Specific Considerations (2021\u0026ndash;2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJauniaux et al., 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-risk PAS patients with prior uterine surgery and anterior low-lying placenta/placenta previa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInvasive placentation forms impacting maternal health globally; Increasing PAS prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMulti-modal ultrasound imaging; Multidisciplinary team-based care with full logistic support; Immediate access to comprehensive blood products, adult and neonatal ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMaximized safe outcomes for mothers and newborns through structured care protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I (Guidelines)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSylvester-Armstrong et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAS patients managed via standardized multidisciplinary protocol (n\u0026thinsp;=\u0026thinsp;36) vs historic controls (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComposite maternal morbidity, surgical complications, massive blood loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandardized multidisciplinary protocol implementation (58% adherence); Enhanced blood product management; Systematic ICU protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70% reduction in composite maternal morbidity (95% CI: 0.11\u0026ndash;0.82); Median blood loss decreased from 2,000 to 1,100 mL; 68% reduction in transfusion requirements (95% CI: 0.12\u0026ndash;0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eXin et al., 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAS with cervical implantation (n\u0026thinsp;=\u0026thinsp;166)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCervical width abnormalities, abundant cervical blood flow, bladder line interruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAI-based early warning model; Risk factor screening via logistic regression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWorse maternal outcomes in cervical implantation group vs lower uterine implantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirendra \u0026amp; Jigyasa, 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAS pregnancies (n\u0026thinsp;=\u0026thinsp;32), mean age 31 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50% had placenta previa, 75% previous cesareans\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultidisciplinary approach; Early antenatal detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHysterectomy rate 87.5%; 2 maternal deaths; Better perinatal outcomes with antenatal detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMachado-G\u0026eacute;d\u0026eacute;on et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA patients (44\u0026ndash;54 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40% increased IUFD (ages 46\u0026ndash;49); 4-fold maternal mortality risk; 17% increased SGA risk (ages 44\u0026ndash;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced maternal monitoring protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigher maternal mortality and IUFD rates in extreme AMA groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKim et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA with IVF cycles (n\u0026thinsp;=\u0026thinsp;1,368 patients; 520 PGT-A vs 848 non-PGT-A cycles)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigher aneuploidy risk; Early pregnancy loss 34.3% in AMA without PGT-A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePGT-A protocols; Careful candidate selection for high-risk populations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePGT-A improved implantation rates (39.3% vs 16.2%); Live birth rates (42.0% vs 21.8%); Reduced pregnancy loss (16.7% vs 34.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoini et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-risk AMA/IVF patients with RIF, RPL, SMF (n\u0026thinsp;=\u0026thinsp;1,368 cycles)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrent implantation failure; Pregnancy loss rates up to 50% in RPL group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePGT-A implementation; Targeted selection criteria for high-risk candidates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant improvements across groups: RIF (47.0% vs 28.6% LBR); RPL (49.1% vs 24.2% LBR); Reduced loss rates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVimercati et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-risk patients with placenta previa and suspected PAS (n\u0026thinsp;=\u0026thinsp;102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetroplacental myometrial thinning (\u0026lt;\u0026thinsp;1mm), vascular lacunae, \"Riddled cervix\" sign indicating extensive cervical/parametrial involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpecialized ultrasound assessment protocols; Risk stratification based on sonographic markers; Surgical planning guided by ultrasound features\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients with \"riddled cervix\" sign had worst surgical outcomes; Key ultrasound features significantly associated with PAS and surgical complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZarudskaya et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-risk population with anterior placenta previa/low-lying placenta and prior cesarean deliveries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncreased mean PAI total score in PAS cases compared to non-PAS cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiparametric PAI score assessment for prenatal PAS prediction with high sensitivity and specificity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,044 cases analyzed across 11 studies; Consistent diagnostic tool performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I (Systematic Review)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA women (\u0026ge;\u0026thinsp;35 years) with IVF-ET singleton pregnancies (n\u0026thinsp;=\u0026thinsp;20,882)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlacental abnormalities (aRR\u0026thinsp;=\u0026thinsp;1.87); Placenta accreta (aRR\u0026thinsp;=\u0026thinsp;2.52); Placenta previa (aRR\u0026thinsp;=\u0026thinsp;1.68); PPH (aRR\u0026thinsp;=\u0026thinsp;2.03); Preeclampsia (aRR\u0026thinsp;=\u0026thinsp;1.52); GDM (aRR\u0026thinsp;=\u0026thinsp;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced placental surveillance protocols; Multidisciplinary team approach; Prophylactic hemorrhage management; CS rate optimization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCS mediated 21.47% of PPH risk and 26.15% of neonatal jaundice risk in IVF-ET pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGaner Herman et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA patients (\u0026gt;\u0026thinsp;35 years) undergoing IVF treatments (n\u0026thinsp;=\u0026thinsp;151 studies reviewed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo clear advantage to specific stimulation protocols; Assisted hatching shows decreased live birth rates; Multiple embryo transfer increases multiple pregnancy risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAvoid routine ICSI; Avoid routine assisted hatching; Consider single embryo transfer to reduce multiple pregnancy complications; Standard FSH protocols without LH addition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAssisted hatching associated with decreased live birth rates; Multiple embryo transfer increases live birth rates but with higher multiple pregnancy rates; PGT-A shows similar live birth rates as no testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel I (Systematic Review)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaur et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAS cases with multiple risk factors including IVF (n\u0026thinsp;=\u0026thinsp;85 cases from 9,088 deliveries)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIVF as significant PAS risk factor (7.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); Combined with multiparity (82.4%) and prior cesareans (88.2%) creates highest risk profile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRegion-specific weighted scoring system for early PAS identification; Structured referral pathways; Multidisciplinary team approach for resource-limited settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePAS incidence 0.94%; Placenta accreta 35.3%, increta 34.1%, percreta 30.6%; Early detection model developed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHe et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA nulliparous women (\u0026ge;\u0026thinsp;35 years) with IVF-conceived DCDA twins (n\u0026thinsp;=\u0026thinsp;47 matched with 94 YMA controls)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiscordant twin growth (significantly higher, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); Greater intraoperative blood loss during cesarean delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTargeted prenatal surveillance for twin growth trajectories; Enhanced intraoperative hemorrhage management protocols; Tailored clinical protocols for high-risk demographic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo significant differences in PTB, LBW, placental complications, GDM, hypertensive disorders, or PPH compared to younger counterparts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeng et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA primiparas with ART (n\u0026thinsp;=\u0026thinsp;2,329)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreeclampsia risk (aOR 1.89); Cesarean delivery (aOR 2.31); Preterm birth (aOR 1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTargeted antenatal surveillance; Individualized management protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNICU admission increased 2.38-fold; No difference in GDM (33.18% vs 31.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHu et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF/ICSI patients with PAS across 974 cesarean deliveries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIVF/ICSI increases PPH risk 9.20-fold (95% CI: 2.68\u0026ndash;9.22); Red cell transfusion \u0026ge;4U risk 3.71-fold (95% CI: 1.21\u0026ndash;11.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced prenatal management protocols; Adequate blood product reserves during delivery; Specialized hemorrhage control strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo increased depth of placental implantation but higher bleeding complications requiring transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel III\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChamani et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF patients undergoing preimplantation genetic testing (PGT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPROM rates higher with PGT (OR 1.29, 95% CI 1.04\u0026ndash;1.60, p\u0026thinsp;=\u0026thinsp;0.02); Lower BMI in PGT patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced monitoring protocols for PPROM risk in PGT-IVF pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo increased PAS risk with embryo biopsy (OR 0.78, 95% CI 0.22\u0026ndash;2.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II (Systematic Review)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDonovan \u0026amp; Zuckerwise, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAS patients requiring multidisciplinary care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificant maternal hemorrhage and surgical morbidity risks with increasing PAS incidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTeam-based, patient-centered, multidisciplinary care approach; Evidence-based management from diagnosis through postpartum care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEmphasis on optimizing patient outcomes and experience through coordinated care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel V (Expert Opinion)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSu et al., 2024 (ASCO Guideline)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCancer survivors requiring fertility preservation with subsequent AMA pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReduced live birth rates: Oocyte cryopreservation 26\u0026ndash;32%; Embryo cryopreservation 35\u0026ndash;41%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimized IVF protocols for preserved gametes; Enhanced prenatal monitoring for high-risk pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLive birth rates significantly lower than fresh cycles requiring modified expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLevel II (Guideline)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: \u003cem\u003eaOR: adjusted odds ratio; aRR: adjusted relative risk; AI: artificial intelligence; AMA: advanced maternal age; ART: assisted reproductive technology; BMI: body mass index; CI: confidence interval; CS: cesarean section; DCDA: dichorionic diamniotic; DE-IVF: donor egg in vitro fertilization; ET: embryo transfer; FSH: follicle-stimulating hormone; GA: gestational age; GDM: gestational diabetes mellitus; HMP: high-order multiple pregnancy; ICSI: intracytoplasmic sperm injection; ICU: intensive care unit; IUFD: intrauterine fetal demise; IVF: in vitro fertilization; LBR: live birth rate; LH: luteinizing hormone; NICU: neonatal intensive care unit; OR: odds ratio; PAI: placental accreta index; PAS: placenta accreta spectrum; PGT-A: preimplantation genetic testing for aneuploidy; PHI: pregnancy-induced hypertension; PPH: postpartum hemorrhage; PPROM: preterm premature rupture of membranes; PTB: preterm birth; RIF: recurrent implantation failure; RPL: recurrent pregnancy loss; SGA: small for gestational age; SMF: severe male factor.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAs quantified in\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e, PAS incurs a substantial economic burden due to significantly higher transfusion volumes and ICU utilization [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan additionalcitationids=\"CR130 CR131 CR132\" citationid=\"CR129\" class=\"CitationRef\"\u003e129\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR133\" class=\"CitationRef\"\u003e133\u003c/span\u003e, \u003cspan additionalcitationids=\"CR137 CR138 CR139 CR140 CR141 CR142 CR143\" citationid=\"CR136\" class=\"CitationRef\"\u003e136\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e]. This underscores the cost-effectiveness of preventative strategies. Prenatal diagnosis is a critical component, as it is associated with a significant reduction in transfused red blood cell units (mean difference: -1.96 units) and intraoperative blood loss (mean difference: -0.65) [\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e]. Therefore, early identification through advanced imaging, such as the placenta percreta demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, followed by the proactive implementation of structured PBM and multidisciplinary care at high-level facilities, is paramount to optimizing outcomes and containing costs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcomes \u0026amp; Economics of the High-Risk Obstetric Triad (AMA, IVF, PAS)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy Focus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMaternal Morbidity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeonatal Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCost Analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQuality of Life\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistorical \u0026amp; Foundational Studies (1991\u0026ndash;2002)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeoud et al., 1991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF multiple pregnancy outcomes (triplets/quadruplets)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFirst trimester bleeding: 53.3% (triplets), 80% (quadruplets); Premature labor: 92.3% (triplets), 67% (quadruplets); PIH: 28.6% (triplets), 67% (quadruplets); GDM: 38.5% (triplets), 33% (quadruplets)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean GA: 31.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 wk (triplets), 30.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 wk (quadruplets); Mean BW: 1663\u0026thinsp;\u0026plusmn;\u0026thinsp;423g (triplets), 1232\u0026thinsp;\u0026plusmn;\u0026thinsp;181g (quadruplets); Perinatal mortality: 2.2% (triplets), 0% (quadruplets)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHospitalization: 22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;19.4 days (triplets), 56.0\u0026thinsp;\u0026plusmn;\u0026thinsp;30.5 days (quadruplets); Neonatal stay: 28.1\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2 days (triplets), 69.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5 days (quadruplets)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchieve et al., 1998\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF pregnancy outcomes in Central New York population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificantly increased risk of PROM and preterm delivery in IVF pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigher rates of preterm delivery associated with IVF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRegional perinatal data system utilized across all 23 hospitals in 14-county region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGarceau et al., 2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEconomic evaluation of assisted reproductive techniques (57 studies)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specifically assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specifically assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIUI more cost-effective than IVF; vasectomy reversal more cost-effective than ICSI; poor prognosis factors decrease cost-effectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Outcomes Research (2014\u0026ndash;2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCiancimino et al., 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMA outcomes (\u0026gt;\u0026thinsp;35 years) vs controls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpontaneous abortion (OR 12.82); Preterm delivery (OR 69.84); Cesarean section (OR 2.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCongenital malformations (OR 3.94); No significant differences in Apgar scores or NICU admissions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBadeghiesh et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF pregnancies vs spontaneous conception in AMA (38\u0026ndash;43 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHypertensive disorders (aOR\u0026thinsp;=\u0026thinsp;1.31); GDM (aOR\u0026thinsp;=\u0026thinsp;1.26); Preterm delivery (aOR\u0026thinsp;=\u0026thinsp;1.45); Cesarean section (aOR\u0026thinsp;=\u0026thinsp;1.84); PPH (aOR\u0026thinsp;=\u0026thinsp;1.68); Maternal infection (aOR\u0026thinsp;=\u0026thinsp;1.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComparable neonatal outcomes between groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViolette et al., 2023 (Data: 2012\u0026ndash;2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eART and abnormal placentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS: 2.8 vs 1.0 per 1000 deliveries (aOR 2.06); Placenta previa: 24.5 vs 8.6 per 1000 (aOR 2.98); Vasa previa: 2.3 vs\u0026thinsp;\u0026lt;\u0026thinsp;0.3 per 1000 (aOR 11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeng et al., 2025 (Data: 2016\u0026ndash;2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eART outcomes in AMA primiparous women (\u0026ge;\u0026thinsp;35 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreeclampsia (aOR 1.89); Cesarean delivery (aOR 2.31); Preterm birth (aOR 1.55); No significant differences in GDM (33.18% vs 31.31%) or placental abruption (0.95% vs 1.42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNICU admission (aOR 2.38); Higher neonatal morbidity rates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi et al., 2025 (Data: 2016\u0026ndash;2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF-ET outcomes in AMA women (\u0026ge;\u0026thinsp;35 years) vs spontaneous conception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePlacental abnormalities (aRR\u0026thinsp;=\u0026thinsp;1.87); Placenta accreta (aRR\u0026thinsp;=\u0026thinsp;2.52); Placenta previa (aRR\u0026thinsp;=\u0026thinsp;1.68); GDM (aRR\u0026thinsp;=\u0026thinsp;1.30); Preeclampsia (aRR\u0026thinsp;=\u0026thinsp;1.52); PPH (aRR\u0026thinsp;=\u0026thinsp;2.03); Cesarean section (aRR\u0026thinsp;=\u0026thinsp;1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeonatal asphyxia (aRR\u0026thinsp;=\u0026thinsp;2.45); Respiratory distress (aRR\u0026thinsp;=\u0026thinsp;1.61); Neonatal jaundice (aRR\u0026thinsp;=\u0026thinsp;1.36); Preterm birth (aRR\u0026thinsp;=\u0026thinsp;1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHamada et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerinatal outcomes in very AMA (\u0026ge;\u0026thinsp;45 years) at full term\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntrapartum CD rates: AMA 17.0%, moderate AMA 27.1%, very AMA 35.3%; Higher blood loss in moderate AMA group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo significant differences in BW, Apgar scores, UA pH, respiratory support needs, or NICU admission within 24h across age groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHu et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIVF/ICSI impact on PAS severity and pregnancy complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostpartum hemorrhage (OR\u0026thinsp;=\u0026thinsp;9.20); Red cell transfusion \u0026ge;4U (OR\u0026thinsp;=\u0026thinsp;3.71); No increased PAS grading severity (OR\u0026thinsp;=\u0026thinsp;0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specifically assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaur et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAS incidence and risk factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePAS incidence 0.94%; IVF as significant risk factor (7.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05); Multiparity (82.4%), prior C-sections (88.2%), placenta previa (70.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specifically assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChamani et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review of PGT embryo biopsy effects on placental implantation (8 studies)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo increased PAS risk with PGT (OR 0.78, 95% CI 0.22\u0026ndash;2.76); PPROM rates 29% higher (OR 1.29, 95% CI 1.04\u0026ndash;1.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGaner Herman et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review of IVF interventions in AMA patients (151 studies)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultiple embryo transfer increases multiple pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSimilar live birth rates with PGT-A vs no testing; Assisted hatching decreases live birth rates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCost-effectiveness not routinely assessed across interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSi et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEconomic evaluation of ART treatments (12 studies)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specifically assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLive birth rate used as outcome indicator in 50% of studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDirect non-medical and indirect costs included in only 2 studies; Cost-effectiveness thresholds needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWada et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eART accessibility post-insurance coverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.0% increase in ART patients; 22.9% increase in 25\u0026ndash;34 age group; Improved rural access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZarudskaya et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review of PAI score for PAS prediction (1,044 cases)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWomen with PAS had increased mean PAI total scores compared to those without PAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSu et al., 2024 (ASCO Guideline)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReproductive and safety outcomes after oncofertility treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specifically assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specifically assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e:\u003cem\u003eaOR: adjusted odds ratio; aRR: adjusted relative risk; AMA: advanced maternal age; ART: assisted reproductive technology; BW: birth weight; CD: cesarean delivery; CI: confidence interval; ET: embryo transfer; GA: gestational age; GDM: gestational diabetes mellitus; ICSI: intracytoplasmic sperm injection; IUI: intrauterine insemination; IVF: in vitro fertilization; NICU: neonatal intensive care unit; OR: odds ratio; PAI: placental accreta index; PAS: placenta accreta spectrum; PGT: preimplantation genetic testing; PHI: pregnancy-induced hypertension; PPH: postpartum hemorrhage; PPROM: preterm premature rupture of membranes; PROM: premature rupture of membranes; UA pH: umbilical artery pH.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e4. Future Directions: Integrating Innovation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe field of PAS management must embrace technological innovation to further de-risk patient care, as the condition's increasing prevalence now affects 1 in 2500 pregnancies [\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e]. Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e catalogs promising advances, from AI-enhanced diagnostic imaging and embryo selection to novel hemostatic agents [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e, \u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e131\u003c/span\u003e, \u003cspan additionalcitationids=\"CR147 CR148 CR149 CR150 CR151 CR152 CR153 CR154 CR155 CR156 CR157 CR158 CR159 CR160 CR161 CR162 CR163\" citationid=\"CR146\" class=\"CitationRef\"\u003e146\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR164\" class=\"CitationRef\"\u003e164\u003c/span\u003e]. The integration of such technologies, guided by structured frameworks like the one proposed in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, holds the potential to revolutionize early detection, surgical planning, and personalized care pathways.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEmerging Technologies and Future Directions in Managing the High-Risk Obstetric Triad (AMA/IVF/PAS)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTechnology/Approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStage of Development\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProposed Mechanism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreliminary Results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePotential Application\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistorical \u0026amp; Early Development (1990\u0026ndash;2007)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKim, 1990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGIFT/ZIFT Procedures; Micromanipulation Technologies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical implementation; Clinical development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced gamete/zygote transfer techniques; Direct gamete manipulation for fertilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePregnancy rates comparable to natural fecundity; Improved understanding of human fertilization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAlternative to IVF for AMA patients; Enhanced IVF outcomes in complex cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoghissi \u0026amp; Leach, 1992\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnhanced IVF protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical refinement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eImproved pharmacologic agents and surgical preservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSustained research led to IVF refinement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAMA patients requiring ART\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFauser et al., 2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlternative stimulation protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical investigation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNovel gonadotropin formulations and protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReduced side effects with maintained efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSafer stimulation protocols for high-risk AMA patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarzal et al., 2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnti-M\u0026uuml;llerian Hormone Markers; Comparative Genomic Hybridization PGS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical validation; Technology development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOHSS risk prediction through hormonal assessment; Enhanced chromosomal screening accuracy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEffective OHSS prevention strategies; Superior embryo selection protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRisk stratification in AMA-IVF cases; Genetic risk reduction in AMA pregnancies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModern Technologies (2010\u0026ndash;2015)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwain \u0026amp; Smith, 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicrofluidic embryo culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResearch development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDynamic culture with controlled fluid flow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePromising early results\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved embryo quality in high-risk cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeseguer et al., 2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicrofluidic sperm selection; Integrated IVF lab-on-a-chip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResearch development; Conceptual design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eViability-based sperm selection through narrow channels; Fully automated processing from gametes to embryo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEnhanced sperm quality assessment; Theoretical perfect embryo selection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved outcomes for AMA-IVF patients; Complete ART automation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDatta et al., 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime-lapse Embryo Monitoring; Preimplantation Genetic Screening; Advanced Sperm Selection Procedures; Embryo-Glue Transfer Medium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical implementation; Clinical practice; Clinical validation; Clinical trials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContinuous embryo development tracking without incubator disruption; Chromosomal abnormality detection in embryos pre-transfer; Enhanced sperm quality assessment and selection techniques; Hyaluronic acid-enriched medium mimicking natural environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImproved embryo selection accuracy; Reduced miscarriage rates and improved live birth rates; Improved fertilization and embryo quality; Enhanced embryo adhesion and implantation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnhanced IVF outcomes in AMA patients through better embryo assessment; Critical for AMA patients with increased aneuploidy risk; Optimized outcomes for male factor infertility in AMA/IVF cases; Supportive therapy for high-risk obstetric cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdvanced AI \u0026amp; Machine Learning Applications (2020\u0026ndash;2025)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedrosa et al., 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMicrofluidic Sperm Selection Devices; AI-Based Sperm Selection Systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical Development; Early Clinical Testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-invasive sperm sorting based on motility and morphology patterns; Machine learning algorithms for automated sperm evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEnhanced sperm quality identification for IVF procedures; Objective, reproducible sperm quality assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAMA/IVF outcomes optimization through superior gamete selection; Standardized ART protocols for AMA patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurgaud et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvanced Embryo Culture Models; Blastoid Generation Technology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResearch phase; Development phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEnhanced understanding of human embryonic development through improved culture conditions; Creation of embryo-like structures for developmental studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePotential to reduce 75% IVF cycle failure rate; Establishing new knowledge base for ART improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImproved IVF success rates for AMA patients; Enhanced embryo selection in high-risk pregnancies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdullah et al., 2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAI-Integrated IVF Automation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical Development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eArtificial intelligence integration across patient treatment pathway, gamete/embryo selection, and endometrial evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePromises personalization and partial automation of IVF processes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReducing labor-intensive procedures, improving accessibility and affordability for AMA-IVF patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHew et al., 2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAI-Enhanced IVF Quality Control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical Implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeural networks and deep learning for automated embryo/sperm selection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIncreased accuracy, consistency, and operational efficiency in IVF laboratories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandardizing processes, improving patient outcomes, reducing human error in AMA-IVF cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDanaei et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ennU-Net Deep Learning Model; DenseNet-PAS Algorithm; Radiomics-Clinical Integration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical validation; Clinical validation; Research phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAutomated segmentation and classification of PAS using MRI/ultrasound imaging; Integration of quantitative imaging features with clinical data for PAS prediction; Combines quantitative imaging biomarkers with demographic and obstetric factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSuperior performance over traditional diagnostic methods with high AUC scores; Demonstrated superior performance in PAS classification; Improved prediction of surgical morbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEarly PAS detection and risk stratification in high-risk pregnancies; Enhanced diagnostic accuracy and optimized surgical planning; Comprehensive risk assessment for AMA/IVF patients with PAS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLee, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFluorescence Lifetime Imaging Microscopy; AI-Powered Smartphone Ultrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical research; Pilot studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReal-time metabolic assessment via NAD(P)H and flavine adenine dinucleotide quantification; Automated follicle segmentation using smartphone-compatible devices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMetabolic signatures correlate with developmental competence; Supports self-assessment of ovarian follicles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNon-invasive embryo quality evaluation beyond morphological criteria; Improved ovarian stimulation tracking in AMA patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQaderi et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGradient Boosting Trees for NOA; Random Forests for IVF Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical validation; Clinical application\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMachine learning prediction of sperm retrieval success; Multi-parameter success prediction modeling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAUC 0.807, 91% sensitivity (119 patients); AUC 84.23% (486 patients)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnhanced male factor assessment in AMA/IVF cases; Personalized treatment protocols for high-risk triad patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLi et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIPTW-Adjusted Risk Modeling; Mediation Analysis Framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical validation; Research implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStabilized inverse probability treatment weighting for IVF-AMA outcomes; Quantifying cesarean section's mediating role in adverse outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePlacenta accreta risk 2.52-fold increased; PPH risk 2.03-fold increased; CS explains 21.47% of PPH risk and 26.15% of neonatal jaundice risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePrecision risk stratification for AMA-IVF patients with PAS susceptibility; Targeted intervention strategies to reduce cascade complications in high-risk obstetric triad\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGiaxi et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAI/ML Diagnostic Systems; ML-Based Perinatal Outcome Prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRapid clinical adoption; Clinical implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3D/4D ultrasound and MRI-based automated diagnosis; Integrated risk modeling for mortality, hemorrhage, and neonatal complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHigh accuracy achieved across pregnancy risk assessment domains; Significant improvements in PPH and neonatal respiratory distress prediction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReal-time PAS detection and preeclampsia prediction in AMA-IVF populations; Comprehensive outcome forecasting for high-risk obstetric triad management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRacowsky et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaboratory Automation Systems; Multimodal AI Embryo Selection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental validation; Clinical integration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrecision-controlled dish preparation, denudation, and micromanipulation; High-resolution imaging combined with metabolic and proteomic profiling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEqual or superior precision compared to skilled human operators; Superior consistency in embryo evaluation and accelerated training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandardized embryo handling for high-risk AMA-IVF cases; Comprehensive embryo assessment for PAS-risk AMA patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlikani et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAI-Integrated Quality Management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDevelopment phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eData-driven benchmarks and automated processes for standardization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetter predictable outcomes in IVF laboratories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandardized care protocols for high-risk obstetric populations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePetrogiannis et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlatelet-Rich Plasma Treatment (PRP); Mitochondrial Replacement Therapy (MRT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical investigation; Research development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOvarian rejuvenation through growth factor delivery; Oocyte competence enhancement through mitochondrial function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImproved ovarian function in poor-prognosis patients; Improved oocyte quality in aging patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAMA ovarian reserve enhancement; AMA oocyte quality restoration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKaur et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAS Risk Stratification Model\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical validation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRegion-specific weighted scoring integrating clinical predictors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94% PAS incidence; IVF risk factor (7.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEarly identification and structured referral pathways for high-risk obstetric cases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHu et al., 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnhanced Blood Management Protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTargeted hemorrhage prevention in IVF/ICSI-PAS patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.20-fold increased PPH risk; 3.71-fold increased transfusion need \u0026ge;4U\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOptimized blood product reserves and prenatal management for IVF-conceived PAS patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBentov \u0026amp; Schenker, 2025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvanced Patient Stratification Systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical integration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRisk profiling for complex medical conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBetter outcomes in medically complex patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePersonalized AMA-IVF-PAS management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eACOG Committee, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReal-world Data Collection Systems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImplementation phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLongitudinal safety and efficacy monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImproved device evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEvidence-based technology adoption in obstetric care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e: \u003cem\u003eAI: artificial intelligence; AMA: advanced maternal age; ART: assisted reproductive technology; AUC: area under the curve; CS: cesarean section; GIFT: gamete intrafallopian transfer; ICSI: intracytoplasmic sperm injection; IPTW: inverse probability of treatment weighting; IVF: in vitro fertilization; ML: machine learning; MRI: magnetic resonance imaging; MRT: mitochondrial replacement therapy; NAD(P)H: nicotinamide adenine dinucleotide phosphate; NOA: non-obstructive azoospermia; OHSS: ovarian hyperstimulation syndrome; PAS: placenta accreta spectrum; PGT: preimplantation genetic testing; PGS: preimplantation genetic screening; PPH: postpartum hemorrhage; PRP: platelet-rich plasma; ZIFT: zygote intrafallopian transfer.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWhile the available literature demonstrates successful implementation of conservative management strategies including uterine artery embolization combined with methotrexate therapy to reduce morbidity and mortality in carefully selected cases [\u003cspan citationid=\"CR165\" class=\"CitationRef\"\u003e165\u003c/span\u003e], and innovative surgical techniques to control hemorrhage while avoiding hysterectomy [\u003cspan citationid=\"CR166\" class=\"CitationRef\"\u003e166\u003c/span\u003e, \u003cspan citationid=\"CR167\" class=\"CitationRef\"\u003e167\u003c/span\u003e] the adoption of emerging technologies can build upon these foundations. Together, these integrated innovations aim to further reduce the substantial risks associated with this high-morbidity obstetric condition.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eBased on our case analysis and evidence synthesis, we propose a structured approach with the following recommendations, which align with current best practices for PAS management [\u003cspan citationid=\"CR168\" class=\"CitationRef\"\u003e168\u003c/span\u003e]: first, implement \u003cb\u003eUniversal Screening \u0026amp; Referral\u003c/b\u003e, mandating PAS ultrasound at 18\u0026ndash;20 weeks for patients with advanced maternal age and IVF pregnancy with a prior uterine scar, triggering immediate referral to a regional PAS center of excellence; second, ensure \u003cb\u003eCentralized, Protocolized Care\u003c/b\u003e exclusively at designated Level IV centers with 24/7 multidisciplinary availability, governed by institutional checklists for preoperative planning; third, adopt a \u003cb\u003eProactive Hemostasis Bundle\u003c/b\u003e as part of comprehensive patient blood management (PBM), including preoperative anemia correction, routine intraoperative cell salvage, tranexamic acid, and goal-directed transfusion therapy, incorporating novel diagnostics and pharmaceuticals regarding hemostasis [\u003cspan citationid=\"CR168\" class=\"CitationRef\"\u003e168\u003c/span\u003e]; and fourth, establish \u003cb\u003eSpecialized Registries \u0026amp; Research\u003c/b\u003e to specifically track outcomes for this subpopulation to generate higher-quality evidence, addressing current data heterogeneity, while prioritizing cost-effectiveness analyses and the integration of emerging technologies [\u003cspan citationid=\"CR168\" class=\"CitationRef\"\u003e168\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe patient with Advanced Maternal Age, IVF conception, and suspected Placenta Accreta Spectrum represents one of the most formidable challenges in contemporary obstetrics. This triad creates a synergistic risk profile that demands the highest level of coordinated, preemptive care. By recognizing its unique pathophysiology, implementing rigid management protocols centered on multidisciplinary expertise and comprehensive hemorrhage control, and developing standardized referral pathways, we can strive to improve outcomes for these highest-risk pregnancies. This represents an urgent priority for global maternal healthcare systems.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Maternal Age\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn Vitro Fertilization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePlacenta Accreta Spectrum\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMPH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMassive Peripartum Hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePBM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient Blood Management\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFET\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFrozen Embryo Transfer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eD\u0026amp;C\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDilatation and Curettage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePGT-A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreimplantation Genetic Testing for Aneuploidies.\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 Written informed consent was obtained from the patient for publication of this case report and the accompanying de-identified medical images. This case report was conducted in accordance with the Declaration of Helsinki. As this was a retrospective analysis of a single clinical case for educational purposes, formal IRB approval was not required per the policies of West China Second University Hospital, Sichuan University. The patient consent form explicitly permits publication of de-identified clinical data and images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003eThe patient has provided written informed consent for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials \u003c/strong\u003eAll data generated or analysed during this study are included in this published article. \u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests. \u003cstrong\u003eFunding:\u003c/strong\u003e 1. National Key Research and Development Program of China (2022YFC3600304)\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eNational Key Research and Development Program of China (2022YFC2704700)\u003c/li\u003e\n \u003cli\u003eCadre Health Care Committee of Sichuan Province, China (2023-1701)\u003c/li\u003e\n \u003cli\u003ePrincipal Investigator Foundation of Tianfu Jincheng Laboratory (TFJCPI20250037)\u003cbr\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003eS.W:\u003c/strong\u003e Conceptualization, Writing \u0026ndash; Original Draft, Investigation, Project administration. \u003cstrong\u003eS.Z:\u003c/strong\u003e Methodology, Formal Analysis, Data Curation, Writing \u0026ndash; Review \u0026amp; Editing. \u003cstrong\u003eJ.Z:\u003c/strong\u003e Investigation, Validation, Writing \u0026ndash; Review \u0026amp; Editing. \u003cstrong\u003eL.H:\u003c/strong\u003e Investigation, Resources, Writing \u0026ndash; Review \u0026amp; Editing. \u003cstrong\u003eH.Z:\u003c/strong\u003e Resources, Visualization, Writing \u0026ndash; Review \u0026amp; Editing. \u003cstrong\u003eX.X:\u003c/strong\u003e Conceptualization, Supervision, Writing \u0026ndash; Review \u0026amp; Editing, Funding acquisition.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003cbr\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors thank the multidisciplinary team involved in the patient\u0026apos;s care, including the departments of Interventional Radiology, Neonatology, and Transfusion Medicine.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWu S, Kocherginsky M, Hibbard JU. 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J Perinat Med. 2022;51(4):439\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Advanced Maternal Age, In Vitro Fertilization, Placenta Accreta Spectrum, Multidisciplinary Team Care, Patient Blood Management, Peripartum Hemorrhage","lastPublishedDoi":"10.21203/rs.3.rs-8663115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8663115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: The convergence of Advanced Maternal Age (AMA ≥35), In Vitro Fertilization (IVF) conception, and Placenta Accreta Spectrum (PAS) disorders represents a clinical nexus of extreme obstetric risk, characterized by a high probability of massive peripartum hemorrhage (MPH). This triad necessitates a paradigm shift from reactive to proactive, protocol-driven management.\u003c/p\u003e\n\u003cp\u003eCase presentation: A 54-year-old G4P2 with an IVF-conceived twin pregnancy and two prior cesarean deliveries presented at 34 1/7 weeks with catastrophic hemorrhage. Prenatal MRI confirmed placenta percreta. An emergency classical cesarean hysterectomy with partial cystectomy was performed by a multidisciplinary team employing a comprehensive hemostatic strategy including prophylactic arterial balloon occlusion, tranexamic acid, intraoperative cell salvage, and a massive transfusion protocol. Estimated blood loss was 4,500 mL. Both neonates required NICU admission but were discharged in stable condition.\u003c/p\u003e\n\u003cp\u003eConclusions: This case exemplifies the synergistic pathophysiology and amplified morbidity of the AMA/IVF/PAS triad. Effective management mandates: 1) Aggressive prenatal diagnosis with early MRI; 2) Mandatory delivery at a Level IV center with a pre-assembled, multidisciplinary team; and 3) Implementation of a proactive Patient Blood Management plan. We propose a structured clinical pathway and standardized referral algorithm to optimize outcomes for this uniquely high-risk population.\u003c/p\u003e","manuscriptTitle":"The Quintessential High-Risk Triad: Advanced Management Strategies for Placenta Accreta Spectrum in Patients with Advanced Maternal Age and IVF Conception","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 16:24:19","doi":"10.21203/rs.3.rs-8663115/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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