Risk Factors for Peripartum Hysterectomy Among Pregnancies with Suspected Placenta Accreta Spectrum in Preoperative Obstetric Imaging Screening: a Retrospective Cohort Study

Risk Factors for Peripartum Hysterectomy Among Pregnancies with Suspected Placenta Accreta Spectrum in Preoperative Obstetric Imaging Screening: a Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Factors for Peripartum Hysterectomy Among Pregnancies with Suspected Placenta Accreta Spectrum in Preoperative Obstetric Imaging Screening: a Retrospective Cohort Study Lulu Wang, Tianjiao Liu, Yang Yang, Yalan Li, Li Xiao, Xin Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4801980/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jan, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 16 You are reading this latest preprint version Abstract Objective : This study aimed to identify risk factors for peripartum hysterectomy among pregnancies complicated by suspected Placenta Accreta Spectrum (PAS) in preoperative obstetric imaging screening. Methods : Data were retrospectively extracted from the Longitudinal Placenta Accreta Spectrum Study (LoPASS), covering pregnancies with PAS from January 2018 to March 2023 at our institute. Patients were divided into Control and Hysterectomy groups based on whether they underwent hysterectomy. Sociodemographic, obstetric, and clinical characteristics were compared between the groups. Multivariate logistic regression analysis was performed on the characteristics with statistical significance to explore risk factors for peripartum hysterectomy. Results : Among 523 pregnancies with suspected PAS, 20 underwent hysterectomy. The Hysterectomy group had a significantly higher mean age (34.50±5.05 vs. 31.66±4.43 years, p=0.005) and pre-pregnancy BMI (26.35±3.27 vs. 23.84±3.99, p=0.006). The Hysterectomy group also had a higher proportion of patients with more than 2 gravidities (100% vs. 61.6%, p=0.022) and multiple parities (90.0% vs. 39.9%, p<0.001). Higher percentages of placenta percreta (90.0% vs. 28.2%, p<0.001), placenta attaching to the anterior uterine wall (57.9% vs. 31.8%, p=0.033), and higher PAS ultrasonographic scores (11.42±2.54 vs. 6.21±2.55, p<0.0001) were observed in the Hysterectomy group. Perioperative outcomes revealed significantly longer surgical durations (171.90±49.27 vs. 53.46±24.41 minutes, p<0.001) and higher rates of preterm birth (100.0% vs. 55.3%, p<0.001). Intraoperative blood loss was also substantially greater in the Hysterectomy group (2695.00±1241.17 ml vs. 764.31±385.10 ml, p<0.001). Variables significantly associated with increased peripartum hysterectomy risk included prior cesarean sections (OR=1.44, p=0.048), placenta attaching to the anterior uterine wall (OR=0.73, p=0.015), placenta completely covering the uterine incision (OR=1.27, p=0.035), gestational hypertensive disorder (OR=1.69, p=0.042), placenta percreta (OR=2.31, p=0.032), and PAS ultrasonographic score higher than 10 (OR=2.71, p=0.008). Conclusion : Prior cesarean sections, placenta location, gestational hypertensive disorder, placenta percreta, and a PAS ultrasonographic score higher than 10 are risk factors for peripartum hysterectomy in pregnancies with suspected PAS. This underscores the importance of early and consistent obstetric imaging examinations of the placenta and active preparation for emergency cesarean sections in such pregnancies. Risk Factors Hysterectomy Placenta Accreta Spectrum Cesarean Sections Peripartum Hemorrhagic Morbidity Figures Figure 1 Background Placenta Accreta Spectrum(PAS) refers to the abnormal implantation of placental tissue onto the uterine myometrium. Based on the histological depth of placental adherence, this spectrum can be divided into placenta accreta, placenta increta, and placenta percreta. It interferes the extending of growing uterus during pregnancy and hinders placental detachment during delivery thus may cause uncontrollable hemorrhage and subsequently may be cause of increased maternal morbidity and mortality. Its prevalence reportedly increases along with the previous cesarean deliveries, from 0.3% in pregnant women who experienced cesarean section once to 6.7% in women underwent 6 prior cesarean sections. 1 , 2 One of the most severe complications associated with PAS is the need for peripartum hysterectomy, a life-saving procedure in cases of uncontrollable hemorrhage with a global prevalence at about 1 in 1,000 deliveries. 3 While advances in obstetric care have reduced maternal mortality rates, peripartum hysterectomy remains a rare but critical intervention to prevent life-threatening hemorrhage. 4 – 6 Understanding the risk factors contributing to the necessity of peripartum hysterectomy in pregnancies complicated by Placenta Accreta Spectrum (PAS) is essential for establishing effective management and prevention strategies, as well as for preoperative counseling. Previous studies have identified several risk factors associated with the need for peripartum hysterectomy. 7 , 8 However, studies that mainly focused on hysterectomy among the PAS-complicated pregnancies are relatively rare. Furthermore, the unique obstetric characteristics such as advanced maternal age, high proportion of multiparous women and high cesarean section rate of Chinese population due to social and policy factors underscores the importance of investigating regional or population-specific risk factors for peripartum hysterectomy. 9 – 11 This retrospective cohort study aims to elucidate the risk factors associated with peripartum hysterectomy among pregnancies complicated by PAS in our institution. By analyzing a large cohort of PAS complicated pregnancy, we seek to identify demographic, obstetric, and clinical factors that differs between hysterectomy group and non-hysterectomy groups, and also screen out the risk factors which might predict the occurrence of peripartum hysterectomy. The findings of this study may potentially facilitate the clinical decision-making, and the refinement of guideline for reducing the incidence of peripartum hysterectomy and improving maternal outcomes of PAS. Materials and methods Study design The current study was derived from the Longitudinal Placenta Accreta Spectrum Study (LoPASS), a cohort study on PAS conducted in Chengdu, Sichuan province, China, aiming to ascertain the impacts of both genetic factors and environmental influences on the onset of PAS, as well as to establish novel early screening and interfering method to improve the maternal and neonatal outcomes (registered in the Chinese Clinical Trial Registry, ID: ChiCTR2100052428, date: October 26 th , 2021) . Figure 1 depicted the flowchart of study design of current study. From January 2018 to March 2023, among approximately 15,000 childbirth cases at our institute, all patients prenatally diagnosed with suspected PAS (ultrasound PAS score higher than 5) were included in this study. Patients with placenta previa, twin or multiple pregnancies were excluded. The patient management strategy of patients with PAS was described in our previous publication. 12 Based on underwent hysterectomy or not, the patients were divided into Control and Hysterectomy groups. Subsequently, a comparative analysis was conducted on both groups’ demographic characteristics, sociodemographic features, maternal and neonatal outcomes, and clinical features related to hemorrhagic disorders. Following this, a multivariate logistic regression analysis was performed to explore risk factors that differs between both groups or reportedly associated with peripartum hysterectomy, which includes maternal age, pre-pregnancy Body Mass Index (BMI), weight gain during pregnancy, conception mode, gestational hypertensive disorder (GHD), gravidity, parity, previous cesarean sections, placenta covering uterine incision, , location of uterine incision, and type of PAS. Diagnosis of PAS According to the currently widely accepted guidelines regarding the diagnosis of PAS, it is acknowledged that definitive diagnosis of PAS requires pathological examination following hysterectomy. 13-15 However, in order to facilitate early screening of pregnancies complicated by PAS and to enable rigorous and timely obstetric management for improved maternal and neonatal outcomes, we employed medical imaging methods especially ultrasonography and magnetic resonance imaging (MRI) if necessary for thorough examination of the placenta prior to cesarean section, as recommended by some previous studies. 1,16 The PAS ultrasonic scoring criteria applied in this study was based on the previous studies which analyzed prenatal ultrasound imaging characteristics including placental location and thickness, presence or absence of the low echoic zone behind the placenta, continuity of the bladder line, morphology of placental lacunae, blood flow signals at the placental base, integrity of cervical morphology, presence of cervical blood sinuses, and history of cesarean section. Each item is scored from 0 to 2 points, and the total score is calculated. 17,18 A same set of Color Doppler ultrasound diagnostic equipment (GE volusion E8, General Electric, Boston, the United States) and standard default parameters with a probe frequency of 3.5 MHz were applied. Moreover, the ultrasonic predictive diagnosis of PAS in this study was performed by the same group of approximately eight to ten experienced senior obstetric ultrasound doctors who were trained before the commencement of this study using 100 anonymized cases to ensure the consistency and reproducibility of scoring among different doctors. When a patient's ultrasound PAS score is between 5 and 10, we consider her as suspected adhesive PAS. When the ultrasound PAS score is greater than 10, we consider the patient as having suspected severe PAS (increta or percreta). Through these means, we preliminarily diagnose suspected PAS and its subtypes, which includes accrete (placental tissue implants onto the myometrium),increta (into the myometrium), or percreta (penetrating through the myometrium to neighboring organ), based on the depth of placental implantation. 2,19 In cases which underwent hysterectomy, the diagnose of PAS was based on the finding of postoperative pathological investigations. Indication of Cesarean section for patients with PAS According to relevant clinical guidelines and previous literature, performing cesarean section slightly before the expected due date may potentially improve maternal and neonatal outcomes in pregnancies complicated by PAS. 13 Therefore, for PAS-complicated pregnancies, our hospital performs cesarean section at around 36 th week of gestation for pregnant women without vaginal bleeding, at about 34 th week of gestation for those with recurrent mild vaginal bleeding, and for pregnant women experiencing sudden vaginal bleeding exceeding 100ml, or with notable fetal activity reduction accompanied by abnormal fetal heart monitoring or abnormal umbilical cord blood flow, emergency cesarean section is performed. 12 Indications for peripartum hysterectomy Our institute applied criteria similar to those described in previous literature for performing cesarean hysterectomy. 20 Specifically, indications include intraoperative bleeding exceeding 1500 mL with ongoing active bleeding, deemed uncontrollable within a short timeframe and threating the patient's life. Ethical statement This study was conducted with approval obtained from the Ethics Committee of the Chengdu Women’s and Children’s Central Hospital (Approval No.201830). All the identifiable information such as patients’ name, ID number, home address, phone number, etc., was deleted before statistical analysis for privacy concerns. Statistical analysis The statistical analysis for this study was performed using Statistical Package for the Social Sciences (SPSS) software version 25.0 (IBM Inc., Armonk, NY, USA). Categorical data were assessed using Fisher’s exact test or Chi square test, and results were expressed as frequencies and percentages. For continuous variables, means and standard deviations were calculated using either Student’s t-test or least significant difference Student’s t-test. To investigate the correlation between maternal characteristics and the occurrence of hysterectomy, multivariate logistic regression analysis was conducted. Covariates were selected based on significantly different characteristics identified in the univariate analysis and factors previously reported that may be relevant to peripartum hysterectomy, which includes maternal age, pre-pregnancy BMI, weight gain during pregnancy, parity, gravidity, conception mode, types and of placenta previa or PAS, location of placenta, types of gestation hypertensive disorder (GHD). All statistical tests were two-tailed, with statistical significance set as p value lower than 0.05. Result Sociodemographic and obstetric characteristics of study cohort Table1 listed the sociodemographic, obstetric, and other clinical characteristics of the study cohort. There were 523 pregnant women with placenta previa included in this study, among whom 20 women underwent hysterectomy. Patients were thus divided into the Control group and the hysterectomy group. Notably, the mean age was significantly higher in the Hysterectomy group compared to the Control group (34.50±5.05 vs. 31.66±4.43 years, p = 0.005). Moreover, there was a statistically significant difference in BMI before pregnancy between the two groups (26.35±3.27 vs. 23.84±3.99, p = 0.006). As for obstetric features between both groups, significant differences were observed in gravidity and parity between the two groups. Specifically, a higher proportion of women in the Hysterectomy group had a gravidity of 3 or more compared to the Control group (100% vs. 61.6%, p = 0.022), and similarly, a higher proportion of women in the Hysterectomy group had a parity of 2 or more compared to the Control group (90.0% vs. 39.9%, p < 0.001). Furthermore, there was a significant difference in the times of previous cesarean sections, with a higher proportion of women in the Hysterectomy group having undergone cesarean sections twice previously (p < 0.001). Correspondingly, we also observed a significantly higher proportion of patients with placenta attaching to the anterior uterine in Hysterectomy group all as compared to their counterparts in the Control group (57.9 %vs 31.8%, p =0.033). As for types of PAS, the Hysterectomy group also exhibited higher frequencies of placenta percreta compared to Control group (90.0% vs 28.2%, p < 0.001). In addition, gestational hypertension and mild preeclampsia were more common in the Hysterectomy group (20.0% vs 1.4%, p < 0.001). Preoperative Clinical features of Hysterectomy group and Control group Table 2 showed the preoperative clinical characteristics of both groups. In general, the prevalence of B type hepatitis, syphilis, anemia, and recurrent spontaneous abortion (RSA) did not significantly differ between the groups. Whilst, Diabetes Mellitus, categorized into Type I and Type II, showed significant discrepancies (p<0.001), though results from oral glucose tolerance tests (OGTT) revealed varied levels across different time points, although statistical significance was not consistently observed. Perioperative maternal and neonatal outcomes in both group Table 3 illustrated the perioperative outcomes of the Control and Hysterectomy groups. Notably, the surgical duration was substantially longer in the Hysterectomy group compared to the Control group (171.90±49.27 vs. 53.46±24.41 minutes, p < 0.001). Additionally, , the incidence of preterm birth (100.0% vs. 55.3%, p < 0.001), neonatal asphyxia (40.0% vs. 10.0%, p < 0.001), and hypoproteinemia of the mother (100.0% vs. 55.3%, p < 0.001) was also significantly higher in the Hysterectomy group compared to the Control group. Hemorrhagic morbidity-related characteristics of Hysterectomy and Control groups Table 4 presented the hemorrhagic morbidity-related characteristics of the Control and Hysterectomy groups. Notably, there were significant differences in various parameters related to blood loss and transfusion between the two groups. For instance, intraoperative blood loss (ml) was substantially higher in the Hysterectomy group compared to the Control group (2695.00±1241.17 vs. 764.31±385.10, p < 0.001). Similarly, there were significant differences in intraoperative urine output, fluid infusion volume, hematocrit levels, plasma transfusion, and autologous blood transfusion between the two groups (all p < 0.001). Risk factor analysis for peripartum hysterectomy in PAS-completed pregnancy In our risk factor analysis for peripartum hysterectomy among pregnancies complicated by PAS, several variables exhibited statistically significant associations (shown in Table 5 ). Specifically, an increased likelihood of undergoing hysterectomy was observed with previous cesarean sections (OR=1.44, 95% CI: 1.21, 8.46, p=0.048) , placenta attaching site (anterior, lateral, or posterior wall) (OR=0.73, 95% CI: 0.62, 0.91 p=0.015), placenta covering uterine incision(OR=1.27, 95% CI: 1.14, 3.27, p=0.035), and types of GHD (OR=1.69, 95% CI: 1.24, 5.77, p=0.042). Moreover, placenta percreta also demonstrated a notable association with peripartum hysterectomy risk (OR=2.31, 95% CI: 1.76, 5.11, p=0.032). Conversely, other variables including maternal age, pre-pregnancy BMI, weight gain during pregnancy, conception mode (natural conception or in vitro fertilization, IVF), Gestational Diabetes Mellitus (GDM), gravidity, and parity did not exhibit statistically significant associations with peripartum hysterectomy in our analysis. Discussion Peripartum hysterectomy remains a rare yet critical intervention for managing life-threatening hemorrhage in pregnancies complicated by PAS. While there have been some studies on the risk factors for cesarean hysterectomy among Chinese obstetric patients, there is a relative scarcity of research focusing specifically on pregnancies complicated by PAS. 21-23 In this retrospective cohort study, we compared the demographic features, obstetric, and other clinical characteristics, as well as hemorrhagic morbidity-related indicators between the hysterectomy group and the control group and also identified the risk factors associated with peripartum hysterectomy within this specific obstetric context. The present study found several factors that predicts hysterectomy among prenatally suspected PAS, including the number of previous cesarean sections, placenta attaching to the anterior uterine wall, gestational hypertension, percreta, placenta covering the uterine incision, and PAS ultrasonographic score greater than 10. These findings may offer clinical guidance in several areas, such as determining whether and when to refer pregnant women with PAS in remote areas; timing of delivery or cesarean section; preoperative preparation, particularly in preparing for possible severe maternal hemorrhage; intraoperative strategies such as uterine artery ligation or, in cases with preoperative imaging signs of placenta percreta, preparing for the placement of an aortic balloon catheter; and preventing adverse surgical outcomes, such as consulting with urologists preoperatively for cystoscopy to assess bladder involvement and placing ureteral stents to reduce the risk of ureteral injury during uterine artery ligation. 17 The diagnostic criteria of PAS tend to vary in different nations and guidelines. 13-15 According to the ISUOG guideline, the diagnosis of PAS can only be made after the performance of hysterectomy based on the finding of postoperative pathologic investigation of resected uterine and the placenta. However, our previous study, with detailed preoperative imaging examination of patients with suspected PAS, has achieved a success rate of diagnosis of PAS at about 80-90%, which encouraged us to screening out pregnancies with potentially severe PAS using medical imaging. 12 The incidence rate of placenta previa among our cohort of pregnant women with PAS was 3.97%. In comparison, a multicenter international study on risk factors for cesarean hysterectomy in women with postpartum hemorrhage in the peripartum period reported an incidence rate of approximately 5.10% for cesarean hysterectomy. 20 Considering that their study included pregnant women without PAS, our rate of cesarean hysterectomy appears relatively lower. The overall peripartum hysterectomy rate in our hospital over the past five years has been around 1.5-7.7 per thousand births, which is comparable compared to the approximately 5 per thousand pregnancies reported in another retrospective study based on the ethnic Han Chinese population. 8,12 Our multivariate logistic regression model revealed that certain obstetric characteristics such as previous cesarean section, placenta completely covering uterine incision, placenta attaching to the anterior uterine wall, GHD, and type of PAS were identified as risk factors for undergoing hysterectomy. Conversely, maternal age, pre-pregnancy BMI, Weight gain during pregnancy, conception mode (IVF or natural conception), GDM, gravidity, parity, and scarred uterine were not predictive of hysterectomy risk. These findings are similar with our previous investigations into the risk factors for emergency cesarean section among pregnancies complicated by PAS. 12 Although some previous studies have suggested that advanced maternal age and parity might be risk factors for peripartum hysterectomy, and our study found that the mean age and parity of the Hysterectomy group was significantly higher than that of the control group, our data did not reveal age as a risk factor for peripartum cesarean section. 8,24 Consistent with previous literature, our study also identified a history of previous cesarean sections as a significant risk factor for peripartum hysterectomy among women with PAS. Specifically, each additional cesarean section was associated with a 44% increased likelihood of undergoing hysterectomy, highlighting the importance of considering obstetric history in the management of PAS-complicated pregnancies. This finding also highlights the need for cautious evaluation and counseling regarding the mode of delivery. Strict avoidance of cesarean section without medical indication may help mitigate the risk of complications such as PAS and peripartum hysterectomy, given that cesarean section rate in megacities of mainland China is already relatively high. 9 Intriguingly, placenta completely covering the uterine incision, or locating on the anterior wall emerged as other critical risk factor for peripartum hysterectomy in our study. In consistent with our study, Jing also reported that placenta is located on the anterior wall is correlated to the possibility of massive postpartum hemorrhage, and attachment of placenta to the uterine incision site was significantly associated with PAS disorders, 25 demonstrating the high necessity of assessing placentation patients with PAS during the mid to late stages of pregnancy using medical imaging methods. The increased difficulty in cesarean section procedures when the placenta adheres to the anterior uterine wall, it may limit surgical visibility. Consequently, surgeons encounter challenges in performing the cesarean section. Our study also identified GHD as a significant risk factor for peripartum hysterectomy among women with PAS. Han's team similarly found a significant association between gestational hypertensive disorder and placental abnormalities. 26 This finding highlights the complex interplay between hypertensive disorders of pregnancy and placental abnormalities, necessitating close monitoring and multidisciplinary management in GHD complicated pregnancies. While the precise pathophysiological mechanisms remain unclear, this may be linked to aberrations in the invasive capacity of trophoblast cells and the remodeling ability of small blood vessels within the placenta of these patients. Early diagnosis and intervention for GHD may help mitigate the risk of severe complications such as placental abruption and peripartum hysterectomy. 27,28 We did not find any association between the mode of conception and peripartum hysterectomy, despite some previous studies suggesting that assisted reproductive technologies (ART) such as IVF and ICSI may increase the risk of PAS or peripartum hemorrhage. 29,30 Theoretically, there may indeed be a correlation between such ART pregnancies and the occurrence of placenta previa. This could be attributed, on one hand, to characteristics inherent to IVF recipient themselves, such as advanced maternal age, high psychological stress, history of multiple uterine interventions, parity, and previous miscarriages or abortions. 31,32 On the other hand, the manipulation involved in such ART and the ovulation-inducing hormones applied during ART may induce stimulation of uterine contractions and thus potentially causes PP. ART may also lead to metabolic and epigenetic changes in the embryo, potentially leading to abnormal trophoblast differentiation, increased placental size, and consequently, an elevated risk of PP. 33-35 While the association between ART and the incidence of PAS remains controversial. Our findings revealed that early, timely, and consistent monitoring of placenta using medical imaging is of great importance. When the placenta is located on the posterior uterine wall or the patient has a thick abdominal wall, MRI serves as another important medical imaging modality to ultrasound for diagnosing PAS. MRI can reveal the anatomical structures of the implantation site and the blood supply of the surrounding tissues. It provides a more detailed view of the extent of parametrium and ureter involvement, which helps guide intraoperative strategies to avoid highly vascularized placental areas, thereby reducing the risk of hemorrhage. 36,37 Many previous studies had showed that ultrasound or MRI findings at early third trimester and even early first trimester might predict the occurrence of PAS and other surgical outcomes. 38,39 Our research team has also conducted studies on the application of MRI to monitor the dynamic changes in placental position during pregnancy, and found that more than half of the PP diagnosed at 28th-week placenta previa by MRI were still previa at the 36 weeks of gestation, highlighting the active obstetric imaging examination and early preparation for cesarean section during 3 rd trimester for PAS complicated gestation. 40 Of course, the use of demographic and obstetric characteristics to predict uterine hysterectomy or peripartum hemorrhage has greater applicability, especially for women managed in medical institutes with limited source of blood supply and obstetric surgical experts or equipment. For them, timely referral into qualified medical institution is of considerable necessity. This study has several notable strengths and limitations. One key strength is its relatively large sample size, which included almost all the cases of PAS in a tertiary medical institution that manages maternal and child healthcare for a metropolitan area with a population of 20 million and its surrounding satellite cities. Additionally, the study's detailed examination of obstetric and perioperative characteristics offers a comprehensive understanding of the factors influencing outcomes in patients with placenta previa. However, the generalizability of the findings is limited by the single-center design. Conducted within a single institution, the results may not be directly applicable to other regions or populations with different demographic, socio-economic, or healthcare characteristics. The retrospective nature of the study may also introduce potential biases related to the accuracy and completeness of medical records. Moreover, our study relied mainly on imaging to screen for suspected PAS and included only a small number of patients who underwent hysterectomy with postoperative pathological confirmation of PAS. Therefore, some mild cases or those with relatively superficial placental invasion might be omitted. Therefore, a multicenter prospective study with a randomized controlled trial (RCT) design is warranted to provide more solid clinical evidence for facilitating the prenatal examination and preliminary diagnosis of PAS. Conclusion The prior cesarean deliveries, placental positioning on the anterior uterine wall, GHD, and types of PAS are predicative for peripartum hysterectomy in cases of PAS-complicated pregnancies, underscoring the significance of timely referral, prompt and regular obstetric surveillance of placenta in third trimester and proactive preparation for potential blood transfusion and cesarean delivery in PAS pregnancies. Abbreviations BMI Body Mass Index GDM Gestational Diabetes Mellitus GHD Gestational Hypertensive Disorder ICSI Intracytoplasmic Sperm Injection ISUOG International Society of Ultrasound in Obstetrics and Gynecology IVF In Vitro Fertilization LoPASS Longitudinal Placenta Accreta Spectrum Study MRI Magnetic Resonance Imaging OGTT Oral Glucose Tolerance Test PAS Placenta Accreta Spectrum RSA Recurrent Spontaneous Abortion Declarations Funding Financially support for present study was provided by Yingcai Scheme, Chengdu Women's and Children's Central Hospital(CWCCH) (No.YC2023004), Japan-China Sasakawa Medical Fellowship Program (No.4408), Fifth Round of Chengdu Municipal Science and Technology Research Program (2021-YF05-00627-SN), Chengdu High-level Key Clinical Specialty Construction Project, and Tianfu Jincheng Laboratory Foundation (TFJC2023010001). Ethic Statement The study was conducted with the ethic approval obtained from institutional review board of Chengdu Women's and Children's Central Hospital (No. 2018117) and the written consent form of recruited patients. All identifiable characteristics of patients were deleted while transcribing data from the hospital information system to protect patients’ privacy. Author contribution LW, TL and Xin Li conceptualized this study and drafted the manuscript. Xin Li, YL and YY collected the data. TL, Xin Li, LW, and YY analyzed the data. SW and Li Xiao supervised the study and also revised the manuscript. Acknowledgement None Declaration The authors declare no conflict of interests. Data Availability The datasets analyzed in present study are available from the corresponding author on request. References Silver, R. M. & Branch, D. W. Placenta Accreta Spectrum. The New England journal of medicine 378 , 1529-1536, doi:10.1056/NEJMcp1709324 (2018). Bloomfield, V., Rogers, S. & Leyland, N. Placenta accreta spectrum. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 192 , E980, doi:10.1503/cmaj.200304 (2020). van den Akker, T., Brobbel, C., Dekkers, O. M. & Bloemenkamp, K. W. M. Prevalence, Indications, Risk Indicators, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis. Obstetrics and gynecology 128 , 1281-1294, doi:10.1097/aog.0000000000001736 (2016). Gueli Alletti, S. et al. Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin. Journal of minimally invasive gynecology 27 , 22-23, doi:10.1016/j.jmig.2019.06.001 (2020). İçen, M. S. et al. Hypogastric artery ligation in postpartum haemorrhage: a ten-year experience at a tertiary care centre. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 41 , 536-540, doi:10.1080/01443615.2020.1755623 (2021). Morel, O. et al. Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques. Journal of visceral surgery 148 , e95-102, doi:10.1016/j.jviscsurg.2011.02.002 (2011). Kallianidis, A. F. et al. Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis. Obstetrics and gynecology 141 , 35-48, doi:10.1097/aog.0000000000005022 (2023). Yang, M. J. & Wang, P. H. Peripartum hysterectomy risk factors in Taiwan. Journal of the Chinese Medical Association : JCMA 73 , 399-400, doi:10.1016/s1726-4901(10)70086-1 (2010). Li, H. T., Hellerstein, S., Zhou, Y. B., Liu, J. M. & Blustein, J. Trends in Cesarean Delivery Rates in China, 2008-2018. Jama 323 , 89-91, doi:10.1001/jama.2019.17595 (2020). Cao, J. et al. Trends in maternal age and the relationship between advanced age and adverse pregnancy outcomes: a population-based register study in Wuhan, China, 2010-2017. Public health 206 , 8-14, doi:10.1016/j.puhe.2022.02.015 (2022). Zeng, Y. & Hesketh, T. The effects of China's universal two-child policy. Lancet (London, England) 388 , 1930-1938, doi:10.1016/s0140-6736(16)31405-2 (2016). Zhao, H. et al. Risk factors of emergency cesarean section in pregnant women with severe placenta accreta spectrum: a retrospective cohort study. Frontiers in medicine 10 , 1195546, doi:10.3389/fmed.2023.1195546 (2023). Jauniaux, E. et al. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. BJOG : an international journal of obstetrics and gynaecology 126 , e1-e48, doi:10.1111/1471-0528.15306 (2019). Pilloni, E. et al. Accuracy of ultrasound in antenatal diagnosis of placental attachment disorders. Ultrasound Obstet Gynecol 47 , 302-307, doi:10.1002/uog.14893 (2016). Cali, G. et al. Prenatal ultrasound staging system for placenta accreta spectrum disorders. Ultrasound Obstet Gynecol 53 , 752-760, doi:10.1002/uog.20246 (2019). Jauniaux, E. & Bhide, A. Prenatal ultrasound diagnosis and outcome of placenta previa accreta after cesarean delivery: a systematic review and meta-analysis. American journal of obstetrics and gynecology 217 , 27-36, doi:10.1016/j.ajog.2017.02.050 (2017). Chong Yiwen, Z. A., Wang Yan, Liu Zhaohui, Chen Yunshan, Zhao Yangyu. Value of ultrasonic scoring system for predicting risks of placenta accreta. Chin J Perinat Med Vol. 19, No. 9 , 705-709, doi:10.3760/cma.j.issn.1007-9408.2016.09.014 (2016). Chong, Y., Zhang, A., Wang, Y., Chen, Y. & Zhao, Y. An ultrasonic scoring system to predict the prognosis of placenta accreta: A prospective cohort study. Medicine 97 , e12111, doi:10.1097/md.0000000000012111 (2018). Hecht, J. L. et al. Classification and reporting guidelines for the pathology diagnosis of placenta accreta spectrum (PAS) disorders: recommendations from an expert panel. Mod Pathol 33 , 2382-2396, doi:10.1038/s41379-020-0569-1 (2020). Huque, S. et al. Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial. BMC pregnancy and childbirth 18 , 186, doi:10.1186/s12884-018-1829-7 (2018). Jin, R., Guo, Y. & Chen, Y. Risk factors associated with emergency peripartum hysterectomy. Chinese medical journal 127 , 900-904 (2014). Chen, M. et al. Peripartum hysterectomy between 2009 and 2010 in Sichuan, China. Int J Gynaecol Obstet 120 , 183-186, doi:10.1016/j.ijgo.2012.09.012 (2013). Wei, Q. et al. Peripartum hysterectomy in 38 hospitals in China: a population-based study. Archives of gynecology and obstetrics 289 , 549-553, doi:10.1007/s00404-013-3002-x (2014). Jou, H. J., Hung, H. W., Ling, P. Y., Chen, S. M. & Wu, S. C. Peripartum hysterectomy in Taiwan. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 101 , 269-272, doi:10.1016/j.ijgo.2007.12.004 (2008). Jing, L., Wei, G., Mengfan, S. & Yanyan, H. Effect of site of placentation on pregnancy outcomes in patients with placenta previa. PloS one 13 , e0200252, doi:10.1371/journal.pone.0200252 (2018). Han, X., Guo, Z., Yang, X., Yang, H. & Ma, J. Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder. JAMA network open 5 , e2228002, doi:10.1001/jamanetworkopen.2022.28002 (2022). Sinkey, R. G. et al. Prevention, Diagnosis, and Management of Hypertensive Disorders of Pregnancy: a Comparison of International Guidelines. Current hypertension reports 22 , 66, doi:10.1007/s11906-020-01082-w (2020). Ives, C. W., Sinkey, R., Rajapreyar, I., Tita, A. T. N. & Oparil, S. Preeclampsia-Pathophysiology and Clinical Presentations: JACC State-of-the-Art Review. Journal of the American College of Cardiology 76 , 1690-1702, doi:10.1016/j.jacc.2020.08.014 (2020). Tang, D., Cheng, Y., Feng, X., Li, X. & Coyte, P. C. The use of IVF/ICSI and risk of postpartum hemorrhage: A retrospective cohort study of 153,765 women in China. Frontiers in public health 11 , 1016457, doi:10.3389/fpubh.2023.1016457 (2023). Zhu, L. et al. Maternal and Live-birth Outcomes of Pregnancies following Assisted Reproductive Technology: A Retrospective Cohort Study. Scientific reports 6 , 35141, doi:10.1038/srep35141 (2016). Nakamura, K., Sheps, S. & Arck, P. C. Stress and reproductive failure: past notions, present insights and future directions. Journal of assisted reproduction and genetics 25 , 47-62, doi:10.1007/s10815-008-9206-5 (2008). Dimitriadis, E., Menkhorst, E., Saito, S., Kutteh, W. H. & Brosens, J. J. Recurrent pregnancy loss. Nature reviews. Disease primers 6 , 98, doi:10.1038/s41572-020-00228-z (2020). Horcajadas, J. A. et al. Effect of controlled ovarian hyperstimulation in IVF on endometrial gene expression profiles. Molecular human reproduction 11 , 195-205, doi:10.1093/molehr/gah150 (2005). Kanatsu-Shinohara, M. et al. Intracytoplasmic sperm injection induces transgenerational abnormalities in mice. The Journal of clinical investigation 133 , doi:10.1172/jci170140 (2023). Jiang, Z. et al. Genetic and epigenetic risks of assisted reproduction. Best practice & research. Clinical obstetrics & gynaecology 44 , 90-104, doi:10.1016/j.bpobgyn.2017.07.004 (2017). Palacios Jaraquemada, J. M. & Bruno, C. H. Magnetic resonance imaging in 300 cases of placenta accreta: surgical correlation of new findings. Acta obstetricia et gynecologica Scandinavica 84 , 716-724, doi:10.1111/j.0001-6349.2005.00832.x (2005). Palacios-Jaraquemada, J. M., Bruno, C. H. & Martín, E. MRI in the diagnosis and surgical management of abnormal placentation. Acta obstetricia et gynecologica Scandinavica 92 , 392-397, doi:10.1111/j.1600-0412.2012.01527.x (2013). Wu, Q. et al. Radiomics analysis of placenta on T2WI facilitates prediction of postpartum haemorrhage: A multicentre study. EBioMedicine 50 , 355-365, doi:10.1016/j.ebiom.2019.11.010 (2019). Otake, Y. et al. Prediction of antenatal bleeding and preterm deliveries using placental magnetic resonance imaging in patients with placenta previa. Japanese journal of radiology , doi:10.1007/s11604-024-01541-3 (2024). Xiong, W. et al. Potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy: A retrospective longitudinal cohort study. Placenta 126 , 164-170, doi:10.1016/j.placenta.2022.07.006 (2022). Tables Table 1 Sociodemographic and Obstetric features of Control and Hysterectomy groups Control （N=503） Hysterectomy （N=20） p Age(y) 31.66±4.43 34.50±5.05 0.005 a BMI before pregnancy(kg/m 2 ) 23.84±3.99 26.35±3.27 0.006 a Weight gain during pregnancy(kg) 12.96±4.05 11.50±6.40 0.432 a Gravidity 0.022 b 0 1(0.2%) 0 1 97(19.3%) 0 2 95(18.9%) 0 ≥3 310(61.6%) 20(100%) Parity ＜0.001 b 0 98(19.5%) 0 1 204(40.6%) 2(10.0%) 2 181(36.1%) 14(70.0%) ≥3 19(3.8%) 4(20.0%) History of artificial abortion 0.648 b 0 167(33.7%) 3(15.0%) 1 127(25.7%) 6(30.0%) 2 117(23.6%) 5(25.0%) ≥3 207(41.2%) 6(30.0%) Method of conception 0.302 b Natural conception 449(89.3%) 20(100.0%) IVF 53(10.5%) 0 Dysmenorrhea 43(8.5%) 0 0.395 b Previous cesarean sections ＜0.001 b 1 313(62.4%) 1(5.0%) 2 170(33.9%) 12(60.0%) 3 15(3.0%) 7(35.0%) ≥4 4(0.8%) 0 Intrauterine inflammation 14(2.8%) 1(5.0%) 0.448 b Intrahepatic cholestasis of pregnancy 25(5.0%) 1(5.0%) 0.999 b GDM 86(17.2%) 4(20.0%) 0.762 b Times of antepartum vaginal bleeding 0.326 b 0 267(53.1%) 11(55.0%) 1 106(21.1%) 1(5.0%) 2 62(12.3%) 4(20.0%) ≥3 68(13.52%) 4(20.0%) Type of PAS ＜0.001 b Accreta 129(25.6%) 0 Increta 231(45.9%) 2(10.0%) Percreta 142(28.2%) 18(90.0%) Placenta attachment site 0.033 b Posterior wall 338(67.2%) 7(36.8%) Lateral wall 5(1.0%) 1(5.3%) Anterior wall 160(31.8%) 11(57.9%) Placenta covering previous incisional scar ＜0.001 c Partial 433(86.1%) 9(45.0%) Complete 70(13.9%) 11(55.0%) Gestational hypertensive disorders 0.001 b None 485(96.6%) 16(80.0%) Gestational hypertension 10(2.0%) 3(15.0%) Mild preeclampsia 4(0.8%) 1(5.0%) Severe preeclampsia 3(0.6%) 0 Polyhydramnios 10(2.0%) 0 0.523 b Oligohydramnios 14(2.8%) 0 0.448 b Nuchal cord 149(29.7%) 2(10.0%) 0.076 b PROM 38(7.6%) 1(5.0%) 0.665 b a Student T test b Fisher exact test c Chi square test Abrreviations: GDM, Gestational Diabetes Mellitus; BMI, Body mass index; PROM, Premature rupture of membranes. Table 2 Preoperative clinical characteristics of Natural conception group and IVF group Control （N=503） Hysterectomy （N=20） p History of blood transfusion 12(2.4%) 1(5.0%) 0.403 a History of abdominal or pelvic surgery 162(32.2%) 5(25.0% ) 0.498 a History of uterine of pelvic endoscopic examination 57(11.3%) 2(10.0%) 0.938 a Comorbidity Hypothyroidism 2(10.0%) 2(10.0%) 0.999 a Chronic hypertension 4(0.8%) 0 0.688 a Diabetes mellitus ＜0.001 a None 500(99.4%) 18(90.0%) Type I 1(0.2%) 2(10.0%) Type II 2(0.4%) 0 OGTT OGTT（fasted） 2.36±1.92 1.56±1.74 0.074 b OGTT（1hd） 7.88±2.83 9.99±3.47 0.202 b OGTT（2h） 6.67±1.58 8.29±3.25 0.083 b B type Hepatitis 0.776 b None 469(93.6% 18(90.0%) Carrier 31(6.2%) 2(10.0%) Hepatitis 1(0.2%) 0 Syphilis 8(1.6%) 0 0.861 a Anemia 0.515 a None 303(60.4%) 11(55.0%) iron-deficiency anemia 163(32.5%) 8(40.0%) Thalassemia 26(5.2%) 0 Other types 10(2.0%) 1(5.0%) RSA 5(1.0%) 0 0.903 a PAS ultrasonographic score 6.21±2.55 11.42±2.54 <0.0001 b a Fisher exact test b Student T test Abbreviations: RSA, recurrent spontaneous abortion; OGTT, oral glucose tolerance test; PAS, Placenta Accreta Spectrum Table 3 Perioperative maternal and neonatal outcomes of Control group and Hysterectomy group Control （N=503） Hysterectomy （N=20） p Surgical duration(min) 53.46±24.41 171.90±49.27 ＜0.001 a Postoperative Antibiotic Administration (h) 55.76±41.88 128.40±86.80 ＜0.001 a Postoperative ICU administration(days) 0.05±0.37 3.00±2.13 ＜0.001 a Preterm birth 278(55.3%) 20(100.0%) ＜0.001 b Neonatal anomaly 8(1.6%) 0 0.857 b FGR 20(4.0%) 1(5.0%) 0.567 b Twin or multiple gestation 19(3.8%) 0 0.375 b single umbilical artery 2(0.4%) 1(5.0%) 0.111 b Abnormal fetal presentation 94(18.8%) 2(10.0%) 0.554 b Fetal developmental abnormalities 10(2.0%) 1(5.0%) 0.358 b Neonatal asphyxia ＜0.001 b None 451(90.0%) 12(60.0%) Mild 49(9.8%) 7(35.0%) Severe 1(0.2%) 1(5.0%) Maternal fever 101(20.2%) 7(35.0%) 0.153 c Hypoproteinemia 11(2.2%) 13(65.0%) ＜0.001 c Ileus 4(0.8%) 0 0.688 b Urine retention 0 0 - Hypoxemia 3(0.6%) 0 0.728 b a Student T test b Fisher exact test c Chi square test Abrreviations: FGR, fetal growth restriction; ICU, intensive care unit; Table 4 Hemorrhagic morbidity related characteristics of Control group and Hysterectomy group Control （N=503） Hysterectomy （N=20） p Blood loss before Cesarean Section 49.46±160.35 89.17±203.04 0.403 a Intraoperative blood loss (ml) 764.31±385.10 2695.00± 1241.17 ＜0.001 a Intraoperative urine output (ml) 685.80±539.82 151.09±108.46 ＜0.001 a Intraoperative fluid infusion volume (ml) 1804.19±640.91 3465.00± 1078.51 ＜0.001 a Hematocrit (u) 0.21±0.79 3.68±3.04 ＜0.001 a Plasma transfusion 11.35±65.97 430.00±421.90 ＜0.001 a Autologous blood transfusion (ml) 26.76±83.72 318.40±184.09 ＜0.001 a Preoperative Hb(g/L) 115.34±12.87 108.70±11.14 0.024 a Postoperative Hb(g/L) b 99.34±15.39 96.50±22.31 0.428 a a Student T test b at 3 rd postoperative day Abrreviations: Hb, hemoglobin Table 5 risk factor analysis for peripartum hysterectomy among pregnancy complicated by PPP OR 95%CI P value Maternal age(year) 1.31 (0.41,2.67) 0.534 Pre-pregnancy BMI(kg/m 2 ) 0.89 (0.77, 1.21) 0.216 Weight gain during pregnancy(kg) 1.31 (0.77, 2.01) 0.229 Conception mode (natural conception or IVF) 0.91 (0.81, 1.98) 0.817 GDM 1.19 (0.89, 1.87) 0.603 Gravidity 0.67 (0.44, 2.11) 0.719 Parity 0.94 (0.11, 3.48) 0.655 Times of previous cesarean sections 1.44 (1.21, 8.46) 0.048 Placenta attachment site (anterior, lateral, or posterior wall) 0.73 (0.62, 0.91) 0.015 GHD 1.69 (1.24, 5.77) 0.042 Type of PAS(Ac-/In-/Per-creta) 2.31 (1.76, 5.11) 0.032 Placenta covering uterine incision 1.27 (1.14, 3.27) 0.035 PAS ultrasonographic score ＞10 2.71 (1.91, 7.26) 0.008 Abrreviations: BMI, Body mass index; IVF, in vitro fertilization; GDM, GDM, Gestational Diabetes Mellitus; GHD, gestational hypertensive disorder; PAS, Placenta Accreta Spectrum Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Jan, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 04 Nov, 2024 Reviews received at journal 25 Oct, 2024 Reviewers agreed at journal 25 Oct, 2024 Reviewers agreed at journal 24 Oct, 2024 Reviews received at journal 26 Sep, 2024 Reviewers agreed at journal 26 Sep, 2024 Reviews received at journal 26 Sep, 2024 Reviewers agreed at journal 20 Sep, 2024 Reviewers agreed at journal 20 Sep, 2024 Reviews received at journal 19 Aug, 2024 Reviewers agreed at journal 29 Jul, 2024 Reviewers invited by journal 29 Jul, 2024 Editor invited by journal 26 Jul, 2024 Editor assigned by journal 26 Jul, 2024 Submission checks completed at journal 26 Jul, 2024 First submitted to journal 25 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4801980","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":343263308,"identity":"37faa608-7dd7-4231-83cc-29cfa15d1462","order_by":0,"name":"Lulu Wang","email":"","orcid":"","institution":"Department of Obstetrics, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China","correspondingAuthor":false,"prefix":"","firstName":"Lulu","middleName":"","lastName":"Wang","suffix":""},{"id":343263310,"identity":"62aef008-acce-4b97-a0d6-fc1ad2f5c51e","order_by":1,"name":"Tianjiao Liu","email":"","orcid":"","institution":"Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China","correspondingAuthor":false,"prefix":"","firstName":"Tianjiao","middleName":"","lastName":"Liu","suffix":""},{"id":343263311,"identity":"53fa13c5-9954-4150-bc33-95628a97412d","order_by":2,"name":"Yang Yang","email":"","orcid":"","institution":"Department of Obstetrics, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Yang","suffix":""},{"id":343263312,"identity":"5813cb69-531c-4f36-82d0-377f6ac88d1d","order_by":3,"name":"Yalan Li","email":"","orcid":"","institution":"The Fourth People’s Hospital of Chengdu, Psychosomatic Medical Center, Chengdu, China","correspondingAuthor":false,"prefix":"","firstName":"Yalan","middleName":"","lastName":"Li","suffix":""},{"id":343263313,"identity":"5e09b395-2024-4b14-b697-bd68b6483951","order_by":4,"name":"Li Xiao","email":"","orcid":"","institution":"Medical Administration Department, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China, China","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Xiao","suffix":""},{"id":343263314,"identity":"7db11637-b2db-4e84-96cf-78dc93b39575","order_by":5,"name":"Xin Li","email":"","orcid":"","institution":"Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"Li","suffix":""},{"id":343263315,"identity":"9f9a37e3-c89e-4a06-acc6-a5c66399a19a","order_by":6,"name":"Sumei Wei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYFACxgYQyQMimBkqGGTYSNRyhoGHCC1IgJmxDaIXLzA43tz8mTfHRoZ/RvLDz4Xz7Hj4JHLMHjDU2ETj1HLmYJs077Y0HokbacbSM7cl87BJ5JgbMBxLy23AocXsRmIbM++2wzwG0jlsQAYzSIuZBGPDYdxa7j8EOmzbf6iWOfVEaLnB2AB02AGolobDhLXYn0lsk5wL9ILE/WfG0jzHjvOw8Twrk0jA4xfJ9uOPP7zdZmfP33P44Weemmo5+fbkbRIfamxwasECBBIYGBKIVw4C/AdIUz8KRsEoGAXDHgAACNNN70Jza1AAAAAASUVORK5CYII=","orcid":"","institution":"Department of Obstetrics, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China","correspondingAuthor":true,"prefix":"","firstName":"Sumei","middleName":"","lastName":"Wei","suffix":""}],"badges":[],"createdAt":"2024-07-25 12:51:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4801980/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4801980/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-07163-5","type":"published","date":"2025-01-20T15:57:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63801288,"identity":"10f880c3-09c6-4c3e-8c33-bffe1d99ce22","added_by":"auto","created_at":"2024-09-02 13:14:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":112783,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of present study\u003c/p\u003e\n\u003cp\u003eAbbreviation: PAS, Placenta accreta spectrum\u003c/p\u003e","description":"","filename":"Figure1schematicdiagramofstudydesign.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4801980/v1/b961ea310501a40adf1319db.jpg"},{"id":74858480,"identity":"9712dbf1-33b3-4cd5-8d83-b63f25fc9241","added_by":"auto","created_at":"2025-01-27 16:10:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1244896,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4801980/v1/4c6663a9-f2c2-4b33-b6d1-90b4f0fcaa77.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk Factors for Peripartum Hysterectomy Among Pregnancies with Suspected Placenta Accreta Spectrum in Preoperative Obstetric Imaging Screening: a Retrospective Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003ePlacenta Accreta Spectrum(PAS) refers to the abnormal implantation of placental tissue onto the uterine myometrium. Based on the histological depth of placental adherence, this spectrum can be divided into placenta accreta, placenta increta, and placenta percreta. It interferes the extending of growing uterus during pregnancy and hinders placental detachment during delivery thus may cause uncontrollable hemorrhage and subsequently may be cause of increased maternal morbidity and mortality. Its prevalence reportedly increases along with the previous cesarean deliveries, from 0.3% in pregnant women who experienced cesarean section once to 6.7% in women underwent 6 prior cesarean sections.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOne of the most severe complications associated with PAS is the need for peripartum hysterectomy, a life-saving procedure in cases of uncontrollable hemorrhage with a global prevalence at about 1 in 1,000 deliveries.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e While advances in obstetric care have reduced maternal mortality rates, peripartum hysterectomy remains a rare but critical intervention to prevent life-threatening hemorrhage.\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Understanding the risk factors contributing to the necessity of peripartum hysterectomy in pregnancies complicated by Placenta Accreta Spectrum (PAS) is essential for establishing effective management and prevention strategies, as well as for preoperative counseling. Previous studies have identified several risk factors associated with the need for peripartum hysterectomy.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, studies that mainly focused on hysterectomy among the PAS-complicated pregnancies are relatively rare. Furthermore, the unique obstetric characteristics such as advanced maternal age, high proportion of multiparous women and high cesarean section rate of Chinese population due to social and policy factors underscores the importance of investigating regional or population-specific risk factors for peripartum hysterectomy.\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis retrospective cohort study aims to elucidate the risk factors associated with peripartum hysterectomy among pregnancies complicated by PAS in our institution. By analyzing a large cohort of PAS complicated pregnancy, we seek to identify demographic, obstetric, and clinical factors that differs between hysterectomy group and non-hysterectomy groups, and also screen out the risk factors which might predict the occurrence of peripartum hysterectomy. The findings of this study may potentially facilitate the clinical decision-making, and the refinement of guideline for reducing the incidence of peripartum hysterectomy and improving maternal outcomes of PAS.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study was derived from the Longitudinal Placenta Accreta Spectrum Study (LoPASS), a cohort study on PAS conducted in Chengdu, Sichuan province, China, aiming to ascertain the impacts of both genetic factors and environmental influences on the onset of PAS, as well as to establish novel early screening and interfering method to improve the maternal and neonatal outcomes (registered in the Chinese Clinical Trial Registry, ID: ChiCTR2100052428, date: October 26\u003csup\u003eth\u003c/sup\u003e, 2021) . \u003cstrong\u003eFigure 1\u003c/strong\u003e depicted the flowchart of study design of current study. From January 2018 to March 2023, among approximately 15,000 childbirth cases at our institute, all patients prenatally diagnosed with suspected PAS (ultrasound PAS score higher than 5) were included in this study. Patients with placenta previa, twin or multiple pregnancies were excluded. The patient management strategy of patients with PAS was described in our previous publication.\u003csup\u003e12\u003c/sup\u003e Based on underwent hysterectomy or not, the patients were divided into Control and Hysterectomy groups. Subsequently, a comparative analysis was conducted on both groups’ demographic characteristics, sociodemographic features, maternal and neonatal outcomes, and clinical features related to hemorrhagic disorders. Following this, a multivariate logistic regression analysis was performed to explore risk factors that differs between both groups or reportedly associated with peripartum hysterectomy, which includes maternal age, pre-pregnancy Body Mass Index (BMI), weight gain during pregnancy, conception mode, gestational hypertensive disorder (GHD), gravidity, parity, previous cesarean sections, placenta covering uterine incision, , location of uterine incision, and type of PAS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis of PAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the currently widely accepted guidelines regarding the diagnosis of PAS, it is acknowledged that definitive diagnosis of PAS requires pathological examination following hysterectomy.\u0026nbsp;\u003csup\u003e13-15\u003c/sup\u003e However, in order to facilitate early screening of pregnancies complicated by PAS and to enable rigorous and timely obstetric management for improved maternal and neonatal outcomes, we employed medical imaging methods especially ultrasonography and magnetic resonance imaging (MRI) if necessary for thorough examination of the placenta prior to cesarean section, as recommended by some previous studies.\u003csup\u003e1,16\u003c/sup\u003e \u0026nbsp;The PAS ultrasonic scoring criteria applied in this study was based on the previous studies which analyzed prenatal ultrasound imaging characteristics including placental location and thickness, presence or absence of the low echoic zone behind the placenta, continuity of the bladder line, morphology of placental lacunae, blood flow signals at the placental base, integrity of cervical morphology, presence of cervical blood sinuses, and history of cesarean section. Each item is scored from 0 to 2 points, and the total score is calculated.\u003csup\u003e17,18\u003c/sup\u003e A same set of Color Doppler ultrasound diagnostic equipment (GE volusion E8, General Electric, Boston, the United States) and standard default parameters with a probe frequency of 3.5 MHz were applied. Moreover, the ultrasonic predictive diagnosis of PAS in this study was performed by the same group of approximately eight to ten experienced senior obstetric ultrasound doctors who were trained before the commencement of this study using 100 anonymized cases to ensure the consistency and reproducibility of scoring among different doctors. When a patient's ultrasound PAS score is between 5 and 10, we consider her as suspected adhesive PAS. When the ultrasound PAS score is greater than 10, we consider the patient as having suspected severe PAS (increta or percreta).\u0026nbsp;Through these means, we preliminarily diagnose suspected PAS and its subtypes, which includes accrete (placental tissue implants onto the myometrium),increta (into the myometrium), or percreta (penetrating through the myometrium to neighboring organ), based on the depth of placental implantation.\u003csup\u003e2,19\u003c/sup\u003e In cases which underwent hysterectomy, the diagnose of PAS was based on the finding of postoperative pathological investigations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndication of Cesarean section for patients with PAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to relevant clinical guidelines and previous literature, performing cesarean section slightly before the expected due date may potentially improve maternal and neonatal outcomes in pregnancies complicated by PAS.\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e Therefore, for PAS-complicated pregnancies, our hospital performs cesarean section at around 36\u003csup\u003eth\u003c/sup\u003e week of gestation for pregnant women without vaginal bleeding, at about 34\u003csup\u003eth\u003c/sup\u003e week of gestation for those with recurrent mild vaginal bleeding, and for pregnant women experiencing sudden vaginal bleeding exceeding 100ml, or with notable fetal activity reduction accompanied by abnormal fetal heart monitoring or abnormal umbilical cord blood flow, emergency cesarean section is performed.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndications for peripartum hysterectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur institute applied criteria similar to those described in previous literature for performing cesarean hysterectomy.\u0026nbsp;\u003csup\u003e20\u003c/sup\u003e Specifically, indications include intraoperative bleeding exceeding 1500 mL with ongoing active bleeding, deemed uncontrollable within a short timeframe and threating the patient's life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted with approval obtained from the Ethics Committee of the Chengdu Women’s and Children’s Central Hospital (Approval No.201830). All the identifiable information such as patients’ name, ID number, home address, phone number, etc., was deleted before statistical analysis for privacy concerns.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe statistical analysis for this study was performed using Statistical Package for the Social Sciences (SPSS) software version 25.0 (IBM Inc., Armonk, NY, USA). Categorical data were assessed using Fisher’s exact test or Chi square test, and results were expressed as frequencies and percentages. For continuous variables, means and standard deviations were calculated using either Student’s t-test or least significant difference Student’s t-test. To investigate the correlation between maternal characteristics and the occurrence of hysterectomy, multivariate logistic regression analysis was conducted. Covariates were selected based on significantly different characteristics identified in the univariate analysis and factors previously reported that may be relevant to peripartum hysterectomy, which includes maternal age, pre-pregnancy BMI, weight gain during pregnancy, parity, gravidity, conception mode, types and of placenta previa or PAS, location of placenta, types of gestation hypertensive disorder (GHD). All statistical tests were two-tailed, with statistical significance set as p value lower than 0.05.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003e\u003cstrong\u003eSociodemographic and obstetric characteristics of study cohort\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable1\u0026nbsp;\u003c/strong\u003elisted the sociodemographic, obstetric, and other clinical characteristics of the study cohort. There were 523 pregnant women with placenta previa included in this study, among whom 20 women underwent hysterectomy. Patients were thus divided into the Control group and the hysterectomy group. Notably, the mean age was significantly higher in the Hysterectomy group compared to the Control group (34.50±5.05 vs. 31.66±4.43 years, p = 0.005). Moreover, there was a statistically significant difference in BMI before pregnancy between the two groups (26.35±3.27 vs. 23.84±3.99, p = 0.006).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs for obstetric features between both groups, significant differences were observed in gravidity and parity between the two groups. Specifically, a higher proportion of women in the Hysterectomy group had a gravidity of 3 or more compared to the Control group (100% vs. 61.6%, p = 0.022), and similarly, a higher proportion of women in the Hysterectomy group had a parity of 2 or more compared to the Control group (90.0% vs. 39.9%, p \u0026lt; 0.001). Furthermore, there was a significant difference in the times of previous cesarean sections, with a higher proportion of women in the Hysterectomy group having undergone cesarean sections twice previously (p \u0026lt; 0.001). Correspondingly, we also observed a significantly higher proportion of patients with placenta attaching to the anterior uterine in Hysterectomy group all as compared to their counterparts in the Control group (57.9 %vs 31.8%, p =0.033). As for types of PAS, the Hysterectomy group also exhibited higher frequencies of placenta percreta compared to Control group (90.0% vs 28.2%, p \u0026lt; 0.001). In addition, gestational hypertension and mild preeclampsia were more common in the Hysterectomy group (20.0% vs 1.4%, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative Clinical features of Hysterectomy group and Control group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e showed the preoperative clinical characteristics of both groups. In general, the prevalence of B type hepatitis, syphilis, anemia, and recurrent spontaneous abortion (RSA) did not significantly differ between the groups. Whilst, Diabetes Mellitus, categorized into Type I and Type II, showed significant discrepancies (p\u0026lt;0.001), though results from oral glucose tolerance tests (OGTT) revealed varied levels across different time points, although statistical significance was not consistently observed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative maternal and neonatal outcomes in both group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e illustrated the perioperative outcomes of the Control and Hysterectomy groups. Notably, the surgical duration was substantially longer in the Hysterectomy group compared to the Control group (171.90±49.27 vs. 53.46±24.41 minutes, p \u0026lt; 0.001). Additionally, , the incidence of preterm birth (100.0% vs. 55.3%, p \u0026lt; 0.001), neonatal asphyxia (40.0% vs. 10.0%, p \u0026lt; 0.001), and hypoproteinemia of the mother (100.0% vs. 55.3%, p \u0026lt; 0.001) was also significantly higher in the Hysterectomy group compared to the Control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHemorrhagic morbidity-related characteristics of Hysterectomy and Control groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e presented the hemorrhagic morbidity-related characteristics of the Control and Hysterectomy groups. Notably, there were significant differences in various parameters related to blood loss and transfusion between the two groups. For instance, intraoperative blood loss (ml) was substantially higher in the Hysterectomy group compared to the Control group (2695.00±1241.17 vs. 764.31±385.10, p \u0026lt; 0.001). Similarly, there were significant differences in intraoperative urine output, fluid infusion volume, hematocrit levels, plasma transfusion, and autologous blood transfusion between the two groups (all p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk factor analysis for peripartum hysterectomy in PAS-completed pregnancy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our risk factor analysis for peripartum hysterectomy among pregnancies complicated by PAS, several variables exhibited statistically significant associations (shown in \u003cstrong\u003eTable 5\u003c/strong\u003e). Specifically, an increased likelihood of undergoing hysterectomy was observed with previous cesarean sections (OR=1.44, 95% CI: 1.21, 8.46, p=0.048) \u0026nbsp;, placenta attaching site\u0026nbsp;(anterior, lateral, or posterior wall)\u0026nbsp;(OR=0.73, 95% CI: 0.62, 0.91 \u0026nbsp;p=0.015), placenta covering uterine incision(OR=1.27, 95% CI: 1.14, 3.27, p=0.035), and types of GHD (OR=1.69, 95% CI: 1.24, 5.77, p=0.042). Moreover, placenta percreta also demonstrated a notable association with peripartum hysterectomy risk (OR=2.31, 95% CI: 1.76, 5.11, p=0.032). Conversely, other variables including maternal age, pre-pregnancy BMI, weight gain during pregnancy, conception mode (natural conception or in vitro fertilization, IVF), Gestational Diabetes Mellitus (GDM), gravidity, and parity did not exhibit statistically significant associations with peripartum hysterectomy in our analysis.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePeripartum hysterectomy remains a rare yet critical intervention for managing life-threatening hemorrhage in pregnancies complicated by PAS. While there have been some studies on the risk factors for cesarean hysterectomy among Chinese obstetric patients, there is a relative scarcity of research focusing specifically on pregnancies complicated by PAS.\u003csup\u003e21-23\u003c/sup\u003e In this retrospective cohort study, we compared the demographic features, obstetric, and other clinical characteristics, as well as hemorrhagic morbidity-related indicators between the hysterectomy group and the control group and also identified the risk factors associated with peripartum hysterectomy within this specific obstetric context.\u003c/p\u003e\n\u003cp\u003eThe present study found several factors that predicts hysterectomy among prenatally suspected PAS, including the number of previous cesarean sections, placenta attaching to the anterior uterine wall, gestational hypertension, percreta, placenta covering the uterine incision, and PAS ultrasonographic score greater than 10. These findings may offer clinical guidance in several areas, such as determining whether and when to refer pregnant women with PAS in remote areas; timing of delivery or cesarean section; preoperative preparation, particularly in preparing for possible severe maternal hemorrhage; intraoperative strategies such as uterine artery ligation or, in cases with preoperative imaging signs of placenta percreta, preparing for the placement of an aortic balloon catheter; and preventing adverse surgical outcomes, such as consulting with urologists preoperatively for cystoscopy to assess bladder involvement and placing ureteral stents to reduce the risk of ureteral injury during uterine artery ligation.\u003csup\u003e17\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe diagnostic criteria of PAS tend to vary in different nations and guidelines.\u0026nbsp;\u003csup\u003e13-15\u003c/sup\u003e According to the ISUOG guideline, the diagnosis of PAS can only be made after the performance of hysterectomy based on the finding of postoperative pathologic investigation of resected uterine and the placenta. However, our previous study, with detailed preoperative imaging examination of patients with suspected PAS, has achieved a success rate of diagnosis of PAS at about 80-90%, which encouraged us to\u0026nbsp;screening out pregnancies with potentially severe PAS using medical imaging.\u0026nbsp;\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe incidence rate of placenta previa among our cohort of pregnant women with PAS was 3.97%. In comparison, a multicenter international study on risk factors for cesarean hysterectomy in women with postpartum hemorrhage in the peripartum period reported an incidence rate of approximately 5.10% for cesarean hysterectomy.\u003csup\u003e20\u003c/sup\u003e Considering that their study included pregnant women without PAS, our rate of cesarean hysterectomy appears relatively lower. The overall peripartum hysterectomy rate in our hospital over the past five years has been around 1.5-7.7 per thousand births, which is comparable compared to the approximately 5 per thousand pregnancies reported in another retrospective study based on the ethnic Han Chinese population.\u003csup\u003e8,12\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur multivariate logistic regression model revealed that certain obstetric characteristics such as previous cesarean section, placenta completely covering uterine incision, placenta attaching to the anterior uterine wall, GHD, and type of PAS were identified as risk factors for undergoing hysterectomy. Conversely, maternal age, pre-pregnancy BMI, Weight gain during pregnancy, conception mode (IVF or natural conception), GDM, gravidity, parity, and scarred uterine were not predictive of hysterectomy risk. These findings are similar with our previous investigations into the risk factors for emergency cesarean section among pregnancies complicated by PAS.\u003csup\u003e12\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough some previous studies have suggested that advanced maternal age and parity might be risk factors for peripartum hysterectomy, and our study found that the mean age and parity of the Hysterectomy group was significantly higher than that of the control group, our data did not reveal age as a risk factor for peripartum cesarean section.\u0026nbsp;\u003csup\u003e8,24\u003c/sup\u003e Consistent with previous literature, our study also identified a history of previous cesarean sections as a significant risk factor for peripartum hysterectomy among women with PAS. Specifically, each additional cesarean section was associated with a 44% increased likelihood of undergoing hysterectomy, highlighting the importance of considering obstetric history in the management of PAS-complicated pregnancies. This finding also highlights the need for cautious evaluation and counseling regarding the mode of delivery. Strict avoidance of cesarean section without medical indication may help mitigate the risk of complications such as PAS and peripartum hysterectomy, given that cesarean section rate in megacities of mainland China is already relatively high.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIntriguingly, placenta completely covering the uterine incision, or locating on the anterior wall emerged as other critical risk factor for peripartum hysterectomy in our study. In consistent with our study, Jing also reported that placenta is located on the anterior wall is correlated to the possibility of massive postpartum hemorrhage, and attachment of placenta to the uterine incision site was significantly associated with PAS disorders,\u003csup\u003e25\u003c/sup\u003e demonstrating the high necessity of assessing placentation patients with PAS during the mid to late stages of pregnancy using medical imaging methods. The increased difficulty in cesarean section procedures when the placenta adheres to the anterior uterine wall, it may limit surgical visibility. Consequently, surgeons encounter challenges in performing the cesarean section.\u003c/p\u003e\n\u003cp\u003eOur study also identified GHD as a significant risk factor for peripartum hysterectomy among women with PAS. Han's team similarly found a significant association between gestational hypertensive disorder and placental abnormalities.\u0026nbsp;\u003csup\u003e26\u003c/sup\u003e This finding highlights the complex interplay between hypertensive disorders of pregnancy and placental abnormalities, necessitating close monitoring and multidisciplinary management in GHD complicated pregnancies. While the precise pathophysiological mechanisms remain unclear, this may be linked to aberrations in the invasive capacity of trophoblast cells and the remodeling ability of small blood vessels within the placenta of these patients. Early diagnosis and intervention for GHD may help mitigate the risk of severe complications such as placental abruption and peripartum hysterectomy.\u003csup\u003e27,28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWe did not find any association between the mode of conception and peripartum hysterectomy, despite some previous studies suggesting that assisted reproductive technologies (ART) such as IVF and ICSI may increase the risk of PAS or peripartum hemorrhage.\u0026nbsp;\u003csup\u003e29,30\u003c/sup\u003e Theoretically, there may indeed be a correlation between such ART pregnancies and the occurrence of placenta previa. This could be attributed, on one hand, to characteristics inherent to IVF recipient themselves, such as advanced maternal age, high psychological stress, history of multiple uterine interventions, parity, and previous miscarriages or abortions.\u003csup\u003e31,32\u003c/sup\u003e On the other hand, the manipulation involved in such ART and the ovulation-inducing hormones applied during ART may induce stimulation of uterine contractions and thus potentially causes PP. ART may also lead to metabolic and epigenetic changes in the embryo, potentially leading to abnormal trophoblast differentiation, increased placental size, and consequently, an elevated risk of PP.\u0026nbsp;\u003csup\u003e33-35\u003c/sup\u003e While the association between ART and the incidence of PAS remains controversial.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings revealed that early, timely, and consistent monitoring of placenta using medical imaging is of great importance. When the placenta is located on the posterior uterine wall or the patient has a thick abdominal wall, MRI serves as another important medical imaging modality to ultrasound for diagnosing PAS. MRI can reveal the anatomical structures of the implantation site and the blood supply of the surrounding tissues. It provides a more detailed view of the extent of parametrium and ureter involvement, which helps guide intraoperative strategies to avoid highly vascularized placental areas, thereby reducing the risk of hemorrhage.\u003csup\u003e36,37\u003c/sup\u003e Many previous studies had showed that ultrasound or MRI findings at early third trimester and even early first trimester might predict the occurrence of PAS and other surgical outcomes.\u003csup\u003e38,39\u003c/sup\u003e Our research team has also conducted studies on the application of MRI to monitor the dynamic changes in placental position during pregnancy, and found that more than half of the PP diagnosed at 28th-week placenta previa by MRI were still previa at the 36 weeks of gestation, highlighting the active obstetric imaging examination and early preparation for cesarean section during 3\u003csup\u003erd\u003c/sup\u003e trimester for PAS complicated gestation.\u0026nbsp;\u003csup\u003e40\u003c/sup\u003e Of course, the use of demographic and obstetric characteristics to predict uterine hysterectomy or peripartum hemorrhage has greater applicability, especially for women managed in medical institutes with limited source of blood supply and obstetric surgical experts or equipment. For them, timely referral into qualified medical institution is of considerable necessity.\u003c/p\u003e\n\u003cp\u003eThis study has several notable strengths and limitations. One key strength is its relatively large sample size, which included almost all the cases of PAS in a tertiary medical institution that manages maternal and child healthcare for a metropolitan area with a population of 20 million and its surrounding satellite cities. Additionally, the study's detailed examination of obstetric and perioperative characteristics offers a comprehensive understanding of the factors influencing outcomes in patients with placenta previa. However, the generalizability of the findings is limited by the single-center design. Conducted within a single institution, the results may not be directly applicable to other regions or populations with different demographic, socio-economic, or healthcare characteristics. The retrospective nature of the study may also introduce potential biases related to the accuracy and completeness of medical records. \u0026nbsp;Moreover, our study relied mainly on imaging to screen for suspected PAS and included only a small number of patients who underwent hysterectomy with postoperative pathological confirmation of PAS. Therefore, some mild cases or those with relatively superficial placental invasion might be omitted. Therefore, a multicenter prospective study with a randomized controlled trial (RCT) design is warranted to provide more solid clinical evidence for facilitating the prenatal examination and preliminary diagnosis of PAS.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe prior cesarean deliveries, placental positioning on the anterior uterine wall, GHD, and types of PAS are predicative for peripartum hysterectomy in cases of PAS-complicated pregnancies, underscoring the significance of timely referral, prompt and regular obstetric surveillance of placenta in third trimester and proactive preparation for potential blood transfusion and cesarean delivery in PAS pregnancies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGDM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGestational Diabetes Mellitus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGestational Hypertensive Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntracytoplasmic Sperm Injection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISUOG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Society of Ultrasound in Obstetrics and Gynecology\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\"\u003eLoPASS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLongitudinal Placenta Accreta Spectrum Study\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\"\u003eOGTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOral Glucose Tolerance Test\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\"\u003eRSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRecurrent Spontaneous Abortion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancially support for present study was provided by Yingcai Scheme, Chengdu Women's and Children's Central Hospital(CWCCH) (No.YC2023004), Japan-China Sasakawa Medical Fellowship Program (No.4408), Fifth Round of Chengdu Municipal Science and Technology Research Program (2021-YF05-00627-SN), Chengdu High-level Key Clinical Specialty Construction Project, and Tianfu Jincheng Laboratory Foundation (TFJC2023010001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthic Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted with the ethic approval obtained from institutional review board of Chengdu Women's and Children's Central Hospital (No. 2018117) and the written consent form of recruited patients. All identifiable characteristics of patients were deleted while transcribing data from the hospital information system to protect patients’ privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLW, TL and Xin Li conceptualized this study and drafted the manuscript. Xin Li, YL and YY collected the data. TL, Xin Li, LW, and YY analyzed the data. SW and Li Xiao supervised the study and also revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed in present study are available from the corresponding author on request.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSilver, R. M. \u0026amp; Branch, D. W. Placenta Accreta Spectrum. \u003cem\u003eThe New England journal of medicine\u003c/em\u003e \u003cstrong\u003e378\u003c/strong\u003e, 1529-1536, doi:10.1056/NEJMcp1709324 (2018).\u003c/li\u003e\n\u003cli\u003eBloomfield, V., Rogers, S. \u0026amp; Leyland, N. Placenta accreta spectrum. \u003cem\u003eCMAJ : Canadian Medical Association journal = journal de l\u0026apos;Association medicale canadienne\u003c/em\u003e \u003cstrong\u003e192\u003c/strong\u003e, E980, doi:10.1503/cmaj.200304 (2020).\u003c/li\u003e\n\u003cli\u003evan den Akker, T., Brobbel, C., Dekkers, O. M. \u0026amp; Bloemenkamp, K. W. M. Prevalence, Indications, Risk Indicators, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis. \u003cem\u003eObstetrics and gynecology\u003c/em\u003e \u003cstrong\u003e128\u003c/strong\u003e, 1281-1294, doi:10.1097/aog.0000000000001736 (2016).\u003c/li\u003e\n\u003cli\u003eGueli Alletti, S.\u003cem\u003e et al.\u003c/em\u003e Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin. \u003cem\u003eJournal of minimally invasive gynecology\u003c/em\u003e \u003cstrong\u003e27\u003c/strong\u003e, 22-23, doi:10.1016/j.jmig.2019.06.001 (2020).\u003c/li\u003e\n\u003cli\u003eİ\u0026ccedil;en, M. S.\u003cem\u003e et al.\u003c/em\u003e Hypogastric artery ligation in postpartum haemorrhage: a ten-year experience at a tertiary care centre. \u003cem\u003eJournal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology\u003c/em\u003e \u003cstrong\u003e41\u003c/strong\u003e, 536-540, doi:10.1080/01443615.2020.1755623 (2021).\u003c/li\u003e\n\u003cli\u003eMorel, O.\u003cem\u003e et al.\u003c/em\u003e Pelvic arterial ligations for severe post-partum hemorrhage. Indications and techniques. \u003cem\u003eJournal of visceral surgery\u003c/em\u003e \u003cstrong\u003e148\u003c/strong\u003e, e95-102, doi:10.1016/j.jviscsurg.2011.02.002 (2011).\u003c/li\u003e\n\u003cli\u003eKallianidis, A. F.\u003cem\u003e et al.\u003c/em\u003e Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis. \u003cem\u003eObstetrics and gynecology\u003c/em\u003e \u003cstrong\u003e141\u003c/strong\u003e, 35-48, doi:10.1097/aog.0000000000005022 (2023).\u003c/li\u003e\n\u003cli\u003eYang, M. J. \u0026amp; Wang, P. H. Peripartum hysterectomy risk factors in Taiwan. \u003cem\u003eJournal of the Chinese Medical Association : JCMA\u003c/em\u003e \u003cstrong\u003e73\u003c/strong\u003e, 399-400, doi:10.1016/s1726-4901(10)70086-1 (2010).\u003c/li\u003e\n\u003cli\u003eLi, H. T., Hellerstein, S., Zhou, Y. B., Liu, J. M. \u0026amp; Blustein, J. Trends in Cesarean Delivery Rates in China, 2008-2018. \u003cem\u003eJama\u003c/em\u003e \u003cstrong\u003e323\u003c/strong\u003e, 89-91, doi:10.1001/jama.2019.17595 (2020).\u003c/li\u003e\n\u003cli\u003eCao, J.\u003cem\u003e et al.\u003c/em\u003e Trends in maternal age and the relationship between advanced age and adverse pregnancy outcomes: a population-based register study in Wuhan, China, 2010-2017. \u003cem\u003ePublic health\u003c/em\u003e \u003cstrong\u003e206\u003c/strong\u003e, 8-14, doi:10.1016/j.puhe.2022.02.015 (2022).\u003c/li\u003e\n\u003cli\u003eZeng, Y. \u0026amp; Hesketh, T. The effects of China\u0026apos;s universal two-child policy. \u003cem\u003eLancet (London, England)\u003c/em\u003e \u003cstrong\u003e388\u003c/strong\u003e, 1930-1938, doi:10.1016/s0140-6736(16)31405-2 (2016).\u003c/li\u003e\n\u003cli\u003eZhao, H.\u003cem\u003e et al.\u003c/em\u003e Risk factors of emergency cesarean section in pregnant women with severe placenta accreta spectrum: a retrospective cohort study. \u003cem\u003eFrontiers in medicine\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e, 1195546, doi:10.3389/fmed.2023.1195546 (2023).\u003c/li\u003e\n\u003cli\u003eJauniaux, E.\u003cem\u003e et al.\u003c/em\u003e Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. \u003cem\u003eBJOG : an international journal of obstetrics and gynaecology\u003c/em\u003e \u003cstrong\u003e126\u003c/strong\u003e, e1-e48, doi:10.1111/1471-0528.15306 (2019).\u003c/li\u003e\n\u003cli\u003ePilloni, E.\u003cem\u003e et al.\u003c/em\u003e Accuracy of ultrasound in antenatal diagnosis of placental attachment disorders. \u003cem\u003eUltrasound Obstet Gynecol\u003c/em\u003e \u003cstrong\u003e47\u003c/strong\u003e, 302-307, doi:10.1002/uog.14893 (2016).\u003c/li\u003e\n\u003cli\u003eCali, G.\u003cem\u003e et al.\u003c/em\u003e Prenatal ultrasound staging system for placenta accreta spectrum disorders. \u003cem\u003eUltrasound Obstet Gynecol\u003c/em\u003e \u003cstrong\u003e53\u003c/strong\u003e, 752-760, doi:10.1002/uog.20246 (2019).\u003c/li\u003e\n\u003cli\u003eJauniaux, E. \u0026amp; Bhide, A. Prenatal ultrasound diagnosis and outcome of placenta previa accreta after cesarean delivery: a systematic review and meta-analysis. \u003cem\u003eAmerican journal of obstetrics and gynecology\u003c/em\u003e \u003cstrong\u003e217\u003c/strong\u003e, 27-36, doi:10.1016/j.ajog.2017.02.050 (2017).\u003c/li\u003e\n\u003cli\u003eChong Yiwen, Z. A., Wang Yan, Liu Zhaohui, Chen Yunshan, Zhao Yangyu. Value of ultrasonic scoring system for predicting risks of placenta accreta. \u003cem\u003eChin J Perinat Med\u003c/em\u003e \u003cstrong\u003eVol. 19, No. 9\u003c/strong\u003e, 705-709, doi:10.3760/cma.j.issn.1007-9408.2016.09.014 (2016).\u003c/li\u003e\n\u003cli\u003eChong, Y., Zhang, A., Wang, Y., Chen, Y. \u0026amp; Zhao, Y. An ultrasonic scoring system to predict the prognosis of placenta accreta: A prospective cohort study. \u003cem\u003eMedicine\u003c/em\u003e \u003cstrong\u003e97\u003c/strong\u003e, e12111, doi:10.1097/md.0000000000012111 (2018).\u003c/li\u003e\n\u003cli\u003eHecht, J. L.\u003cem\u003e et al.\u003c/em\u003e Classification and reporting guidelines for the pathology diagnosis of placenta accreta spectrum (PAS) disorders: recommendations from an expert panel. \u003cem\u003eMod Pathol\u003c/em\u003e \u003cstrong\u003e33\u003c/strong\u003e, 2382-2396, doi:10.1038/s41379-020-0569-1 (2020).\u003c/li\u003e\n\u003cli\u003eHuque, S.\u003cem\u003e et al.\u003c/em\u003e Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial. \u003cem\u003eBMC pregnancy and childbirth\u003c/em\u003e \u003cstrong\u003e18\u003c/strong\u003e, 186, doi:10.1186/s12884-018-1829-7 (2018).\u003c/li\u003e\n\u003cli\u003eJin, R., Guo, Y. \u0026amp; Chen, Y. Risk factors associated with emergency peripartum hysterectomy. \u003cem\u003eChinese medical journal\u003c/em\u003e \u003cstrong\u003e127\u003c/strong\u003e, 900-904 (2014).\u003c/li\u003e\n\u003cli\u003eChen, M.\u003cem\u003e et al.\u003c/em\u003e Peripartum hysterectomy between 2009 and 2010 in Sichuan, China. \u003cem\u003eInt J Gynaecol Obstet\u003c/em\u003e \u003cstrong\u003e120\u003c/strong\u003e, 183-186, doi:10.1016/j.ijgo.2012.09.012 (2013).\u003c/li\u003e\n\u003cli\u003eWei, Q.\u003cem\u003e et al.\u003c/em\u003e Peripartum hysterectomy in 38 hospitals in China: a population-based study. \u003cem\u003eArchives of gynecology and obstetrics\u003c/em\u003e \u003cstrong\u003e289\u003c/strong\u003e, 549-553, doi:10.1007/s00404-013-3002-x (2014).\u003c/li\u003e\n\u003cli\u003eJou, H. J., Hung, H. W., Ling, P. Y., Chen, S. M. \u0026amp; Wu, S. C. Peripartum hysterectomy in Taiwan. \u003cem\u003eInternational journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics\u003c/em\u003e \u003cstrong\u003e101\u003c/strong\u003e, 269-272, doi:10.1016/j.ijgo.2007.12.004 (2008).\u003c/li\u003e\n\u003cli\u003eJing, L., Wei, G., Mengfan, S. \u0026amp; Yanyan, H. Effect of site of placentation on pregnancy outcomes in patients with placenta previa. \u003cem\u003ePloS one\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e, e0200252, doi:10.1371/journal.pone.0200252 (2018).\u003c/li\u003e\n\u003cli\u003eHan, X., Guo, Z., Yang, X., Yang, H. \u0026amp; Ma, J. Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder. \u003cem\u003eJAMA network open\u003c/em\u003e \u003cstrong\u003e5\u003c/strong\u003e, e2228002, doi:10.1001/jamanetworkopen.2022.28002 (2022).\u003c/li\u003e\n\u003cli\u003eSinkey, R. G.\u003cem\u003e et al.\u003c/em\u003e Prevention, Diagnosis, and Management of Hypertensive Disorders of Pregnancy: a Comparison of International Guidelines. \u003cem\u003eCurrent hypertension reports\u003c/em\u003e \u003cstrong\u003e22\u003c/strong\u003e, 66, doi:10.1007/s11906-020-01082-w (2020).\u003c/li\u003e\n\u003cli\u003eIves, C. W., Sinkey, R., Rajapreyar, I., Tita, A. T. N. \u0026amp; Oparil, S. Preeclampsia-Pathophysiology and Clinical Presentations: JACC State-of-the-Art Review. \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e \u003cstrong\u003e76\u003c/strong\u003e, 1690-1702, doi:10.1016/j.jacc.2020.08.014 (2020).\u003c/li\u003e\n\u003cli\u003eTang, D., Cheng, Y., Feng, X., Li, X. \u0026amp; Coyte, P. C. The use of IVF/ICSI and risk of postpartum hemorrhage: A retrospective cohort study of 153,765 women in China. \u003cem\u003eFrontiers in public health\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 1016457, doi:10.3389/fpubh.2023.1016457 (2023).\u003c/li\u003e\n\u003cli\u003eZhu, L.\u003cem\u003e et al.\u003c/em\u003e Maternal and Live-birth Outcomes of Pregnancies following Assisted Reproductive Technology: A Retrospective Cohort Study. \u003cem\u003eScientific reports\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 35141, doi:10.1038/srep35141 (2016).\u003c/li\u003e\n\u003cli\u003eNakamura, K., Sheps, S. \u0026amp; Arck, P. C. Stress and reproductive failure: past notions, present insights and future directions. \u003cem\u003eJournal of assisted reproduction and genetics\u003c/em\u003e \u003cstrong\u003e25\u003c/strong\u003e, 47-62, doi:10.1007/s10815-008-9206-5 (2008).\u003c/li\u003e\n\u003cli\u003eDimitriadis, E., Menkhorst, E., Saito, S., Kutteh, W. H. \u0026amp; Brosens, J. J. Recurrent pregnancy loss. \u003cem\u003eNature reviews. Disease primers\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 98, doi:10.1038/s41572-020-00228-z (2020).\u003c/li\u003e\n\u003cli\u003eHorcajadas, J. A.\u003cem\u003e et al.\u003c/em\u003e Effect of controlled ovarian hyperstimulation in IVF on endometrial gene expression profiles. \u003cem\u003eMolecular human reproduction\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 195-205, doi:10.1093/molehr/gah150 (2005).\u003c/li\u003e\n\u003cli\u003eKanatsu-Shinohara, M.\u003cem\u003e et al.\u003c/em\u003e Intracytoplasmic sperm injection induces transgenerational abnormalities in mice. \u003cem\u003eThe Journal of clinical investigation\u003c/em\u003e \u003cstrong\u003e133\u003c/strong\u003e, doi:10.1172/jci170140 (2023).\u003c/li\u003e\n\u003cli\u003eJiang, Z.\u003cem\u003e et al.\u003c/em\u003e Genetic and epigenetic risks of assisted reproduction. \u003cem\u003eBest practice \u0026amp; research. Clinical obstetrics \u0026amp; gynaecology\u003c/em\u003e \u003cstrong\u003e44\u003c/strong\u003e, 90-104, doi:10.1016/j.bpobgyn.2017.07.004 (2017).\u003c/li\u003e\n\u003cli\u003ePalacios Jaraquemada, J. M. \u0026amp; Bruno, C. H. Magnetic resonance imaging in 300 cases of placenta accreta: surgical correlation of new findings. \u003cem\u003eActa obstetricia et gynecologica Scandinavica\u003c/em\u003e \u003cstrong\u003e84\u003c/strong\u003e, 716-724, doi:10.1111/j.0001-6349.2005.00832.x (2005).\u003c/li\u003e\n\u003cli\u003ePalacios-Jaraquemada, J. M., Bruno, C. H. \u0026amp; Mart\u0026iacute;n, E. MRI in the diagnosis and surgical management of abnormal placentation. \u003cem\u003eActa obstetricia et gynecologica Scandinavica\u003c/em\u003e \u003cstrong\u003e92\u003c/strong\u003e, 392-397, doi:10.1111/j.1600-0412.2012.01527.x (2013).\u003c/li\u003e\n\u003cli\u003eWu, Q.\u003cem\u003e et al.\u003c/em\u003e Radiomics analysis of placenta on T2WI facilitates prediction of postpartum haemorrhage: A multicentre study. \u003cem\u003eEBioMedicine\u003c/em\u003e \u003cstrong\u003e50\u003c/strong\u003e, 355-365, doi:10.1016/j.ebiom.2019.11.010 (2019).\u003c/li\u003e\n\u003cli\u003eOtake, Y.\u003cem\u003e et al.\u003c/em\u003e Prediction of antenatal bleeding and preterm deliveries using placental magnetic resonance imaging in patients with placenta previa. \u003cem\u003eJapanese journal of radiology\u003c/em\u003e, doi:10.1007/s11604-024-01541-3 (2024).\u003c/li\u003e\n\u003cli\u003eXiong, W.\u003cem\u003e et al.\u003c/em\u003e Potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy: A retrospective longitudinal cohort study. \u003cem\u003ePlacenta\u003c/em\u003e \u003cstrong\u003e126\u003c/strong\u003e, 164-170, doi:10.1016/j.placenta.2022.07.006 (2022).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Sociodemographic and Obstetric features of Control and Hysterectomy groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003e（N=503）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003cp\u003e（N=20）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eAge(y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e31.66\u0026plusmn;4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e34.50\u0026plusmn;5.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.005\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eBMI before pregnancy(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e23.84\u0026plusmn;3.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e26.35\u0026plusmn;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.006\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eWeight gain during pregnancy(kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e12.96\u0026plusmn;4.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e11.50\u0026plusmn;6.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.432\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.022\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e1(0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e97(19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e95(18.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e310(61.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e20(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e98(19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e204(40.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e181(36.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e14(70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e19(3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e4(20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eHistory of artificial abortion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.648\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e167(33.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e3(15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e127(25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e6(30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e117(23.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e5(25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e207(41.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e6(30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eMethod of conception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.302\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eNatural conception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e449(89.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e20(100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eIVF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e53(10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eDysmenorrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e43(8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.395\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious cesarean sections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e313(62.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e170(33.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e12(60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e15(3.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e7(35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e4(0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eIntrauterine inflammation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e14(2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.448\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eIntrahepatic cholestasis of pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e25(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.999\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eGDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e86(17.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e4(20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.762\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eTimes of antepartum vaginal bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.326\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e267(53.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e11(55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e106(21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e62(12.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e4(20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e68(13.52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e4(20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eType of PAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e129(25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e231(45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePercreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e142(28.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e18(90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePlacenta attachment site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.033\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePosterior wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e338(67.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e7(36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eLateral wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e5(1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior wall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e160(31.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e11(57.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePlacenta covering previous incisional scar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePartial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e433(86.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e9(45.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eComplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e70(13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e11(55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eGestational hypertensive disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e485(96.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e16(80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eGestational hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e10(2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e3(15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eMild preeclampsia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e4(0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eSevere preeclampsia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e3(0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePolyhydramnios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e10(2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.523\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eOligohydramnios\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e14(2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.448\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eNuchal cord\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e149(29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.076\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003ePROM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.305605786618443%\" valign=\"top\"\u003e\n \u003cp\u003e38(7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.43399638336347%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.518987341772153%\" valign=\"top\"\u003e\n \u003cp\u003e0.665\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea Student T test\u003c/p\u003e\n\u003cp\u003eb Fisher exact test\u003c/p\u003e\n\u003cp\u003ec Chi square test\u003c/p\u003e\n\u003cp\u003eAbrreviations: GDM, Gestational Diabetes Mellitus; BMI, Body mass index; PROM, Premature rupture of membranes.\u003c/p\u003e\n\u003cp\u003eTable 2 Preoperative clinical characteristics of Natural conception group and IVF group\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003e（N=503）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003cp\u003e（N=20）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eHistory of blood transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e12(2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.403\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eHistory of abdominal or pelvic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e162(32.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e5(25.0% )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.498\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eHistory of uterine of pelvic endoscopic examination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e57(11.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.938\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eComorbidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eHypothyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.999\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eChronic hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e4(0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.688\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e500(99.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e18(90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eType I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e1(0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eType II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e2(0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eOGTT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eOGTT（fasted）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e2.36\u0026plusmn;1.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e1.56\u0026plusmn;1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.074\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eOGTT（1hd）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e7.88\u0026plusmn;2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e9.99\u0026plusmn;3.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.202\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eOGTT（2h）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e6.67\u0026plusmn;1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e8.29\u0026plusmn;3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.083\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eB type Hepatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.776\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e469(93.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e18(90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eCarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e31(6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eHepatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e1(0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eSyphilis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e8(1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.861\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eAnemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.515\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e303(60.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e11(55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eiron-deficiency anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e163(32.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e8(40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eThalassemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e26(5.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eOther types\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e10(2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003eRSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e5(1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e0.903\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.818181818181817%\" valign=\"top\"\u003e\n \u003cp\u003ePAS ultrasonographic score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e6.21\u0026plusmn;2.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e11.42\u0026plusmn;2.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.90909090909091%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.0001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea Fisher exact test\u003c/p\u003e\n\u003cp\u003eb Student T test\u003c/p\u003e\n\u003cp\u003eAbbreviations: RSA, recurrent spontaneous abortion; OGTT, oral glucose tolerance test; PAS, Placenta Accreta Spectrum\u003c/p\u003e\n\u003cp\u003eTable 3 Perioperative maternal and neonatal outcomes of Control group and Hysterectomy group\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"561\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003e（N=503）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003cp\u003e（N=20）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eSurgical duration(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e53.46\u0026plusmn;24.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e171.90\u0026plusmn;49.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative Antibiotic Administration (h)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e55.76\u0026plusmn;41.88\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e128.40\u0026plusmn;86.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative ICU administration(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e0.05\u0026plusmn;0.37\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e3.00\u0026plusmn;2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003ePreterm birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e278(55.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e20(100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eNeonatal anomaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e8(1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.857\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eFGR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e20(4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.567\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eTwin or multiple gestation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e19(3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.375\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003esingle umbilical artery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e2(0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.111\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eAbnormal fetal presentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e94(18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e2(10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.554\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eFetal developmental abnormalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e10(2.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.358\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eNeonatal asphyxia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e451(90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e12(60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e49(9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e7(35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e1(0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e1(5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal fever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e101(20.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e7(35.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.153\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eHypoproteinemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e11(2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e13(65.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eIleus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e4(0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.688\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eUrine retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.607142857142858%\" valign=\"top\"\u003e\n \u003cp\u003eHypoxemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.392857142857142%\" valign=\"top\"\u003e\n \u003cp\u003e3(0.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.728\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea Student T test\u003c/p\u003e\n\u003cp\u003eb Fisher exact test\u003c/p\u003e\n\u003cp\u003ec Chi square test\u003c/p\u003e\n\u003cp\u003eAbrreviations: FGR, fetal growth restriction; ICU, intensive care unit;\u003c/p\u003e\n\u003cp\u003eTable 4 Hemorrhagic morbidity related characteristics of Control group and Hysterectomy group\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"565\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003e（N=503）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003cp\u003e（N=20）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003eBlood loss before Cesarean Section\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e49.46\u0026plusmn;160.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e89.17\u0026plusmn;203.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e0.403\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003eIntraoperative blood loss (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e764.31\u0026plusmn;385.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e2695.00\u0026plusmn;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;1241.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003eIntraoperative urine output (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e685.80\u0026plusmn;539.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e151.09\u0026plusmn;108.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003eIntraoperative fluid infusion volume (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e1804.19\u0026plusmn;640.91\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e3465.00\u0026plusmn;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;1078.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003eHematocrit (u)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e0.21\u0026plusmn;0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e3.68\u0026plusmn;3.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003ePlasma transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e11.35\u0026plusmn;65.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e430.00\u0026plusmn;421.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003eAutologous blood transfusion (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e26.76\u0026plusmn;83.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e318.40\u0026plusmn;184.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Hb(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e115.34\u0026plusmn;12.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e108.70\u0026plusmn;11.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e0.024\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.4070796460177%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative Hb(g/L)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e99.34\u0026plusmn;15.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e96.50\u0026plusmn;22.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.460176991150444%\" valign=\"top\"\u003e\n \u003cp\u003e0.428\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea Student T test\u003c/p\u003e\n\u003cp\u003eb at 3\u003csup\u003erd\u003c/sup\u003e postoperative day\u003c/p\u003e\n\u003cp\u003eAbrreviations: Hb, hemoglobin\u003c/p\u003e\n\u003cp\u003eTable 5 risk factor analysis for peripartum hysterectomy among pregnancy complicated by PPP\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"569\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"bottom\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"bottom\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal age(year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.41,2.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.534\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003ePre-pregnancy BMI(kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.77, 1.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eWeight gain during pregnancy(kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.77, 2.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.229\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eConception mode\u003c/p\u003e\n \u003cp\u003e(natural conception or IVF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.81, 1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.817\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eGDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.89, 1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.603\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.44, 2.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.719\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.11, 3.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.655\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eTimes of previous cesarean sections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(1.21, 8.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003ePlacenta attachment site (anterior, lateral, or posterior wall)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(0.62, 0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eGHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(1.24, 5.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003eType of PAS(Ac-/In-/Per-creta)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e2.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(1.76, 5.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003ePlacenta covering uterine incision\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(1.14, 3.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.58523725834798%\" valign=\"top\"\u003e\n \u003cp\u003ePAS ultrasonographic score\u0026nbsp;＞10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.85940246045694%\" valign=\"top\"\u003e\n \u003cp\u003e2.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e(1.91, 7.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.27768014059754%\" valign=\"top\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbrreviations: BMI, Body mass index; IVF, in vitro fertilization; GDM, GDM, Gestational Diabetes Mellitus; GHD, gestational hypertensive disorder; PAS, Placenta Accreta Spectrum\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Risk Factors, Hysterectomy, Placenta Accreta Spectrum, Cesarean Sections, Peripartum Hemorrhagic Morbidity","lastPublishedDoi":"10.21203/rs.3.rs-4801980/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4801980/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: This study aimed to identify risk factors for peripartum hysterectomy among pregnancies complicated by suspected Placenta Accreta Spectrum (PAS) in preoperative obstetric imaging screening.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Data were retrospectively extracted from the Longitudinal Placenta Accreta Spectrum Study (LoPASS), covering pregnancies with PAS from January 2018 to March 2023 at our institute. Patients were divided into Control and Hysterectomy groups based on whether they underwent hysterectomy. Sociodemographic, obstetric, and clinical characteristics were compared between the groups. Multivariate logistic regression analysis was performed on the characteristics with statistical significance to explore risk factors for peripartum hysterectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Among 523 pregnancies with suspected PAS, 20 underwent hysterectomy. The Hysterectomy group had a significantly higher mean age (34.50±5.05 vs. 31.66±4.43 years, p=0.005) and pre-pregnancy BMI (26.35±3.27 vs. 23.84±3.99, p=0.006). The Hysterectomy group also had a higher proportion of patients with more than 2 gravidities (100% vs. 61.6%, p=0.022) and multiple parities (90.0% vs. 39.9%, p\u0026lt;0.001). Higher percentages of placenta percreta (90.0% vs. 28.2%, p\u0026lt;0.001), placenta attaching to the anterior uterine wall (57.9% vs. 31.8%, p=0.033), and higher PAS ultrasonographic scores (11.42±2.54 vs. 6.21±2.55, p\u0026lt;0.0001) were observed in the Hysterectomy group. Perioperative outcomes revealed significantly longer surgical durations (171.90±49.27 vs. 53.46±24.41 minutes, p\u0026lt;0.001) and higher rates of preterm birth (100.0% vs. 55.3%, p\u0026lt;0.001). Intraoperative blood loss was also substantially greater in the Hysterectomy group (2695.00±1241.17 ml vs. 764.31±385.10 ml, p\u0026lt;0.001). \u0026nbsp;Variables significantly associated with increased peripartum hysterectomy risk included prior cesarean sections (OR=1.44, p=0.048), placenta attaching to the anterior uterine wall (OR=0.73, p=0.015), placenta completely covering the uterine incision (OR=1.27, p=0.035), gestational hypertensive disorder (OR=1.69, p=0.042), placenta percreta (OR=2.31, p=0.032), and PAS ultrasonographic score higher than 10 (OR=2.71, p=0.008).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Prior cesarean sections, placenta location, gestational hypertensive disorder, placenta percreta, and a PAS ultrasonographic score higher than 10 are risk factors for peripartum hysterectomy in pregnancies with suspected PAS. This underscores the importance of early and consistent obstetric imaging examinations of the placenta and active preparation for emergency cesarean sections in such pregnancies.\u003c/p\u003e","manuscriptTitle":"Risk Factors for Peripartum Hysterectomy Among Pregnancies with Suspected Placenta Accreta Spectrum in Preoperative Obstetric Imaging Screening: a Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-02 13:14:38","doi":"10.21203/rs.3.rs-4801980/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-04T18:10:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-26T02:08:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55641957833015103027312869941552678439","date":"2024-10-25T04:57:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294709910599885612748641099491949132560","date":"2024-10-24T18:36:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-26T19:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313898582610666797251418849928407865133","date":"2024-09-26T12:37:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-26T09:30:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96626377887681161318338338737693165934","date":"2024-09-20T16:37:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13873658637936656676366794532966505556","date":"2024-09-20T11:46:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-19T18:31:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289454261446474178804281738140423431013","date":"2024-07-29T15:19:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-29T09:49:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-26T11:04:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-26T08:28:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-26T08:27:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-07-25T12:50:35+00:00","index":"","fulltext":""}],"status":"published","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}}],"origin":"","ownerIdentity":"005cac56-f69c-4d77-a215-19f1c31bca6e","owner":[],"postedDate":"September 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:02:59+00:00","versionOfRecord":{"articleIdentity":"rs-4801980","link":"https://doi.org/10.1186/s12884-025-07163-5","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-01-20 15:57:50","publishedOnDateReadable":"January 20th, 2025"},"versionCreatedAt":"2024-09-02 13:14:38","video":"","vorDoi":"10.1186/s12884-025-07163-5","vorDoiUrl":"https://doi.org/10.1186/s12884-025-07163-5","workflowStages":[]},"version":"v1","identity":"rs-4801980","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4801980","identity":"rs-4801980","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}