Characteristics, Outcomes and Prevalence of Pregnant Women with Placenta Accreta Spectrum in Black Lion Hospital - Five years retrospective study , Addis Ababa, Ethiopia, 2023

Characteristics, Outcomes and Prevalence of Pregnant Women with Placenta Accreta Spectrum in Black Lion Hospital - Five years retrospective study , Addis Ababa, Ethiopia, 2023 | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Characteristics, Outcomes and Prevalence of Pregnant Women with Placenta Accreta Spectrum in Black Lion Hospital - Five years retrospective study , Addis Ababa, Ethiopia, 2023 Fuad Ahmed Mohammed, Yared Tesfaye Wube, Fikremelekot Temesigen Gondere, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3889075/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Placenta accreta spectrum is known to be associated with significant maternal morbidity and mortality usually because of catastrophic hemorrhage during delivery. The Prevalence rates ranged from 0.01 to 1.1% with an overall pooled prevalence of 0.17% (95% confidence interval, 0.14–0.19). The aim of this study was to determine the prevalence, characteristics and outcome of pregnant mothers with placenta accreta spectrum in black lion hospital. Methodology: An institution based cross-sectional study from January 1, 2018 to December 31, 2022. FIGO classification system for the clinical diagnosis of placenta accreta spectrum disorder were used to define cases and enroll the participants. Data was cleaned, entered and analyzed using SPSS version 26.0 statistical software and MS excel. Descriptive statistics were used to describe baseline characteristics. Result From the 24,844 deliveries, prevalence of cesarean delivery- 37.3%; prevalence of placenta accreta spectrum to be 0.1% (1 out of 994) and of which, 16 (64%)- abnormally adherent type (grade 1) and 9 (36%)-abnormally invasive type [grade 2 (24%) and grade 3 (12%)]. Placenta accreta spectrum was suspected prenatally in 28% of the mothers. Risk factors identified in 92% (23 out of 25) of the mothers were either placenta previa or cesarean delivery; in 60% (15 out of 25) of the mothers both placenta previa and prior cesarean delivery. Average estimated blood loss of 1568 ( ± 849) ml and 17 out of 25 (68%) were transfused. There was no maternal death and intensive care unit admission. Conclusion and Recommendations: The prevalence of cesarean delivery is very high as compared to the national figure. Antenatal suspicion or prenatal diagnosis of placenta accreta spectrum is very low thus all pregnant mothers with risk factors especially mothers with cesarean delivery and placenta previa should be screened for placenta accreta spectrum. Mothers with suspected placenta accreta spectrum should be managed with optimal preparation as possible. Placenta accrete spectrum placenta previa cesarean Ethiopia Figures Figure 1 Figure 2 Figure 3 1. Background Placenta accreta spectrum (PAS) is known to be associated with significant maternal morbidity and mortality usually because of catastrophic hemorrhage during delivery. Historically Irving and Hertig defined placenta accreta as the abnormal adherence either in whole or in part of “the afterbirth” to the underlying uterine wall. Even though, their work is pioneer in introducing the subject, none of their cases had villus tissue invading the myometrium and their diagnosis was made clinically when the placenta fails to delivered following birth of the baby [ 1 ]. The clinical signs of PAS disorder especially non invasive or partially adherent placenta can be very similar to those of placental retention which lead to wide heterogeneity in the definition and evaluation of the prevalence of PAS in the general obstetric population [ 2 ][ 3 ]. PAS is strictly defined as direct attachment of the placental trophoblast to the uterine myometrium , with no normal intervening decidua or basalis layer [ 4 ]. With the development of advanced imaging modality PAS has been diagnosed during prenatal period but irrespective of the imaging modality used, prenatal diagnosis of PAS disorders remains subjective, with accuracy depending on the experience of the operator. Additionally, there is no published consensus on the definition of the ultrasound markers used commonly for PAS. Many signs have been described under different names, and in other cases the same term has been used for different findings [ 5 ]. Recently group of experts provide a unified standard definition of commonly used ultrasound marker for prenatal diagnosis of PAS and later their recommendation was accepted in FIGO consensus guideline of PAS [ 5 ][ 6 ]. Prenatal diagnosis of PAS is very important to decrease perinatal morbidity and mortality though PAS was expected before delivery only in half of the cases. Studies showed that Major complications like massive obstetric hemorrhage, need for transfusion, surgical trauma, maternal death were high in those PAS diagnosed only during the time of delivery than those expected to have PAS during antenatal period [ 4 ][ 7 ]. Total primary hysterectomy, delayed secondary hysterectomy and expectant management by living the placenta in situ are the main types of management for PAS and choosing which type depends on prenatal diagnosis, intraoperative or clinical finding, and experience of the surgeon, the facility and the local protocol if any [ 2 ][ 7 ][ 8 ]. Worldwide rate of PAS is increasing through time to time due to increased rate of cesarean delivery (CD). The use of cesarean section (CS) has steadily increased worldwide and will continue increasing over the current decade where both unmet need and overuse are expected to coexist. The average global CS rate (CSR) is 21.1% of all births (Range: 5% − 42.8%). Projections showed that by 2030, 38 million (28.5%) women worldwide will give birth by CS annually. From these, 33.5 million of them are in Low and Middle Income Countries (LMIC), ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia [ 9 ][ 10 ][ 11 ]. According to the Ethiopian Demography and Health Survey (EDHS), CSR increased from 0.7% in 2000 to 1.9% in 2016 in the nation, with increment across all regions. Addis Ababa had the highest CSR (21.4%) in 2016 and the greatest increase since 2000. The overall prevalence of CD in selected hospitals in Addis Ababa was 38% [ 12 ][ 13 ]. With increased rate of CD in Ethiopia especially in capital city - Addis Ababa, it is expected that the prevalence of PAS will be increased [ 9 ][ 10 ][ 11 ]. Screening all mothers with risk factors for PAS, planned delivery and multidisciplinary team (MDT) approach are found important in decreasing adverse perinatal outcome of mothers with PAS [ 7 ][ 10 ][ 14 ]. To our knowledge in Ethiopia the prevalence and outcome of PAS is not known and hospitals experience in antenatal detection and management of PAS not yet studied. To understand the current problem and to improve the practice for the future, the current practice must be evaluated and the magnitude of the problem should be known. This study will fill the gap in determining the prevalence, characteristics and outcome of pregnant mothers with PAS. Since black lion hospital is a tertiary referral hospital, conducting such kind of study will have a role in future improvement in handling these cases. This study also has a significant role as a base line study on which future prospective and national and regional studies could be planned. 2. Objectives 2.1. General objective To determine the characteristics, outcome and prevalence of pregnant mothers with PAS in black lion hospital, Addis Ababa, Ethiopia, from January 1, 2018 to December 31, 2022. 2.2. Specific objectives .To determine the prevalence of PAS in Black Lion Hospital during the study period. To determine characteristics of pregnant mothers with PAS in Black Lion Hospital during the study period. To determine major maternal outcome of mothers managed for PAS in Black Lion Hospital during the study period. 3. Methodology 3.1. Study Area The study area is black lion hospital, one of tertiary referral teaching hospital found in the capital city, Addis Ababa, Ethiopia. The hospital has an estimated annual delivery rate 4000 to 7500. In related to PAS the department of obstetrics and gynecology of the hospital organized with expertise like maternal fetal medicine ,gynecologic oncologist and other expertise like anesthesiologist, neonatologist and intensive care person also available in the hospital which makes the hospital ideal to handle cases of PAS, though having resource limitation [ 15 ]. 3.2. Study Design and Period An Institutional based a five year retrospective cross sectional study of January 1, 2018 to December 31, 2022. 3.3. Populations 3.3.1. Sampling Population All deliveries attended in black lion hospital during the study period 3.3.2. Study Population All mothers diagnosed to have PAS. 3.4. Eligibility Criteria Inclusion criteria All mothers diagnosed to have PAS and fulfill the criteria of FIGO classification for the diagnosis of PAS. Exclusion criteria Mothers with incomplete data. 3.5. Variables of the Study Dependent variable PAS Independent variables Age Parity History of CD History of placenta previa (PP) History of curettage and myomectomy Antenatal diagnosis of PAS Gestational Age (GA) at delivery PP in current pregnancy Mode of delivery CD type (Emergency CS, Elective CS) Classification 3.6. Operational Definitions Maternal outcomes included: maternal ICU admission, clinically determined estimated blood loss (EBL), number of units of packed red cells transfused, hysterectomy, organ injury, maternal infection, anemia, relaparatomy and maternal death. 3.7. Data Collection Method The data for the study was collected using a semi-structured questionnaire from patient chart and electronic patient data base. The questionnaire consisted of four parts: socio-demographic characteristics, Obstetric history, Current Pregnancy and maternal outcome sections. 3.8. Data Processing and Analysis After data collection, each questionnaire was checked for completeness before entering into software. Coding of individual questionnaires was checked before data entry in to the software. Data was entered in to SPSS version 26 statistical package and MS excel. Further, data cleaning was performed to check for outliers, missed values and any inconsistencies before the data analysis. Descriptive statistical analysis was used to analyze the data and displayed using frequency, percentages and tables for easy interpretation. 3.9. Ethical Considerations An ethical clearance and permission letter was obtained from the obstetrics and gynecology department of Addis Ababa University (Black Lion Hospital). It was given to the heads of the hospital, the registry unit and labor ward of the hospital. After permission was granted from them, we started the data collection. 3.10. Result Dissemination Plan The final result of this paper was submitted to black lion hospital, department of obstetrics and gynecology. The research outputs was presented to the college community and other concerned stakeholders. It might also be submitted to international peer review journals for possible publication. 4. Results A total of 24,844 deliveries were registered during this five years study period and 9,276 of them were cesarean delivery. This made the prevalence of CD in the Black Lion Specialized Hospital to be 37.3%. During this study period, 25 of the mothers had developed PAS. Therefore, the sample size of this study became 25. 4.1. Socidemographic Characteristics Table 1: Socidemographic characteristics of mothers with PAS, Black Lion Hospital, Addis Ababa, Ethiopia, 2023. Variables Frequency (N=25) Proportion (%) Maternal age 35 years 6 24 Residence Urban 24 96 Rural 1 4 Educational Level (n=21, Unknown level=4) no formal education 2 9.5 primary school 7 33.3 secondary school 7 33.3 College and above 5 23.8 Marital Status Married 25 100 Other ------- ------- A total of 25 mothers, who had developed PAS; were registered during the five years study period. Of which, more than three-fourth (76%) of them were younger than 35 years of age while all of them were married in marital status. Majority (96%) of the participants were urban dwellers while 12 (57.1%) of them had been to school at least up to secondary school (Table 1). 4.2. Obstetric Characteristics Table 2: Obstetric Characteristics of Mothers with PAS, Black Lion Hospital, Addis Ababa, Ethiopia, 2023. Variable Frequency (N=25) Proportion (%) Parity Nulliparous 3 12 Primiparous 3 12 Multipara 19 76 History of Cesarean Delivery None 9 36 Once 5 20 ≥Twice 11 44 History of uterine surgery and procedure Yes 6 24 No 19 76 Presence of placenta previa Yes 18 72 No 7 28 From the total participants, the majority (76%) of the mothers were multipara while 11 (44%) of them had previous cesarean deliveries of at least twice but 9 (36%) of them did not have any cesarean delivery history previously. The majority of the mothers had not had any previous history of uterine surgery or related procedure and 18 (72%) of them had developed PP during this last delivery (Table 2). 4.3. Characteristics of Mothers with PAS From January 1, 2018 to December 31, 2022 period, there were 25 mothers with PAS out of the total 24,844 deliveries. These made the prevalence of PAS to be 0.001 or 1 out of 994 deliveries. 4.3.1. Associated Risk Factors of PAS At least one of the three risk factors were present in 92% (23 out of 25) of the mothers with PAS. Six (24%) of the mothers had previous uterine surgery/procedure. Either PP or CD were present in 76% (19 out of 25) of the mothers with PAS while in 60% (15 out of 25) of the mothers both PP and CD were identified as combined risk factors for the PAS (Figure 1). Only 8% (2 out of 25) of the mothers did not have any of the three risk factors. 4.3.2. Distribution of PAS with Gestational Week In 12% (3 out of 25) of the mothers with PAS, their gestational week level was unknown. Their gestational week in 20% (5 out of 25) of them was less than 34 weeks but the pregnancy was term pregnancy ( > 37 weeks) in 40% (10 out of 25) of the mothers with PAS (Figure 2). 4.3.3. Classification of PAS in the Participants Among the 25 mothers with PAS, 16 (64%) of the adherent placenta were abnormally adherent one (grade 1) while 9 (36%) of the PAS were the invasive type [grade 2 (24%) and grade 3 (12%)]. Six out of the 9 (66.7%) abnormally invasive placenta type of PAS were with antenatal suspicions while the rest three (33.3%) were without antenata suspicion (Figure 3). 4.3.4. Distribution of PAS by the Management given There was an antenatal suspicion of PAS in 6.3% (1 out of 16) of mothers with abnormally adherent placenta(grade 1) while in 50% (3 out of 6) and all (3 out of 3) of mothers with grade 2 and grade 3 of abnormally invasive placenta, respectively. Vaginal delivery was attended in 31.5% (5 out of 16) of mothers with abnormally adherent placenta (grade 1) while scheduled and emergency CD were performed in 43.8% (7 out of 16) and 25% (4 out of 16) of them, respectively. Scheduled hysterectomy was done for all mothers with grade 3 of abnormally invasive placenta and for 33.3% (2 out of 6) of mothers with grade 2 abnormally adherent mothers, and additionally; an emergency hysterectomy was done for 66.7% (4 out of 6) of mothers with grade 2 abnormally invasive placenta (Table 3). The gestational age at the time of delivery was > 37 weeks in 56.3% (9 out of 16) and in 16.7% (1 out of 6) of mothers with grade 1 and grade 2 type of PAS, respectively. In 18.8% (3 out of 16) of mothers with grade 1 PAS and in none of the mothers with abnormally invasive placenta, their gestational age at the time of delivery was unknown. Histological confimation was not made in all of the mothers with abnormally adherent placenta (grade 1) but it was done for 83.3% (5 out of 6) and in all three of the mothers with grade 2 and grade 3 abnormally invasive placenta, respectively (Table 3). Table 3: PAS Distribution by Management given, Black Lion Hospital, Addis Ababa, Ethiopia, 2023. Variables Abnormally adherent placenta Grade 1, N=16 Abnormally invasive placenta N=9 Grade 2, N=6 Grade 3, N=3 Antenatal suspicion yes 1 3 3 no 15 3 --- Mode of Delivery vaginal 5 --- --- CD scheduled 7 --- --- CD emergency 4 --- --- hysterectomy scheduled --- 2 3 hysterectomy emergency --- 4 --- Gestational age at the time of delivery <34 weeks 3 1 0 34 to 37 weeks 1 4 3 ≥37 weeks 9 1 0 Un known 3 0 0 Average GA ( + Sd) 36.2 ( + 3.7) 34.1 ( + 2.9) 35.3 ( + 1.1) Histology confirmation Missed NA 1 ----- Confirmed NA 5 3 4.3.5. Outcomes of the Mother with PAS The quarterly measurement of the maternal estimated blood losses were 900ml (Q1), 1300ml (Q2) and 2150ml (Q3) with average ( + SD) estimated blood loss being 1568 ( + 849) ml. The estimated blood loss documented showed that the amount of losses were 1500ml in 10 (40%) of mothers with PAS. From the 17 (68%) mothers who were transfused with blood, 35.3% (6 out of 17) of them were transfused with less than 2 units of blood while the other 41.2% (7 out of 17) and 23.5% (4 out of 17) of them were transfused with 2-5 units and more than 5 units of blood, respectively. On average, 2.64 ( + 2.3) units of blood were given for these mothers. The majority, 15 (60%), of the mothers with PAS were subjected to an operation time span of 1-2 hours. The average operation time passed for a single mother with PAS was 98 ( + 46) minutes with the maximum and minimum being 2hours, respectively. Table 4: Outcomes of Mother with PAS at Black Lion Hospital, Addis Ababa, Ethiopia, 2023. Variable Frequency Proportion Average + SD Estimated blood loss <1500 ML 15 60 1568 ( + 849) ML ≥1500 ML 10 40 Blood Transfusion yes 17 68 no 8 32 Number of Units transfused (n=18) 5 unit 4 23.5 Hospital stay 7days 3 12 Operation Time <1hr 6 24 98 ( + 46) minute 1-2hr 15 60 ≥2hr 4 16 Hemoglobin level at the time of discharge 7 - 9.9 g/dl 10 52 9.9 ( + 1.3)g/dl 10 -10.9 g/dl 7 28 ≥11g/dl 5 20 Upon assessing their discharge conditions, more than half (56%) of the mothers with PAS were discharged after less than 5 days stay at hospital while 8 (32%) of them were discharged after staying in the hospital in the range between 5-7 days. The hemoglobin level at the time of discharge, the average hemoglobin level at discharge for a single mother was 9.9 ( + 1.3) g/dl and only 5 (20%) of them were discharged with hemoglobin level of > 11g/dl (Table 4). Maternal death was not documented among the mothers with PAS and moreover, there was no also an ICU admission for them. 4.3.6. Maternal Outcomes with Classification of PAS Six 6 out of the 25 (24%) of the mothers with PAS were suspected prenatally. All of the prenatally suspected mothers in this study were those with abnormally invasive PAS type. More specifically, 66.7% (6 out of 9) abnormally invasive placenta type of PAS were detected with antenatal suspicions while the rest three (33.3%) were without antenatal suspicion. Twelve out of the 16 (75%) abnormally adherent but only 3 out of the 9 (33.3%) abnormally invasive PAS had an estimated blood loss of 1500ml. There was an average estimated blood loss of 1212 ( + 931) ml in mothers with abnormally adherent PAS and of 2220 ( + 931) ml in mothers with abnormally invasive PAS. Blood transfusion was given for 62.5% (10 out of 16) of mothers with grade 1 PAS while it was given for 66.7% (4 out of 6) and for all (3 out of 3) of the mothers with grade 2 and grade 3 PAS, respectively. On average ( + SD), 1.5 ( + 1.4) units of blood was given for mothers with grade 1 PAS, and similarly, average units of blood given for mothers with grade 2 and grade 3 PAS were 3.8 ( + 3.3) and 5 ( + 1) units, respectively (Table 5).The average ( + SD) operation time taken showed that the longest span taken was for mothers with grade 3 PAS with 153.3 ( + 55.1) minutes and the shortest span taken being for mothers with grade 1 PAS, 82 ( + 42) minutes in average. Table 5: Outcomes of Mother with PAS Classifications, Black Lion Hospital, Addis Ababa, Ethiopia, 2023. Variables Abnormally adherent placenta (N=16) Abnormally invasive placenta Total (N=9) With antenatal suscipion (n=6) Without antenatal suscipion (n=3) Estimated blood loss(ml) <1500 12 (75%) 3 (33.3%) 3 (50%) --- ≥1500 4 (25%) 6 (66.7%) 3 (50%) 3 (100%) Average Blood Loss ( + sd) 1212 ( + 561) 2220 ( + 931) 1950 ( + 757) 2700 ( + 1153) Blood transfusion yes 10 (62.5%) 7 (77.8%) 4 (66.7%) 3 (100%) no 6 (37.5%) 2 (22.2%) 2 (33.3%) --- Average unit transfused ( + sd) 1.5 ( + 1.4) 4.2 ( + 2.8) 3.8 ( + 3.3) 5 ( + 1) Average operation time in minute ( + sd) 82 ( + 42) 132 ( + 49) 121.6 ( + 48.7) 153.3 ( + 55.1) Organ injury (N=2) --- 2 2 --- Maternal infection(N=3) 1 2 1 1 Relaparatomy (N=3) --- 3 2 1 Average Hb (g/dl) level at discharge ( + sd) 10.3 ( + 1.5) 9.5 ( + 0.7) 9.5 ( + 0.9) 9.5 ( + 0.4) Average hospital stay in days ( + sd) 4.3 ( + 1.9) 5.4 ( + 3.3) 4.3 ( + 2.8) 7.6 ( + 3.8) Organ injury during operation time had occurred in two (8%) of the mothers with PAS and both being in mothers with grade 2 PAS. Maternal infection had occurred in three (12%) of the mothers with PAS and these were one from each grades of PAS. Relaparatomy was required in three (12%) of the mothers and two of these were for mothers with grade 2 PAS while one was for mother with grade 3 PAS (Table 5). Upon assessing the condition in which the mothers with PAS were discharged, the average ( + SD) hemoglobin level was 10.3 ( + 1.5)g/dl for mothers with abnormally adherent placenta while 9.5 ( + 0.9)g/dl and 9.5 ( + 0.5)g/dl for mothers with grade 2 and grade 3 PAS, respectively (Table 5). The average ( + SD) hospital stay before discharge was 4.3 days for mothers with grade 1 ( + 1.9) and grade 2 ( + 2.8) PAS while it was 7.6 ( + 3.8) days for mothers with grade 3 type of PAS (Table 5). 5. Discussion Based on the current study, the prevalence of CD in Black Lion Hospital was 37.3% which is very high. This finding is line with the finding of a previous study done in Addis Ababa (38.3%) [ 16 ]. These high rate of CD in both studies could be partly explained by the fact that Black Lion Hospital being the highest tertiary hospital in the country to where more complicated obstetrics and gynecologic cases are referred. The CD rate in this study is by far higher than from the 2019 EDHS report where the prevalence of CD was 5.44% [ 17 ]. This difference might be explained by the differences in the study participants as the EDHS report was done based a multilevel analysis as a nation level but the current study was done only at a single hospital found in a relatively more urbanized city of the nation. Our finding is also comparable to the overall prevalence of CD in selected hospitals in Addis Ababa was 38% [ 12 ][ 13 ]. This high rate of CD in the current study was also comparable to the study in Nigeria (34.7%) [ 7 ]. This might also be explained by the increasing rate of CD globally. The prevalence of PAS in this study is 1 out of 994 deliveries. This prevalence rate of PAS is high. This might be explained by the rising CD incidence and practices. This finding is comparable to the findings of Italy (0.84/1000 births) [ 18 ] and Israel (1.2/1000 births) [ 19 ]. These similarities could be explained by the similarities of the study design applied. It was also in line with a meta analysis finding which reported as the PAS prevalence rates ranging between 0.01 to 1.1% [ 20 ]. But, it is by far higher than a study finding of Morocco (1/5824 births) [ 21 ] and USA (1/2510 births) [ 22 ]. These similarities and differences of the findings might be partly explained by the similarities and differences in the socidemographic characteristics, geographical locations and study periods. The high rate of PAS in the current study might also be explained by the high CD rate in Addis Ababa. Our finding also supported by the fact that with increasing rate of CD in Ethiopia especially in capital city - Addis Ababa could probably increases the prevalence of PAS [ 9 ][ 10 ][ 11 ]. The prevalence of PAS in the current study is lower than from those findings of the Nigerians (1/282 births) [ 7 ], Egyptians (9/1000 births) [ 23 ], Canadians (1/588 births) [ 24 ], Americans (1/533 births and 1/731) [ 8 ][ 25 ] and Germans (2.49/1000 births) [ 26 ]. This difference can be explained by the fact that screening is more effective in more developed countries than in low- and middle-income countries like Ethiopia. It could also be due to the rising incidence of CD and urbanization in those aforementioned countries. The majority (92%) of the participants had at least one of the three associated risk factors for PAS. This might be due to the fact that any uterine procedure could end up with scar on the uterine wall which might result in failure of normal decidualization . This resulting decidual defect has an adverse effect on early implantation by creating conditions for preferential attachment of the blastocyst to scar tissue and facilitating abnormally deep invasion of the extravillous trophoblast [ 20 ]. This high figure of association between PAS and the three risk factors could also further explained by the concepts proposed to explain the abnormal placentation in PAS including a primary defect of the trophoblast function and a secondary basalis defect on the scared area [ 20 ]. In this study we found that a prior CD was documented in 16 (64%) of mothers with PAS. This higher proportion of prior CD presence in mothers with PAS might be explained by the fact that the strongest risk factor for PAS and PP is a prior CD. Scared myometrium from previous CD can result in failure of decidualization in the area of scar which can have an impact on both implantation and placentation [ 4 ]. Moreover, having a previous CD history in a mother increases the chance of developing PAS. Miller et al, in their studies stated that the risk of PAS in a mother with a history of previous CDs increases by 12% [ 22 ]. The high CD rate in Addis Ababa [ 16 ] might also partly explain the finding of high association between prior CD and PAS in this study. This is in line with the reports of a study in Texas of USA where they found a higher rate of previous CD history in both the unexpected PAS (89.9%) and expected PAS (64.8%) [ 27 ]. It was also in line with the findings of the Nigerian (82%) [ 7 ] and Americans in their two studies (73% and 49.55%) [ 8 ][ 22 ]. This association could be also explained by previous studies claiming increase in cesarean rates in most middle and high income countries led to an increase in the prevalence of PAS [ 24 ][ 28 ]. PP is regarded as one of the major risk factors associated with PAS. Jauniaux and Burtonne stated PP as one of the single most important risk factor, occurring in around 50% of all cases of PAS disorders [ 1 ]. The current study has identified the coexistence of PP in 18 (72%) of mothers with PAS which is high figure. This is in line with the study done in Aba town of Southeast Nigeria (73%) [ 7 ], as well as with studies done in Chicago (31.53%) and California (89%) states of USA [ 8 ][ 22 ]. This could be due to the fact that a low-lying placenta may cause a defective or improper endo-myometria l interface (over the internal Os) which does not allow for healthy placental implantation to occur [ 24 ]. This figure of high association between PAS and PP in this study could be explained by the fact that there is a 10% risk of a mother to develop PAS in the presence of PP (without previous uterine surgery) [ 22 ]. This might also be further supported by the study findings in Morocco where 100% [ 29 ] of their patients were presented with PP and in the Texas study of USA where PP where detected in both unexpected (74.6%) and expected (37.3%) PAS [ 27 ]. Moreover, the current finding is also be supported by the finding of a study done in UK by Jauniaux and Bhide [ 4 ]. In their cohort study, 328 (8.4%) pregnancies with PP were complicated by PAS [ 4 ]. In the current study, in 60% (15 out of 25) of the mothers both PP and CD were identified as combined risk factors for the PAS. This finding of high proportion can be explained by the fact that PP and previous CD act synergistically to further increase the risk of PAS. Miller et al., mentioned that the risk of PAS increases sharply to as high as 25% in the presence of a combined one prior CD and PP [ 22 ]. It was comparable to the findings of the Italian study where higher rates of a concomitant PP and prior CS were detected in both antenatal suspected (62.1%) and unsuspected (28.7%) PAS [ 19 ]. All the three risk factors were absent in 8% of the participants in this study. This was lower than the study done in Italy where 22.2% of their mothers with PAS have no known risk factors [ 19 ]. In this study, PAS in 60% (15 out of 25) of the participants was in the presence of both PP and CD as combined risk factors. These could be explained by the fact that the incidence of PAS could dramatically decreased in the absence of any risk factors but it could increases in the presence of PP and prior CD as combined. Similarly, the study in USA reported an incidence rate of 1/68 000 births (0.0015%) in the absence of any risk factor [ 22 ]. The gestational age of mothers with PAS in this study showed as unknown in 12%, < 34 weeks in 20%, 34–37 weeks in 28% and ≥ 37 weeks in 40% of the participants. These variation in gestational age of the participants could be explained by the fact PAS can occur at any stage of a pregnancy. According to Comstock as cited by Umezuruke, et al [ 7 ], PAS can be present at any stage of gestation from first trimester to term. Therefore, individuals who are at risk of PAS at term are also already at risk for it in the first trimester [ 7 ]. Among the 25 mothers with PAS in this study, the majority, 64% (16), were grade 1 and followed by grade 2 and 3 with 24% and 12%, respectively. These findings were in line with the findings of Miller et al, where grade 1, grade 2 and grade 3 constitutes 68.1%, 23.4% and 8.5% of their participants with PAS, respectively [ 22 ]. Although prenatal diagnosis of PAS is difficult, Diagnosing PAS prenatally is very important for possible accurate diagnosis and preparation for delivery. It is reported that antenatal US a sensitivity of 77–90% and specificity of 71–98% [ 30 ]. However, only 24% (6 out of 25) of the mothers with PAS were suspected prenatally in the current study. This figure of antenatal suspicion was very low. This lower figure in Black Lion Hospital can be explained by the fact that screening is more effective in developed countries than in low- and middle-income countries like Ethiopia. Unlike to this study, more number of PAS were suspected during pregnancy in Italy (50%), Morocco (50%) and USA (53.2%) (n = 84) women [ 19 ][ 21 ][ 25 ]. More specifically, all of the prenatally suspected PAS in this study were the abnormally invasive type. In line with this, all the prenatally suspected PAS were the morbidly adherent type in the other similar study of USA [ 25 ]. Similarly, severe PAS ( increta/percreta ) were more common in the prenatally suspected PAS group (66.1%) than in the unsuspected PAS group (16.7%) of the USA study [ 27 ]. Even in the presence of known risk factors, the antenatal diagnosis of PAS with less severe degrees of invasion may be challenging. Generally, the prenatal ultrasound is subjective and requires specialized expertise for both doing the examination as well as interpreting it. In the current study, histological confirmation was only for mothers abnormally invasive PAS.of which, it was done for 83.3% (5 out of 6) mothers with grade 2 PAS and in all three of the mothers with grade 3 PAS. This finding was better than the Moroccan study where only 48% (62) of their mothers with PAS had histologic confirmation [ 21 ]. The estimated blood loss documented showed that the amount of losses were < 1500ml in 15 (60%) and ≥ 1500ml in 10 (40%) of mothers with PAS. Twelve out of the 16 (75%) abnormally adherent and only 3 out of the 9 (33.3%) abnormally invasive PAS had an estimated blood loss of < 1500ml. All mothers with grade 3 PAS had an estimated blood loss of ≥ 1500ml. These could be explained by the more aggressive and invasive nature of the abnormally invasive PAS types. The above finding can also be further supported by the findings of this study in which the average estimated blood loss of 1212 ( ± 931) ml in mothers with abnormally adherent PAS and of 2220 ( ± 931) ml in mothers with abnormally invasive PAS. Therefore, prenatal suspicion is paramount to decrease maternal morbidity and mortality. Prenatal suspicion or diagnosis may create an opportunity for multidisciplinary input in the management of the condition. Whenever antenatal suspicion and detection is missed, bleeding is usually imminent as the retained and exposed placental tissue is in direct contact with the maternal circulation. Bleeding will be profuse as uterine artery blood flow increases as much as 50-fold during pregnancy [ 31 ]. In the current study, 68% (17) of the mothers were transfused with blood. This is in line the study in Italy where 73% of women were transfused with RBC units [ 19 ]. The average amount of blood loss was 1568 ( ± 849) and the average number of blood transfused was 2.64 ( ± 2.3) units. This was slightly better than the Nigerian study where the median blood loss and transfused in theirs participants were 2 liters and 4 units [ 7 ]. The more aggressive and morbidly adherent PAS types are grade 2 and 3 PAS. The PAS being the more morbidly adherent, it is expected that the more mothers will bleed and transfused. In this study, three out of the 6 (50%) mothers with grade 2 PAS and all mothers with grade 3 PAS had an estimated blood loss of ≥ 1500ml. There was an average estimated blood loss of 1212 ( ± 931) ml in mothers with abnormally adherent PAS and of 2220 ( ± 931) ml in mothers with abnormally invasive PAS. In other words, more amount of blood was lost in mothers with invasive type than adherent type of PAS. This could be explained by the fact that placenta is more exposed and firm contact with maternal circulation in the case of the abnormally invasive PAS types. Moreover, the average units of blood given for mothers with grade 2 and grade 3 PAS in this study were 3.8 ( ± 3.3) and 5 ( ± 1) units, respectively. The average ( ± SD) operation time taken showed that the longest span taken was for mothers with grade 3 PAS with 153.3 ( ± 55.1) minutes and the shortest span taken being for mothers with grade 1 PAS, 82 ( ± 42) minutes in average. Organ injury during operation time had occurred in two (8%) of the mothers with PAS and both being in mothers with grade 2 PAS. Maternal infection had occurred in three (12%) of the mothers with PAS and these were one from each grades of PAS. Re-laparotomy was required in three (12%) of the mothers and two of these were for mothers with grade 2 PAS while one was for mother with grade 3 PAS. As expected a prolonged average ( ± SD) hospital stay before discharge was documented for mothers with abnormally invasive PAS In this study, the average hospital stay showed that 4.3days for mothers with grade 1 ( ± 1.9) and grade 2 ( ± 2.8) PAS while it was 7.6 ( ± 3.8) days for mothers with grade 3 type of PAS. Maternal mortality in PAS remains rare. This is a reflection of increasing antenatal detection and planned delivery [ 24 ]. There was no maternal death and ICU admission requirement for mothers with PAS in the current study. Unlike to this, there was one maternal death in each of the Nigerian (9%), Italian (2.6%) and Moroccan (17%) studies [ 7 ][ 19 ][ 21 ]. These disparities in the studies mentioned above might be due to the differences in the health facilities and expertise involved in those study areas. 6. Limitation of the study This study was aimed to determine the prevalence, characteristics and outcome of pregnant mothers with PAS in Black Lion Hospital. In spite of this big intention, the study was not free of limitations. It was done at single government hospital and hence, it might not be possible to generalize the current findings to the entire pregnant women of Addis Ababa. The other limitation is the cross-sectional nature of the study design; which could not reveal the exact causal association among the ongoing risks and miss diagnosis/results of imaging modalities. The rare nature of the problem also against the study design applied in this study. 7. Conclusion and Recommendation 7.1. Conclusion The prevalence of CD in Black Lion Hospital is very high. This is one of the highest rate of CS in the world. The prevalence rate of PAS is high. This trend is probably correlated to the high rate of CD and certain risk factors such as PP, with mucosal erosion. Both CD and PP are the most identified risk factors for the PAS. The practice of antenatal suspicion and diagnosis of PAS is very low. However, antenatal detection in this study has decreased maternal morbidity and mortality. There was no maternal death and ICU admission requirement for mothers with PAS in this study. Therefore, there was a low maternal complication rate in the hospital. 7.2. Recommendations It is important to promote educational efforts to support obstetricians in safely reducing primary CD and admitting women with prior CD to a trial of labor. coordinated, multi-faceted efforts should be directed to increase antenatal suspicion and diagnosis of PAS by rising awareness of relevant risk factors with referral of patients at risk for targeted ultrasound assessment by expert sonographers/radiologists. A future and detailed study involving different government and private health facilities is recommended. A future study with cohort study design with multidisciplinary experts is recommended. Declarations Ethics approval and consent to participate An ethical clearance and permission letter was obtained from the obstetrics and gynecology department of Addis Ababa University (Black Lion Hospital). As the study was a retrospective one, there was no need for ethical clearance of using human tissue for experiment. Hence, informed consent was waived/deemed unnecessary by the Ethical Review Committee of Addis Ababa University. It was given to the heads of the hospital, the registry unit and labor ward of the hospital. After permission was granted from them, we started the data collection. Consent for Publication Not Applicable. Availability of data and Materials The datasets used and analyzed for this study are available from the corresponding author on reasonable request. Funding Not applicable, as it was initially intended for academic output. Acknowledgment We would like to acknowledge the Addis Ababa University, School of Medicine, Department of Obstetrics and Gynecology for letting us accomplished with this paper, and Black Lion Hospital which provide us the data and other necessary documents during the patients’ data review, analysis and summary preparation process. We want to extend our sincere gratitude to the research team members who helped us from data collections to everything. Author’s contributions Protocol preparation and literature review: TY, MFA. Data analysis and interpretation: TY, MFA. Drafting of the manuscript and revision of the manuscript: TY, GFT, TK, MFA. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. References Jauniaux E., Burton G. J. (2018). Pathophysiology of placenta accreta spectrum disorders: A review of current findings. Clin. Obstet. Gynecol. 61, 743–754. Jauniaux E., Hussein A.M., Fox K.A., Collins S.L., New evidence-based diagnostic and management strategies for placenta accreta spectrum disorders. Best Pract. Res. Clin. Obstet. Gynaecol. 2019;61:75–88. Jauniaux E, Grnbeck L,Bunce C, et al . Epidemiology of placenta previa accreta: a systematic review andmeta-analysis. BMJ Open 2019;9:e031193. Jauniaux E, Bhide A, Burton GJ. Pathophysiology of accreta. In: SilverR, ed. Placenta accreta syndrome . Portland: CRC Press; 2017:13–28. Collins SL, Ashcroft A, Braun T, et al. Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP). Ultrasound Obstet Gynecol . 2016;47:271–275. Jauniaux E, Bhide A, Kennedy A, Woodward P, Hubinont C, Collins S; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and screening. Int J Gynaecol Obstet. 2018;140:274–280. Umezuruke C, Nkwocha G; Placenta accreta in Aba, south eastern, Nigeria , Nigerian journal of medicine : 2007, vol 16, no 3; 220-222. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: Twenty-yearanalysis. Am J Obstet Gynecol . 2005;192:1458–1461. Betran AP, Ye J, Moller A-B, et al. Trends and projections of caesarean section rates: global and regional estimates. BMJ Global Health 2021;6:e005671. doi:10.1136/ bmjgh-2021-005671. Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders:Epidemiology. Int J Gynecol Obstet . 2018;140:265–273. Gonca Yetkin Yildirim , Nadiye Koroglu , Aysu Akca Merve Talmac , Selin Dikmen ,Gokhan Yıldırım , Ibrahim Polat Ismail Ozdemir What is new in peripartum hysterectomy? A seventeen year experience in a tertiary hospital, Taiwanese Journal of Obstetrics & Gynecology 60 (2021) 95-98. Federal Ministry of Health (FMOH). Ethiopia Demographic and Health Survey. 2016, Addis Ababa, Ethiopia. Gebremedhin S. Trend and socio-demographic differentials of Caesarean section rate in Addis Ababa, Ethiopia: analysis based on Ethiopia demographic and health surveys data. Bio Med Central. 2014;11(14). Eller AG, Bennett MA, Sharshiner M, Masheter C, Soisson AP, Dodson M, Silver RM. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet. Gynecol. 2011;117(2 Pt 1):331–337. http://www.aau.edu.et/chs/tikur-anbessa-specialized-hospital/ [accessed on 23 February 2023]. Tsegaye H, Desalegne B, Wassihun B, Bante A, Fikadu K, Debalkie M, et al. Prevalence and associated factors of caesarean section in Addis Ababa hospitals, Ethiopia. Pan African Medical Journal. 2019;34:136. Hailegebreal S, Gilano G, Seboka BT, Ahmed MH, Simegn AE, Tesfa GA, et al. Prevalence and associated factors of caesarian section in Ethiopia: a multilevel analysis of the 2019 Ethiopia Mini Demographic Health Survey, Addis Ababa, Ethiopia. BMC Pregnancy and Childbirth (2021) 21:798 . Esh-Broder E, Ariel I, Abas-Bashir N, Bdolah Y, Hochner Celnikier D. Placenta accreta is associated with IVF pregnancies: a retrospective chart review. BJOG 2011; 118:1084–1089. Ornaghi S, Maraschini A, Donati S, on behalf of The Regional Obstetric Surveillance System Working Group (2021) Characteristics and outcomes of pregnant women with placenta accreta spectrum in Italy: A prospective population based cohort study. PLoS ONE 16(6): e0252654. https://doi.org/10.1371/journal.pone.0252654. Jauniaux E, Bunce C, Grønbeck L, Langhoff-Roos J Prevalence and main outcomes of placenta accreta spectrum: a systematic review and metaanalysis. Am J Obstet Gynecol 2019;220: doi.org/10.1016/j.ajog.2019.01.233. Slaoui A, Talib S, Nah A, Moussaoui KE, Benzina I, Zeraidi N, et al. Placenta accreta in the department of gynaecology and obstetrics in Rabat, Morocco: case series and review of the literature, Rabat, Morocco. Pan African Medical Journal . 2019;33:86. doi:10.11604/pamj.2019.33.86.17700. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa–placenta accreta. Am J Obstet Gynecol. (1997) 177:210–4 . Gelany SE, Mosbeh MH, Ibrahim EM, Mohammed M, Khalifa EM, Abdelhakium AK, et al. Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study, Egypt. BMC Pregnancy and Childbirth (2019) 19:313. Balayla J, and Bondarenko D. Placenta accreta and the risk of adverse maternal and neonatal outcomes, Quebec, Canada. J. Perinat. Med. 2013; 41(2): 141—149. Bailit Jl, Grobman W, Rice MM, Reddy UM, Wapner RJ, Varner MW, et al. Morbidly Adherent Placenta Treatments and Outcomes, Cleveland, USA. Obstet Gynecol . 2015 March ; 125(3): 683–689. Bluth A, Schindelhauer A, Nitzsche K, Wimberger P, Birdir C. Placenta accreta spectrum disorders—experience of management in a German tertiary perinatal centre, Germany. Archives of Gynecology and Obstetrics (2021) 303:1451–1460. Erfani H, Fox KA, Clark SL, Rac M, Rocky Hui SK, Rezaei A, Aalipour S, Shamshirsaz AA, Nassr AA, Salmanian B, Stewart KA, Kravitz ES, Eppes C, Coburn M, Espinoza J, Teruya J, Belfort MA, Shamshirsaz AA. Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team. Am J Obstet Gynecol. 2019 Oct;221(4):337-337. Varlas VN, Bors RG, Birsanu S, Maxim B, Clotea E, Mihailov M. Maternal and fetal outcome in placenta accreta spectrum (PAS) associated with placenta previa: a retrospective analysis from a tertiary center, Bucharest, Romania. JOURNAL of MEDICINE and LIFE; 2021: 14(3):367-375. Lamrissi A, Benjelloun AT, Harit A, Fichtali A, Bouhya S. Prenatal diagnosis and management of placenta accreta in a Moroccan high-level maternity. Casablanca, Morocco. International Journal of Surgery Open 43 (2022):100497. Warshak CR, Eskander R, Hull AD, Scioscia AL, Mattrey RF, Benirschke K, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol. 2006;108(Pt 1):573 – 81. Pastore MB, Jobe SO, Ramadoss J, Magness RR. Estrogen receptor-alpha and estrogen receptor-beta in the uterine vascular endothelium during pregnancy: functional implications for regulating uterine blood flow. Semin Reproductive Med. 2012;30:46 – 61. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies 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-3889075","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":273547416,"identity":"8fe6d795-5a1b-40ae-ac7e-3a8e5df9a83e","order_by":0,"name":"Fuad Ahmed Mohammed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYJACZiCWAzEOPCBFizFYSwIpWhIbQCyitOjOSH/4uHCPTfr8sMMPgbbYyek2ENBidiPH2HjGs7TcjbfTDIBako3NDhDWwibNc+Bw7sbZCSAtBxK3EdaS/vw3UEu64ez0D8RqSTBjBmpJkJfOIdaWM2+MpWccSDPcIJ1TcCDBgBi/HE9/+LnggI28/Oz0zR8+VNjJEdQCBwZglQbEKgcB+QZSVI+CUTAKRsGIAgBMckf/Iay9dAAAAABJRU5ErkJggg==","orcid":"","institution":"Ethiopian Public Health Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Fuad","middleName":"Ahmed","lastName":"Mohammed","suffix":""},{"id":273547418,"identity":"41045652-77bc-4d76-822f-78ad6ae42375","order_by":1,"name":"Yared Tesfaye Wube","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yared","middleName":"Tesfaye","lastName":"Wube","suffix":""},{"id":273547420,"identity":"d53bb2bc-ccd8-4591-b678-84c8d2865f29","order_by":2,"name":"Fikremelekot Temesigen Gondere","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fikremelekot","middleName":"Temesigen","lastName":"Gondere","suffix":""},{"id":273547422,"identity":"3a0703a7-9baa-428d-9475-e69879700f08","order_by":3,"name":"Kiflom Tesfaye","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kiflom","middleName":"","lastName":"Tesfaye","suffix":""}],"badges":[],"createdAt":"2024-01-22 21:44:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3889075/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3889075/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51396080,"identity":"4a461549-363a-4738-8731-7127ce9b94fc","added_by":"auto","created_at":"2024-02-20 20:13:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31217,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRisk Factors in Mothers with PAS, Black Lion Hospital, Addis Ababa, Ethiopia, 2023.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3889075/v1/2ee67034fae85d8debccccde.png"},{"id":51396081,"identity":"b9fa333f-66a8-4876-814d-23e6285e55c9","added_by":"auto","created_at":"2024-02-20 20:13:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":120318,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMothers with PAS by Gestational Age, Black Lion Hospital, Addis Ababa, Ethiopia, 2023.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3889075/v1/ffdc50efa8b464914d4f18d4.png"},{"id":51396082,"identity":"1963e280-5aec-4954-aa71-dfc0baa904b3","added_by":"auto","created_at":"2024-02-20 20:13:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":114347,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eClassification of PAS in mothers at Black Lion Hospital, Addis Ababa, Ethiopia, 2023.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3889075/v1/2dce4247d99e4de6654769a4.png"},{"id":89004626,"identity":"8c70f46c-7be9-4e20-ae8a-bd1925a89728","added_by":"auto","created_at":"2025-08-13 16:01:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1760175,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3889075/v1/92819953-04db-4c10-84a3-c2d21027f344.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Characteristics, Outcomes and Prevalence of Pregnant Women with Placenta Accreta Spectrum in Black Lion Hospital - Five years retrospective study , Addis Ababa, Ethiopia, 2023","fulltext":[{"header":"1. Background","content":"\u003cp\u003ePlacenta accreta spectrum (PAS) is known to be associated with significant maternal morbidity and mortality usually because of catastrophic hemorrhage during delivery. Historically Irving and Hertig defined placenta accreta as the abnormal adherence either in whole or in part of \u0026ldquo;the afterbirth\u0026rdquo; to the underlying uterine wall. Even though, their work is pioneer in introducing the subject, none of their cases had villus tissue invading the \u003cem\u003emyometrium\u003c/em\u003e and their diagnosis was made clinically when the placenta fails to delivered following birth of the baby [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe clinical signs of PAS disorder especially non invasive or partially adherent placenta can be very similar to those of placental retention which lead to wide heterogeneity in the definition and evaluation of the prevalence of PAS in the general obstetric population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. PAS is strictly defined as direct attachment of the placental \u003cem\u003etrophoblast\u003c/em\u003e to the uterine \u003cem\u003emyometrium\u003c/em\u003e, with no normal intervening \u003cem\u003edecidua\u003c/em\u003e or basalis layer [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With the development of advanced imaging modality PAS has been diagnosed during prenatal period but irrespective of the imaging modality used, prenatal diagnosis of PAS disorders remains subjective, with accuracy depending on the experience of the operator. Additionally, there is no published consensus on the definition of the ultrasound markers used commonly for PAS. Many signs have been described under different names, and in other cases the same term has been used for different findings [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecently group of experts provide a unified standard definition of commonly used ultrasound marker for prenatal diagnosis of PAS and later their recommendation was accepted in FIGO consensus guideline of PAS [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Prenatal diagnosis of PAS is very important to decrease perinatal morbidity and mortality though PAS was expected before delivery only in half of the cases. Studies showed that Major complications like massive obstetric hemorrhage, need for transfusion, surgical trauma, maternal death were high in those PAS diagnosed only during the time of delivery than those expected to have PAS during antenatal period [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTotal primary hysterectomy, delayed secondary \u003cem\u003ehysterectomy\u003c/em\u003e and expectant management by living the placenta in situ are the main types of management for PAS and choosing which type depends on prenatal diagnosis, intraoperative or clinical finding, and experience of the surgeon, the facility and the local protocol if any [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWorldwide rate of PAS is increasing through time to time due to increased rate of cesarean delivery (CD). The use of cesarean section (CS) has steadily increased worldwide and will continue increasing over the current decade where both unmet need and overuse are expected to coexist. The average global CS rate (CSR) is 21.1% of all births (Range: 5% \u0026minus;\u0026thinsp;42.8%). Projections showed that by 2030, 38\u0026nbsp;million (28.5%) women worldwide will give birth by CS annually. From these, 33.5\u0026nbsp;million of them are in Low and Middle Income Countries (LMIC), ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to the Ethiopian Demography and Health Survey (EDHS), CSR increased from 0.7% in 2000 to 1.9% in 2016 in the nation, with increment across all regions. Addis Ababa had the highest CSR (21.4%) in 2016 and the greatest increase since 2000. The overall prevalence of CD in selected hospitals in Addis Ababa was 38% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. With increased rate of CD in Ethiopia especially in capital city - Addis Ababa, it is expected that the prevalence of PAS will be increased [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Screening all mothers with risk factors for PAS, planned delivery and multidisciplinary team (MDT) approach are found important in decreasing adverse perinatal outcome of mothers with PAS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo our knowledge in Ethiopia the prevalence and outcome of PAS is not known and hospitals experience in antenatal detection and management of PAS not yet studied. To understand the current problem and to improve the practice for the future, the current practice must be evaluated and the magnitude of the problem should be known. This study will fill the gap in determining the prevalence, characteristics and outcome of pregnant mothers with PAS. Since black lion hospital is a tertiary referral hospital, conducting such kind of study will have a role in future improvement in handling these cases. This study also has a significant role as a base line study on which future prospective and national and regional studies could be planned.\u003c/p\u003e"},{"header":"2. Objectives","content":"\u003cp\u003e\u003cstrong\u003e2.1. General objective\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTo determine the characteristics, outcome and prevalence of pregnant mothers with PAS in black lion hospital, Addis Ababa, Ethiopia, from January 1, 2018 to December 31, 2022.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Specific objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e.To determine the prevalence of PAS in Black Lion Hospital during the study period.\u003c/li\u003e\n \u003cli\u003eTo determine characteristics of pregnant mothers with PAS in Black Lion Hospital during the study period.\u003c/li\u003e\n \u003cli\u003eTo determine major maternal outcome of mothers managed for PAS in Black Lion Hospital during the study period.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"3. Methodology","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Study Area\u003c/h2\u003e \u003cp\u003eThe study area is black lion hospital, one of tertiary referral teaching hospital found in the capital city, Addis Ababa, Ethiopia. The hospital has an estimated annual delivery rate 4000 to 7500. In related to PAS the department of obstetrics and gynecology of the hospital organized with expertise like maternal fetal medicine ,gynecologic oncologist and other expertise like \u003cem\u003eanesthesiologist, neonatologist\u003c/em\u003e and intensive care person also available in the hospital which makes the hospital ideal to handle cases of PAS, though having resource limitation [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Study Design and Period\u003c/h2\u003e \u003cp\u003eAn Institutional based a five year retrospective cross sectional study of January 1, 2018 to December 31, 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Populations\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1. Sampling Population\u003c/h2\u003e \u003cp\u003eAll deliveries attended in black lion hospital during the study period\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2. Study Population\u003c/h2\u003e \u003cp\u003eAll mothers diagnosed to have PAS.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Eligibility Criteria\u003c/h2\u003e \u003cp\u003e\u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e \u003c/p\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAll mothers diagnosed to have PAS and fulfill the criteria of FIGO classification for the diagnosis of PAS.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion criteria\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMothers with incomplete data.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Variables of the Study\u003c/h2\u003e \u003cp\u003e \u003cb\u003eDependent variable\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePAS\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eIndependent variables\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHistory of CD\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHistory of placenta previa (PP)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHistory of curettage and myomectomy\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAntenatal diagnosis of PAS\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGestational Age (GA) at delivery\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePP in current pregnancy\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMode of delivery\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCD type (Emergency CS, Elective CS)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClassification\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.6. Operational Definitions\u003c/h2\u003e \u003cp\u003eMaternal outcomes included: maternal ICU admission, clinically determined estimated blood loss (EBL), number of units of packed red cells transfused, hysterectomy, organ injury, maternal infection, anemia, \u003cem\u003erelaparatomy\u003c/em\u003e and maternal death.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.7. Data Collection Method\u003c/h2\u003e \u003cp\u003eThe data for the study was collected using a semi-structured questionnaire from patient chart and electronic patient data base. The questionnaire consisted of four parts: socio-demographic characteristics, Obstetric history, Current Pregnancy and maternal outcome sections.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.8. Data Processing and Analysis\u003c/h2\u003e \u003cp\u003eAfter data collection, each questionnaire was checked for completeness before entering into software. Coding of individual questionnaires was checked before data entry in to the software. Data was entered in to SPSS version 26 statistical package and MS excel. Further, data cleaning was performed to check for outliers, missed values and any inconsistencies before the data analysis. Descriptive statistical analysis was used to analyze the data and displayed using frequency, percentages and tables for easy interpretation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.9. Ethical Considerations\u003c/h2\u003e \u003cp\u003e An ethical clearance and permission letter was obtained from the obstetrics and gynecology department of Addis Ababa University (Black Lion Hospital). It was given to the heads of the hospital, the registry unit and labor ward of the hospital. After permission was granted from them, we started the data collection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.10. Result Dissemination Plan\u003c/h2\u003e \u003cp\u003eThe final result of this paper was submitted to black lion hospital, department of obstetrics and gynecology. The research outputs was presented to the college community and other concerned stakeholders. It might also be submitted to international peer review journals for possible publication.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cp\u003eA total of 24,844 deliveries were registered during this five years study period and 9,276 of them were cesarean delivery. This made the prevalence of CD in the Black Lion Specialized Hospital to be 37.3%. During this study period, 25 of the mothers had developed PAS. Therefore, the sample size of this study became 25.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1. Socidemographic Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1: Socidemographic characteristics of mothers with PAS, Black Lion Hospital, Addis Ababa, Ethiopia,\u0026nbsp;\u003c/em\u003e\u003cem\u003e2023.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.62686567164179%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.611940298507463%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (N=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.761194029850746%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e\u0026lt; 35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.4066985645933%\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026gt;\u003c/u\u003e 35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.4066985645933%\"\u003e\n \u003cp\u003e\u0026nbsp; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.1866028708134%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Level (n=21, Unknown level=4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003eno formal education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003eprimary school\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003esecondary school\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003eCollege and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.160148975791433%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.560521415270017%\"\u003e\n \u003cp\u003e\u0026nbsp;-------\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.71880819366853%\"\u003e\n \u003cp\u003e-------\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eA total of 25 mothers, who had developed PAS; were registered during the five years study period. Of which, more than three-fourth (76%) of them were younger than 35 years of age while all of them were married in marital status. Majority (96%) of the participants were urban dwellers while 12 (57.1%) of them had been to school at least up to secondary school (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2. Obstetric Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: Obstetric Characteristics of Mothers with PAS, Black Lion Hospital, Addis Ababa, Ethiopia,\u0026nbsp;\u003c/em\u003e\u003cem\u003e2023.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (N=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eNulliparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003ePrimiparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eMultipara\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of Cesarean Delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; 9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eOnce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026ge;Twice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of uterine surgery and procedure \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePresence of \u0026nbsp; \u0026nbsp; placenta previa\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.9054820415879%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.843100189035916%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; 7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.251417769376182%\" valign=\"bottom\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFrom the total participants, the majority (76%) of the mothers were \u003cem\u003emultipara\u003c/em\u003e while 11 (44%) of them had previous cesarean deliveries of at least twice but 9 (36%) of them did not have any cesarean delivery history previously. The majority of the mothers had not had any previous history of uterine surgery or related procedure and 18 (72%) of them had developed PP during this last delivery (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3. Characteristics of Mothers with PAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom January 1, 2018 to December 31, 2022 period, there were 25 mothers with PAS out of the total 24,844 deliveries. These made the prevalence of PAS to be 0.001 or 1 out of 994 deliveries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.1. Associated Risk Factors of PAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt least one of the three risk factors were present in 92% (23 out of 25) of the mothers with PAS. Six (24%) of the mothers had previous uterine surgery/procedure. Either PP or CD were present in 76% (19 out of 25) of the mothers with PAS while in 60% (15 out of 25) of the mothers both PP and CD were identified as combined risk factors for the PAS (Figure 1). Only 8% (2 out of 25) of the mothers did not have any of the three risk factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.2. Distribution of PAS with Gestational Week\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 12% (3 out of 25) of the mothers with PAS, their gestational week level was unknown. Their gestational week in 20% (5 out of 25) of them was less than 34 weeks but the pregnancy was term pregnancy (\u003cu\u003e\u0026gt;\u003c/u\u003e 37 weeks) in 40% (10 out of 25) of the mothers with PAS (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.3. Classification of PAS in the Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 25 mothers with PAS, 16 (64%) of the adherent placenta were abnormally adherent one (grade 1) while 9 (36%) of the PAS were the invasive type [grade 2 (24%) and grade 3 (12%)]. Six out of the 9 (66.7%) abnormally invasive placenta type of PAS were with antenatal suspicions while the rest three (33.3%) were without antenata suspicion (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.4. Distribution of PAS by the Management given\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was an antenatal suspicion of PAS in 6.3% (1 out of 16) of mothers with abnormally adherent placenta(grade 1) while in 50% (3 out of 6) and all (3 out of 3) of mothers with grade 2 and grade 3 of abnormally invasive placenta, respectively. Vaginal delivery was attended in 31.5% (5 out of 16) of mothers with abnormally adherent placenta (grade 1) while scheduled and emergency CD were performed in 43.8% (7 out of 16) and 25% (4 out of 16) of them, respectively. Scheduled hysterectomy was done for all mothers with grade 3 of abnormally invasive placenta and for 33.3% (2 out of 6) of mothers with grade 2 abnormally adherent mothers, and additionally; an emergency hysterectomy was done for 66.7% (4 out of 6) of mothers with grade 2 abnormally invasive placenta (Table 3).\u003c/p\u003e\n\u003cp\u003eThe gestational age at the time of delivery was \u003cu\u003e\u0026gt;\u003c/u\u003e 37 weeks in 56.3% (9 out of 16) and in 16.7% (1 out of 6) of mothers with grade 1 and grade 2 type of PAS, respectively. In 18.8% (3 out of 16) of mothers with grade 1 PAS and in none of the mothers with abnormally invasive placenta, their gestational age at the time of delivery was unknown. \u003cem\u003eHistological\u003c/em\u003e confimation was not made in all of the mothers with abnormally adherent placenta (grade 1) but it was done for 83.3% (5 out of 6) and in all three of the mothers with grade 2 and grade 3 abnormally invasive placenta, respectively (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3:\u0026nbsp;\u003c/em\u003e\u003cem\u003ePAS Distribution by Management given,\u0026nbsp;\u003c/em\u003e\u003cem\u003eBlack Lion Hospital, Addis Ababa, Ethiopia,\u0026nbsp;\u003c/em\u003e\u003cem\u003e2023.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.604166666666668%\" rowspan=\"2\" valign=\"top\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbnormally adherent placenta Grade 1, N=16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.0625%\" colspan=\"2\" valign=\"bottom\" style=\"width: 50.8711%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbnormally invasive placenta N=9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"53.57142857142857%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2, N=6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"46.42857142857143%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3, N=3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntenatal suspicion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.521739130434782%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.869565217391305%\" valign=\"bottom\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.652173913043477%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.869565217391305%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.08695652173913%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of Delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.521739130434782%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.869565217391305%\" valign=\"bottom\"\u003e\n \u003cp\u003evaginal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.652173913043477%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.869565217391305%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.08695652173913%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003eCD scheduled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003eCD emergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003ehysterectomy scheduled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003ehysterectomy emergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational age at the time of delivery\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.521739130434782%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.869565217391305%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026lt;34 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.652173913043477%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.869565217391305%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.08695652173913%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003e34 to 37 weeks\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026ge;37 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003eUn known\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003eAverage GA (\u003cu\u003e+\u003c/u\u003e Sd)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e36.2 (\u003cu\u003e+\u003c/u\u003e 3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e34.1 (\u003cu\u003e+\u003c/u\u003e 2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e35.3 (\u003cu\u003e+\u003c/u\u003e 1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistology confirmation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"4.521739130434782%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.869565217391305%\" valign=\"bottom\"\u003e\n \u003cp\u003eMissed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.652173913043477%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003e\u0026nbsp;NA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.869565217391305%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.08695652173913%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e-----\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.2367941712204%\" valign=\"bottom\"\u003e\n \u003cp\u003eConfirmed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.961748633879782%\" valign=\"bottom\" style=\"width: 16.1289%;\"\u003e\n \u003cp\u003eNA \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.85792349726776%\" valign=\"bottom\" style=\"width: 23.7129%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.94353369763206%\" valign=\"bottom\" style=\"width: 26.1621%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.5. Outcomes of the Mother with PAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quarterly measurement of the maternal estimated blood losses were 900ml (Q1), 1300ml (Q2) and 2150ml (Q3) with average (\u003cu\u003e+\u003c/u\u003e SD) estimated blood loss being 1568 (\u003cu\u003e+\u003c/u\u003e 849) ml.\u003c/p\u003e\n\u003cp\u003eThe estimated blood loss documented showed that the amount of \u0026nbsp; losses were \u0026lt; 1500ml in 15 (60%) and \u003cu\u003e\u0026gt;\u003c/u\u003e 1500ml in 10 (40%) of mothers with PAS. From the 17 (68%) mothers who were transfused with blood, 35.3% (6 out of 17) of them were transfused with less than 2 units of blood while the other 41.2% (7 out of 17) and \u0026nbsp;23.5% (4 out of 17) of them were transfused with 2-5 units and more than 5 units of blood, respectively. On average, 2.64 (\u003cu\u003e+\u003c/u\u003e 2.3) units of blood were given for these mothers. The majority, 15 (60%), of the mothers with PAS were subjected to an operation time span of 1-2 hours. The average operation time passed for a single mother with PAS was 98 (\u003cu\u003e+\u003c/u\u003e 46) minutes with the maximum and minimum being \u0026lt; 1hour and \u003cu\u003e\u0026gt;\u003c/u\u003e 2hours, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4: Outcomes of Mother with PAS at Black Lion Hospital, Addis Ababa, Ethiopia,\u003c/em\u003e\u003cem\u003e\u0026nbsp;2023.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.326241134751776%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.425531914893616%\" valign=\"top\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.78014184397163%\" valign=\"top\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProportion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.46808510638298%\" valign=\"top\" style=\"width: 14.418%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage \u003cu\u003e+\u003c/u\u003e SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated blood loss\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.631205673758867%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.69503546099291%\"\u003e\n \u003cp\u003e\u0026lt;1500 ML\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.425531914893616%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.78014184397163%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.46808510638298%\" rowspan=\"2\" style=\"width: 14.418%;\"\u003e\n \u003cp\u003e1568 (\u003cu\u003e+\u003c/u\u003e 849) ML\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e\u0026ge;1500 ML\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood Transfusion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.631205673758867%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.69503546099291%\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.425531914893616%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.78014184397163%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.46808510638298%\" rowspan=\"2\" style=\"width: 14.418%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Units transfused\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.631205673758867%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.69503546099291%\"\u003e\n \u003cp\u003e\u0026lt;2 unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.425531914893616%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.78014184397163%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.46808510638298%\" rowspan=\"3\" style=\"width: 14.418%;\"\u003e\n \u003cp\u003e2.64 (\u003cu\u003e+\u003c/u\u003e 2.3) units\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e2-5 unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e41.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e\u0026gt; 5 unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHospital stay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.631205673758867%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.69503546099291%\"\u003e\n \u003cp\u003e\u0026lt;5days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.425531914893616%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.78014184397163%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.46808510638298%\" rowspan=\"3\" style=\"width: 14.418%;\"\u003e\n \u003cp\u003e4.92 (\u003cu\u003e+\u003c/u\u003e 2.39) days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e5-7days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e\u0026gt;7days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation Time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.631205673758867%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.69503546099291%\"\u003e\n \u003cp\u003e\u0026lt;1hr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.425531914893616%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e\u0026nbsp;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.78014184397163%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.46808510638298%\" rowspan=\"3\" style=\"width: 14.418%;\"\u003e\n \u003cp\u003e98 (\u003cu\u003e+\u003c/u\u003e 46) minute\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e1-2hr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e\u0026ge;2hr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemoglobin level at the time of discharge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.631205673758867%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.69503546099291%\"\u003e\n \u003cp\u003e7 - 9.9 g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.425531914893616%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.78014184397163%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.46808510638298%\" rowspan=\"3\" style=\"width: 14.418%;\"\u003e\n \u003cp\u003e9.9 (\u003cu\u003e+\u003c/u\u003e 1.3)g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e10 -10.9 g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.10526315789474%\"\u003e\n \u003cp\u003e\u0026ge;11g/dl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.61842105263158%\" style=\"width: 10.7148%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.276315789473685%\" style=\"width: 11.082%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eUpon assessing their discharge conditions, more than half (56%) of the mothers with PAS were discharged after less than 5 days stay at hospital while 8 (32%) of them were discharged after staying in the hospital in the range between 5-7 days. The hemoglobin level at the time of discharge, the average hemoglobin level at discharge for a single mother was 9.9 (\u003cu\u003e+\u003c/u\u003e 1.3) g/dl and only 5 (20%) of them were discharged with hemoglobin level of \u003cu\u003e\u0026gt;\u003c/u\u003e 11g/dl (Table 4). Maternal death was not documented among the mothers with PAS and moreover, there was no also an ICU admission for them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3.6. Maternal Outcomes with Classification of PAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix 6 out of the 25 (24%) of the mothers with PAS were suspected prenatally. All of the prenatally suspected mothers in this study were those with abnormally invasive PAS type. More specifically, 66.7% (6 out of 9) abnormally invasive placenta type of PAS were detected with antenatal suspicions while the rest three (33.3%) were without antenatal suspicion. Twelve out of the 16 (75%) abnormally adherent but only 3 out of the 9 (33.3%) abnormally invasive PAS had an estimated blood loss of \u0026lt;1500ml. Three out of the 6 (50%) mothers with grade 2 PAS and all mothers with grade 3 PAS had an estimated blood loss of \u003cu\u003e\u0026gt;\u003c/u\u003e1500ml. There was an average estimated blood loss of 1212 (\u003cu\u003e+\u003c/u\u003e 931) ml in mothers with abnormally adherent PAS and of 2220 (\u003cu\u003e+\u003c/u\u003e 931) ml in mothers with abnormally invasive PAS. Blood transfusion was given for 62.5% (10 out of 16) of mothers with grade 1 PAS while it was given for 66.7% (4 out of 6) and for all (3 out of 3) of the mothers with grade 2 and grade 3 PAS, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn average (\u003cu\u003e+\u003c/u\u003e SD), 1.5 (\u003cu\u003e+\u003c/u\u003e 1.4) units of blood was given for mothers with grade 1 PAS, and similarly, average units of blood given for mothers with grade 2 and grade 3 PAS were 3.8 (\u003cu\u003e+\u003c/u\u003e 3.3) and 5 (\u003cu\u003e+\u003c/u\u003e 1) units, respectively (Table 5).The average (\u003cu\u003e+\u003c/u\u003e SD) operation time taken showed that the longest span taken was for mothers with grade 3 PAS with 153.3 (\u003cu\u003e+\u003c/u\u003e 55.1) minutes and the shortest span taken being for mothers with grade 1 PAS, 82 (\u003cu\u003e+\u003c/u\u003e 42) minutes in average.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 5: Outcomes of Mother with PAS Classifications, Black Lion Hospital, Addis Ababa, Ethiopia,\u0026nbsp;\u003c/em\u003e\u003cem\u003e2023.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" rowspan=\"2\" valign=\"bottom\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbnormally adherent placenta \u0026nbsp;(N=16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"55.887521968365554%\" colspan=\"3\" valign=\"bottom\" style=\"width: 59.9609%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Abnormally invasive \u0026nbsp;placenta \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.446540880503143%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (N=9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith antenatal suscipion (n=6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.59119496855346%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWithout antenatal suscipion (n=3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated blood loss(ml) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.586994727592268%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.072056239015817%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;1500\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e12 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e3 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e3 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.962962962962964%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge;1500\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.604938271604937%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e4 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5761316872428%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e6 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e3 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.633744855967077%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e3 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage Blood Loss (\u003cu\u003e+\u003c/u\u003esd)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e1212 (\u003cu\u003e+\u003c/u\u003e 561)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e2220 (\u003cu\u003e+\u003c/u\u003e 931)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e1950 (\u003cu\u003e+\u003c/u\u003e 757)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e2700 (\u003cu\u003e+\u003c/u\u003e 1153)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood transfusion\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.586994727592268%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.072056239015817%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eyes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e10 (62.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e7 (77.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e4 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e3 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.962962962962964%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eno\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.604938271604937%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e6 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5761316872428%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e2 (22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.22222222222222%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e2 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.633744855967077%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage unit transfused (\u003cu\u003e+\u0026nbsp;\u003c/u\u003esd)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e1.5 (\u003cu\u003e+\u003c/u\u003e 1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e4.2 (\u003cu\u003e+\u003c/u\u003e 2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e3.8 (\u003cu\u003e+\u003c/u\u003e 3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e5 (\u003cu\u003e+\u003c/u\u003e 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage operation time in minute (\u003cu\u003e+\u003c/u\u003e sd)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e82 (\u003cu\u003e+\u003c/u\u003e 42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e132 (\u003cu\u003e+\u003c/u\u003e 49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e121.6 (\u003cu\u003e+\u003c/u\u003e 48.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e153.3 (\u003cu\u003e+\u003c/u\u003e 55.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrgan injury (N=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal infection(N=3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelaparatomy (N=3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage Hb (g/dl) level at discharge (\u003cu\u003e+\u003c/u\u003e sd)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e10.3 (\u003cu\u003e+\u003c/u\u003e 1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e9.5 (\u003cu\u003e+\u003c/u\u003e 0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e9.5 (\u003cu\u003e+\u003c/u\u003e 0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e9.5 (\u003cu\u003e+\u003c/u\u003e 0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage hospital stay in days (\u003cu\u003e+\u003c/u\u003e sd)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.659050966608085%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" style=\"width: 14.7891%;\"\u003e\n \u003cp\u003e4.3 (\u003cu\u003e+\u003c/u\u003e 1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.57469244288225%\" valign=\"bottom\" style=\"width: 19.1973%;\"\u003e\n \u003cp\u003e5.4 (\u003cu\u003e+\u003c/u\u003e 3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.98066783831283%\" valign=\"top\" style=\"width: 16.166%;\"\u003e\n \u003cp\u003e4.3 (\u003cu\u003e+\u003c/u\u003e 2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.332161687170476%\" valign=\"top\" style=\"width: 23.959%;\"\u003e\n \u003cp\u003e7.6 (\u003cu\u003e+\u003c/u\u003e 3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eOrgan injury during operation time had occurred in two (8%) of the mothers with PAS and both being in mothers with grade 2 PAS. Maternal infection had occurred in three (12%) of the mothers with PAS and these were one from each grades of PAS. Relaparatomy was required in three (12%) of the mothers and two of these were for mothers with grade 2 PAS while one was for mother with grade 3 PAS (Table 5).\u003c/p\u003e\n\u003cp\u003eUpon assessing the condition in which the mothers with PAS were discharged, the average (\u003cu\u003e+\u003c/u\u003e SD) hemoglobin level was 10.3 (\u003cu\u003e+\u003c/u\u003e 1.5)g/dl for mothers with abnormally adherent placenta while 9.5 (\u003cu\u003e+\u003c/u\u003e 0.9)g/dl and 9.5 (\u003cu\u003e+\u003c/u\u003e 0.5)g/dl for mothers with grade 2 and grade 3 PAS, respectively (Table 5). The average (\u003cu\u003e+\u003c/u\u003e SD) hospital stay before discharge was 4.3 \u0026nbsp;days for mothers with grade 1 (\u003cu\u003e+\u003c/u\u003e 1.9) and grade 2 (\u003cu\u003e+\u003c/u\u003e 2.8) PAS while it was 7.6 (\u003cu\u003e+\u003c/u\u003e 3.8) days for mothers with grade 3 type of PAS (Table 5).\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eBased on the current study, the prevalence of CD in Black Lion Hospital was 37.3% which is very high. This finding is line with the finding of a previous study done in Addis Ababa (38.3%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These high rate of CD in both studies could be partly explained by the fact that Black Lion Hospital being the highest tertiary hospital in the country to where more complicated obstetrics and gynecologic cases are referred. The CD rate in this study is by far higher than from the 2019 EDHS report where the prevalence of CD was 5.44% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This difference might be explained by the differences in the study participants as the EDHS report was done based a multilevel analysis as a nation level but the current study was done only at a single hospital found in a relatively more urbanized city of the nation.\u003c/p\u003e \u003cp\u003eOur finding is also comparable to the overall prevalence of CD in selected hospitals in Addis Ababa was 38% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This high rate of CD in the current study was also comparable to the study in Nigeria (34.7%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This might also be explained by the increasing rate of CD globally.\u003c/p\u003e \u003cp\u003eThe prevalence of PAS in this study is 1 out of 994 deliveries. This prevalence rate of PAS is high. This might be explained by the rising CD incidence and practices. This finding is comparable to the findings of Italy (0.84/1000 births) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and Israel (1.2/1000 births) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These similarities could be explained by the similarities of the study design applied. It was also in line with a meta analysis finding which reported as the PAS prevalence rates ranging between 0.01 to 1.1% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. But, it is by far higher than a study finding of Morocco (1/5824 births) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and USA (1/2510 births) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These similarities and differences of the findings might be partly explained by the similarities and differences in the socidemographic characteristics, geographical locations and study periods. The high rate of PAS in the current study might also be explained by the high CD rate in Addis Ababa. Our finding also supported by the fact that with increasing rate of CD in Ethiopia especially in capital city - Addis Ababa could probably increases the prevalence of PAS [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of PAS in the current study is lower than from those findings of the Nigerians (1/282 births) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], Egyptians (9/1000 births) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Canadians (1/588 births) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Americans (1/533 births and 1/731) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Germans (2.49/1000 births) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This difference can be explained by the fact that screening is more effective in more developed countries than in low- and middle-income countries like Ethiopia. It could also be due to the rising incidence of CD and urbanization in those aforementioned countries.\u003c/p\u003e\u003cp\u003eThe majority (92%) of the participants had at least one of the three associated risk factors for PAS. This might be due to the fact that any uterine procedure could end up with scar on the uterine wall which might result in failure of normal \u003cem\u003edecidualization\u003c/em\u003e. This resulting \u003cem\u003edecidual\u003c/em\u003e defect has an adverse effect on early implantation by creating conditions for preferential attachment of the \u003cem\u003eblastocyst\u003c/em\u003e to scar tissue and facilitating abnormally deep invasion of the \u003cem\u003eextravillous trophoblast\u003c/em\u003e [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This high figure of association between PAS and the three risk factors could also further explained by the concepts proposed to explain the abnormal \u003cem\u003eplacentation\u003c/em\u003e in PAS including a primary defect of the \u003cem\u003etrophoblast\u003c/em\u003e function and a secondary \u003cem\u003ebasalis\u003c/em\u003e defect on the scared area [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study we found that a prior CD was documented in 16 (64%) of mothers with PAS. This higher proportion of prior CD presence in mothers with PAS might be explained by the fact that the strongest risk factor for PAS and PP is a prior CD. Scared \u003cem\u003emyometrium\u003c/em\u003e from previous CD can result in failure of \u003cem\u003edecidualization\u003c/em\u003e in the area of scar which can have an impact on both implantation and \u003cem\u003eplacentation\u003c/em\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, having a previous CD history in a mother increases the chance of developing PAS. Miller et al, in their studies stated that the risk of PAS in a mother with a history of previous CDs increases by 12% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe high CD rate in Addis Ababa [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] might also partly explain the finding of high association between prior CD and PAS in this study. This is in line with the reports of a study in Texas of USA where they found a higher rate of previous CD history in both the unexpected PAS (89.9%) and expected PAS (64.8%) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. It was also in line with the findings of the Nigerian (82%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and Americans in their two studies (73% and 49.55%) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This association could be also explained by previous studies claiming increase in cesarean rates in most middle and high income countries led to an increase in the prevalence of PAS [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e][\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePP is regarded as one of the major risk factors associated with PAS. Jauniaux and Burtonne stated PP as one of the single most important risk factor, occurring in around 50% of all cases of PAS disorders [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The current study has identified the coexistence of PP in 18 (72%) of mothers with PAS which is high figure. This is in line with the study done in Aba town of Southeast Nigeria (73%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], as well as with studies done in Chicago (31.53%) and California (89%) states of USA [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This could be due to the fact that a low-lying placenta may cause a defective or improper \u003cem\u003eendo-myometria\u003c/em\u003el interface (over the internal Os) which does not allow for healthy placental implantation to occur [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis figure of high association between PAS and PP in this study could be explained by the fact that there is a 10% risk of a mother to develop PAS in the presence of PP (without previous uterine surgery) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This might also be further supported by the study findings in Morocco where 100% [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] of their patients were presented with PP and in the Texas study of USA where PP where detected in both unexpected (74.6%) and expected (37.3%) PAS [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Moreover, the current finding is also be supported by the finding of a study done in UK by Jauniaux and Bhide [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In their cohort study, 328 (8.4%) pregnancies with PP were complicated by PAS [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the current study, in 60% (15 out of 25) of the mothers both PP and CD were identified as combined risk factors for the PAS. This finding of high proportion can be explained by the fact that PP and previous CD act synergistically to further increase the risk of PAS. Miller et al., mentioned that the risk of PAS increases sharply to as high as 25% in the presence of a combined one prior CD and PP [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. It was comparable to the findings of the Italian study where higher rates of a concomitant PP and prior CS were detected in both antenatal suspected (62.1%) and unsuspected (28.7%) PAS [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll the three risk factors were absent in 8% of the participants in this study. This was lower than the study done in Italy where 22.2% of their mothers with PAS have no known risk factors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In this study, PAS in 60% (15 out of 25) of the participants was in the presence of both PP and CD as combined risk factors. These could be explained by the fact that the incidence of PAS could dramatically decreased in the absence of any risk factors but it could increases in the presence of PP and prior CD as combined. Similarly, the study in USA reported an incidence rate of 1/68 000 births (0.0015%) in the absence of any risk factor [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe gestational age of mothers with PAS in this study showed as unknown in 12%, \u0026lt; 34 weeks in 20%, 34\u0026ndash;37 weeks in 28% and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;37 weeks in 40% of the participants. These variation in gestational age of the participants could be explained by the fact PAS can occur at any stage of a pregnancy. According to Comstock as cited by Umezuruke, et al [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], PAS can be present at any stage of gestation from first trimester to term. Therefore, individuals who are at risk of PAS at term are also already at risk for it in the first trimester [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Among the 25 mothers with PAS in this study, the majority, 64% (16), were grade 1 and followed by grade 2 and 3 with 24% and 12%, respectively. These findings were in line with the findings of Miller et al, where grade 1, grade 2 and grade 3 constitutes 68.1%, 23.4% and 8.5% of their participants with PAS, respectively [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough prenatal diagnosis of PAS is difficult, Diagnosing PAS prenatally is very important for possible accurate diagnosis and preparation for delivery. It is reported that antenatal US a sensitivity of 77\u0026ndash;90% and specificity of 71\u0026ndash;98% [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, only 24% (6 out of 25) of the mothers with PAS were suspected prenatally in the current study. This figure of antenatal suspicion was very low. This lower figure in Black Lion Hospital can be explained by the fact that screening is more effective in developed countries than in low- and middle-income countries like Ethiopia. Unlike to this study, more number of PAS were suspected during pregnancy in Italy (50%), Morocco (50%) and USA (53.2%) (n\u0026thinsp;=\u0026thinsp;84) women [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMore specifically, all of the prenatally suspected PAS in this study were the abnormally invasive type. In line with this, all the prenatally suspected PAS were the morbidly adherent type in the other similar study of USA [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Similarly, severe PAS (\u003cem\u003eincreta/percreta\u003c/em\u003e) were more common in the prenatally suspected PAS group (66.1%) than in the unsuspected PAS group (16.7%) of the USA study [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Even in the presence of known risk factors, the antenatal diagnosis of PAS with less severe degrees of invasion may be challenging. Generally, the prenatal ultrasound is subjective and requires specialized expertise for both doing the examination as well as interpreting it. In the current study, \u003cem\u003ehistological\u003c/em\u003e confirmation was only for mothers abnormally invasive PAS.of which, it was done for 83.3% (5 out of 6) mothers with grade 2 PAS and in all three of the mothers with grade 3 PAS. This finding was better than the Moroccan study where only 48% (62) of their mothers with PAS had \u003cem\u003ehistologic\u003c/em\u003e confirmation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe estimated blood loss documented showed that the amount of losses were \u0026lt;\u0026thinsp;1500ml in 15 (60%) and \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;1500ml in 10 (40%) of mothers with PAS. Twelve out of the 16 (75%) abnormally adherent and only 3 out of the 9 (33.3%) abnormally invasive PAS had an estimated blood loss of \u0026lt;\u0026thinsp;1500ml. All mothers with grade 3 PAS had an estimated blood loss of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;1500ml. These could be explained by the more aggressive and invasive nature of the abnormally invasive PAS types. The above finding can also be further supported by the findings of this study in which the average estimated blood loss of 1212 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;931) ml in mothers with abnormally adherent PAS and of 2220 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;931) ml in mothers with abnormally invasive PAS. Therefore, prenatal suspicion is paramount to decrease maternal morbidity and mortality. Prenatal suspicion or diagnosis may create an opportunity for multidisciplinary input in the management of the condition.\u003c/p\u003e \u003cp\u003eWhenever antenatal suspicion and detection is missed, bleeding is usually imminent as the retained and exposed placental tissue is in direct contact with the maternal circulation. Bleeding will be profuse as uterine artery blood flow increases as much as 50-fold during pregnancy [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the current study, 68% (17) of the mothers were transfused with blood. This is in line the study in Italy where 73% of women were transfused with RBC units [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The average amount of blood loss was 1568 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;849) and the average number of blood transfused was 2.64 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.3) units. This was slightly better than the Nigerian study where the median blood loss and transfused in theirs participants were 2 liters and 4 units [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe more aggressive and morbidly adherent PAS types are grade 2 and 3 PAS. The PAS being the more morbidly adherent, it is expected that the more mothers will bleed and transfused. In this study, three out of the 6 (50%) mothers with grade 2 PAS and all mothers with grade 3 PAS had an estimated blood loss of \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;1500ml. There was an average estimated blood loss of 1212 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;931) ml in mothers with abnormally adherent PAS and of 2220 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;931) ml in mothers with abnormally invasive PAS. In other words, more amount of blood was lost in mothers with invasive type than adherent type of PAS. This could be explained by the fact that placenta is more exposed and firm contact with maternal circulation in the case of the abnormally invasive PAS types. Moreover, the average units of blood given for mothers with grade 2 and grade 3 PAS in this study were 3.8 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.3) and 5 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1) units, respectively.\u003c/p\u003e \u003cp\u003eThe average (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD) operation time taken showed that the longest span taken was for mothers with grade 3 PAS with 153.3 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;55.1) minutes and the shortest span taken being for mothers with grade 1 PAS, 82 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;42) minutes in average. Organ injury during operation time had occurred in two (8%) of the mothers with PAS and both being in mothers with grade 2 PAS. Maternal infection had occurred in three (12%) of the mothers with PAS and these were one from each grades of PAS. Re-laparotomy was required in three (12%) of the mothers and two of these were for mothers with grade 2 PAS while one was for mother with grade 3 PAS. As expected a prolonged average (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD) hospital stay before discharge was documented for mothers with abnormally invasive PAS In this study, the average hospital stay showed that 4.3days for mothers with grade 1 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;1.9) and grade 2 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.8) PAS while it was 7.6 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.8) days for mothers with grade 3 type of PAS.\u003c/p\u003e \u003cp\u003eMaternal mortality in PAS remains rare. This is a reflection of increasing antenatal detection and planned delivery [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. There was no maternal death and ICU admission requirement for mothers with PAS in the current study. Unlike to this, there was one maternal death in each of the Nigerian (9%), Italian (2.6%) and Moroccan (17%) studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These disparities in the studies mentioned above might be due to the differences in the health facilities and expertise involved in those study areas.\u003c/p\u003e"},{"header":"6. Limitation of the study","content":"\u003cp\u003eThis study was aimed to determine the prevalence, characteristics and outcome of pregnant mothers with PAS in Black Lion Hospital. In spite of this big intention, the study was not free of limitations. It was done at single government hospital and hence, it might not be possible to generalize the current findings to the entire pregnant women of Addis Ababa. The other limitation is the cross-sectional nature of the study design; which could not reveal the exact causal association among the ongoing risks and miss diagnosis/results of imaging modalities. The rare nature of the problem also against the study design applied in this study.\u003c/p\u003e"},{"header":"7. Conclusion and Recommendation","content":"\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e7.1. Conclusion\u003c/h2\u003e \u003cp\u003eThe prevalence of CD in Black Lion Hospital is very high. This is one of the highest rate of CS in the world. The prevalence rate of PAS is high. This trend is probably correlated to the high rate of CD and certain risk factors such as PP, with mucosal erosion. Both CD and PP are the most identified risk factors for the PAS. The practice of antenatal suspicion and diagnosis of PAS is very low. However, antenatal detection in this study has decreased maternal morbidity and mortality. There was no maternal death and ICU admission requirement for mothers with PAS in this study. Therefore, there was a low maternal complication rate in the hospital.\u003c/p\u003e \u003cp\u003e \u003cb\u003e7.2. Recommendations\u003c/b\u003e \u003c/p\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIt is important to promote educational efforts to support obstetricians in safely reducing primary CD and admitting women with prior CD to a trial of labor.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ecoordinated, multi-faceted efforts should be directed to increase antenatal suspicion and diagnosis of PAS by rising awareness of relevant risk factors with referral of patients at risk for targeted ultrasound assessment by expert sonographers/radiologists.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA future and detailed study involving different government and private health facilities is recommended.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA future study with cohort study design with multidisciplinary experts is recommended.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn ethical clearance and permission letter was obtained from the obstetrics and gynecology department of Addis Ababa University (Black Lion Hospital). As the study was a retrospective one, there was no need for ethical clearance of using human tissue for experiment. Hence, informed consent was waived/deemed unnecessary by the Ethical Review Committee of Addis Ababa University. It was given to the heads of the hospital, the registry unit and labor ward of the hospital. After permission was granted from them, we started the data collection. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and Materials \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed for this study are available from the corresponding author on reasonable request. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, as it was initially intended for academic output.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the Addis Ababa University, School of Medicine, Department of Obstetrics and Gynecology for letting us accomplished with this paper, and Black Lion Hospital which provide us the data and other necessary documents during the patients\u0026rsquo; data review, analysis and summary preparation process. We want to extend our sincere gratitude to the research team members who helped us from data collections to everything. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProtocol preparation and literature review: TY, MFA. Data analysis and interpretation: TY, MFA. Drafting of the manuscript and revision of the manuscript: TY, GFT, TK, MFA. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJauniaux E., Burton G. J. (2018). Pathophysiology of placenta accreta spectrum disorders: A review of current findings. \u003cem\u003eClin. Obstet. Gynecol.\u003c/em\u003e 61, 743\u0026ndash;754.\u003c/li\u003e\n\u003cli\u003eJauniaux E., Hussein A.M., Fox K.A., Collins S.L., New evidence-based diagnostic and management strategies for placenta accreta spectrum disorders. Best Pract. Res. Clin. Obstet. Gynaecol. 2019;61:75\u0026ndash;88.\u003c/li\u003e\n\u003cli\u003eJauniaux E, Grnbeck L,Bunce C, \u003cem\u003eet al\u003c/em\u003e. Epidemiology of placenta previa accreta: a systematic review andmeta-analysis.\u003cem\u003eBMJ Open\u003c/em\u003e2019;9:e031193.\u003c/li\u003e\n\u003cli\u003eJauniaux E, Bhide A, Burton GJ. Pathophysiology of accreta. In: SilverR, ed. \u003cem\u003ePlacenta accreta syndrome\u003c/em\u003e. Portland: CRC Press; 2017:13\u0026ndash;28.\u003c/li\u003e\n\u003cli\u003eCollins SL, Ashcroft A, Braun T, et al. Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP). \u003cem\u003eUltrasound Obstet Gynecol\u003c/em\u003e. 2016;47:271\u0026ndash;275.\u003c/li\u003e\n\u003cli\u003eJauniaux E, Bhide A, Kennedy A, Woodward P, Hubinont C, Collins S; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and screening. Int J Gynaecol Obstet. 2018;140:274\u0026ndash;280.\u003c/li\u003e\n\u003cli\u003eUmezuruke C, Nkwocha\u003cem\u003e G; \u003c/em\u003ePlacenta accreta in Aba, south eastern, Nigeria\u003cem\u003e, Nigerian journal of medicine\u003c/em\u003e: 2007, vol 16, no 3; 220-222.\u003c/li\u003e\n\u003cli\u003eWu S, Kocherginsky M, Hibbard JU. Abnormal placentation: Twenty-yearanalysis. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2005;192:1458\u0026ndash;1461.\u003c/li\u003e\n\u003cli\u003eBetran AP, Ye J, Moller A-B, et al. Trends and projections of caesarean section rates: global and regional estimates. BMJ Global Health 2021;6:e005671. doi:10.1136/ bmjgh-2021-005671.\u003c/li\u003e\n\u003cli\u003eJauniaux E, Chantraine F, Silver RM, Langhoff-Roos J; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders:Epidemiology. \u003cem\u003eInt J Gynecol Obstet\u003c/em\u003e. 2018;140:265\u0026ndash;273.\u003c/li\u003e\n\u003cli\u003eGonca Yetkin Yildirim , Nadiye Koroglu , Aysu Akca Merve Talmac , Selin Dikmen ,Gokhan Yıldırım , Ibrahim Polat Ismail Ozdemir What is new in peripartum hysterectomy? A seventeen year experience in a tertiary hospital, \u003cem\u003eTaiwanese Journal of Obstetrics \u0026amp; Gynecology\u003c/em\u003e 60 (2021) 95-98.\u003c/li\u003e\n\u003cli\u003eFederal Ministry of Health (FMOH). Ethiopia Demographic and Health Survey. 2016, Addis Ababa, Ethiopia.\u003c/li\u003e\n\u003cli\u003eGebremedhin S. Trend and socio-demographic differentials of Caesarean section rate in Addis Ababa, Ethiopia: analysis based on Ethiopia demographic and health surveys data. Bio Med Central. 2014;11(14).\u003c/li\u003e\n\u003cli\u003eEller AG, Bennett MA, Sharshiner M, Masheter C, Soisson AP, Dodson M, Silver RM. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet. Gynecol. 2011;117(2 Pt 1):331\u0026ndash;337.\u003cem\u003e \u003c/em\u003e\u003c/li\u003e\n\u003cli\u003ehttp://www.aau.edu.et/chs/tikur-anbessa-specialized-hospital/ [accessed on 23 February 2023]. \u003c/li\u003e\n\u003cli\u003eTsegaye H, Desalegne B, Wassihun B, Bante A, Fikadu K, Debalkie M, et al. Prevalence and associated factors of caesarean section in Addis Ababa hospitals, Ethiopia.\u003cem\u003ePan African Medical Journal.\u003c/em\u003e 2019;34:136.\u003c/li\u003e\n\u003cli\u003eHailegebreal S, Gilano G, Seboka BT, Ahmed MH, Simegn AE, Tesfa GA, et al. Prevalence and associated factors of caesarian section in Ethiopia: a multilevel analysis of the 2019 Ethiopia Mini Demographic Health Survey, Addis Ababa, Ethiopia. \u003cem\u003eBMC Pregnancy and Childbirth (2021) 21:798\u003c/em\u003e. \u003c/li\u003e\n\u003cli\u003eEsh-Broder E, Ariel I, Abas-Bashir N, Bdolah Y, Hochner Celnikier D. Placenta accreta is associated with IVF pregnancies: a retrospective chart review. BJOG 2011; 118:1084\u0026ndash;1089. \u003c/li\u003e\n\u003cli\u003eOrnaghi S, Maraschini A, Donati S, on behalf of The Regional Obstetric Surveillance System Working Group (2021) Characteristics and outcomes of pregnant women with placenta accreta spectrum in Italy: A prospective population based cohort study. PLoS ONE 16(6): e0252654. https://doi.org/10.1371/journal.pone.0252654. \u003c/li\u003e\n\u003cli\u003eJauniaux E, Bunce C, Gr\u0026oslash;nbeck L, Langhoff-Roos J Prevalence and main outcomes of placenta accreta spectrum: a systematic review and metaanalysis. Am J Obstet Gynecol 2019;220: doi.org/10.1016/j.ajog.2019.01.233. \u003c/li\u003e\n\u003cli\u003eSlaoui A, Talib S, Nah A, Moussaoui KE, Benzina I, Zeraidi N, et al. Placenta accreta in the department of gynaecology and obstetrics in Rabat, Morocco: case series and review of the literature, Rabat, Morocco. \u003cem\u003ePan African Medical Journal\u003c/em\u003e. 2019;33:86. doi:10.11604/pamj.2019.33.86.17700. \u003c/li\u003e\n\u003cli\u003eMiller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa\u0026ndash;placenta accreta. Am J Obstet Gynecol. (1997) 177:210\u0026ndash;4\u003cem\u003e. \u003c/em\u003e\u003c/li\u003e\n\u003cli\u003eGelany SE, Mosbeh MH, Ibrahim EM, Mohammed M, Khalifa EM, Abdelhakium AK, et al. Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study, Egypt. BMC Pregnancy and Childbirth (2019) 19:313. \u003c/li\u003e\n\u003cli\u003eBalayla J, and Bondarenko D. Placenta accreta and the risk of adverse maternal and neonatal outcomes, Quebec, Canada. \u003cem\u003eJ. Perinat. Med.\u003c/em\u003e 2013; 41(2): 141\u0026mdash;149. \u003c/li\u003e\n\u003cli\u003eBailit Jl, Grobman W, Rice MM, Reddy UM, Wapner RJ, Varner MW, et al. Morbidly Adherent Placenta Treatments and Outcomes, Cleveland, USA. \u003cem\u003eObstet Gynecol\u003c/em\u003e. 2015 March ; 125(3): 683\u0026ndash;689. \u003c/li\u003e\n\u003cli\u003eBluth A, Schindelhauer A, Nitzsche K, Wimberger P, Birdir C. Placenta accreta spectrum disorders\u0026mdash;experience of management in a German tertiary perinatal centre, Germany. \u003cem\u003eArchives of Gynecology and Obstetrics\u003c/em\u003e (2021) 303:1451\u0026ndash;1460. \u003c/li\u003e\n\u003cli\u003eErfani H, Fox KA, Clark SL, Rac M, Rocky Hui SK, Rezaei A, Aalipour S, Shamshirsaz AA, Nassr AA, Salmanian B, Stewart KA, Kravitz ES, Eppes C, Coburn M, Espinoza J, Teruya J, Belfort MA, Shamshirsaz AA. Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team. Am J Obstet Gynecol. 2019 Oct;221(4):337-337. \u003c/li\u003e\n\u003cli\u003eVarlas VN, Bors RG, Birsanu S, Maxim B, Clotea E, Mihailov M. Maternal and fetal outcome in placenta accreta spectrum (PAS) associated with placenta previa: a retrospective analysis from a tertiary center, Bucharest, Romania. \u003cem\u003eJOURNAL of MEDICINE and LIFE; \u003c/em\u003e2021: 14(3):367-375. \u003c/li\u003e\n\u003cli\u003eLamrissi A, Benjelloun AT, Harit A, Fichtali A, Bouhya S. Prenatal diagnosis and management of placenta accreta in a Moroccan high-level maternity. Casablanca, Morocco. \u003cem\u003eInternational Journal of Surgery Open \u003c/em\u003e43 (2022):100497. \u003c/li\u003e\n\u003cli\u003eWarshak CR, Eskander R, Hull AD, Scioscia AL, Mattrey RF, Benirschke K, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol. 2006;108(Pt 1):573 \u0026ndash; 81.\u003c/li\u003e\n\u003cli\u003ePastore MB, Jobe SO, Ramadoss J, Magness RR. Estrogen receptor-alpha and estrogen receptor-beta in the uterine vascular endothelium during pregnancy: functional implications for regulating uterine blood flow. \u003cem\u003eSemin Reproductive Med. \u003c/em\u003e2012;30:46 \u0026ndash; 61. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Placenta accrete spectrum, placenta previa, cesarean, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-3889075/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3889075/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePlacenta accreta spectrum is known to be associated with significant maternal morbidity and mortality usually because of catastrophic hemorrhage during delivery. The Prevalence rates ranged from 0.01 to 1.1% with an overall pooled prevalence of 0.17% (95% confidence interval, 0.14\u0026ndash;0.19). The aim of this study was to determine the prevalence, characteristics and outcome of pregnant mothers with placenta accreta spectrum in black lion hospital.\u003c/p\u003e\u003ch2\u003eMethodology: An institution based\u003c/h2\u003e \u003cp\u003ecross-sectional study from January 1, 2018 to December 31, 2022. FIGO classification system for the clinical diagnosis of placenta accreta spectrum disorder were used to define cases and enroll the participants. Data was cleaned, entered and analyzed using SPSS version 26.0 statistical software and MS excel. Descriptive statistics were used to describe baseline characteristics.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eFrom the 24,844 deliveries, prevalence of cesarean delivery- 37.3%; prevalence of placenta accreta spectrum to be 0.1% (1 out of 994) and of which, 16 (64%)- abnormally adherent type (grade 1) and 9 (36%)-abnormally invasive type [grade 2 (24%) and grade 3 (12%)]. Placenta accreta spectrum was suspected prenatally in 28% of the mothers. Risk factors identified in 92% (23 out of 25) of the mothers were either placenta previa or cesarean delivery; in 60% (15 out of 25) of the mothers both placenta previa and prior cesarean delivery. Average estimated blood loss of 1568 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;849) ml and 17 out of 25 (68%) were transfused. There was no maternal death and intensive care unit admission.\u003c/p\u003e\u003ch2\u003eConclusion and Recommendations:\u003c/h2\u003e \u003cp\u003eThe prevalence of cesarean delivery is very high as compared to the national figure. Antenatal suspicion or prenatal diagnosis of placenta accreta spectrum is very low thus all pregnant mothers with risk factors especially mothers with cesarean delivery and placenta previa should be screened for placenta accreta spectrum. Mothers with suspected placenta accreta spectrum should be managed with optimal preparation as possible.\u003c/p\u003e","manuscriptTitle":"Characteristics, Outcomes and Prevalence of Pregnant Women with Placenta Accreta Spectrum in Black Lion Hospital - Five years retrospective study , Addis Ababa, Ethiopia, 2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-20 20:13:10","doi":"10.21203/rs.3.rs-3889075/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b4ea912d-d0ae-4c18-a0af-dc8037937416","owner":[],"postedDate":"February 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-13T15:53:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-20 20:13:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3889075","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3889075","identity":"rs-3889075","version":["v1"]},"buildId":"cTy_lsJlmDsVRNrSptgXS","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}