Feto–Maternal Outcome with Placenta Accreta Spectrum: A Cross-Sectional Study

(1) Background: Placenta accreta spectrum (PAS) is a pathologic invasion of the placental trophoblasts to the myometrium and beyond. This study evaluates the demographic features, risk indicators, feto–maternal outcome, and treatment options in PAS women at our center. (2) Methods: This is a retrospective study carried out in 39 patients with placenta accreta spectrum in our tertiary health care center Sri Maharaja Gulab Singh (SMGS) Hospital, from July 2019 to September 2020. (3) Results: Most patients in our study were in the 30–35 years age group. The previous lower segment Caesarean section (LSCS) was the most critical risk factor for PAS in our research. Thirty-two of the women with PAS (82.05%) had undergone a hysterectomy, and eight patients did not undergo a hysterectomy. Twenty-eight patients needed Intensive Care Unit (ICU) care, 13 of them required ventilatory support, and three of them died due to hemorrhagic shock. In our study, preterm birth occurred in 26 patients (53.84%), while 21 (53.8%) required Neonatal Intensive Care Unit (NICU) admission, and six (15.4%) had early neonatal death and stillbirth. (4) Conclusion: PAS is a devastating event in women’s pregnancy. It leads to high maternal morbidity, mortality, and adverse neonatal outcome. The critical risk indicators for PAS are previous LSCS and placenta previa. Every case with these two concurrent conditions should be operated on in a planned way in the presence of senior obstetricians and of an anesthesiology team.


Introduction
"Placenta accreta spectrum (PAS), formerly known as the morbidly adherent placenta, is de ned as pathologic invasion of the placental trophoblasts to the myometrium and beyond" [ ]. It is divided into several types described as accreta (adheres to the myometrium), increta (invades deep to the myometrium), and percreta (the invasion reaches to the uterine serosa and beyond) [ -]. The incidence of PAS increases due to the increasing number of cesarean sections. In one study, the incidence of PAS increased ten-fold, mainly due to the increased number of Cesarean Sections (CS) being performed [ ]. In females with placenta previa, the risk of PAS is %, %, %, %, and %, for the st, nd, rd, th, and th or more cesarean sections, respectively [ ]. Other risk factors included "advanced maternal age, multiparity, prior uterine surgeries or Timisoara Med. , ( ), ; doi: . /tmj http://www.tmj.ro , ( ), curettage, and Asherman syndrome" [ -]. The treatment in females with PAS is planned hysterectomy with the placenta in situ with no attempt to deliver the placenta. Despite such an ideal approach, PAS is still associated with high maternal morbidity and mortality [ , ]. In India, obstetric hemorrhage is one of the signi cant causes of maternal mortality ( %). This may be because most women in India are already anemic before they start bleeding [ ]. The women with suspected placenta accreta should be transferred to tertiary centers for delivery to ensure access to blood banks, availability of senior obstetricians, and experienced ICUs [ , ]. Our study evaluates the demographic pro le, high-risk factors, materno-fetal outcome, and management options in women of PAS at our center.

Materials and Methods
This retrospective study was carried out in patients with placenta accreta spectrum in our tertiary health care center, Sri Maharaja Gulab Singh (SMGS) hospital, Government Medical College Jammu, India, from July to September .
All the women who were diagnosed as having placenta accreta spectrum on ultrasonography or intra-operatively were included in the study. The primary diagnostic modality for antenatal diagnosis is obstetric ultrasonography. Features of placenta accreta visible by ultrasonography may be present as early as the rst trimester; however, most women are diagnosed in the second and third trimesters. Perhaps the most important ultrasonographic association of placenta accreta spectrum in the second and third trimesters is the presence of placenta previa, which is present in more than % of accretes. Other gray-scale abnormalities that are associated with placenta accreta spectrum include multiple vascular lacunae within the placenta, loss of the normal hypoechoic zone between the placenta and myometrium, decreased retroplacental myometrial thickness (less than mm), abnormalities of the uterine serosa-bladder interface, and extension of placenta into myometrium, serosa, or bladder. The use of color ow Doppler imaging may facilitate the diagnosis. Turbulent lacunar blood ow is the most common nding for placenta accreta spectrum on color ow Doppler imaging. Other Doppler ndings include increased subplacental vascularity, gaps in myometrial blood ow, and vessels bridging the placenta to the uterine margin. All patients enrolled were evaluated by a single expert operator using an ultrasound system equipped with a -MHz transabdominal transducer and a -MHz transvaginal transducer (Voluson , GE Medical Systems, Zipf, Austria).
The diagnosis of placenta previa was based on the presence of placental tissue covering the internal cervical os, whereas low-lying placenta was diagnosed when the placenta was within cm from the internal cervical os, but did not cover it. All enrolled patients signed a written informed consent. Patients with incomplete clinical and instrumental data and those who gave birth in another hospital were excluded.
Demographic data including age, parity, socioeconomic status, obstetric history, including the previous history of cesarean section or dilatation and curettage, gestational age at delivery, and any intra-operative or post-operative events were recorded. A note was also made about current pregnancy investigations and outcomes like exact placental localization, mode of delivery, estimated blood loss, number of blood transfusions, procedures required to control bleeding, intra-operative or post-operative complications, transfer to intensive care unit, and duration of hospital stay. Neonatal outcomes were reviewed for birth weight, neonatal intensive care unit admissions, and perinatal mortality.
The study was conducted according to the guidelines of the Declaration of Helsinki. Ethical review and approval were waived for this study, due to its retrospective design. , ( ),

Results
During the study period, there were , deliveries, out of which patients were diagnosed with placenta accreta spectrum, which provides an incidence of . % at our institution. Most patients in our study were in the -years age group. Out of patients, patients ( . %) were secundiparas, patients ( . %) were diagnosed antenatally by color Doppler, patients ( . %) presented in the labor room with antepartum hemorrhage, while patients ( . %) were diagnosed intraoperatively during LSCS. Previous LSCS was the most critical risk factor for PAS in our study. A total of subjects ( . %) delivered between -weeks of pregnancy.  History of uterine curettage . % Thirty-two of the women with PAS ( . %) had undergone hysterectomy, and eight patients did not undergo a hysterectomy. For the females who did not undergo hysterectomy, treatment included uterine artery ligation (n = ), hypogastric artery ligation (n = ), balloon tamponade (n = ), two or more uterotonics (n = ), and wedge resection of the uterus to which placenta is attached (n = ). Twenty-eight patients needed ICU care, and of them required ventilatory support; three of them died due to hemorrhagic shock. Nineteen patients had blood loss of more than L, and needed more than four units of blood. Twelve of our patients had Disseminated Intravascular Coagulation (DIC). The bladder was injured in patients, and one had a ureteric injury. Maternal complications, estimated blood loss, and number of transfusions are shown in Tables -, respectively.

Blood transfusion One or more units of packed red cells . % Four or more units of packed red cells . % Fresh frozen plasma (FFP) transfusion
. % In our study, preterm birth occurred in cases ( . %). Twenty-one patients required NICU admissions ( . %), and six each had early neonatal death and stillbirth ( . %). Table shows the perinatal outcomes in our study.

Discussion
The incidence of morbidly adherent placenta varies between . and . percent of deliveries, depending on the used de nition of placenta accreta and the study population, and has risen dramatically over the last three decades, coinciding with the rise in CS rates [ ]. Maternal age > years, past cesarean sections, and concurrent placenta previa were all risk factors for placenta accreta. Fitzpatrick et al. found similar results. [ ]. Additionally, another study by Farquhar C.M. in reported "that older maternal age, past cesarean section, placenta previa were independent risk indicators for PAS disorders" [ ]. The surgical delivery was done in all cases in this study. In the present study, . % of subjects underwent a hysterectomy. According to previous studies, MAP is the most common indication for immediate postpartum hysterectomy, amounting to half of all emergency peripartum hysterectomies [ , ]. Comstock C.H., in his study, found that "hysterectomy is the gold standard in management" [ ]. According to our study, . % of the patients underwent a hysterectomy, . % had prolonged hospital stay, . % ICU admission, . % required blood transfusion, . % required FFP transfusion, . % required bladder repair, and the mortality rate was . %, which is similar to the results of Desai R. et al. [ ]. A review of studies conducted between and found that "the most important maternal outcomes include the need for postpartum transfusion and peripartum , ( ), hysterectomy," as found in our study [ ]. In our study, patients ( . %) had planned hysterectomy and had an unplanned hysterectomy ( . %), which was similar to the study by Robinson et al. [ ]. Scheduled delivery in PAS results in less blood loss, shorter operative time, and blood transfusions. Every attempt should be made to decrease the loss of blood and arrangement for properly cross-matched blood should be done before surgery. Women with PAS delivered before term due to the bleeding. An unplanned delivery occurs or a planned delivery is scheduled before weeks in the case of antenatal diagnosis of PAS. As a result, the babies born to these women were often preterm, had low birth weight, and had low APGAR scores. In our study, preterm birth occurred in cases ( . %), required NICU admissions ( . %), and each had early neonatal death and stillbirth ( . %), which is consistent with the review of Desai R et al. [ ]. Some other studies produced similar ndings [ , ].

Conclusion
PAS is a devastating event in women's pregnancy. It leads to high maternal morbidity, mortality, and adverse neonatal outcome. The important risk indicators for PAS are previous LSCS and placenta previa. Every case with these two concurrent conditions should be operated on in a planned way in the presence of senior obstetricians and the anesthetist team. Funding: This research received no external funding.

Con icts of Interest:
The authors declare no con ict of interest.