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Background Placenta accreta spectrum (PAS) disorders have become a significant life-threatening issue due to its increased incidence, morbidity and mortality. Several studies have tried to identify the risk factors for PAS disorders. The ideal management for PAS disorders is a matter of debate. The study objectives were to evaluate the incidence and risk factors of PAS disorders and to compare different management strategies at a tertiary referral hospital, Minia, Egypt. Methods This prospective study included 102 women diagnosed with PAS disorders admitted to Minia Maternity university hospital, Egypt between January 2017 to August 2018. These cases were categorized into three groups according to the used approach for management: Group (A) , ( n  = 38) underwent cesarean hysterectomy, group (B) , ( n  = 48) underwent cesarean section (CS) with cervical inversion and ligation of both uterine arteries and group (C) , ( n  = 16): the placenta was left in place. Results The incidence of PAS disorders during the study period was 9 / 1000 maternities (0.91%). The mean age of cases was 32.4 ± 4.2 years, 60% of them had a parity ≥3 and 82% of them had ≥2 previous CSs. Also, 1/3 of them had previous history of placenta previa. Estimated blood loss (EBL) and blood transfusion in group A were significantly higher than other groups. Group (C) had higher mean hospital stay duration. Group A was associated with significantly higher complication rate. Conclusions The incidence of PAS disorders was 0.91%. Maternal age > 32 years, previous C.S. (≥ 2), multiparity (≥ 3) and previous history of placenta previa were risk factors. The management of PAS disorders should be individualized. Women with PAS disorders who completed their family should be offered cesarean hysterectomy. Using the cervix as a tamponade combined with bilateral uterine artery ligation appears to be a safe alternative to hysterectomy in patients with focal placenta accreta and low parity desiring future fertility. Patients with diffuse placenta accreta keen to preserve the uterus could be offered the option of leaving the placenta aiming at conservative management after proper counseling. Trial registration Registered 28th October 2015, ClinicalTrials.gov NCT02590484 .

Backgrounds Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS. Methods A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS. Results ① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and β-HCG regression time ( P  < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination. Conclusions Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.

Placenta accreta spectrum (PAS) is a serious pregnancy complication caused by abnormal placental attachment to the uterus. In this Perspective, Eric Jauniaux and colleagues discuss emerging evidence that challenges our long-held pathophysiological understanding of PAS, and argue that a critical reassessment of definition, diagnosis, and management is overdue.

Placenta accreta spectrum and uterine scar dehiscence in cases of low‐lying or previa placentas have become an issue of intense debate among experts due to their common etiological origin. Some authors argue both conditions as a continuum while others maintain their distinct nature, while acknowledging both conditions could occur simultaneously. This ongoing debate has significant implications for diagnosis, patient counseling, and management. In this article, we present both sides of this debate, discuss diagnostic and management challenges, and call for standardization of terminology. This review explores the ongoing debate on whether placenta accreta spectrum and uterine scar dehiscence are distinct entities or part of a continuum. It discusses diagnostic challenges, surgical implications, and clinical consequences, emphasizing how misclassification may affect counseling, operative strategy, and outcomes, and calling for clearer definitions and standardized terminology.

Objective Placenta accreta spectrum (PAS) is a leading cause of severe bleeding during childbirth and often requires complex surgery and blood transfusions. The aim of this study was to investigate whether prenatal ultrasound findings, particularly those reflecting vascular and cervical topography, can more accurately predict the need for transfusions. Methods Sixty-one surgically confirmed PAS cases from two tertiary centers were analyzed. The uterine spairing surgery and cesarean hysterectomy groups were compared in terms of antenatal ultrasonographic markers. Transfusion burden was first adjusted for preoperative hemoglobin level and cesarean hysterectomy status; then residual variability in the model was examined to assess the independent prognostic contribution of ultrasound markers. Findings The need for transfused erythrocyte suspension (RBC) was significantly higher in women undergoing cesarean hysterectomy compared to those undergoing uterine-sparing surgery (2.7 ± 1.7 vs. 1.4 ± 1.3 units, p  = 0.003). After correction, uterovesical hypervascularity (β = 0.565, p  = 0.034) and placental vessel extension to the cervix (β = 0.640, p  = 0.011) remained independently associated with transfusion burden. Conclusion While classic findings such as loss of clear zone and placental lacunae support the diagnosis of PAS, vascular findings in the lower uterine segment and cervical region better reflect surgical difficulty and hemorrhagic burden. Focusing on these prognostic ultrasound markers can strengthen preoperative risk assessment, improve multidisciplinary surgical planning, and contribute to more reliable prediction of transfusion needs.

Background Placenta accreta spectrum (PAS) is a potentially life-threatening obstetric condition characterized by abnormal placental adherence or invasion of the myometrium. Its incidence has increased markedly over the past decade, largely paralleling the global rise in cesarean delivery rates. Antenatal diagnosis of PAS allows for planned delivery in tertiary centers with experienced multidisciplinary teams, which has been consistently associated with reduced maternal morbidity. Ultrasonography, including two-dimensional grayscale and color Doppler imaging, remains the primary diagnostic modality with high sensitivity. Although cesarean hysterectomy is widely accepted as the standard treatment for PAS, it is associated with substantial surgical morbidity due to the highly vascular nature of the condition. In selected cases, conservative and uterine-preserving approaches, including expectant management with the placenta left in situ, may be considered for women desiring uterine preservation. Objective To compare maternal outcomes between women with antenatally suspected PAS and those diagnosed intraoperatively, managed at a tertiary university hospital over a 16-year period. Methods This retrospective observational study was conducted at a tertiary referral center. Hospital records were reviewed to identify all women who underwent cesarean delivery for placenta previa and/or PAS between January 2009 and January 2025. Antenatal evaluation for PAS included two-dimensional grayscale and color Doppler ultrasonography. Women with an antenatal diagnosis were classified as suspected PAS (sPAS), whereas those diagnosed intraoperatively were classified as unsuspected PAS (uPAS). Management strategies included immediate cesarean hysterectomy or expectant management with the placenta left in situ. Patients managed expectantly were followed for up to one year postpartum to assess maternal outcomes and uterine preservation. Results A total of 308 PAS cases were managed during the study period, including 229 sPAS cases and 79 uPAS cases. At least one established risk factor for PAS was present in 92% of patients, with placenta previa being the most common. Planned surgical management was achieved in 38% of cases. The median gestational age at delivery was 257 days (range, 176–276 days). Attempts at placental removal were significantly more frequent in the uPAS group compared with the sPAS group (93.7% vs. 56%, p  < 0.001). Mean estimated blood loss was significantly lower in the sPAS group (300 mL) than in the uPAS group (1000 mL; p  < 0.001). Cesarean hysterectomy was performed in 79 cases, while 64 patients were managed expectantly. Among the expectantly managed patients, uterine preservation was achieved in 68% at one year postpartum, without major maternal morbidity or maternal mortality. Conclusions In PAS, maternal outcomes are closely associated with planned management strategies implemented in experienced multidisciplinary centers. While antenatal suspicion facilitates preoperative preparation and avoidance of placental manipulation, outcomes should not be interpreted as reflecting a causal benefit of diagnosis alone. Expectant management may allow uterine preservation in selected patients but carries a considerable burden of secondary interventions and maternal morbidity, underscoring the need for careful patient selection, individualized decision-making, and thorough counseling.

Placenta accreta spectrum (PAS) is a serious obstetric complication, characterized by the placenta accreta and increta to the uterine wall, which fails to detach spontaneously from the uterine following childbirth, potentially resulting in severe hemorrhage and additional complications. The incidence of PAS is increasing in the world, which is mainly attributed to a global escalation in cesarean section rates, underscoring the critical need to elucidate its molecular pathogenesis and to devise efficacious clinical interventions. Recent studies have identified novel molecular mechanisms that have significantly enhanced our comprehension of disease pathophysiology and informed predictive and therapeutic strategies. Here, we review the principal molecular pathogenesis of PAS, explore the potential translation of these findings into clinical applications, and assess the impact of emerging technologies on advancing research in this domain.

ObjectivesTo examine the evidence regarding the effectiveness and safety of endovascular interventional modalities for haemorrhage control in abnormal placentation deliveries.MethodsMEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to July 2017. Blood loss volume was regarded as the primary endpoint. Other important results are described. Random and fixed effects models were used for the meta-analysis.ResultsOf 385 studies identified, 69 (1,811 patients, mean age 32.9 years, range 23–39 years) were included. Mean gestational age at delivery was 35.1 weeks (range 27–38 weeks). Of 1,395 patients who underwent endovascular intervention, 587 (42%) had placenta accreta, 254 (18%) placenta increta and 313 (22%) placenta percreta. Prophylactic balloon occlusion of the internal iliac arteries (PBOIIA) was performed in 470 patients (33.6%), of the abdominal aorta (PBOAA) in 460 patients (33%), of the uterine artery (PBOUA) in 181 patients (13%), and of the common iliac arteries (PBOCIA) in 21 patients (1.5%). Primary embolization of the UA was performed in 246 patients (18%), of the pelvic collateral arteries in 12 patients (0.9%), and of the anterior division of the IIA in 5 patients (0.3%). Follow-up ranged from 0.5 to 42 months. Endovascular intervention was associated with less blood loss than no endovascular intervention (p < 0.001) with the lowest blood loss volume in patients who underwent PBOAA (p < 0.001). PBOAA was associated with a lower rate of hysterectomy (p = 0.030). Endovascular intervention did not result in increases in operative time or hospital stay.ConclusionsEndovascular intervention is effective in controlling haemorrhage in abnormal placentation deliveries. PBOAA was associated with a lower rate of hysterectomy and less blood loss than other modalities.Key points• Endovascular intervention in abnormal placentation deliveries is effective in reducing blood loss.• Endovascular intervention did not result in longer operative time or hospital stay.• Prophylactic balloon occlusion of the abdominal aorta is superior to other modalities.

Background Placenta accreta spectrum disorder (PASD) is a major obstetric complication associated with life-threatening haemorrhage. Prophylactic internal iliac artery balloon occlusion (IIABO) is used in many centres to reduce intraoperative blood loss but success rates are variable. Methods We reviewed 20 consecutive patients with PASD over a twenty-one-month period stratified by procedure type [total abdominal hysterectomy (TAH) versus conservative myometrial repair (MR)] and balloon occlusion use. Estimated blood loss (EBL) was recorded. Welch’s t-tests compared groups, and a two-way analysis of variance (ANOVA) assessed the effects of balloon use and procedure type. Effect sizes were expressed as Cohen’s d and η². Results Mean EBL was significantly lower with balloon use than without (1600 ± 666 mL vs. 3222 ± 1871 mL, p  = 0.034, Cohen’s d = − 1.15). Two-way ANOVA confirmed a main effect of balloon use (η² = 0.28), while procedure type showed no independent effect ( p  = 0.504). However, EBL values were widely dispersed— with balloons: median 1500 mL (interquartile range {IQR} 1200–1850), range 800–3000; without balloons: median 3000 mL (IQR 1600–5000), range 900–6000 which highlighted the variable efficacy at an individual level. Conclusion Prophylactic balloon occlusion reduces blood loss overall in both TAH and MR for PASD, but its efficacy is highly variable. Collateral circulation and scar defect morphology likely underpin this variability, and further research should focus on refining preoperative risk stratification to guide individualised surgical planning with the aid of available imaging techniques.

Background Cesarean hysterectomy as a traditional therapeutic maneuver for placenta accreta spectrum (PAS) has been associated with serious morbidity, conservative management has been used in many institutions to treat women with PAS. This systematic review aims to compare maternal outcomes according to conservative management or cesarean hysterectomy in women with placenta accreta spectrum disorders. Methods A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and four Chinese databases (Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Wanfang database and VIP database) to May 2024. Included studies were to be retrospective or prospective in design and compare and report relevant maternal outcomes according to conservative management (the placenta left partially or totally in situ) or cesarean hysterectomy in women with PAS. A risk ratio (RR) with 95% confidence interval (95% CI) was calculated for categorical outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. The Newcastle-Ottawa Quality Assessment Scale was used to assess the observational studies. All analyses were performed using STATA version 18.0. Results Eight studies were included in the meta-analysis. Compared with cesarean hysterectomy, PAS women undergoing conservative management showed lower estimated blood loss [WMD − 1623.83; 95% CI: -2337.87, -909.79], required fewer units of packed red blood cells [WMD − 2.37; 95% CI: -3.70, -1.04] and units of fresh frozen plasma transfused [WMD − 0.40; 95% CI: -0.62, -0.19], needed a shorter mean operating time [WMD − 73.69; 95% CI: -90.52, -56.86], and presented decreased risks of bladder injury [RR 0.24; 95% CI: 0.11, 0.50], ICU admission [RR 0.24; 95% CI: 0.11, 0.52] and coagulopathy [RR 0.20; 95% CI: 0.06, 0.74], but increased risk for endometritis [RR 10.91; 95% CI: 1.36, 87.59] and readmission [RR 8.99; 95% CI: 4.00, 12.21]. The incidence of primary or delayed hysterectomy rate was 25% (95% CI: 19–32, I 2  = 40.88%) and the use of uterine arterial embolization rate was 78% (95% CI: 65–87, I 2  = 48.79%) in conservative management. Conclusion Conservative management could be an effective alternative to cesarean hysterectomy when women with PAS desire to preserve the uterus and are informed about the limitations of conservative management. Prospero ID CRD42023484578.