Study population
The “Placenta Accreta Spectrum International Database (PAS-ID)” is a multicentre international database of women diagnosed with PAS that was initiated on January 21st, 2020 by Middle-East Obstetrics and Gynaecology Graduate Education (MOGGE) Foundation (ClinicalTrials.gov identifier: NCT04384510). A consortium of 11 PAS referral centres, which conduct both caesarean hysterectomy and uterus preservation, contributed to the study. These centres locate in 9 countries (Portugal, Russia, Turkey, Taiwan, Indonesia, China, Pakistan, Egypt, and Cameroon), which present 3 different continents. Data of PAS patients were retrospectively collected between January 1st, 2010 and December 31st, 2019. Inclusion criteria included clinical and histopathological diagnosis of PAS, management, and delivery by the respective center, including at least 6 weeks of postpartum follow-up. Women with deficient documentation, inadequate antenatal or postpartum follow-up, or no documented authorization to use clinical data for research purposes, were excluded from the study. Variability of PAS management protocols were limited among centres and over time within the same center. In general, diagnosis of PAS was made by greyscale transabdominal and transvaginal ultrasound with Doppler assessment during mid-trimester foetal anatomy scan, which might be repeated if necessary. Magnetic resonance imaging was confined to cases where extent of invasion beyond the uterus is suspicious. Women with PAS Patients were counselled on management options. Deliveries was planned between 35 and 37 weeks of gestation unless earlier delivery was indicated for emergency situations or due to another obstetric indication. Either preoperative or intraoperative ultrasound was performed to localize the placenta. Intraoperatively, adequate exposure of the lower uterine segment was made prior to delivery, the uterus was incised away from placental site. Once the foetus was delivered, uterine bleeding and placental invasion were assessed to determine surgical approach. Common uterus preserving procedures included swing of placental bed, vascular ligation, and compression sutures, most commonly B-Lynch and Nausicaa sutures (9). Uterine wall resection was considered when area of invasion was localized, and re-approximation of uterine edges was achievable. Blood transfusion was determined by clinical assessment until laboratory test results were available. Interventional radiology was not available in most centres and was offered to a few patients if it was supported by a multidisciplinary team decision. Postoperative admission to intensive care unit (ICU) versus high dependency unit was decided by the surgeon and the anaesthetist based on maternal hemodynamic stability, laboratory tests, and the presence of other risk factors.