Introduction
Placenta accreta spectrum (PAS) refers to a spectrum of pathological placental adherence disorders, in which trophoblastic growth invades the deeper tissue of the uterine wall to various degrees (1). PAS has drawn considerable attention in the current century since the incidence of PAS has increased significantly in response to the rising trend of caesarean deliveries (CD) (2). The incidence of PAS rose from 1 in 4,000 deliveries in the 70s of the last century to 1 in 533 to 1 in 730 deliveries in the last decade (3). PAS is associated with significant maternal morbidity including massive obstetric haemorrhage, coagulopathy, ICU admission, mechanical ventilation, infection, and prolonged hospitalization. Maternal mortality reaches 30% in some reports (4).
Caesarean hysterectomy is, by far, the most widely accepted management of PAS since it promotes controlled surgical circumstances and precludes massive bleeding from placental disruption. Caesarean hysterectomy is endorsed by the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) as a primary approach in women with PAS (5, 6). Nevertheless, the practice of uterine preservation, which comprise several procedures that aim at stopping uterine bleeding without removing the uterus, is widely adopted worldwide (7). This practice is driven by high motivation of many women to preserve their future fertility, which has led to increasing experience of performing these procedures (8). However, evidence on efficacy and safety of most uterus preserving procedures are limited due to paucity of consistent studies and limited sample size. These factors have resulted in a wide gap between evidence-based recommendations and current practice regarding PAS management in many countries of the world.
Placenta accreta spectrum international database (PAS-ID) is a large international multi-center study of women with confirmed diagnosis of PAS. The objective of this study is to compare perioperative massive blood loss between women who underwent uterus preserving procedures and caesarean hysterectomy. In addition, the study aims at identifying antenatal and intrapartum risk factors associated with massive bleeding in women with PAS.