Placenta accreta spectrum (PAS) represents a group of obstetric disorders characterized by abnormal adherence of the placenta to the myometrium due to partial or complete absence of the decidua basalis. This pathological condition includes three subtypes: placenta accreta, increta, and percreta, depending on the depth of trophoblastic invasion. While rare in earlier decades, the incidence of PAS has increased dramatically in parallel with the global rise in cesarean section rates and uterine surgeries [1]. The condition has emerged as a leading cause of obstetric hemorrhage and peripartum hysterectomy, contributing significantly to maternal morbidity and mortality [2].

In normal pregnancy, the placenta separates from the uterine wall after delivery. However, in PAS, this process is disrupted due to morbid placental adherence, often necessitating surgical intervention. The most frequently implicated risk factor is a history of prior cesarean delivery, especially when associated with anterior placenta previa. Additional risk factors include advanced maternal age, multiparity, uterine curettage, and assisted reproductive technologies [3, 4]. The pathogenesis is attributed to defective decidualization and scarring that predispose to abnormal placental implantation.

Surgical management of PAS is particularly challenging, with high risks of massive hemorrhage, need for blood transfusion, urologic injuries, and postoperative complications. The standard of care often involves cesarean hysterectomy, although in selected cases, conservative approaches such as placental removal or segmental uterine resection may be attempted [5]. The choice of intervention depends on the extent of placental invasion, intraoperative findings, desire for future fertility, and available surgical expertise.

Despite advances in prenatal imaging and surgical techniques, intraoperative decision-making in PAS remains complex. Multidisciplinary care involving obstetricians, anesthesiologists, urologists, and general surgeons is critical in optimizing outcomes. Antenatal diagnosis through ultrasound and magnetic resonance imaging (MRI) has been shown to reduce surgical morbidity by allowing better preoperative planning [6]. However, in resource-limited settings, many cases are diagnosed intraoperatively, increasing the risk of adverse outcomes.

The current literature lacks consensus on the optimal surgical strategy for PAS, with most available data derived from case series or retrospective analyses. There is a pressing need to evaluate the comparative effectiveness and safety of various surgical approaches. This study was undertaken to assess the clinical outcomes of different surgical interventions in patients with PAS, focusing on intraoperative challenges, postoperative complications, and overall maternal morbidity. It aims to provide insight into real-world surgical experiences in a tertiary care setting over a defined study period.

This retrospective observational study was conducted in the Department of General Surgery at Gouri Devi Institute of Medical Sciences, Durgapur, over a one-year period from March 2009 to February 2010. The study aimed to evaluate the clinical outcomes and challenges associated with various surgical interventions for placenta accreta spectrum (PAS).

Study Design and Setting: All cases diagnosed intraoperatively with PAS—confirmed by clinical suspicion and subsequent histopathological verification—were included. The study was conducted in a tertiary care hospital with available support from multidisciplinary teams including obstetricians, general surgeons, urologists, and anesthesiologists.

Participants and Inclusion Criteria: Patients aged 20–45 years who underwent cesarean delivery and were found to have PAS intraoperatively were eligible. Inclusion was limited to those who had complete documentation, histopathological confirmation of PAS, and consent for participation in the institutional registry. Exclusion criteria included suspected but unconfirmed cases of PAS, incomplete records, and patients managed conservatively without surgical intervention.

Surgical Interventions: Patients were categorized into three groups based on the surgical intervention performed:

1. Cesarean hysterectomy (removal of uterus with placenta in situ)
2. Conservative placental removal (manual or piecemeal)
3. Segmental uterine resection (partial myometrial excision)

All procedures were performed under general anesthesia with intraoperative monitoring. Preoperative cross-matching and blood availability were ensured.

Data Collection: Medical records were reviewed for demographic data (age, parity, gestational age), history of previous cesarean sections, placental location, and surgical findings. Intraoperative variables included estimated blood loss (EBL), operative duration, and need for urological consultation. Postoperative outcomes included transfusion requirement, ICU admission, bladder or bowel injury, infection, length of hospital stay, and 30-day maternal morbidity.

Statistical Analysis: All data were entered into Microsoft Excel and analyzed using SPSS version 16.0. Categorical variables were expressed as percentages and compared using the Chi-square test or Fisher’s exact test where applicable.

Continuous variables were expressed as mean ± standard deviation (SD) and compared using one-way analysis of variance (ANOVA). A p-value of <0.05 was considered statistically significant. Confidence intervals were set at 95%.

The study was approved by the Institutional Ethics Committee.

Fig 1: Complication rates of surgical procedure

Table 1: Demographic Characteristics (n = 42)

Table 2: Distribution of Surgical Interventions

Table 3: Intraoperative Outcomes

Table 4: Postoperative Outcomes

Table 5: Maternal Morbidity by Risk Factors

The study comprised 42 patients diagnosed with placenta accreta spectrum (PAS). The mean maternal age was 32.4 years, and the average gestational age at delivery was 36.2 weeks. Notably, 85.7% had a history of previous cesarean sections, and 61.9% presented with placenta previa.

Cesarean hysterectomy was the most commonly performed surgical intervention (61.9%), followed by conservative removal (23.8%) and segmental resection (14.3%). Intraoperative outcomes demonstrated significant differences across procedures. The mean estimated blood loss was highest in the cesarean hysterectomy group (2100 mL), compared to 1500 mL in conservative removal and 1650 mL in segmental resection (p < 0.05). Operative time was also longest for hysterectomy (120 minutes) versus other procedures (p < 0.05). Bladder injuries occurred exclusively in the hysterectomy group (11.5%, p = 0.09), while transfusion requirements were significantly more frequent in this group (88.5%, p = 0.03).

Postoperatively, ICU admission was required in 42.3% of hysterectomy cases versus 30.0% and 33.3% in the other groups, though not statistically significant. Infection rates and complication rates were highest in the hysterectomy group, though without statistical significance. The only significant postoperative parameter was length of hospital stay, which was longest for hysterectomy patients (8.5 days, p < 0.05).

Risk factor analysis revealed that complication rates were significantly elevated among patients with >2 prior cesareans (42.1%, p = 0.01), placenta previa (35.7%, p = 0.04), and emergency surgeries (50.0%, p = 0.005).

The bar chart further illustrates that overall complication rates were highest with cesarean hysterectomy (30.8%) and lowest with segmental resection (16.7%).

Placenta accreta spectrum (PAS) disorders represent one of the most formidable challenges in modern obstetrics due to their association with massive hemorrhage, surgical complexity, and high maternal morbidity [7]. This study aimed to assess the clinical outcomes and intraoperative challenges associated with different surgical strategies used in the management of PAS in a tertiary care setup.

The rationale for this study stems from the growing incidence of PAS globally, attributed primarily to increasing cesarean section rates and other uterine interventions [8]. In our cohort, 85.7% of patients had a history of cesarean delivery, reinforcing its role as a major predisposing factor. Placenta previa, another strong risk factor, was present in 61.9% of cases, consistent with previously published data [9].

The findings of this study reveal that cesarean hysterectomy, although the most definitive treatment, was associated with the highest intraoperative blood loss (2100 mL), prolonged operative time (120 minutes), and increased need for transfusions (88.5%). These results are in line with earlier studies demonstrating that hysterectomy in PAS often entails greater surgical morbidity due to distorted pelvic anatomy and dense adhesions [10]. Conversely, conservative techniques such as placental removal and segmental uterine resection showed lower complication rates, although they may carry risks of retained placental tissue and delayed hemorrhage [11].

Postoperative morbidity, including infection, ICU admission, and extended hospital stay, was also more prevalent among patients undergoing cesarean hysterectomy. While the difference in infection and ICU stay was not statistically significant, the hospital stay was significantly longer (p < 0.05). This corroborates prior findings where aggressive surgical approaches, though effective in hemorrhage control, are often followed by longer recovery times [12].

Our risk factor analysis highlights that patient with more than two previous cesarean deliveries, placenta previa, or those requiring emergency surgery were significantly more likely to develop complications (p < 0.05). These findings emphasize the importance of antenatal detection and planned delivery under optimal settings to reduce maternal risk.

This study has practical implications for clinicians managing PAS. While cesarean hysterectomy remains the gold standard, the decision must be individualized. Where feasible, segmental resection or conservative placental removal may offer comparable safety with reduced morbidity in selected patients [13]. Multidisciplinary preparedness, availability of blood products, and urological support remain critical components of care.

This study highlights the clinical complexity and high-risk nature of surgical interventions in placenta accreta spectrum (PAS). Cesarean hysterectomy remains the most commonly employed and definitive surgical treatment; however, it is associated with increased intraoperative blood loss, transfusion requirements, and prolonged hospital stay. In contrast, conservative removal and segmental uterine resection may offer acceptable outcomes in selected cases with reduced morbidity. Risk factors such as multiple prior cesarean sections, placenta previa, and emergency surgeries significantly increased the likelihood of complications. These findings underscore the need for early antenatal diagnosis, individualized surgical planning, and multidisciplinary involvement to optimize maternal outcomes. Institutional preparedness and surgical expertise play pivotal roles in improving safety in PAS management.

Acknowledgement

The authors extend their gratitude to the departmental staff for their valuable support during patient care and data retrieval for this study.

Conflicts of Interest

The authors declare no conflicts of interest related to this study.

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