Management and outcomes of 308 placenta accreta spectrum cases at a multidisciplinary tertiary center in Turkey: a 16-year experience

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. 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. 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. 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. 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.