Original Articles

Novel Risk Factors for Placenta Accreta Spectrum in Women Without Prior Cesarean Section: Insights From a Case-Control Study

Abstract

Placenta accreta spectrum (PAS) is a significant contributor to maternal morbidity and mortality, often complicating pregnancies due to abnormal placental attachment. While cesarean section (CS) remains the most recognized risk factor, nearly one-third of PAS cases occur in women without a history of CS. Identifying risk factors in these women is critical for improving early detection and management. This study aims to investigate maternal characteristics and risk factors associated with PAS in women without a history of CS, focusing on surgical histories and other potential predictors. A case-control study was conducted at the Maternity Teaching Hospital in Sulaimania, Kurdistan Region, Iraq. The study included 120 pregnant women diagnosed with placenta previa: 60 with PAS (cases) and 60 without PAS (controls). Women with a history of CS or uterine surgery were excluded. Data on maternal age, body mass index (BMI), parity, uterine surgical history, and other clinical factors were analyzed. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors. Significant risk factors for PAS included previous uterine myomectomy by laparotomy (OR 65.23, 95% CI: 7.85-541.72, P<0.0001), uterine septum excision (OR 9.45, 95% CI: 1.10-81.23, P=0.022), and a history of multiple endometrial biopsies (OR 3.92, 95% CI: 1.03-14.93, P=0.045). Repeated uterine curettage also emerged as a significant predictor (OR 3.78, 95% CI: 1.05-13.59, P=0.042). Conversely, traditional risk factors such as multiparity, gestational hypertension, and diabetes mellitus were not significantly associated with PAS in this cohort. Our study highlights uterine myomectomy, septum excision, repeated biopsies, and curettage as significant risk factors for PAS in women without a history of CS. These findings emphasize the importance of careful monitoring and risk assessment in such patients to improve early detection and management of PAS.

1. Matsuzaki S, Mandelbaum RS, Sangara RN, McCarthy LE, Vestal NL, Klar M, et al. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am J Obstet Gynecol 2021;225:534-e1.
2. Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. American J Obstet Gynaecol 2018;218:75-87.
3. Heller DS. The Placenta Accreta Spectrum. Benirschke's Pathology of the Human Placenta 2022:271-80.
4. Abdelhafez MM, Ahmed KA, Mohd Daud MN, Eldiasty AM, Jeffree MS, Kadir F, et al. Placenta accreta spectrum: A current literature review. J Diagn Med Sonogr 2023;39:599-613.
5. Silveira C, Kirby A, Melov SJ, Nayyar R. Placenta accreta spectrum: We can do better. Aust N Z J Obstet Gynaecol 2022;62:376-82.
6. Ogawa K, Jwa SC, Morisaki N, Sago H. Risk factors and clinical outcomes for placenta accreta spectrum with or without placenta previa. Arch Gynecol Obstet 2022;305:607-15.
7. Imafuku H, Tanimura K, Shi Y, Uchida A, Deguchi M, Terai Y. Clinical factors associated with a placenta accreta spectrum. Placenta 2021;112:180-4.
8. Abu Hashim H, Shalaby EM, Hussien MH, El Rakhawy M. Diagnostic accuracy of the placenta accreta index for placenta accreta spectrum: A prospective study. Int J Gynecol Obstet 2022;156:71-6.
9. Morlando M, Collins S. Placenta accreta spectrum disorders: challenges, risks, and management strategies. Int J Womens Health 2020:1033-45.
10. Palacios-Jaraquemada JM, D’Antonio F. Posterior placenta Accreta Spectrum disorders: risk factors, diagnostic accuracy, and Surgical Management. Maternal-Fetal Medicine 2021;3:268-73.
11. Carusi DA, Duzyj CM, Hecht JL, Butwick AJ, Barrett J, Holt R, O'Rinn SE, Afshar Y, Gilner JB, Newton JM, Shainker SA. Knowledge gaps in placenta accreta spectrum. Am J Perinatol 2023;40:962-9.
12. El Gelany S, Mosbeh MH, Ibrahim EM, Mohammed MM, Khalifa EM, Abdelhakium AK, et al. Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study. BMC pregnancy and childbirth 2019;19:1-8.
13. Romeo V, Verde F, Sarno L, Migliorini S, Petretta M, Mainenti PP, et al. Prediction of placenta accreta spectrum in patients with placenta previa using clinical risk factors, ultrasound and magnetic resonance imaging findings. La radiologia medica 2021;126:1216-25.
14. Einerson BD, Weiniger CF. Placenta accreta spectrum disorder: updates on anesthetic and surgical management strategies. International Journal of Obstetric Anesthesia 2021;46:102975.
15. Hobson SR, Kingdom JC, Murji A, Windrim RC, Carvalho JC, Singh SS, et al. No. 383-screening, diagnosis, and management of placenta accreta spectrum disorders. J Obstet Gynaecol Can 2019;41:1035-49.
16. Silver RM, Barbour KD. Placenta accreta spectrum: accreta, increta, and percreta. Obstetrics and Gynecology Clinics. 2015;42(2):381-402.
17. Badr DA, Al Hassan J, Wehbe GS, Ramadan MK. Uterine body placenta accreta spectrum: A detailed literature review. Placenta 2020; 95:44-52.
18. Mohr-Sasson A, Timor I, Meyer R, Stockheim D, Orvieto R, Mashiach R. Placenta accreta spectrum in subsequent pregnancy following myomectomy. J Matern Fetal Neonatal Med 2022;35:4332-7.
19. Duzyj CM, Cooper A, Mhatre M, Han CS, Paidas MJ, Illuzzi JL, Sfakianaki AK. Placenta accreta: a spectrum of predictable risk, diagnosis, and morbidity. Am J Perinatol 2019;361031-8.
20. Mandelbaum RS, Melville SJ, Violette CJ, Guner JZ, Doody KA, Matsuzaki S, et al. The association between uterine adenomyosis and adverse obstetric outcomes: a propensity score‐matched analysis. Acta Obstetricia et Gynecologica Scandinavica 2023;102:833-42.
21. Komatsu H, Taniguchi F, Harada T. Impact of adenomyosis on perinatal outcomes: a large cohort study (JSOG database). BMC Pregnancy and Childbirth 2023;23:579.
22. Liu X, Wang Y, Wu Y, Zeng J, Yuan X, Tong C, Qi H. What we know about placenta accreta spectrum (PAS). Eur J Obstet Gynecol Reprod Biol 2021; 259:81-9.
23. Baldwin HJ, Patterson JA, Nippita TA, Torvaldsen S, Ibiebele I, Simpson JM, Ford JB. Antecedents of abnormally invasive placenta in primiparous women: risk associated with gynecologic procedures. Obstetrics & Gynecology 2018;131:227-33.
24. Miller HE, Leonard SA, Fox KA, Carusi DA, Lyell DJ. Placenta accreta spectrum among women with twin gestations. Obstetrics & Gynecology 2021;137(1):132-8.
25. El Gelany S, Mosbeh MH, Ibrahim EM, Mohammed MM, Khalifa EM, Abdelhakium AK, et al. Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study. BMC pregnancy and childbirth 2019; 19:1-8.
26. Kılıçcı Ç, Eken MK, İlhan G, Çöğendez E, Şanverdi İ, Keskin M, et al. Evaluation of Risk Factors, Incidence, Perinatal and Maternal Outcome of Placenta Previa Cases with and without Placenta Accreta Spectrum. Duzce Med J 2018;19:75-80.
Files
IssueVol 63 No 2 (2025) QRcode
SectionOriginal Articles
DOI https://doi.org/10.18502/acta.v63i2.18970
Keywords
Placenta accreta spectrum Pregnancy complications Risk factors Cesarean section
Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
1.
Bakir Mahmood M. Novel Risk Factors for Placenta Accreta Spectrum in Women Without Prior Cesarean Section: Insights From a Case-Control Study. Acta Med Iran. 2025;63(2):143-148.