Evaluation of the Uterine Cavity Following Conservative Management of Placenta Accreta Using Diagnostic Hysteroscopy: A Prospective Cohort Study

Abstract

Background and Aim:

Placenta accreta spectrum (PAS) is a serious obstetric condition characterized by abnormal placental attachment to the uterine wall, with increasing prevalence linked to prior cesarean deliveries. Conservative management of PAS aims to preserve fertility but may lead to uterine complications. This study evaluates uterine cavity integrity and abnormalities using diagnostic hysteroscopy following conservative management of PAS to guide future management strategies.

Patients and Methods:

This prospective cohort study included 90 patients with morbidly adherent placenta managed conservatively at Ain Shams University Hospital over 1 year. Women underwent uterine preservation surgeries, including uterine artery ligation, placental-myometrial bloc excision, and/or internal iliac artery ligation. Diagnostic hysteroscopies were performed 3–6 months post-surgery to evaluate uterine cavity abnormalities. Primary outcomes included hysteroscopic findings, while secondary outcomes assessed menstrual patterns and fertility potential.

Results:

Hysteroscopic evaluation identified abnormalities in 52 patients, including fine fibrous adhesions (40.38%), niches (13.46%), uterine adhesions (11.5%), and extensive fibrous scarring (13.46%). Less frequent findings included endometrial polyps (9.61%), incomplete healed scars (3.84%), cervical stenosis (3.84%), and incomplete tubal ostia with soft tissue (3.84%). Postsurgical menstrual patterns and fertility outcomes were unaffected in most cases. Significant associations were noted between hysteroscopic abnormalities, management techniques, and postoperative outcomes.

Conclusions:

Conservative management of PAS preserves uterine function in most cases, with fine fibrous adhesions being the most prevalent abnormality. Future larger studies are needed to further evaluate the impact of these findings on fertility and subsequent pregnancy outcomes.

Introduction

Placenta accreta spectrum (PAS) is a serious obstetric condition characterized by abnormal placental attachment to the uterine wall. It encompasses three types based on the degree of invasion: placenta accreta, where the villi attach directly to the myometrium; placenta increta, involving deeper myometrial invasion; and placenta percreta, where the placental tissue invades through the uterine serosa. The prevalence of PAS ranges from 0.01% to 1.1%, with a significantly increased risk in women with prior cesarean deliveries—rising from 0.24% after the first cesarean to 6.74% after the sixth.^1,2 The pathophysiology of PAS is linked to abnormal decidualization and excessive trophoblastic invasion during placentation.³ Diagnosis is typically suspected during the second or third trimester based on ultrasonographic findings, such as the loss of the retroplacental zone and abnormal vascular patterns, with color Doppler and magnetic resonance imaging (MRI) aiding in cases of inconclusive results.⁴ PAS is associated with significant intraoperative and postoperative complications, including severe hemorrhage, adjacent organ injury, and coagulopathy.⁵ Conservative management strategies aim to preserve the uterus and maintain fertility, employing techniques such as placental-myometrial resection, uterine artery embolization, or leaving the placenta in situ, though these approaches carry risks of infection, hemorrhage, and recurrent PAS in future pregnancies.⁶ Hysteroscopy, a minimally invasive procedure for intrauterine evaluation, offers a reliable method for assessing the uterine cavity after conservative PAS management. It is particularly useful for diagnosing complications such as intrauterine adhesions and evaluating uterine integrity posttreatment.⁷ This study was designed to evaluate the uterine cavity following conservative management of PAS using diagnostic hysteroscopy to provide insights into uterine recovery and inform future management strategies.

Patients and Methods

This prospective cohort study included 90 patients diagnosed with morbidly adherent placenta (MAP) who underwent conservative uterine surgery at Ain Shams University Maternity Hospital over an18 -month period that started in April 2023. All patients were evaluated 3 months postoperatively using diagnostic hysteroscopy. Ethical approval was obtained from the hospital’s ethics committee, and written informed consent was secured from all participants. The study adhered to ethical principles, with strict confidentiality measures and the right for participants to withdraw at any stage. Inclusion criteria included women with a history of conservative MAP management within the last 3–6 months and a desire for future pregnancy. Exclusion criteria encompassed contraindications to hysteroscopy, such as pregnancy, active pelvic infection, or confirmed cervical/endometrial cancer; complicated cases requiring re-surgery or hysterectomy; missing surgical data; and refusal to participate. Patients were diagnosed with MAP through clinical and imaging criteria, including ultrasonography and Doppler features (e.g., myometrial thickness <1 mm, placental blood lakes, and loss of the hypoechoic retroplacental zone). A comprehensive assessment was performed for all participants, encompassing history-taking, clinical examination, laboratory investigations, and transvaginal ultrasonography. Diagnostic hysteroscopy was conducted during the follicular phase for menstruating women. A 2.9 mm rigid hysteroscope was used with normal saline as the distension medium, and misoprostol was administered preoperatively for cervical ripening. The procedure systematically evaluated the uterine cavity, assessing for intrauterine adhesions, scar thinning, endometrial fibrosis, and cervical stenosis. Identified abnormalities, such as adhesions or polyps, were addressed during the procedure. The primary outcome included postoperative intrauterine adhesions. The secondary outcomes included tubal patency, cervical lesions, cesarean scar thinning, and cervical stenosis.

Sample size calculation

Using the Open Epi program for sample size calculation, and after reviewing results from the previous relevant study,⁵ showed that the commonest complication detected after conservative management of placenta accreta by using hysteroscopy was cervical stenosis (30%), with a margin of error ±10% at 95% confidence level, and after 10% adjustment for dropout rate, a sample size of at least 90 participants will be needed as a total number of cases.

Statistical analysis

Normally distributed numerical data were statistically described in terms of mean ± standard deviation (±SD), while non-normal data were represented as median and range or interquartile range. Qualitative (categorical) data were described in frequencies (number of cases) and percentage. Numerical data were tested for the normal assumption using Kolmogorov–Smirnov test. Comparison of numerical variables between the study groups was done using Student’s t test for independent samples in comparing normally distributed data and Mann–Whitney U test for independent samples when data are not normally distributed. For comparing categorical data, chi-square test was performed. Exact test was used instead when the expected frequency is <5. A probability value (p-value) <0.05 is considered statistically significant. All statistical calculations were done using computer programs Microsoft Excel 2016 (Microsoft Corporation, NY, USA) and IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY, USA) release 22 for Microsoft Windows.

Results

This prospective study, conducted at Ain Shams University Maternity Hospital from April 2023 to October 2024, included 90 women who underwent conservative surgical management for placenta accreta. Each participant was evaluated 3 months after the procedure using hysteroscopy to assess the uterine cavity. Table 1 shows the study participants had an average age of 32 years (SD = 5.1) and a mean body mass index (BMI) of 25.5 (SD = 2.88). The mean gestational age at the time of delivery was 35.24 weeks (SD = 2.92). These findings indicate a population of predominantly older reproductive-age women with a consistent BMI profile. Table 2 shows the obstetric history highlighted the frequency of prior cesarean sections among the participants, reflecting their previous reproductive experiences and potential risk factors for placenta accreta. Table 3 details the contraceptive methods used by the participants, the regularity of their menstrual cycles, and the occurrence of vaginal spotting following the conservative surgical procedure. Table 4 shows management approaches, including the need for blood transfusions and intensive care unit admissions, were documented. The table also reports the patients’ menstrual patterns and hysteroscopic findings, providing insight into the outcomes following conservative treatment. In Table 5, abnormal hysteroscopic findings were identified in 52 patients (57.8%). The most common abnormalities included fine fibrous adhesions (40.38%), niches or scar defects (13.46%), and uterine adhesions (11.5%). These abnormalities are indicative of scar-related complications that may influence future reproductive outcomes. In Table 6, a comparison has been done between women with normal and abnormal hysteroscopic findings. The analysis revealed significant differences in management strategies and menstrual patterns between women with normal and abnormal hysteroscopic findings. Notably, abnormal findings were associated with altered menstrual cycles, with a statistically significant p-value of 0.003. The results highlight the high prevalence of abnormal hysteroscopic findings in women treated conservatively for placenta accreta. These findings emphasize the need for careful post-treatment monitoring to identify complications and guide management to optimize reproductive outcomes in this population.

Table 1.

Demographic Characteristics of Patients (n = 90)

Variable	Mean	Standard deviation	Minimum	Maximum
Age (years)	32	5.1	23	40
BMI (kg/m²)	25.5	2.88	23	27
GA (weeks)	35.24	2.92	26	38

BMI, body mass index.

Table 2.

Obstetric History of Patients (n = 90)

Variable	N	%
Frequency of previous CS
1 cs	3	3.3
2 cs	16	17.8
3 cs	27	30.0
4 cs	27	30.0
5 cs	14	15.6
6 cs	3	3.3

Data are presented as number and percentage (%).

Table 3.

Contraceptive Use, Regularity of Menstruation, and Incidence of Vaginal Spotting Post Conservative Procedure (n = 90)

Variable	N	%
Contraception
Nil	14	15.60
COC	27	30.00
POP	5	5.60
IMPLANON	14	15.50
Tubal ligation	16	17.80
Depoprovera	11	12.20
Condom	3	3.30
Menstruation
Absent	35	38.9
Regular	55	61.1
Vaginal spotting
Present	8	8.9
Absent	82	91.1

Data are presented as number and percentage (%).

Table 4.

Type of Management Strategies, Blood Transfusion, ICU Admission, Menstrual Pattern, and Hysteroscopic Findings

Variable	N	%
Blood transfusion
Yes	82	91.1
No	8	8.9
Type of management
Cervico-isthmical suture	51	56.7
Cervico-isthmical suture Bilateral uterine artery lig	22	24.4
Bilateral uterine artery lig	14	15.6
B-lynch suture	3	3.3
Number of patients with abnormal hysteroscopic findings
Normal findings	38	42.2
Abnormal findings	52	57.8
Single abnormal findings	33	63.5
Two abnormal findings	19	36.5

Data are presented as number and percentage (%).

ICU, intensive care unit.

Table 5.

Abnormal Hysteroscopic Findings (n = 52)

Variable	N	%
Abnormal hysteroscopic findings
Uterine adhesion	6	11.5
Niche	7	13.46
Fine fibrous adhesion at scar site	21	40.38
Endometrial polyp	5	9.61
Cervical stenosis	2	3.84
Extensive fibrous scar	7	13.46
Incomplete healed scar	2	3.84
Incomplete of right tube ostium with soft tissue	2	3.84

Comparison of Findings: Current Study Versus Previous Research

Study	Abnormal findings	Key outcomes	Comparison to current study
Khallaf et al.⁷	Fine fibrous adhesions (45%), no niches or uterine adhesions.	90% normal findings after uterine-preserving PAS surgeries.	Lower rate of abnormal findings compared with our study, suggesting potential differences in management protocols.
AbdAlla et al.⁵	Cervical stenosis (30%), uterine irregularities (15%), and adhesions (15%).	Highlighted variability in hysteroscopic findings across cohorts.	Greater focus on cervical abnormalities than our study, which showed fewer cervical stenosis cases.
Talamonte et al.¹¹	Pseudo-cavities (90%) and multiple findings in 50%.	Linked pseudo-cavities to postmenstrual spotting, often observed with endometrial polyps and granulomas.	Consistent with niche findings in our study, highlighting scar-related menstrual irregularities.
Bij de Vaate et al.¹²	CS-related niches in 56%.	Niche formation associated with postmenstrual spotting.	Similar niche prevalence (13.46%) in our study, aligning with CS-related scar defects and menstrual issues.
Antila-Långsjö et al.¹³	Multiple CSs increased risks for scar defects and incomplete healing.	Highlighted demographic and healing variations.	Our study found no significant difference in outcomes based on CS history (p = 0.152).
Hayakawa et al.¹⁴	Increased wedge defects with advanced gestational age, multiple pregnancies, and PROM.	Identified delivery and pregnancy-related risk factors for scar defects.	Findings support risk factors influencing abnormal scar healing, like our scar-related abnormalities.
Bennich et al.¹⁵	Closure methods did not significantly affect myometrial thickness.	Suggested potential implications on uterine healing.	Similar findings suggesting incision closure methods may influence outcomes.
Sentilhes et al.¹⁶	IUAs, amenorrhea linked to retained tissue, and scarring post-PAS management.	34/96 women conceived within 17.3 months on average post-management.	Higher adhesions rate than our study (11.5%), likely due to differences in surgical and postoperative care.
Hequet et al.¹⁷	Chronic intrauterine retention and fibrotic changes.	Emphasized the need for hysteroscopic resection for retained products.	Consistent with findings of fibrous adhesions (40.38%) in our study.
El-Mazny et al.¹⁸	High prevalence of IUAs and scar defects in prior patients with CS.	Implicated conservative PAS management in extensive fibrosis.	Similar findings but our cohort had fewer adhesions and scar defects compared with El-Mazny’s population.
Feng et al.¹⁹	Normal uterine cavity in post-CS scar defect cases.	Highlighted potential variability in PAS outcomes due to management methods.	Contrasts with our higher rate of hysteroscopic abnormalities, reflecting methodological differences.

Table 6.

Comparison of Frequency of Previous CS, Contraception, Type of Management Strategies, Blood Transfusion, ICU Admission, Menstrual Pattern, and Hysteroscopic Findings Between Women with Normal and Abnormal Hysteroscopic Findings

Parameters	Normal hysteroscopic findings (n = 38)	Abnormal hysteroscopic findings (n = 52)	p-Value
Frequency of previous CS			0.152
1 cs	1 (2.6%)	2 (3.8%)
2 cs	5 (13.2%)	11 (21.2%)
3 cs	12 (31.6%)	15 (28.8%)
4 cs	11 (28.9%)	16 (30.8%)
5 cs	7 (18.4%)	7 (13.5%)
6 cs	2 (5.3%)	1 (1.9%)
Contraception			0.067
Nil	6 (15.8%)	8 (15.4%)
COC	10 (26.3%)	17 (32.7%)
POP	2 (5.3%)	3 (5.8%)
IMPLANON	9 (23.7%)	5 (9.6%)
Tubal ligation	7 (18.4%)	9 (17.3%)
Depoprovera	4 (10.5%)	7 (13.5%)
Condom	1 (2.6%)	2 (3.8%)
Type of management			0.0002
Bilateral uterine artery ligation	3 (7.9%)	11 (21.2%)
B-lynch suture	3 (7.9%)	0 (0%)
Cervico-isthmical suture	16 (42.1%)	36 (69.2%)
Cervico-isthmical suture + Bilateral uterine artery ligation	16 (42.1%)	5 (9.6%)
Blood transfusion			0.049
Yes	38 (100%)	47 (90.4%)
No	0 (0%)	5 (9.6%)
ICU admission			0.132
Yes	0 (0%)	3 (5.8%)
No	38 (100%)	49 (94.2%)
Menstrual pattern after surgery			0.003
Normal menstrual pattern	30 (78.9%)	25 (48.1%)
No cycle due to contraception	8 (21.1%)	27 (51.9%)

Data are presented as mean and standard deviation (±SD), median (interquartile range), and number and percentage (%).

Bold values indicate significance.

Discussion

MAP, encompassing placenta accreta, increta, and percreta, significantly contributes to maternal morbidity and mortality. It is characterized by varying depths of placental invasion, from attachment beyond Nitabuch’s layer in accreta to myometrial invasion in increta and serosal penetration in percreta.⁸ Optimal management includes planned delivery at 34–35 weeks with corticosteroids and multidisciplinary coordination.⁹ Ultrasound remains the primary diagnostic tool, with sensitivity between 77% and 93% and specificity of 71%–98%, while Doppler and MRI enhance diagnostic accuracy.¹⁰

For women desiring future fertility, conservative uterine preservation surgeries have been developed, including uterine artery ligation and placental-myometrial excision. However, these procedures pose risks such as hemorrhage, DIC, adhesions, and infection.⁷ Our study aimed to evaluate the uterine cavity post-conservative management of PAS in 90 cases using diagnostic hysteroscopy. Abnormal hysteroscopic findings were observed in 57.8% of patients, with common abnormalities including fibrous adhesions (40.38%), niches (13.46%), and uterine adhesions (11.5%). Normal findings were noted in 42.2% of participants.

Findings such as fibrous adhesions and niches suggest incomplete healing, potentially leading to menstrual irregularities and complications in future pregnancies. Hequet et al. reported similar fibrotic changes, underscoring the importance of hysteroscopic resection for retained placental tissue.¹⁷ Specific management techniques, such as cervico-isthmical suturing and uterine artery ligation, were significantly associated with abnormal hysteroscopic findings (p = 0.0002). These results align with Bennich et al., who noted that incision closure methods influence uterine healing.¹⁵ Likewise, Donnez et al. observed dehiscence at the cesarean scar in patients attempting to conceive, with hysteroscopy revealing retained menstrual blood and fibrous abnormalities, which parallels our findings of scar-related abnormalities.²⁰

Case reports by Greenberg et al. and Yee et al. highlighted localized fibrosis and retained placental tissue after uterine artery embolization, consistent with our findings of scar-related abnormalities.^21,22

Conclusions

This study provides insight into post-PAS uterine cavity outcomes, with a higher rate of abnormalities observed than in previous studies, possibly due to procedural or sample differences. Further research is needed to standardize management approaches and evaluate their long-term effects on uterine health and fertility outcomes.

Strengths

Comprehensive hysteroscopic evaluation post-PAS management.

Detailed analysis of surgical techniques and outcomes.

Limitations

Single-center design limits generalizability.

Lack of long-term follow-up to assess reproductive outcomes.

Variability in surgical methods among patients.

Footnotes

Authors’ Contributions

A.N.S. contributed to data gathering, article development, and study design. M.S.K. worked on the article’s analysis and modification. H.R.K. confirmed the analytic techniques. M.S.K. and A.N.S. performed theoretical formalism development, analytical calculations, and numerical simulations. A.S.S.E.-D.A. evaluated the findings and carried out the implementation. R.T.A. aided with data analysis and essay revision. All authors participated in this article with the cases they performed, read the completed article, and approved it for publication.

Ethics Approval

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. The protocol was reviewed and approved by the Scientific and Ethics Committee of the OBGYN department, Ain Shams University, under protocol number MS-753-2023 on April 4, 2023.

Consent to Participate

Informed consent was obtained from all participants included in the study. Participants were provided with detailed information about the study objectives, procedures, potential risks and benefits, confidentiality measures, and their right to withdraw at any time without consequences. Written consent was obtained from each participant before their inclusion in the study. Additionally, participants’ confidentiality was strictly maintained throughout the research process, and all data were anonymized to ensure privacy.

Data Availability

All data generated or analyzed during this study are included in this published article as related information files.

Author Disclosure Statement

The authors declare that they have no competing interests.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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