{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,15]],"date-time":"2025-10-15T18:14:53Z","timestamp":1760552093333,"version":"build-2065373602"},"reference-count":32,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2024,4,22]],"date-time":"2024-04-22T00:00:00Z","timestamp":1713744000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Placenta accreta spectrum (PAS) disorders are placental conditions associated with significant maternal morbidity and mortality. While antenatal vaginal bleeding in the setting of PAS is common, the implications of this on overall outcomes remain unknown. Our primary objective was to identify the implications of antenatal vaginal bleeding in the setting of suspected PAS on both maternal and fetal outcomes. Materials and Methods: We performed a case-control study of patients referred to our PAS center of excellence delivered by cesarean hysterectomy from 2012 to 2022. Subsequently, antenatal vaginal bleeding episodes were quantified, and components of maternal morbidity were assessed. A maternal composite of surgical morbidity was utilized, comprised of blood loss \u2265 2 L, transfusion \u2265 4 units of blood, intensive care unit (ICU) admission, and post-operative length of stay \u2265 4 days. Results: During the time period, 135 cases of confirmed PAS were managed by cesarean hysterectomy. A total of 61\/135 (45.2%) had at least one episode of bleeding antenatally, and 36 (59%) of these had two or more bleeding episodes. Increasing episodes of antenatal vaginal bleeding were associated with emergent delivery (p &lt; 0.01), delivery at an earlier gestational age (35 vs. 34 vs. 33 weeks, p &lt; 0.01), and increased composite maternal morbidity (76, 84, and 94%, p = 0.03). Conclusions: Antenatal vaginal bleeding in the setting of PAS is associated with increased emergent deliveries, earlier gestational ages, and maternal composite morbidity. This important antenatal event may aid in not only counseling patients but also in the coordination of multidisciplinary teams caring for these complex patients.<\/jats:p>","DOI":"10.3390\/medicina60040677","type":"journal-article","created":{"date-parts":[[2024,4,22]],"date-time":"2024-04-22T09:53:52Z","timestamp":1713779632000},"page":"677","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Association between Antenatal Vaginal Bleeding and Adverse Perinatal Outcomes in Placenta Accreta Spectrum"],"prefix":"10.3390","volume":"60","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5110-1317","authenticated-orcid":false,"given":"J. Connor","family":"Mulhall","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Division of Fetal Intervention, Baylor College of Medicine, Texas Children\u2019s Hospital, Houston, TX 77030, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kayla E.","family":"Ireland","sequence":"additional","affiliation":[{"name":"Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John J.","family":"Byrne","sequence":"additional","affiliation":[{"name":"Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick S.","family":"Ramsey","sequence":"additional","affiliation":[{"name":"Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Georgia A.","family":"McCann","sequence":"additional","affiliation":[{"name":"Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, TX 78229, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0431-5280","authenticated-orcid":false,"given":"Jessian L.","family":"Munoz","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Division of Fetal Intervention, Baylor College of Medicine, Texas Children\u2019s Hospital, Houston, TX 77030, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,4,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"B2","DOI":"10.1016\/j.ajog.2018.09.042","article-title":"Placenta accreta spectrum","volume":"219","author":"Cahill","year":"2018","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"544","DOI":"10.1097\/AOG.0000000000005075","article-title":"Ultrasonography of the explanted uterus in placenta accreta spectrum: Correlation with intraoperative findings and gross pathology","volume":"141","author":"Einerson","year":"2023","journal-title":"Obstet. Gynecol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1104","DOI":"10.1097\/AOG.0000000000003793","article-title":"Placenta accreta spectrum disorder: Uterine dehiscence, not placental invasion","volume":"135","author":"Einerson","year":"2020","journal-title":"Obstet. Gynecol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"381","DOI":"10.1016\/j.ogc.2015.01.014","article-title":"Placenta accreta spectrum: Accreta, increta, and percreta","volume":"42","author":"Silver","year":"2015","journal-title":"Obstet. Gynecol. Clin. N. Am."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"752","DOI":"10.1002\/uog.20246","article-title":"Prenatal ultrasound staging system for placenta accreta spectrum disorders","volume":"53","author":"Cali","year":"2019","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2382","DOI":"10.1038\/s41379-020-0569-1","article-title":"Classification and reporting guidelines for the pathology diagnosis of placenta accreta spectrum (PAS) disorders: Recommendations from an expert panel","volume":"33","author":"Hecht","year":"2020","journal-title":"Mod. Pathol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1458","DOI":"10.1016\/j.ajog.2004.12.074","article-title":"Abnormal placentation: Twenty-year analysis","volume":"192","author":"Wu","year":"2005","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1529","DOI":"10.1056\/NEJMcp1709324","article-title":"Placenta accreta spectrum","volume":"378","author":"Silver","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"329","DOI":"10.3109\/14767058.2011.576720","article-title":"Approaches to reduce urinary tract injury during management of placenta accreta, increta, and percreta: A systematic review","volume":"25","author":"Tam","year":"2012","journal-title":"J. Matern. Fetal. Neonatal Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1002\/uog.13194","article-title":"Prenatal identification of invasive placentation using ultrasound: Systematic review and meta-analysis","volume":"42","author":"Iacovella","year":"2013","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"10692","DOI":"10.1080\/14767058.2022.2157716","article-title":"Impact of placenta accreta spectrum (PAS) pathology on neonatal respiratory outcomes in cesarean hysterectomies","volume":"35","author":"Munoz","year":"2022","journal-title":"J. Matern. Fetal. Neonatal Med."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Toussia-Cohen, S., Castel, E., Friedrich, L., Mor, N., Ohayon, A., Levin, G., and Meyer, R. (2024). Neonatal outcomes in pregnancies complicated by placenta accreta- a matched cohort study. Arch. Gynecol. Obstet., 1\u20137.","DOI":"10.1007\/s00404-023-07353-6"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"960","DOI":"10.1055\/s-0040-1701196","article-title":"Accuracy and interobserver reliability of magnetic resonance imaging for placenta accreta spectrum disorders","volume":"38","author":"Einerson","year":"2021","journal-title":"Am. J. Perinatol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1097\/AOG.0b013e3181f3588d","article-title":"Effectiveness of timing strategies for delivery of individuals with placenta previa and accreta","volume":"116","author":"Robinson","year":"2010","journal-title":"Obstet. Gynecol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"101229","DOI":"10.1016\/j.ajogmf.2023.101229","article-title":"Placenta accreta spectrum care infrastructure: An evidence-based review of needed resources supporting placenta accreta spectrum care","volume":"6","author":"Fitzgerald","year":"2024","journal-title":"Am. J. Obstet. Gynecol. MFM"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"241.e1","DOI":"10.1016\/j.ajog.2013.09.044","article-title":"Risk factors for unscheduled delivery in patients with placenta accreta","volume":"210","author":"Bowman","year":"2014","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1080\/14767050802038124","article-title":"Idiopathic bleeding during the second half of pregnancy as a risk factor for adverse perinatal outcome","volume":"21","author":"Harlev","year":"2008","journal-title":"J. Matern. Fetal. Neonatal Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2288224","DOI":"10.1080\/01443615.2023.2288224","article-title":"Vaginal bleeding in pregnancy and adverse clinical outcomes: A systematic review and meta-analysis","volume":"44","author":"Karimi","year":"2024","journal-title":"J. Obstet. Gynaecol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1002\/uog.27465","article-title":"Determinants of emergency cesarean delivery in pregnancies complicated by placenta previa with or without placenta accreta spectrum disorder: Analysis of adopad cohort","volume":"63","author":"Group","year":"2024","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1738","DOI":"10.1055\/a-2126-7337","article-title":"Risk of severe maternal morbidity in patients with placenta accreta spectrum disorders referred from rural communities to a regional placenta accreta spectrum center","volume":"40","author":"Munoz","year":"2023","journal-title":"Am. J. Perinatol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1016\/j.ygyno.2022.06.025","article-title":"Importance of the gynecologic oncologist in management of cesarean hysterectomy for placenta accreta spectrum (pas)","volume":"166","author":"Munoz","year":"2022","journal-title":"Gynecol. Oncol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"61.e1","DOI":"10.1016\/j.ajog.2023.03.028","article-title":"Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum","volume":"229","author":"Munoz","year":"2023","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1016\/j.ajog.2014.11.018","article-title":"Center of excellence for placenta accreta","volume":"212","author":"Silver","year":"2015","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1054","DOI":"10.1055\/s-0041-1732453","article-title":"Youtube as a source of patient information regarding placenta accreta spectrum","volume":"40","author":"Castillo","year":"2023","journal-title":"Am. J. Perinatol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"179.e1","DOI":"10.1016\/j.ajog.2019.08.035","article-title":"Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum","volume":"222","author":"Zuckerwise","year":"2020","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"6644","DOI":"10.1080\/14767058.2021.1918670","article-title":"Prediction of clinical outcomes in women with placenta accreta spectrum using machine learning models: An international multicenter study","volume":"35","author":"Shazly","year":"2022","journal-title":"J. Matern. Neonatal Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1002\/ijgo.13993","article-title":"Placenta accreta risk\u2014Antepartum score in predicting clinical outcomes of placenta accreta spectrum: A multicenter validation study","volume":"158","author":"Shazly","year":"2022","journal-title":"Int. J. Gynecol. Obstet."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1523","DOI":"10.1002\/jum.15530","article-title":"Predicting placenta accreta spectrum: Validation of the placenta accreta index","volume":"40","author":"Happe","year":"2021","journal-title":"J. Ultrasound Med."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Smith, D.D., Adesomo, A.A., Gonzalez-Brown, V.M., Russo, J., Shellhaas, C., Costanstine, M.M., and Frey, H.A. (2024). Sonographic predictors of antepartum bleeding in placenta previa. Am. J. Perinatol.","DOI":"10.1055\/a-2257-3106"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1159\/000064695","article-title":"Anticipation of uterine bleeding in placenta previa based on vaginal sonographic evaluation","volume":"54","author":"Saitoh","year":"2002","journal-title":"Gynecol. Obstet. Investig."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Nieto-Calvache, A.J., Aryananda, R.A., Palacios-Jaraquemada, J.M., Cininta, N., Grace, A., Benavides-Calvache, J.P., Campos, C.I., Messa-Bryon, A., Vallecilla, L., and Sarria, D. (2024). One-step conservative surgery vs. hysterectomy for placenta accreta spectrum. A feasibility randomized controlled trial. Am. J. Obstet. Gynecol. MFM, 101333.","DOI":"10.1016\/j.ajogmf.2024.101333"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1016\/j.ejogrb.2023.12.006","article-title":"Risk factors of massive blood transfusion (mtp) in cesarean hysterectomy for placenta accreta spectrum","volume":"293","author":"Munoz","year":"2024","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/4\/677\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T14:32:08Z","timestamp":1760106728000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/4\/677"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,22]]},"references-count":32,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2024,4]]}},"alternative-id":["medicina60040677"],"URL":"https:\/\/doi.org\/10.3390\/medicina60040677","relation":{},"ISSN":["1648-9144"],"issn-type":[{"type":"electronic","value":"1648-9144"}],"subject":[],"published":{"date-parts":[[2024,4,22]]}}}