European Journal of Cardiovascular Medicine

Placenta accreta spectrum includes accreta, increta, and percreta, depending on the depth of placental invasion. Placenta accreta spectrum (PAS) is the term used to describe a range of abnormalities in which the placental trophoblast abnormally attaches to or invades the uterine wall, particularly the myometrium. It is often referred to as a “morbidly adherent placenta.” This spectrum is categorized into three forms

Placenta accreta: where the placenta adheres directly to the myometrium without intervening decidua.

Placenta increta : w h e r e t h e trophoblastic tissue invades into the m u s c u l a r  l a y e r  o f  t h e  u t e r u s

The severity of maternal complications in PAS disorders depends mainly on antenatal diagnosis, and on the depth.

(myometrium).

Placenta percreta: the most severe form, where placental tissue penetrates through the uterine wall and may extend into surrounding organs such as the bladder or pelvic structures.

The four independent risk factors for placenta accrete include older maternal age, prior caesarean section, placenta previa diagnosed prior to birth and multiple birth [1]

Ultrasound is the preferred imaging modality for the prenatal diagnosis of PAS and can be diagnosed on ultrasound as early as the first trimester.

MRI may be considered as an adjunct to ultrasound imaging but is not routinely recommended.[2] and extension of trophoblast invasion[3]. A multidisciplinary  approach  has been proven to improve the maternal outcomes [4].

Here is a case series of three patients admitted in Lalla Ded hospital, a tertiary care centre in Srinagar, Kashmir on the same day (9/5/2025) and were taken for elective operation the next day i.e on 10/5/2025. They were operated upon within a span of three hours, each operation lasting for around 45-60 minutes.

CASE 1 (MRD:3748): A 28y female

G5P1L1A3 previous one LSCS, last childbirth 4yrs back, previous all abortions managed medically, with no other co morbidities was admitted at POG 37 weeks with usg documenting placenta posterior wall covering os with multiple placental lakes noted 40*4 mm f/s/o placenta accreta.

Preop investigations were done. Her hb on admission was 12.3 gm %, WBC 12000/cmm, Platelets 146000/cmm. With proper consent and counseling, she was taken for elective operation on 10th May 2025. The operation began at 12:00 pm and lasted till 12:45 pm.

Intraoperatively, abdomen opened by midline incision, lscs as done and baby delivered by breech extraction. Placenta was found low lying with features of accrete. Decision for subtotal caesarean hysterectomy was taken. Patient received one-unit packed rbc intraoperatively. Post operative period was uneventful. Repeat hemoglobin was

10.2 gm% and patient was discharged on POD 4.

CASE 2 (MRD: 3699): A 36y female

G4P3L3 pervious three LSCS, last chid birth 4yrs back with gestational diabetes admitted at POG 37 weeks 6 days with usg documenting placenta anterior wall with lower margin reaching up-to internal os with focal loss of hypo echoic zone at urinary bladder interface however no signs of increta or percreta.

Preoperatively hb as 10.2 gm%, WBC 7000/cmm, Platelets 135000/cmm.Blood sugars were well controlled with HbA1c of 5.4%.

Patient was taken in the theatre at 1:45 pm on 10th May 2025, and the operation lasted 60 minutes.

Abdomen was opened by midline incision; baby delivered through breech via classical incision. Placenta was anterior low-lying covering os with features of Percreta and blood vessels on bladder as engorged and tortuous. Stepwise subtotal caesarean hysterectomy was done. Fe stitches as given on bladder and complete hemostasis achieved. Foleys as kept for 21 days. Intraoperatively, one-unit packed rbcs was transfused. Post operative period was uneventful. Post op Hb as 8.9% and patient as discharged on POD 4 and advised to remove Foleys at the nearest hospital at day 21.

CASE 3 (MRD: 3571): A 29-y female

GP 2 L 2 previous two LSCS last childbirth three years ago with no other comorbidities admitted at POG 36 weeks 6 days with usg documenting placenta anterior wall lower segment covering os with 7mm breech noted in myometrium signs of placenta accreta.

Preop hb as 10.8gm%, WBC 5000/ cmm, Platelets 74000/cmm (MPC 105000/cmm. Patient planned for elective subtotal caesarean hysterectomy on 10/5/2025. Abdomen was opened by midline incision. Baby delivered through breech via classical caesaren. Intraoperatively, placenta was low lying with features of accreta. Stepwise subtotal caesarean hysterectomy was done. The procedure took 70 minutes.

Patient received one-unit packed rbcs intraoperatively. Post op hb was 8.7%. Postop period was uneventful, and patient got discharged POD 4.

Placenta Accreta Spectrum (PAS) is a life-threatening obstetric condition. The most common hypothesis is that an iatrogenic defect of the endometrial myometrial interface leads to failure of normal decidualization at the site of uterine scar leading to abnormal trophoblast invasion. Its incidence has been rising globally, mainly due to increasing rates of caesarean section and uterine surgery [6,7]. In this case series, we describe three patients with PAS who were successfully managed by elective subtotal caesarean hysterectomy within a span of three hours at a tertiary care center in Kashmir.

Antenatal diagnosis:

Antenatal diagnosis is key to improved maternal  and  neonatal  outcomes. Ultrasound is still the first-line imaging modality for PAS, while MRI may be u s e f u l [ 6 , 7 ] . Ti m e l y a n t e n a t a l identification in our series made way for planned surgery with multidisciplinary preparedness, minimizing intraoperative morbidity and mortality.

Risk factors:

Multiple prior caesarean sections, placenta previa, multiparty, advanced maternal age, are proven risk factors in development of PAS.[7] All three of the patients had history of previous caesarean and usg documenting placenta previa.

Importance of shorter operative time:

A reduced intraoperative time directly i n f l u e n c e s p r e o p e r a t i v e a n d postoperative outcomes. Shorter surgeries minimize the duration of blood loss, reduce anesthetic exposure, and l o w e r t h e r i s k o f h y p o t h e r m i a , c o a g u l o p a t h y, a n d m e t a b o l i c derangements [8,9]. This efficiency also reduces transfusion requirements and d e c r e a s e s t h e l i k e l i h o o d o f intraoperative complications such as bladder or ureteric in jury [ 10 ] . Postoperatively, shorter operative intervals are associated with faster recovery, reduced ICU or hospital stay, and fewer wound-related complications. In our patients, this translated to limited transfusion needs (only one unit each) and uneventful recoveries with discharge by day four. These findings are consistent with prior studies and meta-analyses demonstrating that s h o r t e r, w e l l - p l a n n e d s u r g e r i e s significantly improve maternal outcomes [11,12]..

Placenta accreta spectrum is one of the most challenging obstetric emergencies due to its association with massive hemorrhage, surgical morbidity, and maternal mortality. This case series highlights that early antenatal diagnosis, risk stratification, and elective planned surgery in a well-equipped tertiary care setting with shorter operative duration are key to favorable maternal outcomes leading to reduced intraoperative blood l o s s , r e d u c e d c h a n c e s o f I C U admission, and reduced hospital stay.

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