Incidence and Clinical Implications of Placenta Accreta Spectrum (PAS) after Hysteroscopic Treatment for Asherman's Syndrome

Abstract

<h3>Study Objective</h3> To investigate the incidence of placenta accreta spectrum (PAS), predictors for malplacentation and clinical implications in pregnancies after hysteroscopic treatment for Asherman syndrome. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Minimally invasive gynecologic surgery practice in a community teaching hospital. <h3>Patients or Participants</h3> 355 patients hysteroscopically treated for Asherman's Syndrome 01/01/2015 - 03/01/2019 <h3>Interventions</h3> Observational study, retrospectively followed patients after hysteroscopic treatment for Asherman's Syndrome <h3>Measurements and Main Results</h3> Through telephone survey and confirmatory chart review, we identified 97 patients who achieved pregnancy passed the first trimester, following hysteroscopic treatment for Asherman's Syndrome. Among these patients, 23 (23.71%) patients had PAS. History of cesarean section was the only variable statistically significantly associated with having PAS (adjusted OR 4.03, 95% CI 1.31-12.39). PAS was diagnosed antenatally in three patients (13.04%), with patients having placenta previa more likely to be diagnosed (P<0.01). Nine patients (39.13%) with PAS required cesarean hysterectomy, which is 9.28% of those whose pregnancy progressed past first trimester. Factors associated with higher risk for cesarean hysterectomy were etiology of Asherman's syndrome (dilation and evacuation after the second trimester pregnancy or postpartum instrumentation, p<0.01), invasive placenta (increta or percreta, p<0.05) and history of morbidly adherent placenta in previous pregnancies (p<0.05). Two patients (8.70%) had uterine rupture, and another two (8.70%) experienced uterine inversion. For 76.19% patients with PAS, there was antenatal documentation on counseling on Asherman's Syndrome as a risk factor for PAS, however only 11 (47.82%) had documented counseling about the possible risk for having a cesarean hysterectomy. <h3>Conclusion</h3> High incidence of PAS and associated morbidity in pregnancies following hysteroscopic treatment for Asherman's Syndrome, together with the low rate of antenatal diagnosis, stresses the importance of clinical awareness, counseling and delivery planning. Clinicians who treat Asherman's Syndrome, including gynecologic surgeons and reproductive endocrinologists, should properly counsel and empower women to be their own advocates.