Peripartum hysterectomy in Taiwan: Trends, organizational accreditation, and volume effects.

Impact of frozen embryo transfer on placenta accreta and institutional variations.

Introduction: Peripartum/postpartum hysterectomy is a rare but life-saving intervention for uncontrolled obstetric hemorrhage.Placenta accreta spectrum (PAS) and uterine atony are the most common indications; yet their clinical context and operative pathways may differ, particularly in centers where PAS is managed under urgent or emergent conditions.We evaluated indications, surgical management, and outcomes over a 10-year period and explored differences between uterine atony-related and PAS-related cases. Material and Methods:This retrospective, single-center study included women who underwent peripartum or postpartum hysterectomy for uncontrolled obstetric hemorrhage between January 2015 and June 2025.Cases were classified as uterine atony or PAS/placenta previa-related hemorrhage based on operative findings, clinical course, and pathology.Continuous variables were summarized as median [interquartile range (IQR)] and compared using the Mann-Whitney U test; categorical variables were compared using Fisher's exact test.Effect estimates with 95% confidence intervals (bootstrap for continuous variables) are provided in the tables; comparisons were exploratory.Results: Among 31,571 deliveries, 34 hemorrhage-related peripartum/postpartum hysterectomies were identified (incidence: 1.1 per 1,000 deliveries): 18 for uterine atony (52.9%) and 16 for PAS-related

Abstract Background Placenta accreta spectrum (PAS) is a leading cause of obstetric morbidity and peripartum hysterectomy. Rising cesarean delivery rates, advanced maternal age, and assisted reproductive technologies have increased its incidence. Early, standardized diagnosis is essential for multidisciplinary planning and improved outcomes, yet formal screening guidelines are lacking. Objective To raise awareness of the importance of antenatal screening for PAS, summarize key clinical and imaging risk factors, and propose a standardized mid‐trimester ultrasound protocol for high‐risk patients. Methods An expert panel convened under the Pan‐American Society for the Placenta Accreta Spectrum (PAS2) reviewed available evidence, risk stratification models, and prior consensus statements to develop practical recommendations for PAS screening. Results PAS risk rises with the number of prior cesarean deliveries, especially in the setting of concurrent placenta previa or anterior low‐lying placenta. Combined transabdominal and transvaginal ultrasound using grayscale and low‐flow color Doppler (<10 cm/s) best identifies characteristic markers such as loss of the clear zone, myometrial thinning, bladder‐wall interruption, placental bulge, uterovesical hypervascularity, lacunae, and bridging vessels. Standardized imaging protocols and structured reporting improve detection and facilitate referral to specialized centers. Conclusions All patients with placenta previa or low‐lying placenta and prior cesarean delivery should undergo targeted PAS screening at the time of anatomic survey. Early, systematic assessment and referral improve safety and outcomes.

Classical ultrasound signs of placenta accreta spectrum (PAS) at birth, including anomalies of the lower uterine segment (LUS) and uteroplacental and intraplacental circulations, are now well established. The purpose of this study was to evaluate the use of "intracervical lakes" and "the rail sign," which are more recently described signs. We conducted a retrospective analysis of ultrasound imaging data and primary surgical outcomes of consecutive singleton pregnancies in patients with a history of at least one prior CD presenting with an anterior low-lying or placenta previa at 32-36 weeks. Ultrasound findings were recorded using a standardized protocol. The diagnosis of PAS was confirmed when one or more placental lobules could not be digitally separated from the uterine wall at delivery or during the gross examination of hysterectomy or partial myometrial resection (PMR) specimens, and confirmed by histopathology. All analyses were performed using a logistic regression. Of the 227 patients in the cohort, 50 (22%) presented with intracervical lakes on transvaginal scan (TVS) and 97 (47.7%) with a rail sign on transabdominal sonography (TAS). A peripartum hysterectomy (PH) was performed in 116 cases (51%), and 97 patients were managed conservatively: 41 (18%) with PMR and LUS reconstruction, and 70 (31%) with a complex CD, with no intraoperative evidence of PAS. Placental lacunae were the strongest predictors of both PAS and PH, with a high lacunae score (3+) associated with odds ratios (ORs) of 320 (95% confidence interval (CI) 243,4231) for PAS and 9.00 (95% CI 3.01,26.9) for PH, respectively. Associations with PAS were also found for placental bulge (OR 8.24; 95% CI 2.54,26.8) and the rail sign (OR 3.01; 95% CI 1.04,8.67). Increased odds of PH were found for myometrial thinning of < 1mm (OR 5.47; 95% CI 1.69,17.7) and the presence of intracervical lakes (OR 12.3; 95%CI 3.89,39.1). The presence of a rail sign was associated with an increased odds of PAS at birth, whereas the presence of intracervical lakes was associated with an increased odds of peripartum hysterectomy in patients with a history of CD who presented with a placenta previa. This study was prospectively registered. Ethical approval was obtained before the start of this study (Scientific and Research Ethical Committee approval at the University of Cairo, RSEC 021001). The study was conducted in accordance with the Declaration of Helsinki.

Background: Emergency peripartum hysterectomy (EPH) is a life-saving procedure performed to control intractable obstetric hemorrhage. The incidence and indications have evolved over time, necessitating contemporary analysis. Objective: To analyze the incidence, risk factors, indications, and fetomaternal outcomes of peripartum hysterectomy at a tertiary care hospital in South India. Methods: A prospective observational study was conducted at Government Raja Mirasudhar Hospital, Thanjavur for a period of 12 months. All cases of peripartum hysterectomy were analyzed for demographic characteristics, indications, risk factors, surgical details, and maternal and neonatal outcomes. Results: Among 18,527 deliveries, 46 peripartum hysterectomies were performed, yielding an incidence of 2.5 per 1,000 deliveries (0.2%). The incidence was higher following cesarean section (4.8/1000) compared to vaginal delivery (0.7/1000). The majority of women (71.7%) were aged 25-34 years, and 89.1% were multiparous. Abnormally invasive placenta was the leading indication (60.9%), followed by intractable atonic postpartum hemorrhage (32.6%). Major risk factors included multiparity (89.1%), previous cesarean sections (82.9%), and placenta previa (60.9%). Maternal complications included coagulopathy (28.3%), febrile episodes (26.1%), and acute kidney injury (23.9%). Maternal mortality was 4.3%, and perinatal mortality was 12.8%. Conclusion: The incidence of peripartum hysterectomy remains significant, with abnormally invasive placenta being the predominant indication. Previous cesarean sections emerged as a major risk factor, highlighting the importance of judicious use of primary cesarean delivery.

Placenta accreta spectrum (PAS) is a high-risk obstetric condition associated with hemorrhage, urologic injury, and peripartum hysterectomy. Rising cesarean delivery rates continue to increase its prevalence. Variation in surgical management and limited multidisciplinary involvement may contribute to adverse maternal outcomes. To evaluate whether the implementation of a multidisciplinary team (MDT) protocol for PAS was associated with improved perioperative outcomes. This retrospective cohort study included 417 women diagnosed with PAS from 2011 to 2022 at a tertiary center. In 2019, a structured MDT protocol was adopted, incorporating standardized imaging, preoperative conference, routine bilateral ureteral catheter (UC) placement, and on-site urologic support. Outcomes of MDT-managed patients (n = 108) were compared with pre-MDT patients (n = 309). Multivariable logistic regression and generalized linear models adjusted for maternal age, gravidity, prior cesarean delivery, placenta previa, PAS grade, surgical urgency, gestational age, and year of delivery. After adjustment, MDT care was associated with lower odds of urologic injury (aOR 0.34; 95% CI 0.12-0.82), surgical complications (aOR 0.39; 95% CI 0.18-0.78), transfusion (aOR 0.41; 95% CI 0.14-0.93), and hysterectomy (aOR 0.22; 95% CI 0.05-0.91). Adjusted estimated blood loss decreased by 260mL (95% CI - 480 to - 70), and length of stay was reduced by 0.9days (95% CI - 1.4 to - 0.3). Results remained consistent in sensitivity analyses limited to 2017-2022. Implementation of an MDT protocol was associated with reduced perioperative morbidity, supporting multidisciplinary management as a potentially safer strategy for high-risk PAS surgery.

Placenta accreta spectrum (PAS) refers to a group of obstetric complications characterized by abnormal adherence of the placenta to the uterine wall. Worldwide, the prevalence of PAS is increasing, due to the trend of rising caesarean deliveries. We report here a series of 6 cases of placenta accreta that were initially presented to the hospital with bleeding per vagina, abnormal placental position, or invasion on an ultrasound scan Despite having definitive grounds for an emergency lower segment caesarean section (LSCS), the majority of the patients had peripartum hysterectomy. The findings on the ultrasound were subsequently confirmed during surgery and supported by a histological analysis. Peripartum hysterectomy remains the lifesaving procedure over conservative methods for post-partum hemorrhage (PPH) secondary to abnormal placental invasion.

Background: Placenta Previa (PP) is a significant cause of maternal and fetal morbidity and mortality, especially in patients with scared uterus. This study aimed to compare the maternal and neonatal outcomes of PP with and without coverage of a uterine scar in a tertiary hospital in Chattogram, Bangladesh. Materials and methods: A prospective observational study was conducted from January 2024 to June 2024 in Chittagong Medical College Hospital. Consecutively admitted 38 singleton pregnancies with PP with a history of Cesarean Section (CS) or myomectomy were included and divided into two groups: the PP with coverage of a uterine scar group (PPCS group) and the PP without coverage of a uterine group (Non-PPCS group). Maternal and neonatal outcomes between two groups were compared by statistical methods. Results: There were 38 patients with with PP on scared uterus and were further classified into two groups: PPCS (n=23) and Non-PPCS (n=18). Both the groups were comparable in terms of their baseline sociodemographic and clinical characteristics. Placenta accreta spectrum was (95.7% vs. 20%.0, p&lt;0.001), hemorrgage (91.3% vs. 46.7%, p=0.006), urinary bladder injury (26.7% vs. 0%, p=0.031), peripartum hysterectomy (65.2% vs. 6.7%, p=0.001), ligation of uterine artery (56.5% vs. 93.3%, p=0.014) and use of uterine compression suture (30.4% vs. 66.7%, p=0.028) had a significant difference between PPCS group and Non-PPCS group. Neonatal outcomes in terms of prematurity, low birth weight, low APGAR score, need for NICU admission, and perinatal death were similar between two groups. Conclusion: The PPCS group had poorer maternal outcomes than the Non-PPCS group. To counsel their patients appropriately, healthcare providers should be aware of possible complications of placenta previa lying over the uterine scar. Chatt Maa Shi Hosp Med Coll J; Vol.24 (1); Jan 2025; Page 33-36

Background: Antepartum Hemorrhage (APH) is a terrible obstetric emergency associated with maternal and fetal morbidity and mortality worldwide. Objective of this study was to asses the maternal and fetal outcomes as well as to formulate the preventive measures for reducing maternal and fetal complications in patients with APH. Materials and methods: This prospective observational study was conducted at Chattagram Maa-O-Shishu Hospital Medical College, from January to December 2021, on all admitted pregnant women with APH more than 28 weeks gestation. Detailed history, clinical examination, associated conditions, mode of delivery, fetal conditions and investigations were analyzed. Results : A total of 113 APH Cases were reported amongst 5724 pregnant women with its incidence about 2%. The most common cause of APH was placenta previa 80(70.8%) followed by abruptio placenta 28 (24.8%), unexplained 3 (2.7%) and local 2(1.7%) causes. APH was found commonly in patients 72(64%) with age group between 26-30 years, multigravida 95(84%), pregnancy induced hypertension 36 (PIH 32%) previous history of caesarean section 34(30%) and curettage 22(19.2%). Most of the cases 83 (73.5%) were terminated at 34-36 weeks of gestation. There was 1( 0.9%) maternal mortality. However, pregnancy complications were remarkably higher, most common maternal complications were postpartum hemorrhage 45(40%) and maternal shock 6 (5.1%). The commonest mode of delivery was caesarean section 83(73.5%) and in 1(0.9%) case peripartum hysterectomy was needed. Perinatal complications were prematurity 94 (83.1%), perinatal asphyxia 51(45%), stillbirth 26( 23%) and most common causes of early neonatal death were prematurity and neonatal sepsis. Conclusions: APH is associated with significant maternal and fetal morbidity as well as mortality which could be reduced by regular antenatal care, early detection and early referral to higher centers. Better facilities for caesarean section, availability of blood bank and multidisciplinary approach with a good NICU can improve maternal and fetal outcome of APH patients. The incidence of fetal mortality due to abruptio placenta still remains high. Chatt Maa Shi Hosp Med Coll J; Vol.24 (1); Jan 2025; Page 57-62

Outcome of supracervical compared to total hysterectomy for emergency peripartum hemorrhage: a systematic review and meta-analysis.

Background: Peripartum hysterectomy (PH) is among the most challenging and life-saving obstetric procedures, conducted as a last resort in catastrophic obstetric emergencies, primarily involving severe postpartum hemorrhage and placenta accrete spectrum (PAS). With the increasing rates of cesarean sections, the incidence of PAS related complications and emergency hysterectomy is concurrently rising. It is imperative to assess its burden, indications, and outcomes to enhance obstetric care and inform preventive strategies in resource-constrained settings. Aim: To evaluate the incidence, clinical presentation, indications, risk factors, maternal and neonatal outcomes, and associated factors among women who underwent peripartum hysterectomy at a tertiary care obstetric centre of central India. Materials and Methods: A retrospective observational study was conducted after obtaining approval from the Institutional Ethics Committee and included all women who underwent peripartum hysterectomy at our tertiary care centre between January 2025 and December 2025. Demographic characteristics, obstetric history, indications for hysterectomy,transfusion requirements,intraoperative findings,maternal, and neonatal outcomes were analysed descriptively.

This study aimed to evaluate the influence of antenatal diagnosis and surgical management strategies on maternal and neonatal outcomes in placenta accreta spectrum (PAS) disorders, emphasizing risk factors, timing of delivery, and operative approaches. A retrospective cohort analysis was conducted on 210 women with histopathologically confirmed PAS managed at İnönü University Faculty of Medicine between January 2014 and March 2024. Demographic data, antenatal findings, delivery type, and surgical details were compared between elective and emergency procedures, as well as between uterus-preserving surgery and peripartum hysterectomy. Uterus-preserving surgery refers to conservative techniques that aim to avoid peripartum hysterectomy while controlling hemorrhage. Of the total cohort, 66.7% underwent elective surgery, whereas 33.3% required emergency intervention. Emergency deliveries occurred earlier (mean 32.1 vs. 36.0 weeks, p<0.001) and were associated with higher blood loss (799 vs. 511 mL, p<0.001), increased perinatal mortality (20% vs. 1.4%, p<0.001), and greater neonatal morbidity, mainly respiratory distress syndrome (47% vs. 14%, p<0.001). Hysterectomy was required in 45.2% of patients, primarily with placenta percreta (60% vs. 23.5%, p<0.001). Anterior placental location (89.5%) strongly correlated with complete invasion (77.7%) and bladder involvement (27.7%, p=0.038). Bladder injuries were more common in elective cases, while ureteral injuries occurred more often in emergencies (p=0.024). Preoperative hematocrit independently predicted hysterectomy risk (odds ratio: 1.092, p=0.034). Antenatal diagnosis and well-planned elective management significantly improve maternal and neonatal outcomes in PAS. Individualized surgical planning based on invasion depth and maternal condition remains essential to reduce morbidity and mortality.

Case control study on determinants of emergency peripartum hysterectomy among mothers managed at Hawassa University Comprehensive Specialized Hospital

Background. Placenta accreta spectrum (PAS) encompasses abnormal placental implantation with pathological trophoblastic invasion of the myometrium and, in severe cases, adjacent organs. Rising cesarean delivery rates have increased PAS incidence, making it a major cause of severe obstetric hemorrhage and peripartum hysterectomy. Optimal outcomes depend on accurate prenatal diagnosis and coordinated multidisciplinary management. Aim. To synthesize contemporary evidence and guideline recommendations on PAS diagnosis, classification, and management, focusing on imaging standards, operative strategies, and models of care. Material and Methods. A narrative review was based on a targeted search of PubMed/MEDLINE and professional society resources conducted between January 2018 and November 2025. Priority was given to 8 major guideline documents and 5 systematic reviews/meta-analyses; additional observational studies were included for clinical and organizational context. Results. Guideline documents consistently recommend ultrasound as the first-line test for PAS, with MRI reserved for selected cases requiring additional anatomical detail. Planned cesarean hysterectomy without attempted placental removal remains the standard approach for most invasive PAS. Evidence for conservative management and interventional radiology (IR) adjuncts is inconclusive, and recommendations vary. Centralized care and multidisciplinary team management are repeatedly associated with improved maternal outcomes. Conclusions. PAS requires standardized diagnostic pathways and coordinated MDT care in specialized centers. Core recommendations align on early prenatal diagnosis (ultrasound with selective MRI) and planned cesarean hysterectomy for most invasive disease. Uncertainty persists for conservative strategies and IR adjuncts; ongoing prospective studies may inform future guideline updates and refine operative pathways, improving maternal safety and outcomes.

Objective: To evaluate the efficacy of a protocolized mobile tele-Cognitive Behavioral Therapy (Tele-CBT) intervention in reducing symptoms of tokophobia (pathological fear of childbirth) among pregnant women with a history of severe adverse obstetric outcomes. Design: A two-arm, parallel-group Randomized Controlled Trial (RCT). Setting: Department of Obstetrics &amp; Gynaecology, Fatima Memorial Hospital, Lahore, Pakistan. Population or Sample: Pregnant women with a confirmed history of a severe adverse obstetric outcome (e.g., postpartum hemorrhage, peripartum hysterectomy) and a Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) score indicating severe tokophobia. Methods: Eligible participants were randomized to either the intervention group, which received access to a 6-week structured Tele-CBT mobile application alongside standard antenatal care, or the control group, which received standard antenatal care only. The Tele-CBT protocol included modules on psychoeducation, cognitive restructuring, and exposure exercises. Main Outcome Measures: The primary outcome was the change in tokophobia symptoms, measured by the W-DEQ score, from baseline to 36 weeks of gestation. Secondary outcomes included the rate of elective Cesarean Section (CS) and patient-reported birth satisfaction. Results: It is hypothesized that the Analysis of Covariance (ANCOVA), controlling for baseline scores, will show a statistically significant and clinically meaningful reduction in W-DEQ scores in the intervention group compared to the control group (p &lt; 0.01). A significantly lower rate of patient-requested elective CS and higher birth satisfaction scores are also anticipated in the Tele-CBT group. Conclusions: A structured mobile Tele-CBT intervention is a potentially highly effective and scalable treatment for tokophobia in women with prior obstetric trauma, leading to improved psychological readiness for childbirth and more autonomous delivery decisions.

Perioperative outcomes with maternal fetal medicine specialist as primary surgeon for placenta accreta spectrum hysterectomies.

Management of immediate and delayed postpartum hemorrhage with cesarean delivery.

Background Emergency peripartum hysterectomy (EPH) is a life‐saving procedure which involves the surgical removal of uterus and is usually performed for uncontrollable maternal hemorrhage when all other conservative management has failed. The aim of this study was to determine the incidence, indication, risk factors, and perinatal/maternal outcome related to EPH performed in Mendefera Regional Referral Hospital (MRRH). Methods This was a retrospective case–control study that was carried out in women, who underwent EPH over a period of almost 8 years. Controls were women, who had spontaneous vaginal delivery or were delivered by cesarean section (CS), without EPH. The findings were analyzed using Stata 14. Results During the study period, there were a total of 15,527 deliveries and 31 cases of emergency peripartum hysterectomies, giving an incidence of 2 per 1000 deliveries. The mean age, parity, and hospital stay of the cases was 31.5, 4.0, and 5.5, respectively. The main indications for the procedure were uterine atony (38.7%) and uterine rupture (25.8%). Factors showing a significant association with EPH were: being 40+ years of age (OR 10.6; 95% CI 1.5–76.1), being grand multiparous (OR 8.0; 95% CI 2.1–30.4), and CS on the index pregnancy (OR 16.6; 95% CI 7.80–35.95). Subtotal hysterectomy was performed in majority (74%) of cases. The case fatality rate and intrapartum stillbirth rate was 13% and 34.4%, respectively. Conclusion The incidence of EPH in our institution is high and fetal outcome was suboptimal. The commonest indication for EPH was severe hemorrhages most notably caused by uterine atony or uterine rupture, which are largely preventable.

Emergency Peripartum Hysterectomy (EPH) remains a life-saving intervention for obstetric haemorrhage when bleeding is unresponsive to conservative measures. This case series highlights the clinical profiles and outcomes of four women who underwent EPH at a tertiary care center in India over the course of one year. The cases involved risk factors such as Placenta Accreta Spectrum (PAS), uterine rupture, and prior cesarean sections. The findings emphasise the importance of early recognition of highrisk conditions and prompt escalation to surgical management. This series offers valuable insights into the complexities of managing obstetric haemorrhage and reinforces the essential role of a coordinated team approach in improving maternal outcomes.