Long time interval from surgery to pregnancy is associated with placenta accreta spectrum (PAS) in the post-operative women with intrauterine adhesion (IUA)

doi:10.21203/rs.3.rs-2565706/v1

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Research Article

Long time interval from surgery to pregnancy is associated with placenta accreta spectrum (PAS) in the post-operative women with intrauterine adhesion (IUA)

https://doi.org/10.21203/rs.3.rs-2565706/v1

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Purpose

Placenta accreta spectrum (PAS), including placenta increta, placenta percreta, and placenta accreta, is known as morbidly adherent placenta. It is supposed that defective wound healing of endometrium, existing in the short interval pregnancy, will result in the prevalence of PAS. However, the impact of time interval from hysteroscopic surgery to pregnancy on PAS was unknown in the women with intrauterine adhesion (IUA).

Methods

We conducted a retrospective study in which patients diagnosed with IUA and underwent hysteroscopic adhesion lysis and wishing further fertility simultaneously. Clinical data were obtained from electronic medical records and telephone interviews.

Results

A total of 102 patients with IUA achieved successful pregnancy. 55 (53.9%) women were diagnosed with PAS and 47 (46.1%) without. 8 (7.8%) women with PAS were miscarriage. Both the severity of adhesions (p = 0.000) and in-vitro fertilization (IVF) (p = 0.003) were demonstrated as risk factors for PAS. Patients with PAS were significantly more likely to suffer from oligohydramnion (p = 0.035), preterm labor (p = 0.001), larger volume of postpartum hemorrhage (p = 0.000), lower birth weight of newborns (p = 0.005). The average time from surgery to pregnancy in the PAS group was significantly longer than that in the non-PAS group (p = 0.000). Interval time between 12 and 24 months was closely related to the higher rate of PAS (OR = 6.8, 95%CI 2.7–17.0, p = 0.000). A Kaplan–Meier analysis also confirmed the significant association between time interval and the prevalence of PAS (p = 0.000).

Conclusion

The current study demonstrates the severity of IUA and pregnancy achieved by IVF are worse prognoses for the prevalence of PAS. The pregnancies complicated by PAS often get a higher risk of oligohydramnios, postpartum hemorrhage, preterm labor and lower birth weight. Women diagnosed with IUA should achieve pregnancy as soon as possible if treated by hysteroscopic interference.

time interval

placenta accreta spectrum

intrauterine adhesion

hysteroscopy

Placenta accreta spectrum (PAS) disorder includes placenta accreta, increta, and percreta. The presence of PAS often leads to massive postpartum hemorrhage and is associated with major morbidity and mortality in pregnant women [1, 2]. The etiology of PAS has been recognized to be abnormal decidualization caused by endometrial damage, for which the most common reason is prior histories of gynecologic procedures including surgical abortion and hysteroscopic surgery [3]. Many prospective studies have also confirmed other risk factors, including a prior history of cesarean section (CS), advanced maternal age, pregnancies by in vitro fertilization (IVF), a current placenta previa, multiparity and so on [4, 5].

It is well known that trauma of the basal layer of endometrium is the most important reason for intrauterine adhesion (IUA) [6]. Hysteroscopy has been widely used in the diagnosis and treatment of IUA, which can help gynecologists to accurately evaluate uterine cavity and release adhesions [7]. Therefore, both the trauma of endometrium itself and hysteroscopic interference can lead to the high rate of PAS in the women with IUA. The conclusion has been widely confirmed in previous studies [8–10].

It is supposed that defective wound healing of endometrium, existing in the short interval pregnancy, defined as interpregnancy interval less than 18 months, will result in the prevalence of PAS and predispose PAS patients to greater degrees of placental invasion [11, 12]. The studies remind us whether time to pregnancy after hysteroscopy make a difference to the prevalence of PAS in the IUA patients. Despite some studies described the time to pregnancy after hysteroscopy, they did not pay more attention to its influence on PAS [9, 13]. Only one limited report showed it did not influence the incidence of PAS during postoperative pregnancy [14]. Therefore, we design this study to explore the influence of time interval from surgery to pregnancy on the incidence of PAS in the IUA patients in depth.

Ethics Statement

This trial was approved by the institutional review board of Anhui Maternal and Child Health Hospital Affiliated to Anhui Medical University, Hefei, China on September 1, 2022 (YYLL2022-14-01-1.0). The patients were contacted by telephone to obtain verbal informed consent.

Study Design And Population

We conducted this retrospective study in which patients who were present in Anhui Maternal and Child Health Hospital Affiliated to Anhui Medical University from January 2016 to December 2020. Inclusion criteria included symptomatic women with either amenorrhea or decrease in menstrual volume, age between 20 and 40, who were diagnosed with IUA by hysteroscopy and underwent hysteroscopic adhesion lysis and resumed normal uterine cavity after surgery and wished further fertility simultaneously. Exclusion criteria were the following: pre-existing any other infertility factors, including abnormal semen examination in their partners, any major diseases, including severe liver and renal disfunction, cardiovascular, respiratory disorders, pre-gestational diabetes mellitus, thrombophilia, and other chronic diseases.

The degree and extent of IUA were evaluated by hysteroscopy according to the American Fertility Society (AFS) classification system [15]. A 30^o hysteroscopy with an outer sheath diameter of 5 mm (KARL Storz, Germany) was undertaken in the outpatient operation room without anesthesia. Once the patients were diagnosed with IUA, the surgeon cut the adhesions usually by micro-scissors to restore the normal anatomy of the uterine cavity. The bipolar loop or needle electrode, using a 12^o hysteroscopy with an outer sheath diameter of 8 mm (KARL Storz, Germany), was applied under general anesthesia in the inpatient operating room only when meeting with dense muscular adhesions. Normal saline was used as the uterine distension medium, at a pressure between 80 and 120 mmHg. The procedures were conducted by experienced endoscopic surgeons. Hysteroscopic synechiolysis was under surveillance by ultrasound when it was difficult to enter or distinguish the uterine cavity. Following surgery, the patients received estradiol valerate (Progynova, Bayer, Germany) 4 mg/day for 21 days and dydrogesterone (Duphaston, Abbott, Netherlands) 20 mg/day in the last ten days of each estrogen treatment cycle. Next hormone therapy started from the first day of menstrual cycle. Generally, all the therapies were repeated for 3 months. The patients were requested to have a hysteroscopic reexamination in the first post-operation month.

Parameters including maternal age at surgery, Body Mass Index (BMI), history of gravidity and parity, number of caesarean section (CS) and hysteroscopic surgery and type of IUA were collected from electronic medical records. All the objects in our study had moderate (AFS 5–8) to severe adhesions (AFS 9–12), without mild adhesions (AFS 1–4). Time to pregnancy after operation, mode of pregnancy and obstetric and neonatal data were assessed by telephone interviews. Diseases of PAS, encompassing placenta accreta, increta, and percreta, were all recorded. The primary outcome of this study was the impact of time interval to pregnancy on the prevalence of PAS. Other obstetrical and neonatal outcomes were also presented at the same time.

Statistical analysis

All data were analyzed by SPSS version 26.0. The primary outcome measure was divided into PAS group and non-PAS group. Gravidity was divided into 4 grades and time interval 3 grades. Continuous variables are presented with mean ± standard deviation. Categorical variables are presented with frequencies and percentages. T test was used to compare the difference between continuous variables. Chi-square, Trend Chi-square analysis and Continuous Corrective Chi-square analysis were used to compare the difference between categorical variables, as appropriate. Binary logistic regression was applied to analyze the association between PAS and time interval, as an ordinal variable. Kaplan-Meier curves were developed for the PAS group and non-PAS group using the time intervals from surgery to pregnancy, with a log-rank test conducted to compare the survival distributions for the two groups. P-values were two tailed and p-value of < 0.05 was considered statistically significant. The confidence intervals for odds ratios were from 5–95%.

A total of 210 patients with IUA who were treated by hysteroscopy were identified from January 2016 to December 2020 in this study, with 102/210 (48.6%) post-operative patients achieved successful pregnancy, which was defined as gestational age more than 14 weeks, and meanwhile had adequate information available for data extraction in the follow-up period. Among them, 8/102 (7.8%) women were miscarriage, who all were found with PAS, and 94 (92.2%) women progressed into the third trimester and gave birth to 94 infants luckily in the end. 55/102 (53.9%) women were diagnosed with PAS in the pregnancies (Fig. 1).

Demographic data of patients are presented in Table 1. The PAS group was characterized by more severe adhesions (36.4% vs. 6.4%, p=0.000). It seemed that pregnancies achieved by IVF had a higher risk of PAS (21.8% vs. 2.1%, p=0.003). With respect to the gravidity, the PAS group had more prior pregnancy times, though it did not reach a significant difference. There were no significant differences in age, BMI, parity, number of previous CS and hysteroscopic surgery.

Data of obstetrical and neonatal outcomes are summarized in Table 2. All the late-term miscarriage occurred in the women with PAS. Of interest, patients with PAS were significantly more likely to suffer from oligohydramnion simultaneously (12.8% vs. 0, p=0.035). The total percentages of pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM) and premature rupture of fetal membranes (PROM) were 8.5% (8/94), 7.4% (7/94), 8.5% (8/94) in the IUA patients. However, there were no significant differences in PIH, GDM and PROM between PAS group and non-PAS group. Preterm labor happened more often in the patients with PAS (27.7% vs. 2.1%, p=0.001). Delivery mode and newborn gender were equivalent among groups. Volume of postpartum hemorrhage was larger in the women with PAS (561.3 ± 388.9 vs. 251.7 ± 92.3 ml, p=0.000). The birth weight of newborn babies was lower in the women with PAS than those without (2948.5 ± 526.9 vs. 3218.9 ± 364.5 g, p=0.005).

The average time to pregnancy after hysteroscopic adhesion lysis in the PAS group was significantly longer than that in the non-PAS group (14.2 ± 5.7 vs. 10.3 ± 4.4 months, p=0.000). The interval time was divided into three grades, including ≤ 12 months, ≤ 24 months and > 24 months. As a categorical variable, time interval was also significantly associated with PAS (p=0.000) (Table 3). As an ordered variable with time dependence, logistic regression analysis showed interval time between 12 and 24 months was closely related to the higher rate of PAS (OR=6.8, 95% CI 2.7-17.0, p=0.000). Interval time > 24 months seemed to have a correlation with PAS, but it did not reach a significant difference (OR=3.7, 95%CI 0.3-43.4, p=0.297) (Table 4). A Kaplan–Meier analysis was performed to evaluate the impact of interval time on PAS, showing that the prevalence of PAS was significantly associated with time from surgery to pregnancy in the IUA patients (p=0.000) (Fig. 2).

Our retrospective study, for the first time, present the association between the incidence of PAS and the time to pregnancy after hysteroscopic adhesiolysis in the IUA patients. The probability of conception was 48.6% and the live birth rate was 44.8% (94/210) in this study, which were a little lower than that in the previous study (50.7% [16], 63.7% [9] ). To our surprise, about 53.9% of pregnant women were diagnosed with PAS. Comparing with the rate of PAS in the previous study (10.1%) [16], the prevalence was significantly higher in our study. One important reason for that maybe that all the pregnancies with gestational age more than 14 weeks were enrolled in this study when calculating the odds of PAS, whereas only pregnancies up to trimester 3 were included in other studies [9, 13].

Classification of IUA was often described in some researches, whereas only the relationship between the severity of IUA and the pregnancy and live birth rate was showed [17, 18]. The negative correlation between them was confirmed again in this study, with all the miscarriages occurring in the PAS group, which had a more serious AFS grade. It’s the first time to demonstrate the positive correlation between the severity of IUA and the prevalence of PAS. This study verified again that IVF pregnancy was an independent risk factor for the occurrence of PAS, which was in accordance with prior results [5, 19]. The occurrence of PAS had nothing to do with age, which was similar in previous study [19]. So as BMI did [5]. Previous studies had verified that gravidity and parity were significantly higher in the women with PAS versus those without in the women with previous cesarean section [20]. Prior histories of CS and invasive gynecologic procedures were independently associated with the occurrence of PAS [3, 19]. However, there were no significant differences between groups in our research. The most important reason for that was thought to be the objects of the study, which were the patients with IUA and simultaneous received hysteroscopic procedures. As we know, recurrent miscarriages and intrauterine surgeries were identified as risk factors for adhesion [6, 21]. Therefore, the objects itself in this study had similar histories of pregnancy and invasive gynecologic procedures.

Interestingly, the PAS women seemed to be easier to suffer from oligohydramnios at the same time. The result concurred with a recent study, oligohydramnios correlating well with defective placentation and the inadequate remodeling of the spiral arteries [22]. According to previous researches, the severer the IUA was, the greater risk of preterm labor got [9, 23]. Similarly, the prevalence of preterm labor was significantly higher in the PAS group, leading to lower neonatal birth weight. To summarize, the mechanism of those adverse obstetrical outcomes may stem from marked uterine impairment in the PAS women with higher grade of IUA [9]. Researchers had achieved consensus that maternal morbidity and mortality could occur because of severe and sometimes life-threatening hemorrhage, deriving from PAS [24]. Results in our study agreed with previous standpoint, but luckily, there was no maternal morbidity and mortality. Risk of other obstetrical outcomes, such as PIH, GDM and PROM, were similar in both groups. The same were true of the mode of delivery and the ratio of males and females in newborns.

Another important focus of this study was the influence of time to conception from surgery on the prevalence of PAS in the IUA patients. Numbers of researches either described IUA without mention of time interval [10], or only displayed time interval without detailed analysis of its influence on obstetrical outcomes. The median time to conception was 7 months and time to conception leading to a live birth was 15 months in the IUA patients [25]. Another study showed that mean time to conception was equivalent in mild (11.5 months), moderate (12.8 months) and severe (14.2 months) IUAs [23]. Even so, few study pay more attention to the association between time interval and the risk of PAS. Only a recent report demonstrated the non-correlation between time interval and the presence of placenta accreta (6 months in women with placenta accreta versus 7 months in those without) [14]. However, it was surprised to find that risk of PAS was significantly increased in the second year after hysteroscopic surgery in the IUAs in our study. Short interval pregnancy had been supposed to be a hazard factor for adverse obstetrical outcomes such as preterm delivery, low birth weight [26], and uterine rupture in next pregnancies after CS [27]. Some investigators supported the positive correlation between short interval pregnancy and the incidence of PAS [12]. Those previous findings may be based on the hypothesis that incomplete wound healing without enough time would result in adverse placenta-related diseases [27]. It’s worth noting that defective wound healing also took place in the post-operative IUA patients. On the contrary, the high risk of PAS occurred easily in the second year after surgery, not in the first year. Comparing with the pregnancies achieved in the first year, risk of PAS after the second year was increased 2 times in the post-operative IUA patients, though it did not show a significant difference, which maybe the result of the little sample in this study. The only way to elucidate this phenomenon was that uterus cavity in the postsurgical IUA patients, with a high rate of reformation of adhesions (3.1–27.3%) [28, 29], was fibrous and obliterated gradually as time went on. As Einerson et al. [11] proposed a new commentary on the mechanism of PAS, which was more likely secondary to defective decidua and uterine scar dehiscence creating an access route for chorionic villi to get deep within the uterine wall, but not as a disorder of destructive trophoblast invasion. Then we provide estimates of the association that more and more severe defective decidua and uterine scar, caused by uterine cavity fibrosis over time in the postsurgical IUA patients, lead to the higher presence of PAS ultimately. Thus, the results remind us it’s essential to provide pregnancy guidance for the IUA patients to achieve gestation actively since operation.

There are a number of limitations in the presented study. Firstly, this is a retrospective study, with all the pregnancy and obstetrical outcomes obtained by telephone interviews. A prospective study, especially with the PAS diagnosed by practiced pathologists, is needed and the results will be more convincing. In addition, this study did not analyze the risks and outcomes for different types of PAS. As the previous study reporting different obstetrical outcomes in the percreta group and increta group [30], further study will be needed to elucidate their risk factors and outcomes in different types of PAS.

Results from our study indicate that the severity of IUA and pregnancy achieved by IVF are worse prognoses for the prevalence of PAS. The pregnancies complicated by PAS often get a higher risk of oligohydramnios and postpartum hemorrhage simultaneously, and correlate well with a bigger chance of preterm labor and lower birth weight. Women diagnosed with IUA should achieve pregnancy as soon as possible if treated by hysteroscopic interference. In the end, more attention should be payed on the pre-pregnancy, antenatal and intrapartum surveillance in the IUA patients managed by hysteroscopic surgery. Meanwhile, by the limitations in our study, a population based prospective study is recommended to power our conclusions and detail the risk factors and outcomes according to different types of PAS in the postoperative IUA patients.

AFS, American Fertility Society

BMI, Body Mass Index

CS, cesarean section

GDM, gestational diabetes mellitus

IUA, intrauterine adhesion

IVF, in vitro fertilization

PAS, placenta accreta spectrum

PIH, pregnancy-induced hypertension

PROM, premature rupture of fetal membranes

Acknowledgments

We are grateful for the participation of the patients. We thank the clinical personnel who supported this study.

Author contributions

Lan Xiang: Project development, data collection, manuscript writing.

Duoxiang Sun: Data collection, data analysis.

Yali Zhuang: Manuscript revision.

Funding

This study did not receive any specific funding or financial support.

Competing interests The authors report no financial or commercial conflicts of interest.

Ethics approval This trial was approved by the institutional review board of Anhui Maternal and Child Health Hospital Affiliated to Anhui Medical University, Hefei, China on September 1, 2022 (YYLL2022-14-01-1.0).

Consent to participate The patients were contacted by telephone to obtain verbal informed consent.

Baldwin HJ, Patterson JA, Nippita TA, Torvaldsen S, Ibiebele I, Simpson JM, Ford JB (2017) Maternal and neonatal outcomes following abnormally invasive placenta: a population-based record linkage study. Acta Obstet Gynecol Scand 96:1373–1381. https://doi.org/10.1111/aogs.13201
Oyelese Y, Smulian JC (2006) Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 107:927–941. https://doi.org/10.1097/01.AOG.0000207559.15715.98
Baldwin HJ, Patterson JA, Nippita TA, Torvaldsen S, Ibiebele I, Simpson JM, Ford JB (2018) Antecedents of Abnormally Invasive Placenta in Primiparous Women: Risk Associated With Gynecologic Procedures. Obstet Gynecol 131:227–233. https://doi.org/10.1097/AOG.0000000000002434
Thurn L, Lindqvist PG, Jakobsson M, Colmorn LB, Klungsoyr K, Bjarnadottir RI, Tapper AM, Bordahl PE, Gottvall K, Petersen KB, Krebs L, Gissler M, Langhoff-Roos J, Kallen K (2016) Abnormally invasive placenta-prevalence, risk factors and antenatal suspicion: results from a large population-based pregnancy cohort study in the Nordic countries. BJOG 123:1348–1355. https://doi.org/10.1111/1471-0528.13547
Kyozuka H, Yamaguchi A, Suzuki D, Fujimori K, Hosoya M, Yasumura S, Yokoyama T, Sato A, Hashimoto K, Japan E, Children's Study G (2019) Risk factors for placenta accreta spectrum: findings from the Japan environment and Children's study. BMC Pregnancy Childbirth 19:447. https://doi.org/10.1186/s12884-019-2608-9
Hooker AB, Lemmers M, Thurkow AL, Heymans MW, Opmeer BC, Brolmann HA, Mol BW, Huirne JA (2014) Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome. Hum Reprod Update 20:262–278. https://doi.org/10.1093/humupd/dmt045
Pabuccu R, Atay V, Orhon E, Urman B, Ergun A (1997) Hysteroscopic treatment of intrauterine adhesions is safe and effective in the restoration of normal menstruation and fertility. Fertil Steril 68:1141–1143. https://doi.org/10.1016/s0015-0282(97)00375-0
Sonan Y, Aoki S, Enomoto K, Seki K, Miyagi E (2018) Placenta Accreta following Hysteroscopic Lysis of Adhesions Caused by Asherman's Syndrome: A Case Report and Literature Review. Case Rep Obstet Gynecol 2018:6968382. https://doi.org/10.1155/2018/6968382
Deans R, Vancaillie T, Ledger W, Liu J, Abbott JA (2018) Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome. Hum Reprod 33:1847–1853. https://doi.org/10.1093/humrep/dey237
Zhang LP, Wang M, Shang X, Zhang Q, Yang BJ, Xu Y, Li JH, Feng LM (2020) The incidence of placenta related disease after the hysteroscopic adhesiolysis in patients with intrauterine adhesions. Taiwan J Obstet Gynecol 59:575–579. https://doi.org/10.1016/j.tjog.2020.05.018
Einerson BD, Comstock J, Silver RM, Branch DW, Woodward PJ, Kennedy A (2020) Placenta Accreta Spectrum Disorder: Uterine Dehiscence, Not Placental Invasion. Obstet Gynecol 135:1104–1111. https://doi.org/10.1097/AOG.0000000000003793
Munoz JL, Hernandez B, Ireland KE, Ramsey PS (2021) Short interval pregnancy is associated with pathology severity in placenta accreta spectrum (PAS). J Matern Fetal Neonatal Med 1–6. https://doi.org/10.1080/14767058.2021.2005571
Chen L, Zhang H, Wang Q, Xie F, Gao S, Song Y, Dong J, Feng H, Xie K, Sui L (2017) Reproductive Outcomes in Patients With Intrauterine Adhesions Following Hysteroscopic Adhesiolysis: Experience From the Largest Women's Hospital in China. J Minim Invasive Gynecol 24:299–304. https://doi.org/10.1016/j.jmig.2016.10.018
Zhang Y, Zhu X, Zhang T, Zhang Y, Zhang M, Lin X (2022) Analysis of risk factors for obstetric outcomes after hysteroscopic adhesiolysis for Asherman syndrome: A retrospective cohort study. Int J Gynaecol Obstet 156:89–94. https://doi.org/10.1002/ijgo.13616
() The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 49:944–955. https://doi.org/10.1016/s0015-0282(16)59942-7
Guo EJ, Chung JPW, Poon LCY, Li TC (2019) Reproductive outcomes after surgical treatment of asherman syndrome: A systematic review. Best Pract Res Clin Obstet Gynaecol 59:98–114. https://doi.org/10.1016/j.bpobgyn.2018.12.009
Zhao J, Chen Q, Cai D, Duan Z, Li X, Xue X (2017) Dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions. Arch Gynecol Obstet 295:923–927. https://doi.org/10.1007/s00404-017-4314-z
Hui CY, Lau MS, Ng GY, Tan HH (2018) Clinical and Reproductive Outcomes Following Hysteroscopic Adhesiolysis for Asherman Syndrome in an Asian Population. Ann Acad Med Singap 47:36–39
Imafuku H, Tanimura K, Shi Y, Uchida A, Deguchi M, Terai Y (2021) Clinical factors associated with a placenta accreta spectrum. Placenta 112:180–184. https://doi.org/10.1016/j.placenta.2021.08.001
Martimucci K, Bilinski R, Perez AM, Kuhn T, Al-Khan A, Alvarez-Perez JR (2019) Interpregnancy interval and abnormally invasive placentation. Acta Obstet Gynecol Scand 98:183–187. https://doi.org/10.1111/aogs.13478
Berman JM (2008) Intrauterine adhesions. Semin Reprod Med 26:349–355. https://doi.org/10.1055/s-0028-1082393
Miremberg H, Grinstein E, Herman HG, Marelly C, Barber E, Schreiber L, Bar J, Kovo M, Weiner E (2020) The association between isolated oligohydramnios at term and placental pathology in correlation with pregnancy outcomes. Placenta 90:37–41. https://doi.org/10.1016/j.placenta.2019.12.004
Roy KK, Baruah J, Sharma JB, Kumar S, Kachawa G, Singh N (2010) Reproductive outcome following hysteroscopic adhesiolysis in patients with infertility due to Asherman's syndrome. Arch Gynecol Obstet 281:355–361. https://doi.org/10.1007/s00404-009-1117-x
Society of Gynecologic O, American College of O, Gynecologists, the Society for Maternal-Fetal, Cahill M, Beigi AG, Heine R, Silver RP, Wax RM (2018) JR Placenta Accreta Spectrum. Am J Obstet Gynecol 219:B2-B16. https://doi.org/10.1016/j.ajog.2018.09.042
Hooker AB, de Leeuw RA, Twisk JWR, Brolmann HAM, Huirne JAF (2021) Reproductive performance of women with and without intrauterine adhesions following recurrent dilatation and curettage for miscarriage: long-term follow-up of a randomized controlled trial. Hum Reprod 36:70–81. https://doi.org/10.1093/humrep/deaa289
Ihongbe TO, Wallenborn JT, Rozario S, Masho SW (2018) Short interpregnancy interval and adverse birth outcomes in women of advanced age: a population-based study. Ann Epidemiol 28:605–611. https://doi.org/10.1016/j.annepidem.2018.06.007
Stamilio DM, DeFranco E, Pare E, Odibo AO, Peipert JF, Allsworth JE, Stevens E, Macones GA (2007) Short interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean delivery. Obstet Gynecol 110:1075–1082. https://doi.org/10.1097/01.AOG.0000286759.49895.46
Yu D, Wong YM, Cheong Y, Xia E, Li TC (2008) Asherman syndrome–one century later. Fertil Steril 89:759–779. https://doi.org/10.1016/j.fertnstert.2008.02.096
Hanstede MM, van der Meij E, Goedemans L, Emanuel MH (2015) Results of centralized Asherman surgery, 2003–2013. Fertil Steril 104:1561–1568e1561. https://doi.org/10.1016/j.fertnstert.2015.08.039
Zhang H, Dou R, Yang H, Zhao X, Chen D, Ding Y, Ding H, Cui S, Zhang W, Xin H, Gu W, Hu Y, Ding G, Qi H, Fan L, Ma Y, Lu J, Yang Y, Lin L, Luo X, Zhang X, Fan S (2019) Maternal and neonatal outcomes of placenta increta and percreta from a multicenter study in China. J Matern Fetal Neonatal Med 32:2622–2627. https://doi.org/10.1080/14767058.2018.1442429

Table 1 Demographics of study group
Clinical factors	PAS n=55	Non-PAS n=47	P-value
Age	30.6±4.3	29.6±3.2	0.168 ^d
BMI	22.2±1.5	22.3±1.2	0.501 ^d
Grade of IUA			0.000 ^a
Moderate (AFS 5-8)	35(63.6)	44(93.6)
Severe (AFS 9-12)	20(36.4)	3(6.4)
Gravidity			0.075 ^c
1	14(25.5)	9(19.1)
2	13(23.6)	26(55.3)
3	14(25.5)	8(17.0)
≥4	14(25.5)	4(8.5)
Parity			0.225 ^a
0	31(56.4)	32(68.1)
1	24(43.6)	15(31.9)
Prior CS			0.995 ^a
0	48(87.3)	41(87.2)
1	7(12.7)	6(12.8)
Prior hysteroscopic surgery			1.000 ^b
1	50(90.9)	42(89.4)
2	5(9.1)	5(10.6)
Mode of pregnancy			0.003 ^a
spontaneous pregnancy	43(78.2)	46(97.9)
IVF pregnancy	12(21.8)	1(2.1)

Data are expressed as average ± standard deviation or frequency and percentage.

a Chi-square analysis, b Continuous Corrective Chi-square analysis, c Trend Chi-square analysis, d T test.

Abbreviations: PAS, placenta accreta spectrum, BMI, Body Mass Index; IUA, intrauterine adhesion; AFS, American Fertility Society; CS, cesarean section; IVF, in vitro fertilization.

Table 2 Comparison of obstetrical and neonatal outcomes

Outcomes	PAS n=47	Non-PAS n=47	P-value
PIH	6 (12.8%)	2 (4.3%)	0.267 ^b
GDM	4 (8.5%)	3 (6.4%)	1.000^b
PROM	4 (8.5%)	4 (8.5%)	1.000^b
Oligohydramnion	6 (12.8%)	0 (0)	0.035^b
Preterm labor	13 (27.7%)	1 (2.1%)	0.001^a
Mode of delivery			0.376^a
Natural birth CS	30 (63.8%) 17 (36.2%)	34 (72.3%) 13 (27.7%)
Natural birth CS	30 (63.8%) 17 (36.2%)	34 (72.3%) 13 (27.7%)
Postpartum hemorrhage	561.3±388.9	251.7 ± 92.3	0.000 ^c
Newborn gender			0.527^a
Male Female	17 (36.2%) 30 (63.8%)	20 (42.6%) 27 (57.4%)
Male Female	17 (36.2%) 30 (63.8%)	20 (42.6%) 27 (57.4%)
Newborn birth weight	2948.5 ± 526.9	3218.9 ± 364.5	0.005 ^c

Data are expressed as average ± standard deviation or frequency and percentage.

a Chi-square analysis, b Continuous Corrective Chi-square analysis, c T test.

Abbreviations: PAS, placenta accreta spectrum, PIH, pregnancy-induced hypertension; GDM, gestational diabetes mellitus; PROM, premature rupture of fetal membranes; CS, cesarean section.

Table 3 Time interval from surgery to pregnancy assessment

	PAS n=47	Non-PAS n=47	P-value
Time interval	14.2 ± 5.7	10.3 ± 4.4	0.000 ^a
≤12 months	20（36.4）	37（78.7）	0.000 ^b
≤24 months	33（60.0）	9（19.1）
>24 months	2（3.6）	1（2.1）

Data are expressed as average ± standard deviation or frequency and percentage.

a T test, b Trend Chi-square analysis.

Abbreviations: PAS, placenta accreta spectrum.

Table 4 Logistic regression analysis for time interval

Time interval	OR	95% CI	P-value
≤12 months	1.0
≤24 months	6.8	（2.7-17.0）	0.000
>24 months	3.7	（0.3-43.4）	0.297

Note. Binary logistic regression was applied to analyze the association between placenta accreta spectrum and time interval, as an ordinal variable.

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Long time interval from surgery to pregnancy is associated with placenta accreta spectrum (PAS) in the post-operative women with intrauterine adhesion (IUA)

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