As cesarean delivery rates continue to rise worldwide, the long-term obstetric and gynecological complications associated with cesarean scar defects are becoming increasingly prevalent. These include cesarean scar ectopic pregnancies, placenta previa accreta, secondary subfertility, chronic pelvic pain, and intermenstrual bleeding. The objective of this review is to evaluate how the optimization of the hysterotomy location in relation to myometrial thickness and uterine vascularity, together with an appropriate uterine closure technique, could reduce the long-term impact of cesarean scar defects. A wide range of closure techniques has been described, with substantial heterogeneity in study design, outcome measures, and follow-up intervals, limiting definitive conclusions. Emerging evidence suggests that unlocked, interrupted, purse-string, and endometrium-free sutures, along with the use of monofilament or barbed sutures, may reduce cesarean scar formation and thus the risks of scar placentation in subsequent pregnancies. These approaches may promote better healing by reducing tissue compression and ischemia, unlike continuous, locked, endometrium-inclusive sutures, which may impair perfusion. Increasing attention to endometrium-free closure and precise anatomical realignment highlights the importance of meticulous surgical technique in contemporary obstetrics. Surgical repair of cesarean scar defects improves outcomes in patients with chronic gynecological symptoms and subfertility. However, evidence supporting its role in preventing obstetric complications in subsequent pregnancies remains limited, in part because such complications are rare. Moreover, cesarean scar defect repair requires removing the scar tissue and reconstruction using healthy myometrium, which may theoretically increase the risk of dehiscence or uterine rupture in subsequent pregnancies. A key knowledge gap in much of the existing literature is its focus on imaging-defined cesarean scar defects rather than on patient-centered long-term gynecological symptoms. Well-designed, multiarm studies that incorporate standardized postpartum imaging to characterize uterine remodeling over time are essential for identifying best practices. While resource-intensive, advancing this field could improve long-term patient outcomes and reduce healthcare costs.

Placenta accreta spectrum (PAS) is an increasingly common obstetric complication, characterised by the abnormal attachment of placental villous tissue to the uterine wall. Medline, Embase, Scopus, and Google Scholar were searched to identify observational studies that provided data on IVF pregnancies and PAS at birth between September 1980 and April 2025. The methodological quality of studies was assessed using the Newcastle–Ottawa Scale. Data were combined using a random-effects, generic inverse-variance approach, which allows the inclusion of diverse relative risk estimates in a single meta-analysis. The primary measures were the incidence of nulliparity, placenta previa, previous cesarean deliveries, and the type of IVF techniques used. The risk of both PAS and placenta previa was significantly increased in IVF compared to spontaneous conception (SC) pregnancies (p = 0.002 and p = 0.005, respectively), and the risk of PAS was significantly (p = 0.002) increased in patients undergoing frozen embryo transfer (FET) compared to those undergoing fresh embryo transfer. A significantly (p = 0.001) higher number of patients with IVF pregnancies were nulliparous compared to SC pregnancies. Due to the heterogeneity and poor quality of the included studies, the evidence that IVF is an independent factor in the development of PAS during pregnancy remains scant and limited. Any association between IVF and PAS is likely indirect, mediated through higher rates of placenta previa and prior uterine surgery, rather than a direct biological effect of IVF itself.

Background Most cesarean scar ectopic pregnancies fail during the first 2 months of pregnancy, but ongoing cesarean scar ectopic pregnancies are the precursors of placenta accreta spectrum. Objective The aim of this study was to evaluate placentation inside a cesarean scar defect of the lower uterine segment and its relation to development of placenta accreta spectrum. Study design We reviewed the ultrasound and histopathologic findings of 94 patients diagnosed with a first-trimester cesarean scar ectopic pregnancy including 92 managed by transcervical suction curettage and 2 managed by hysterectomy after failed conservative surgery and of 10 patients with ultrasound signs suggestive of accreta placentation during the second (n=2) and third trimester of pregnancy (n=8), managed by cesarean hysterectomy. The ultrasound features of both groups were compared with general histopathological examination. Cytokeratin 7 immunostaining was used to evaluate the migration pattern of extravillous trophoblast in 13 cases of live cesarean scar ectopic pregnancies after surgical evacuation and samples from 9 hysterectomy specimens with placental tissue in situ. Results In the cesarean scar ectopic pregnancy group there were 61/92 (65%) with a live pregnancy and 33 (35%) with a failed pregnancy and 2 with prolonged retention of placental tissue that required an emergency secondary hysterectomy due to uncontrollable hemorrhage after transcervical suction curettage. All cesarean scar ectopic pregnancies presented with marked dilatation of the vascular network around the gestational sac and 32 (34%) cases were reported as presenting with abnormally increased vascularity. Anchoring villi directly attached to the decidua were found in only 7 (11.5%) live pregnancies and not in failed pregnancy. Histopathological examination in failed cesarean scar ectopic pregnancies showed signs of villous retention and degeneration including fibrotic and edematous villi and diffuse perivillous fibrin deposition following embryonic demise but no signs of aneuploidy or trophoblastic hyperplasia. Extravillous trophoblast cells arranged in deep confluent sheets or scattered deep inside the decidua below the anchoring villi were observed in 4 cases of live cesarean scar ectopic pregnancies and deep inside the scar area in 2 samples from the hysterectomy specimens. In second trimester placenta accreta spectrum, there was increased subplacental vascularity and intraplacental lacunae in both cases. Extended remodeling of the lower uterine segment and anomalies of the utero- and intraplacental circulation were found on preoperative ultrasound examination in all third-trimester placenta accreta spectrum cases. All samples (n=35) from the accreta area in cesarean hysterectomy specimens showed histological evidence of myometrial thinning, disarray of myofibers and tissue edema. In 28 of these samples, thick fibrinoid depositions between the scar and the villous tissue were found. Immunostaining of accreta areas showed extravillous trophoblast cells deep below the placental basal plate. They reached but did not breach the uterine serosa in any case. Conclusion Accreta placentation is a progressive phenomenon where villi become abnormally attached inside the myometrial scar, requiring surgical removal. While the adherent villi give rise to large numbers of migratory extravillous trophoblast, the placenta does not spontaneously breach the outer layer of the scar even when it bulges outside the normal uterine boundary.

Placenta accreta spectrum (PAS) has emerged as a pressing global health concern as cesarean delivery rates continue to rise. Once regarded primarily as a placental disorder, PAS is now understood as an abnormal implantation process occurring within uterine scars. Although cesarean hysterectomy remains the predominant management strategy, growing evidence suggests that individualized, uterine-sparing approaches may reduce morbidity and better align with patient preferences. Traditional histopathologic classifications neither correlate with prenatal imaging findings nor reflect surgical complexity, thereby limiting their clinical utility. The PAS topographic classification, developed from intraoperative observations, offers a practical framework for surgical staging and guides patient-specific management strategies. Standardized prenatal ultrasound can anticipate surgical challenges and facilitate preoperative counseling. Despite this, few hospitals currently use this classification. This study qualitatively evaluated the impact of collaborative virtual educational activities designed to disseminate the concepts underlying the topographic classification on the surgical practice of PAS teams. Over a six-month period in 2024, interactive weekly webinars were conducted to discuss the evolving concepts in PAS that justify a shift toward precision medicine. Six months after the webinars concluded, a structured survey documented participants’ perceptions of the impact of these sessions on the management of their PAS patients. A total of 112 invitations to participate in the survey were sent, and 91 responses were received (response rate: 81.2

Placenta accreta spectrum (PAS) is an obstetrical complication in which the placenta abnormally invades the uterine wall, increasing the risk of hemorrhage, surgical morbidity, and maternal mortality. Management is often complex and multidisciplinary, particularly when invasion extends beyond the uterus. For this reason, standardized guidelines are essential to support early diagnosis and coordinated care across specialties. Significant variations in clinical practice guidelines (CPGs) remain, especially between countries with differing levels of income. This systematic review evaluates national and international CPGs published within the last decade to identify areas of agreement, disagreement, and insufficient evidence across all stages of PAS care. To identify CPGs related to PAS, a comprehensive search of professional society websites, PubMed, the GIN Library, and the ECRI Guidelines Trust was conducted. Two independent reviewers evaluated the sources to extract relevant clinical recommendations, which were then sent to a panel of 15 to 18 experts who had authored their own PAS guidelines. During 2 rounds of structured feedback, the panel could comment on, clarify, or revise their own guidelines before the committee would evaluate them for consensus and sufficiency of evidence. Each guideline was categorized as demonstrating high agreement, poor consensus, or high levels of insufficient evidence. The data were visualized by quantifying the level of agreement and sorting each guideline into categories of epidemiology, diagnosis, antenatal management, surgical management, and postnatal care. A total of 18 articles from 14 national or international societies were included. There was high agreement on epidemiologic risk factors, diagnostic principles, and key elements of antenatal management. A history of cesarean delivery consistently emerged as a major risk factor, especially in patients with concurrent placenta previa. All guidelines supported ultrasound as the primary diagnostic tool, with most recommending standardized descriptors to enhance accuracy. Targeted second-trimester imaging was widely endorsed, with some guidelines supporting first-trimester screening for high-risk patients. There was also strong consensus surrounding antenatal management and the need for specialized care, emphasizing referral to tertiary centers with multidisciplinary expertise, adequate surgical and transfusion resources, and planned delivery around 34 to 35 weeks. In contrast, surgical and peripartum recommendations showed substantial variability and limited evidence, including uncertainty regarding optimal incision type, use of balloon occlusion catheters, anesthesia approaches, and conservative management strategies. Only 1 guideline offered specific recommendations for low- and middle-income countries. These findings indicate that while some aspects of PAS management, such as diagnosis and antenatal care, have a broad consensus, other areas remain under-investigated and lacking consensus. This is especially true for surgical and conservative management in the peripartum period and indicates a need for comparative research and international collaboration to develop standardization. In addition, PAS management in low- and middle-income countries, which often face resource limitations that require flexible and unique practices, is significantly limited. While further research and discussion are needed, this study provides a roadmap for global improvement in PAS management.

Placenta accreta spectrum (PAS) is a life-threatening obstetric condition associated with increasing cesarean delivery rates worldwide. Existing classifications, such as the World Health Organization International Statistical Classification of Diseases and Health-Related Problems and the International Federation of Gynecology and Obstetrics system, describe depth of invasion and histopathological features but do not adequately predict surgical outcomes or guide individualized management. The PAS topographic classification describes the anatomical extent of uterine wall remodeling and the presence of uterovesical adhesions, allowing surgical teams to anticipate intraoperative complexity, organ involvement, and appropriate therapeutic strategies. Although successfully applied in selected centers, its broader evaluation across diverse healthcare settings is lacking. We designed a prospective, multicenter, international cohort study enrolling patients with a high prenatal suspicion of PAS. Eligible patients are aged ≥ 18 years, undergoing surgery after 20 weeks’ gestation, and managed by multidisciplinary PAS teams familiar with the topographic classification. Standardized prenatal ultrasound staging and intraoperative surgical staging are required, with photographic and video documentation. Surgical strategies include one-step conservative surgery, total hysterectomy, and modified subtotal hysterectomy, guided by intraoperative classification. The primary outcome is intraoperative blood loss, measured using a standardized protocol. Secondary outcomes include intraoperative complications, operative time, treatment type, and usability assessments of the classification through structured surveys. Data are collected in REDCap with external review of imaging records. This study will provide the first prospective, multicenter evaluation of the PAS topographic classification, assessing its correlation with clinical outcomes and its feasibility across hospitals with varying resources and surgical expertise. Preliminary results indicate successful implementation in both high- and low-volume centers, with promising adoption of prenatal ultrasound staging and surgical protocols. The collaborative, image-based, and open-access methodology aims to strengthen the reliability of PAS research by harmonizing surgical strategies and allowing external supervision. Ultimately, this project will generate robust multicenter data to inform individualized management strategies and support the integration of the topographic classification into routine clinical practice worldwide. ClinicalTrials.gov Identifier: NCT05922397. Registered on 21 May 2023.

Placenta accreta spectrum (PAS) is a serious pregnancy complication caused by abnormal placental attachment to the uterus. In this Perspective, Eric Jauniaux and colleagues discuss emerging evidence that challenges our long-held pathophysiological understanding of PAS, and argue that a critical reassessment of definition, diagnosis, and management is overdue.

The aim of this study was to evaluate the association between postpartum ultrasound assessment of the cesarean scar and obstetric outcomes in subsequent pregnancies. We conducted a retrospective cohort study at a tertiary referral center between 2020 and 2022. Women who underwent postpartum transvaginal ultrasound assessment of the cesarean scar were compared with a historical reference group (2017–2019) with a previous cesarean delivery who did not undergo scar evaluation between pregnancies. Cesarean scar defects (CSD) were defined according to Delphi consensus criteria. Maternal and neonatal outcomes, including placenta accreta spectrum (PAS), uterine rupture, dehiscence and preterm birth, were compared between groups. During the study period, 481 women underwent postpartum ultrasound assessment of the cesarean scar. Of these, 141 women subsequently conceived and delivered at our institution and were included in the study group. These patients were compared with 393 women in a historical reference group. Among the 105 patients with complete ultrasound assessment according to the Delphi criteria, 30 (28.6

Accreta placentation is a clinicopathologic diagnosis at delivery when 1 or more placental lobules are abnormally attached into a myometrial scar or congenital defect requiring surgical removal. Over 90% of cases of placenta accreta spectrum are found in patients with a prior history of cesarean delivery presenting with a low-lying placenta or a placenta previa developing inside a lower uterine segment scar. Placenta previa accreta is a complex obstetric condition, and management strategies and clinical outcomes are directly linked to the quality of epidemiology data. We have recently questioned the concept of overinvasive placentation and placenta percreta, providing evidence that surgical manipulation of a dehiscent lower uterine segment covering a placenta previa is responsible for the extrusion of part of the placental tissue. Similarly, there is no evidence that villous tissue and extravillous trophoblastic cells can cross the entire uterine wall in accreta areas. Placenta accreta spectrum is the consequence of placental development at sites where the normal decidual and myometrial mechanisms limiting the migration of the extravillous trophoblastic cells are missing, rather than being due to inherently abnormally invasive villous tissue. Placenta accreta has also been increasingly reported in patients with no prior uterine surgery or pathology using clinical criteria similar to those used for uterine atonia and simple placental retention. Cases where a cleavage plane can be identified and the placenta fully detached manually at the time of birth or during gross examination of hysterectomy or partial myometrial resection specimens should not be reported as accreta. Traditional reliance on the absence of the decidua basalis with villous tissue simply apposed to the superficial myometrium to confirm the diagnosis of accreta placentation at histopathologic examination is inadequate and possibly misleading. Instead, pathologists should focus on other diagnostic features, such as deep villous attachment within the scar tissue and distortion of the uteroplacental interface with thick fibrinoid deposition on microscopic examination. There is a need to develop a new clinicopathologic classification based on a detailed topographic intraoperative description of the location and size of the accreta area and the changes associated with uterine remodeling postscarification.

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

OBJECTIVE:This study evaluated whether consecutive ejaculate (CE) strategies improve intrauterine insemination (IUI) live birth rates (LBR) in women over 35 with unexplained or male-factor infertility. It also examined the influence of follicle number and sperm count thresholds on outcomes. METHODS:In this retrospective cohort study (2010-2019), 596 IUI cycles were analysed in 263 nulliparous women-230 with CE and 366 with standard IUI. Among them, 98 patients underwent CE IUI and 165 received non-CE IUI. Patients with total motile sperm count (TMSC) <5×106 were often fast-tracked to IVF, but CE was mostly attempted to boost sperm count beforehand. LBRs per cycle and per woman were compared between groups. RESULTS:LBR per cycle was 11.3% (CE) vs. 13.1% (control) (p=0.52); per woman, 26.5% (CE) vs. 29.1% (control) (p=0.65). Mean ages were similar (37.7 vs. 38.0 years; p=0.34). Success improved with TMSC >10×106; 65.4% (CE) and 87.5% (control). Over six cycles, LBR rose from 10.5% to 13.8% (CE) and 12.3% to 16.7% (control). Outcomes improved with two or three follicles, especially in women over 35. CONCLUSIONS:CE IUI yields LBRs comparable to standard IUI and may offer a cost-effective, less invasive alternative to IVF for male-factor infertility in women over 35. The LBRs per woman undergoing IUI were of a similar magnitude to those reported in IVF cycles. Optimising IUI LBR may involve increasing follicle numbers and using a higher TMSC threshold (>10×106). CE IUI supports healthcare sustainability while expanding fertility treatment access.

Placenta accreta spectrum represents one of the most challenging scenarios in complex cesarean delivery, in which abnormal placental adherence coexists with a scarred myometrium. It remains a leading cause of severe obstetric hemorrhage, maternal morbidity, and peripartum hysterectomy. Although prenatal diagnosis has improved substantially, predicting surgical complexity and selecting the most appropriate operative strategy remain challenging. Traditional concepts centered on the depth of placental invasion do not consistently explain the marked variability in surgical findings or identify which patients are suitable candidates for uterine-preserving surgery. Emerging evidence suggests that placenta accreta spectrum is better understood as a disorder of uterine scar remodeling, in which lesion topography, lower uterine segment anatomy, cervical involvement, and pelvic vascular remodeling are major determinants of operative complexity. These advances have shifted the role of prenatal imaging beyond confirming the diagnosis of placenta accreta spectrum toward defining lesion topography and anticipating the anatomic and vascular findings that influence surgical planning. In parallel, surgical staging and individualized operative strategies have expanded the range of treatment options beyond routine peripartum hysterectomy in selected patients. In this clinical opinion, we synthesize current evidence linking advances in placenta accreta spectrum biology, prenatal imaging, vascular anatomy, and surgical management into a unified clinical framework. We discuss how topography-based ultrasound assessment, combined with surgical staging, may facilitate multidisciplinary planning, improve prediction of operative complexity, and support individualized selection between uterine-preserving surgery and peripartum hysterectomy. Although several of these concepts have previously been described independently, integrating them into a single decision-making framework may help clinicians translate emerging evidence into everyday practice while highlighting priorities for future research and standardized training.

Objective Macroscopic hematuria is a rare but potentially serious perinatal complication. This study aimed to evaluate the relationship between maternal gross hematuria, prenatal ultrasound findings, perinatal outcomes, and histopathologic findings at birth. Data Sources Of note, 3 major electronic databases were searched for articles published between inception and July 2024 using combinations of relevant subject heading terms. Study Eligibility Criteria Only observational studies that provided data on prenatal macroscopic hematuria in pregnancies complicated with placenta accreta spectrum at birth were included. Methods Of note, 2 independent reviewers selected studies and extracted data using a predesigned protocol registered on the International Prospective Register of Systematic Reviews (registration number: CRD42024528300). Results Of the 135 articles reviewed, 17 met our inclusion criteria, describing 18 cases complicated by antenatal macroscopic hematuria. Gestational ages at the first episode of gross hematuria and at delivery ranged from 15 to 30 and 15 and 38 weeks, respectively. Moreover, 12 of 17 patients (70.6%) had an obstetrical history of ≥2 previous cesarean deliveries. Data on prenatal imaging was available in 15 cases and described as placenta percreta with invasion of the bladder. All authors reported on the management, describing cesarean hysterectomy as the main management strategy in 17 cases (94.4%). Massive intraoperative hemorrhage and transfusion were reported by all authors who performed a hysterectomy and provided detailed intraoperative description. There were 2 maternal deaths due to hemorrhagic complications. In 11 cases (61.1%), a partial cystectomy was performed during hysterectomy. In addition, of 175 cases from our prospective database, this study included the data of 3 patients (1.7%) with macroscopic hematuria at 33 to 34 weeks of gestation. All patients who underwent ultrasound examination presented with a major placenta previa, abnormalities of the uterine contour, and abnormalities of uteroplacental and intraplacental circulations. The patients’ intraoperative estimated blood loss was >1.5 L requiring a primary hysterectomy for hemostasis, massive transfusion, and postoperative admission to the intensive care unit. Conclusion Patients with prenatal macroscopic hematuria are at high risk of major peripartum hemorrhagic complications and require emergency preterm delivery and hysterectomy. This information should be integrated into the surgical management plan and patient preoperative counseling.

From a procedure of last resort that caused the death of most mothers and babies, the cesarean delivery has become a lifesaving delivery method and the most common major surgical procedure performed worldwide. The first modern cesarean deliveries, based on accurate anatomic knowledge, were performed 250 years ago. The development of new surgical and anesthesia techniques, antibiotics, uterotonics, blood transfusion, and neonatal care over the last 100 years has transformed the perinatal outcomes of cesarean delivery. The epidemiology of cesarean delivery has changed over the last 30 years with most high- and middle-income countries having rates that surpass 30% and some that exceed 50% of all births. The use of cesarean delivery continues to rise amid inequalities in access to the procedure when medically necessary. Short-term cesarean delivery complications, such as postpartum sepsis and hemorrhage, and long-term postoperative complications, such as permanent defect of the lower uterine segment with a high risk for placentation anomalies in subsequent pregnancies, have a disproportionate impact in low-resource environments. In countries with high numbers of multiple cesarean deliveries, there has been an increase in the incidence of complex cesarean deliveries, including placenta previa accreta, that have a direct impact on maternal morbidity and mortality rates and an indirect impact on local healthcare provision and costs. Obstetrical care bundles, which reduce the indiscriminate use of primary cesarean delivery for nonmedical reasons and also improve access to emergency live-saving cesarean delivery in low-resources communities, are essential. This requires the development of novel and creative alternatives for training, support, and continuous improvement. In low-resource settings with shortages of skilled healthcare personnel, programs can only be sustained by a holistic and cost-effective training approach that includes training in basic obstetrical ultrasonography, the management of complicated labor, and neonatal resuscitation. In well-resourced settings, the limited exposure of modern general obstetrician-gynecologists to open surgical procedures risks leaving them unprepared for increasingly complex caesarean sections surgical procedures. Healthcare systems and educational programs that transcend socioeconomic and geographic factors must evolve to meet contemporary and future demands. Strengthening low-resource health systems by providing access to safe cesarean delivery procedures should be an international priority.

OBJECTIVES:To evaluate the prevalence of symptoms of consensus-defined cesarean scar disorder (CSDi) in nonpregnant women presenting with a history of cesarean delivery (CD) and a postpartum uterine niche. METHODS:We included women who underwent postpartum transvaginal ultrasound (TVS) evaluation of the CD scar between 2020 and 2022 at a specialized gynecological ultrasound clinic. Women diagnosed with a niche, using standardized ultrasound criteria, were invited to complete a structured telephone questionnaire assessing CSDi-related symptoms, based on international consensus criteria. A CSDi was diagnosed when at least 1 primary symptom or at least 2 secondary symptoms were present. RESULTS:Among 481 women evaluated, 72 (15.0%) were diagnosed with a uterine niche. Of these, 50 women (69.4%) completed the questionnaire and were included in the final analysis. The prevalence of post-cesarean scar disorder (PCSD) was 88.0% (44/50). Forty-one women (82.0%) met the diagnostic criteria based on at least 1 primary symptom. Pain during menstrual bleeding (42.0%) and secondary unexplained infertility combined with intrauterine fluid (22.0%) were the most frequent primary symptoms. Quality of life (QoL) scores ranged from 1 to 5, with a median score of 4 (mean ± SD, 3.96 ± 1.09). Most women (36/50, 72%) reported high QoL (score 4-5). CONCLUSIONS:We found an increase in the prevalence of self-reported CSDi-associated symptoms in nonpregnant women with a uterine niche after CD. Although their QoL was generally preserved, further evaluation is needed to determine the clinical relevance of CSDi, including its accurate prevalence and the distribution of symptoms by type and number of prior CDs.