Evaluation of the relationship between the number of cesarean sections and maternal and neonatal mortality and morbidity in patients with placenta

Introduction and aim: The association of placenta accreta spectrum (PAS) disorders, which refers to abnormal adhesion of the placenta to the uterine wall, with cesarean delivery has long been known. PAS disorders which are associated with complications including bleeding, transfusion and multiple organ failure have significant maternal as well as neonatal consequences. Although maternal and neonatal outcomes of placental adhesion disorders have been evaluated in many studies, the effect of the number of previous cesarean sections on maternal and neonatal outcomes in PAS cases has been evaluated in a limited number of studies. The aim of our study was to evaluate maternal and neonatal outcomes according to the number of previous cesarean deliveries in patients with placenta percreta. Material and methods: This study included 150 pregnant women who presented to Harran University Faculty of Medicine, Department of Obstetrics and Gynecology between January 2021 and January 2023 and were diagnosed with placenta percreata on sonographic evaluation. Patients were categorized into three groups according to the number of cesarean sections: 1-2 cesarean sections (Group 1), 3-4 cesarean sections (Group 2), and more than 5 cesarean sections (Group 3). We aimed to compare maternal (preoperative hemoglobin level, length of hospital stay, frequency of cranial transfusion, postoperative complications) and neonatal outcomes (preterm delivery, 1. and 5. min APGAR score, neonatal intensive care unit admission rate) between cesarean section number groups. Results: The mean age of the 150 patients included in the study was 33.3 ± 4.9 years (20-47 years). The mean gestational age was 34.5 ± 2.0 weeks (range 27-39 weeks). Red blood cells and fresh frozen plasma were transfused in 65.3% and 45.3% of the patients, respectively. Complications were observed in 13.3% of patients. The complications were bladder injury (8.0%), postoperative ileus (4.0%) and hematoma (1.3%). Uterine-preservimg surgery was performed in 68% of patients, while 32% were managed with hysterectomy. Maternal death was not observed. The maternal age was similar between the groups. The preterm delivery rate (<34 week) was 16% in group 1, 20% in group 2 and 34% in group 3. The frequency of preterm delivery in group 3 was significantly (p=0.038) higher than in group 1. Moreover, correlation analyses showed that the number of cesarean deliveries and gestational week were negatively correlated (p=0.014). The hysterectomy rate was 10% in group 1, 28% in group 2 and 58% in group 3 (p<0,001). There was no difference between the groups in terms of preoperative hemoglobin level, hospital stay and transfusion frequency. However, group 3 had a higher complication rate than group 1 (p=0.021). Neonatal outcomes (APGAR scores and admission to neonatal intensive care unit) were similar between the groups. Patients who underwent hysterectomy had a longer hospital stay (p=0.006) and higher rates of complications (p=0.018) and neonatal intensive care admission (p=0.042) compared to those who underwent conservative surgery. Conclusion: Increased number of cesarean sections in cases of placenta percreata may be associated with hysterectomy, preterm delivery, maternal and neonatal morbidity. Preventing unnecessary cesarean deliveries may prevent the incidence of PAS, as well as improve maternal and neonatal outcomes in cases of PAS. Key words: Placenta percreta, Number of cesarean sections, Maternal outcomes, Neonatal outcomes