Preeclamptic serum and soluble fms-like tyrosine kinase-1 suppress endothelial inward rectifier potassium currents.

INTRODUCTION: Inward rectifier K+ (Kir) channel, a major factor determining endothelial membrane potential, regulates Ca2+ influx and vasodilator release, which is impaired in preeclamptic blood vessels. Previously, human umbilical vein endothelial cell (HUVEC) Kir currents were shown to decrease after incubating in preeclamptic plasma. We aimed to demonstrate whether sFlt-1, which is high in preeclamptic blood, could inhibit Kir channel function and expression. METHODS: HUVECs were cultured in regular medium, regular medium with added sFlt-1, or serum from preeclampsia patients or normal pregnant women (Control, sFlt-1, PE, or NP, respectively). Using whole-cell patch clamp technique, we identified Kir currents with the Kir blocker 2 mM BaCl2 and compared the currents among groups. The expression of Kir 2.1 and 2.2 channels were determined using immunofluorescent staining. RESULTS: sFlt-1 and PE groups exhibited similar Kir currents, while NP group possessed significantly larger currents, similar to Control group currents. Moreover, sFlt-1 and sFlt-1/PlGF ratio showed strong negative correlation with Kir currents (r = -0.71 and -0.70, respectively; P < 0.05). There were no significant differences in mean fluorescence intensity representing Kir 2.1 and 2.2 channels expression in all four groups. DISCUSSION: This is the first report to demonstrate sFlt-1 inhibition against Kir currents, which could lead to maternal endothelial dysfunction and hypertension seen in preeclampsia. However, channel expression was unaffected by sFlt-1 incubation, suggesting dysfunctions of channel or other processes (e.g., membrane translocation). The present data could pave the way for novel therapies targeting sFlt-1 or Kir to alleviate hypertension in preeclampsia.

A conditional standard for the customized fetal growth trajectory in twin pregnancy.

BACKGROUND: The difference in the birth weights between twins and singletons grows with advancing gestation. Although many fetal weight standards based on ultrasonographic measurements have been created for tracking fetal growth in twin pregnancies, their applicability to other groups is limited by the fact that they are population specific. OBJECTIVE: This study aimed to generate conditional centiles for growth assessment of twin fetuses and to compare them with other population-based growth standards for singleton and twin fetuses. STUDY DESIGN: This was a retrospective, longitudinal study of ultrasound-based estimated fetal weight data of normal twin fetuses delivered after 34 weeks of gestation. Linear mixed effects models that adjusted for maternal characteristics, fetal gender, and chorionicity were used to evaluate the relationship between estimated fetal weight and gestational age. The estimated fetal weight reference values were calculated using conditional centile based on the estimated fetal weight at an earlier gestational age. To compare our results with previous studies, fetal growth curves were generated using a formula we created that included maternal characteristics and the estimated fetal weight at 24 weeks of gestation in these studies. In a subgroup analysis of our low-risk twin babies born at full term, we calculated the number of fetuses who were reclassified as being in the bottom 10th percentile using each of the previous population-based standard. RESULTS: A total of 2644 ultrasounds with a median of 4 scans per fetus from 572 twin pregnancies were included in this analysis. In the cohort, 36% of the fetuses were monochorionic. Maternal age, body mass index, and the interaction between fetal gender and chorionicity were significantly associated with estimated fetal weight. The predicted growth curves matched the growth standard for twins. In our low-risk group, when the singleton standard was used, the incidence of estimated fetal weight <10th percentile was above 20% from gestational week 24 to 38, and this incidence varied when reclassified using other population-based twin standards. CONCLUSION: This conditional growth chart was specifically designed to assess fetal growth in twin pregnancies, but it is generalizable to other populations.

Pharmacogenomics of Preeclampsia therapies: Current evidence and future challenges for clinical implementation.

Preeclampsia is a pregnancy-specific disorder, and it is a leading cause of maternal and perinatal morbidity and mortality. The application of pharmacogenetics to antihypertensive agents and dose selection in women with preeclampsia is still in its infancy. No current prescribing guidelines from the clinical pharmacogenetics implementation consortium (CPIC) exist for preeclampsia. Although more studies on pharmacogenomics are underway, there is some evidence for the pharmacogenomics of preeclampsia therapies, considering both the pharmacokinetic (PK) and pharmacodynamic (PD) properties of drugs used in preeclampsia. It has been revealed that the CYP2D6*10 variant is significantly higher in women with preeclampsia who are non-responsive to labetalol compared to those who are in the responsive group. Various genetic variants of PD targets, i.e., NOS3, MMP9, MMP2, TIMP1, TIMP3, VEGF, and NAMPT, have been investigated to assess the responsiveness of antihypertensive therapies in preeclampsia management, and they indicated that certain genetic variants of MMP9, TIMP1, and NAMPT are more frequently observed in those who are non-responsive to anti-hypertensive therapies compared to those who are responsive. Further, gene-gene interactions have revealed that NAMPT, TIMP1, and MMP2 genotypes are associated with an increased risk of preeclampsia, and they are more frequently observed in the non-responsive subgroup of women with preeclampsia. The current evidence is not rigorous enough for clinical implementation; however, an institutional or regional-based retrospective analysis of audited data may help close the knowledge gap during the transitional period from a traditional approach (a "one-size-fits-all" strategy) to the pharmacogenomics of preeclampsia therapies.

Uterine artery Doppler indices throughout gestation in women with and without previous Cesarean deliveries: a prospective longitudinal case-control study.

To determine whether a history of previous Cesarean delivery (CD) impacts uterine artery (UtA) Doppler indices throughout pregnancy. Women with and without CD (NCD) were prospectively enrolled for sequential assessments of the UtA mean/median pulsatility index (UtA-PI), resistance index (UtA-RI), and systolic/diastolic ratio (UtA-S/D) at 11-13 + 6, 14-19 + 6, 30-34 + 6, and 35-37 + 6 weeks' gestation. Data from 269/269, 246/257, 237/254, and 219/242 CD/NCD participants from each gestational period were available for analysis. Multiples of the median (MoMs) of UtA Doppler indices showed biphasic temporal (Δ) pattern; with an initial dropping until the second trimester, then a subsequent elevation until late in pregnancy (p < 0.05). The measurements and Δs of the UtA indices between CD and NCD were not different (p > 0.05). Mixed-effects modelling ruled out effects from nulliparity (n = 0 and 167 for CD and NCD, respectively) (p > 0.05). History of CD neither influenced the measurements nor the temporal changes of the UtA Doppler indices throughout pregnancy. The biphasic Δs of UtA Doppler indices added to the longitudinal data pool, and may aid in future development of a more personalized prediction using sequential/contingent methodologies, which may reduce the false results from the current cross-sectional screening.

Mentoring a surgical team towards procedural competence in the early learning curve for selective fetoscopic laser photocoagulation.

INTRODUCTION: Selective fetoscopic laser photocoagulation (SFLP) for twin-to-twin transfusion syndrome (TTTS) is challenging for new surgeons at the start of their learning curve. We described an approach utilising telementoring and team-based training to facilitate rapid attainment of the skills required for safe and efficient practice with a limited caseload. METHODS: We conducted a prospective observational study of SFLP performed by the novice primary surgical team in three stages: under direct on-site supervision from an expert mentor (Group 1), with remote tele-guidance from that mentor (Group 2) and independently (Group 3), at an academic tertiary hospital in Singapore. The primary team undertook regular training on high-fidelity tissue models to accelerate skills acquisition and complement the surgical performance. RESULTS: 9 patients diagnosed with Stage 2 TTTS were assessed for procedural characteristics, surgical outcomes and perinatal survival following SFLP. There were no significant differences in operative duration, anastomoses ablated, gestational age or birth weight at delivery. The complications observed were: recurrent TTTS (22.2% of pregnancies), twin anaemia polycythaemia sequence (33.3%), preterm prelabour membrane rupture (22.2%) and delivery at < 32 weeks (44.4%). ≥ 1 twin was live-born in 88.9% of cases, while postnatal survival to six months of ≥ 1 twin occurred in 77.8% of cases. CONCLUSION: Systematic mentoring and specialised skills training are useful in aiding new surgeons to negotiate the steep learning curve and achieve good outcomes at the start of a new practice, particularly in the setting of low patient numbers. This is best paired with dedicated model training to achieve and maintain surgical dexterity for this complex procedure.

Ablative effect of the interstitial laser setting in the human placental model.

AIM: To assess the impact of laser power and time on interstitial ablation generated by neodymium-doped yttrium aluminium garnet (Nd:YAG) and diode laser in the human placental model. METHODS: The experiment was carried out in a simulation model of interstitial laser ablation on ex-vivo placental tissue. One-hundred and forty-four pieces of fresh placentae were interstitially ablated with Nd:YAG or diode laser at various power (15, 20, 25, 30 W)-time (5, 10, 15 s) combinations. The ablation tissues were evaluated using both sonographic and histopathologic measurements. RESULTS: Laser generator, power, and time significantly affected the ablation size (p < 0.001). The coagulation zone continuously increased with extending time at the power of 15, 20, and 25 W. When adjusting to the power of 30 W, increased time from 10 to 15 s did not induce the larger coagulation diameter. The maximal diameter was obtained at the laser power of 20 W for 15 s. The ablation from the diode laser was greater than that from Nd:YAG laser. The sonographic evaluation overestimated the ablation size by an average of 24%. CONCLUSION: Diode laser destroys greater tissue than Nd:YAG laser. Different power settings of interstitial laser ablation produce diverse patterns of correlation between laser time and coagulation size.

Prospective Evaluation of International Prediction of Pregnancy Complications Collaborative Network Models for Prediction of Preeclampsia: Role of Serum sFlt-1 at 11-13 Weeks' Gestation.

The study aimed to investigate whether serum sFlt-1 (soluble fms-like tyrosine kinase-1) at 11-13 weeks' gestation in pregnancies that subsequently developed preeclampsia was different from those without preeclampsia and compare screening performance of the International Prediction of Pregnancy Complications (IPPIC) reported models, which include various combinations of maternal factors, systolic blood pressure, diastolic blood pressure, PlGF (placental growth factor) and sFlt-1 and the competing risk (CR) models, which include various combinations of maternal factors, mean arterial pressure (MAP) and PlGF for predicting any-onset, early-onset, and late-onset preeclampsia. This was a prospective multicenter study in 7877 singleton pregnancies. The differences of the predictive performance between the IPPIC and CR models were compared. There were 141 women (1.79%) who developed preeclampsia, including 13 cases (0.17%) of early-onset preeclampsia and 128 cases (1.62%) of late-onset preeclampsia. In pregnancies that developed preeclampsia compared to unaffected pregnancies, median serum sFlt-1 levels and its MoMs were not significantly different (p>0.05). There was no significant association between gestational age at delivery and log10 sFlt-1 and log10 sFlt-1 MoM (p>0.05). The areas under the curve of CR models were significantly higher than the IPPIC models for the prediction of any-onset and late-onset preeclampsia but not for early-onset preeclampsia. In conclusion, there are no significant differences in the maternal serum sFlt-1 levels at 11-13 weeks' gestation between women who subsequently develop preeclampsia and those who do not. Moreover, the CR models for the prediction of any-onset and late-onset preeclampsia perform better than the IPPIC reported model.

Reference values for fetal Doppler-based cardiocirculatory indices in monochorionic-diamniotic twin pregnancy.

BACKGROUND: Placental anastomoses in monochorionic diamniotic (MCDA) twin pregnancy have a major impact on fetal circulation. This study was designed to define reference ranges of cardiac and vascular Doppler indices in MCDA twin pregnancies. METHODS: This cross-sectional study included 442 uncomplicated MCDA twin fetuses undergoing Doppler ultrasonography at 18-35 weeks of gestation. Left and right myocardial performance index (LV-MPI, RV-MPI), E/A ratio of atrioventricular valves, pulsatility indices of umbilical artery, middle cerebral artery (MCA), and ductus venosus (DV), cerebroplacental ratio, peak systolic velocity of MCA, S/a ratio of DV, and early diastolic filling time of ductus venosus (DV-E) were evaluated under standardized settings. The equation models between Doppler indices and gestational age (GA) were fitted. After adjustment for GA, the correlations between MPI and fetal heart rate (FHR), and between MPI and DV indices were analyzed. RESULTS: Estimated centiles of Doppler indices were derived as a function of GA, being distinct in values from those of singletons. There was no correlation between GA-adjusted MPI and FHR. DV-E was inversely related to LV-MPI. CONCLUSIONS: MCDA twins showed significant changes in some Doppler indices throughout gestation with quantitative differences from singletons, emphasizing the importance of MC twin-specific reference values for clinical application. Further adjustment of MPI for FHR was unnecessary. DV-E is a vascular index indirectly representing fetal diastolic function.

A 10-Year Retrospective Review of Prenatal Applications, Current Challenges and Future Prospects of Three-Dimensional Sonoangiography.

Realistic reconstruction of angioarchitecture within the morphological landmark with three-dimensional sonoangiography (three-dimensional power Doppler; 3D PD) may augment standard prenatal ultrasound and Doppler assessments. This study aimed to (a) present a technical overview, (b) determine additional advantages, (c) identify current challenges, and (d) predict trajectories of 3D PD for prenatal assessments. PubMed and Scopus databases for the last decade were searched. Although 307 publications addressed our objectives, their heterogeneity was too broad for statistical analyses. Important findings are therefore presented in descriptive format and supplemented with the authors' 3D PD images. Acquisition, analysis, and display techniques need to be personalized to improve the quality of flow-volume data. While 3D PD indices of the first-trimester placenta may improve the prediction of preeclampsia, research is needed to standardize the measurement protocol. In highly experienced hands, the unique 3D PD findings improve the diagnostic accuracy of placenta accreta spectrum. A lack of quality assurance is the central challenge to incorporating 3D PD in prenatal care. Machine learning may broaden clinical translations of prenatal 3D PD. Due to its operator dependency, 3D PD has low reproducibility. Until standardization and quality assurance protocols are established, its use as a stand-alone clinical or research tool cannot be recommended.

From non-invasive to invasive fetal therapy: A comprehensive review and current update.

"Fetus as patient" indicates fundamental concept of fetal therapy. With advance in maternal serum analysis and fetal imaging, prenatal screening has become standard of care. Accurate diagnosis in early gestation allows intervention to reverse pathophysiology and delay progression immediately. Non-invasive, minimally invasive and invasive therapies demonstrate their therapeutic potential in certain diseases. Recently, stem cell and gene therapies have been developed to avoid irreversible impairment. To elevate efficacy of treatment modality, extensive studies should be conducted according to regulatory authority. Striking a balance between scientific and ethical integrity is essential, so long-term follow up should be arranged for protecting mother and fetus.

Teaching and training the total percutaneous fetoscopic myelomeningocele repair.

Skin-over-biocellulose for Antenatal Fetoscopic Repair (SAFER) is a recently developed technique for fully percutaneous fetoscopic repair of myelomeningocele. The formation of a neo-dura mater triggered by the use of a biocellulose patch over the placode obviates the need of primary repair of fetal dura mater, and seems to further improve neurodevelopmental outcome. Insufflation of humidified carbon dioxide into the amniotic cavity requires proper training and a different equipment set from those used in the classic "under-water" fetoscopy. To shorten the learning curve of novice teams, we have developed a structured training course encompassing three critical steps: (1) visiting the proctor center, (2) selection of the first case, and (3) on-site training of the surgical team. Upon the site arrival, there will be: (1) theoretical lecture for all specialists involved in the fetal care, (2) simulation training, and (3) surgical proctoring. Proctor team can take over the surgery if the local team cannot complete. This training course has been successfully used in five different countries: Israel, Chile, Italy, USA and England and all local teams are already performing surgeries solo without any failures or maternal morbidity. Teaching new procedures in fetal medicine is challenging, because of the small number of candidate cases, and the direct relation of good outcomes and the number of cases operated. This proposed training modules may be adopted by other teams that want to embark on this type of novel minimally invasive treatment.

Minimizing cross transmission of SARS-CoV-2 in obstetric ultrasound during COVID-19 pandemic.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated infection (COVID-19) is affecting populations worldwide. This statement may serve as guidance for infection prevention and safe ultrasound practices during the COVID-19 pandemic. Ultrasound examination is a fundamental part of obstetric care, yet it is a potential vector for transmission of SARS-CoV-2. Decontamination methods should always be implemented for ultrasound equipment, especially in the presence of suspected or confirmed COVID-19 cases. There must be workflow policies to protect pregnant women and healthcare providers from nosocomial cross transmission of SARS-CoV-2. Cleaning and disinfecting of equipment must be in accordance with their potential of pathogen transmission. Consider using telemedicine and genetic technologies as an adjunctive of obstetric ultrasound to reduce patient crowding. Patient triage and education of healthcare providers of infection prevention are crucial to minimize cross contamination of SARS-CoV-2 during obstetric ultrasound.

Clinical Experiences of Intravenous Hydralazine and Labetalol for Acute Treatment of Severe Hypertension in Pregnant Thai Women.

Response to acute treatment of severe hypertension during pregnancy in Asian women was not known. Labor and delivery checklists of Thai women treated with intravenous hydralazine or labetalol for systolic blood pressure (SBP) ≥ 160 or diastolic blood pressure (DBP) ≥ 110 mm Hg from January 2011 to December 2013 were reviewed as parts of an audit. Primary outcome was prompt achievement of SBP 140-150 and DBP 90-100 mm Hg after the first bolus. Secondary outcomes were medication-related undesired effects. The mean ± standard deviation age and prevalence of chronic hypertension in hydralazine (n = 62) versus labetalol (n = 64) groups were 32.5 ± 6 versus 29.9 ± 6.8 years and 50% versus 21.9%, respectively (P < .05). Magnesium sulfate was promptly administered on admission to every woman to prevent seizure. Targeted blood pressure was timely achieved in 41.9% and 67.2% of the hydralazine and labetalol groups, respectively (P < .05). Nonreassuring fetal heart rate occurred in 51.6% and 32.8% of the hydralazine and labetalol groups, respectively (P = .05). The prevalence of cesarean section and Apgar score < 7 were not significantly different (P > .05). Real-life clinical experiences suggested significant advantages of intravenous labetalol over hydralazine in pregnant women with severe hypertension.

Clinical performance of DNA-based prenatal screening using single-nucleotide polymorphisms approach in Thai women with singleton pregnancy.

BACKGROUND: To review the performance of noninvasive prenatal screening (NIPS) using targeted single-nucleotide polymorphisms (SNPs) approach in mixed-risk Thai women. METHODS: Retrospective analysis of data for detection of trisomy 21 (T21), 18 (T18), 13 (T13), monosomy X (XO), other sex chromosome aneuploidies (SCA), and triploidy/vanishing twins (VT) from a single commercial laboratory. RESULTS: Mean (±SD) gestational age and maternal weight were 13.2 (±2.1) weeks and 125.7 (±22.4) pounds, respectively (n = 8,572). From 462/8,572 (5.4%) no-calls; 1/462 (0.2%) was uninformative SNPs, and 1/462 chose amniocentesis. Redraw settled 323/460 (70%) samples with low fetal fraction (FF); and 8,434/8,572 (98.4%) were finally reportable, with 131 high risks (1.6%). The median (min-max) FF of reportable (n = 8,434) and unreportable samples (n = 137) samples were 10.5% (2.6-37.9) and 3.8% (1-14.1), respectively (p < .05). Fetal karyotypes were available in 106/131 (80.9%) and 52/138 (37.7%) high risk and repeated no-calls, respectively. The positive predictive values (PPVs) for T21 (n = 47), T18 (n = 15), T13 (n = 7), XO (n = 8), other SCA (n = 7), and triploidy/VT were 94%, 100%, 58.3%, 66.7%, 70%, and 57.1%, respectively. None of repeated no-calls had aneuploidies. CONCLUSION: SNP-based NIPS has high PPVs for T21 and T18. Although the proprietary SNPs library is not population-specific, uninformative SNPs are uncommon.

Morphology, intrafetal vascular pattern, and umbilical artery Doppler indices of acardiac twins.

BACKGROUND: Twin reversed arterial perfusion (TRAP) sequence consists of acardiac twin (A) paradoxically perfused by pump twin (P) through an umbilical artery (UA). We proposed characterization of acardiac twins with intrafetal vascular pattern (IVP), and assessed its correlation with morphology and UA Doppler indices. METHODS: We prospectively evaluated 21 cases of TRAP sequence. Morphology (acardia vs hemicardia) and IVP (simple vs complex) of acardiac twins were characterized with ultrasound and color Doppler. Twins weight ratio (A/P Wt) and UA Doppler indices of acardiac and pump twins including (1) difference of systolic/diastolic ratio (UA ∆S/D), (2) difference of resistance index (UA ∆RI), and (3) ratio of pulsatility index (UA PI A/P) were calculated. RESULTS: The median (min, max) gestational age at diagnosis was 18 (11, 27) weeks. Acardia (n = 14) were associated with simple IVP (n = 16) (P < .05). After exclusion of acardia with complex IVP (n = 1), the A/P Wt, UA ∆S/D, UA ∆RI, and UA PI A/P of acardia with simple IVP (n = 13), hemicardia with simple IVP (n = 3), and hemicardia with complex IVP (n = 4) were not significantly different (P > .05). CONCLUSIONS: Most of acardiac twins were acardia with simple IVP. Morphology and IVP of acardiac twins were not associated with UA Doppler indices.

Additional benefits of three-dimensional ultrasound for prenatal assessment of twins.

Three-dimensional ultrasound (3DUS) may provide additional information for prenatal assessment of twins. It may improve the diagnostic confidence of dating, nuchal translucency (NT) and chorionicity assignment in twin pregnancies. The "virtual 3DUS placentoscopy" can guide selective fetoscopic laser photocoagulation (SFLP) to treat twin-twin transfusion syndrome (TTTS). Volumetric assessment of the dysmorphic acardiac twin with the Virtual Organ Computer-aided Analysis (VOCAL) software is more accurate than the conventional ultrasound measurement. Twin anemia polycythemia (TAP) sequence and selective intrauterine growth restriction (sIUGR) may be clinically monitored with 3DUS placental volume (PV) and power Doppler vascular indices. Congenital anomalies are more common in twins. Evaluation of fetal anomalies with 3DUS could assist perinatal management. The 3DUS power Doppler can provide a better understanding of true and false umbilical cord knots, which are commonly found in monoamniotic (MA) twins. Single demise in monochorionic (MC) twin pregnancies can cause severe neurologic morbidity in the surviving co-twin. Prenatal prediction of brain injury in the surviving co-twin with unremarkable neurosonographic examination is difficult. The 3DUS power Doppler may aid in prenatal detection of subtle abnormal cerebral perfusion. Prenatal assessment of conjoined twins with 3DUS is important if emergency postnatal surgical separation is anticipated. There is no significant additional advantage in using real-time 3DUS to guide prenatal interventions. Assessment of the cervix and pelvic floor during twin pregnancies is enhanced with 3DUS. Due to lack of high-quality studies, routine prenatal 3DUS in twin pregnancies needs to be balanced with risks of excessive ultrasound exposure.

Comparison of Mannequin Training Satisfaction with a Conventional Box Trainer and a Low-Fidelity Fetoscopic Surgical Simulator for Selective Fetoscopic Laser Photocoagulation.

BACKGROUND: A low-fidelity fetoscopic surgical simulator (FSS) for training of selective fetoscopic laser photocoagulation (SFLP) was developed. OBJECTIVE: To evaluate and compare training satisfaction with an FSS and with a conventional box trainer (BT). METHODS: The BT consisted of a cleaned human placenta attached to the inside of a plastic storage box with a watertight lock cover and an ultrasound-transparent rubber skin. The FSS consisted of the replica of a monochorionic twin placenta attached to the inside of a spherically shaped, ultrasound-transparent phantom. Tap water was used as an ultrasound conduction agent. Evaluation of the mannequin trainings was conducted on 8 junior maternal-fetal medicine (MFM) attending physicians and 22 MFM fellows. Training satisfaction was scored from 0 to 10 on 8 different domains. RESULTS: The mean satisfaction score (±SD) with the FSS was higher than with the BT in all domains (p < 0.05). The fellows' training satisfaction with the BT was greater than that of the attending physicians in 4 domains: tactile feedback, demonstration of chorionic vessels, feedback on performance, and overall value as learning aid (p < 0.05). CONCLUSIONS: As evaluated by a small group of trainees, our FSS is superior to the BT in mannequin training of SFLP. However, the BT may be more useful for trainees with limited clinical experience.

Retrospective analysis of 113 consecutive cases of placenta accreta spectrum from a single tertiary care center.

Objective: Placenta accreta spectrum (PAS) remains a major cause of maternal morbidity. We sought to assess the characteristics and treatment outcomes of PAS managed at a tertiary care center with high volume of PAS.Study design: Electronic medical records of all patients with diagnosis of PAS from June 2010 to October 2016 were reviewed. Details of obstetric backgrounds, predelivery diagnosis, peripartum management, and outcomes were analyzed.Results: One hundred thirteen women with PAS were identified from 50,448 deliveries during the study period. Vaginal delivery, emergency, and elective cesarean section were accomplished in 41.6, 30.1, and 28.3%, respectively. There was no maternal mortality. Approximately 41.6% of women with PAS had peripartum hysterectomy. There was a fair inverse correlation between intraoperative blood loss and gestational weeks at delivery (r = -0.311; p=.001), but not gestational weeks at diagnosis (p = .249). Cases with predelivery diagnosis (n = 29) had higher intraoperative blood loss than those diagnosed postdelivery (n = 84) (p<.001). Anterior PAS (n = 58) is associated with attachment to previous uterine scar, antepartum bleeding, and intraoperative blood loss compared to posterior PAS (n = 44) (p<.05). The PAS patients with previous uterine surgery had the highest chance of peripartum hysterectomy (p<.001).Conclusions: Contradictory to previous reports, our data suggest a more severe spectrum of PAS in those with predelivery detection earlier gestational weeks at delivery. Peripartum hysterectomy was highest in anterior PAS that attached to the previous uterine scar.