Association of Retained Placenta After Spontaneous Separation With Conversion to Hysterectomy in Cases of Cesarean Sections With Suspected Placenta Accreta Spectrum

AIM: To identify clinical parameters for conversion to cesarean hysterectomy (CH) due to uncontrollable hemorrhage in cesarean sections performed for placenta previa with suspected placenta accreta spectrum (PAS). METHODS: We retrospectively analyzed 44 cases of cesarean sections for placenta previa with suspected PAS performed between 2008 and 2025. Outcomes were assessed based on the intraoperative status of placental separation, with particular emphasis on cases exhibiting placental separation. Univariable analyses were conducted to identify factors associated with increased blood loss. RESULTS: CH was performed in 21 cases without placental separation according to institutional management protocols. Among the 23 cases with placental separation, 12 required CH due to uncontrollable hemorrhage, whereas uterine preservation was successfully accomplished in 11. Within this subgroup, blood loss was significantly greater in cases requiring CH (p = 0.045), and the presence of partial placental remnants was more frequent (odds ratio, 19.25; 95% confidence interval, 1.76-209.5; p = 0.0094). Additionally, the presence of partial placental remnants was associated with increased blood loss (p = 0.015). CONCLUSIONS: Intraoperative placental remnants after spontaneous placental separation were associated with uncontrollable hemorrhage requiring CH. When partial placental remnants are identified after placental separation, careful attention to hemorrhage management and intraoperative decision-making is required.