Full length article The occurrence and severity of intra-abdominal adhesions in cases of pregnancies complicated by placenta accreta: A case control study Gali Garmi a,b , Shabtai Romano a,b , Hadas Rubin a , Eyal Rom a , Sivan Zuarez-Easton a , Raed Salim a,b, * a Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel b Rappaport Faculty of Medicine, Technion, Haifa, Israel A R T I C L E I N F O Article history: Received 5 April 2018 Received in revised form 30 May 2018 Accepted 4 June 2018 Available online xxx Keywords: Cesarean delivery Intra-abdominal adhesions Placenta accreta A B S T R A C T Objective: To examine the occurrence of intra-abdominal adhesions (IAA) among women with placenta accreta (PA). Study design: Case control study conducted at a single teaching hospital on data from January 2004 to December 2016. The cases included women who underwent a cesarean hysterectomy due to PA and had a pathological confirmation of accretion. The controls were matched for delivery date and number of cesarean deliveries (CDs) at a ratio of 1:4. IAA were categorized as “none”, “filmy”, or “dense”. The outcome measures were rate of IAA. In order to detect a 25% difference in overall IAA between the groups, with alpha of 0.05 and 80% power, a sample size of 165 women was needed. Results: Overall, 165 women (33 and 132 in the case and control groups, respectively) were included. Except for maternal age, there were no statistically significant differences between the groups in demographic and obstetric variables. Overall IAA rate was 30.3% and 47.7% in the case and control groups, respectively (RR: 0.64; 95% CI: 0.37–1.10, p = 0.04). Rate of dense adhesions was 15.2% and 32.6% in the case and control groups, respectively (RR: 0.47, 95% CI: 0.20–1.08; p = 0.03). After adjustment for maternal age, there was a significantly lower rate of overall IAA (RR = 0.39; 95% CI: 0.17-0.93; p = 0.02) and dense adhesions (RR = 0.30; 95% CI: 0.11-0.87; p = 0.02) among the cases. Conclusion: The incidence and severity of IAA following CDs are low, among women who develop PA. © 2018 Elsevier B.V. All rights reserved. Introduction Placenta accreta is a devastating pregnancy complication that may lead to substantial and actual life-threatening hemorrhage [1]. There is a recognized association between prior cesarean deliveries and the development of placenta accreta, and the occurrence increases with the number of previous cesarean deliveries [2]. Cesarean delivery is considered a risk factor for intra-abdominal adhesions formation [3]. Intra-abdominal adhesions may lead to bowel obstruction or injury, long-lasting pelvic pain, and occasionally difficult repeat surgery [4–6]. Uterine scar decidualization and intra-abdominal adhesions formation are both considered tissue healing processes [7–10]. A poorly-healed cesarean scar may lead to insufficient decidualiza- tion, which results in trophoblast invading the uterine muscle layers and development of accretion. [8,11]. Matsubara reported according to his experience the phenomenon of rare coexistence of intra-abdominal adhesions and placenta accreta [10]. We aimed in the current study to examine the occurrence of intra-abdominal adhesions among women with placenta accreta. According to the above mentioned data, we hypothesized that the incidence of intra-abdominal adhesions will be lower among women with placenta accreta compared to a matched group of women undergoing repeat cesarean delivery without placenta accreta. Material and methods Case control study conducted at a single teaching hospital using data collected between January 2004, and December 2016. Pregnant women with at least one cesarean delivery who were delivered by a repeat cesarean delivery were included in the study cohort group. The case group included women who underwent a cesarean hysterectomy due to placenta accreta and had a pathological confirmation of accretion. Women with placenta * Corresponding author at: Department of Obstetrics and Gynecology, Emek Medical Center, Afula, 18101, Israel. E-mail address: salim_ra@clalit.org.il (R. Salim). https://doi.org/10.1016/j.ejogrb.2018.06.005 0301-2115/© 2018 Elsevier B.V. All rights reserved. European Journal of Obstetrics & Gynecology and Reproductive Biology 227 (2018) 71–74 Contents lists available at ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb