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Figure legends

Figure 1. A flow diagram of the study population.

During the study period, 4,870 pregnant women visited the Kobe University Hospital. Three

hundred seventy-five pregnancies ended in spontaneous or induced abortion, and 349

pregnant women delivered at other hospitals. A total of 4,146 women delivered and 87 (2.1%)

had PAS. Thirty-one of the 87 had histologically diagnosed PAS, and the remaining 56 had

clinically diagnosed PAS.

19

20

Table 1. Clinical characteristics of 4,146 pregnant women

Women with

placenta accreta spectrum

n=87

36.0 ± 4.8

Women without

placenta accreta spectrum

n=4,059

33.2 ± 5.5

Gravidity

3.2 ± 1.9

2.2 ± 1.4

<0.01

Parity

0.8 ± 0.9

0.6 ± 0.8

<0.05

Prior CS

39.1%

14.8%

<0.01

Prior D&C

56.3%

31.2%

<0.01

Prior hysteroscopic surgery

12.6%

1.0%

<0.01

Prior myomectomy

4.6%

2.4%

0.2

Prior UAE

9.2%

0.2%

<0.01

ART pregnancy

41.4%

13.4%

<0.01

Multiple pregnancy

4.6%

5.6%

1.0

Placenta previa

39.1%

4.5%

<0.01

36.0 ± 3.4

37.1 ± 3.2

<0.01

70.1%

49.1%

<0.01

2,482 ± 3,092

859 ± 601

<0.01

2,568 ± 689

2,713 ± 661

<0.05

Clinical findings

Age (years)

Gestational weeks at delivery

Caesarean delivery

Amount of blood loss at delivery (g)

Birth weight (g)

Data are expressed as average ± standard deviation or percentage.

Abbreviations: CS, caesarean section; D&C, dilation and curettage; UAE, uterine artery embolization;

ART, assisted reproductive technology.

p -value

<0.01

21

Table 2. Univariate and multivariable logistic regression analyses of clinical factors associated with

placenta accreta spectrum

Clinical factors

Univariate analysis

Multivariable analysis

OR (95% CI)

p -value

OR (95% CI)

p -value

Age (years)

1.1 (1.1–1.2)

< 0.01

1.0 (0.98–1.09)

0.2

Parity

1.3 (1.0–1.5)

< 0.05

1.0 (0.7–1.3)

0.8

Prior CS

3.7 (2.4–5.8)

< 0.01

3.3 (1.9–5.7)

< 0.01

Prior D&C

2.9 (1.9–4.4)

< 0.01

2.8 (1.7–4.6)

< 0.01

14.2 (7.0–28.7)

< 0.01

5.7 (2.3–14.4)

< 0.01

1.9 (0.7–5.4)

0.2

41.0 (15.8–107.0)

< 0.01

44.1 (13.8–141.0)

< 0.01

ART pregnancy

4.7 (3.0–7.2)

< 0.01

4.1 (2.4–7.1)

< 0.01

Placenta previa

13.5 (8.6– 21.3)

< 0.01

13.1 (7.9–21.8)

< 0.01

Prior hysteroscopic surgery

Prior myomectomy

Prior UAE

Abbreviations: OR, odds ratio; CI, confidence; CS, caesarean section; D&C, dilation and curettage;

UAE, uterine artery embolization; ART, assisted reproductive technology.

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Table 3. Diagnostic accuracy of each clinical factor associated with placenta accreta spectrum

Sensitivity,

Specificity,

Prior CS

39.1

85.2

5.4

98.5

84.3

Prior D&C

56.3

68.8

3.7

98.7

68.6

Prior hysteroscopic surgery

12.6

99.0

21.2

98.1

97.2

Prior UAE

9.2

99.8

44.4

98.1

97.9

ART pregnancy

41.4

86.8

6.3

98.6

85.9

Placenta previa

39.1

95.5

15.6

98.7

94.3

Clinical findings

Positive predictive Negative predictive

value, %

value, %

Abbreviations: CS, caesarean section; D&C, dilation and curettage; UAE, uterine artery embolization;

ART, assisted reproductive technology

Accuracy,

Supplemental table 1. Clinical characteristics of women with placenta accreta spectrum who received imaging examinations.

US and MRI

n=41

33

only US

n=2

only MRI

n=7

The presence of low-lying placenta

Placenta located on the cesarean scar

Morphological abnormality of placenta

Prior UAE

Prior myometrium resection for adenomyosis

Prior adherent placenta

Prior endometrial curretage 4 times for early-stage endometrial cancer

Prior retained placenta

Clinical findings

The presence of current placenta previa

Abbreviations: US, ultrasound; MRI, magnetic resonance imaging.

Supplemental table 2. Diagnostic accuracy of combination of clinical factors associated with placenta accreta spectrum.

Combination of clinical findings

Positive predictive Negative predictive

Accuracy, %

value, %

value, %

Youden

Sensitivity, %

Specificity, %

Prior CS or D&C

74.7

59.4

3.8

99.1

59.7

0.34

Prior CS or hysteroscopic surgery

44.8

84.4

5.8

98.6

83.6

0.29

Prior CS or UAE

44.8

85.1

6.1

98.6

84.2

0.30

Prior CS or current ART pregnancy

71.3

74.0

5.6

99.2

74.0

0.45

Prior CS or current placenta previa

50.6

81.3

5.5

98.7

80.6

0.32

Prior D&C or hysteroscopic surgery

64.4

68.2

4.2

98.9

68.1

0.33

Prior D&C or UAE

64.4

68.6

4.2

98.9

68.5

0.33

Prior D&C or current ART pregnancy

75.9

61.0

4.0

99.2

61.3

0.37

Prior D&C or current placenta previa

77.0

65.8

4.6

99.3

66.0

0.43

Prior hysteroscopic surgery or UAE

17.2

98.8

23.4

98.2

97.1

0.16

Prior hysteroscopic surgery or current ART pregnancy

48.3

86.2

7.0

98.7

85.4

0.34

Prior hysteroscopic surgery or current placenta previa

46.0

94.5

15.2

98.8

93.5

0.40

Prior UAE or current ART pregnancy

48.3

86.6

7.2

98.7

85.8

0.35

Prior UAE or current placenta previa

46.0

95.2

17.2

98.8

94.2

0.41

Current ART pregnancy or placenta previa

71.3

83.1

8.3

99.3

82.9

0.54

Prior CS or D&C or hysteroscopic surgery

79.3

58.9

4.0

99.3

59.3

0.38

Prior CS or D&C or UAE

80.5

59.3

4.1

99.3

59.7

0.40

Prior CS or D&C, or current ART pregnancy

90.8

52.7

4.0

99.6

53.5

0.43

Prior CS or D&C, or current placenta previa

80.5

56.6

3.8

99.3

57.1

0.37

Prior CS or hysteroscopic surgery or UAE

47.1

84.3

6.0

98.7

83.5

0.31

Prior CS or hysteroscopic surgery, or current ART pregnancy

74.7

73.4

5.7

99.3

73.5

0.48

Prior CS or hysteroscopic surgery, or current placenta previa

56.3

80.5

5.8

98.8

80.0

0.37

Prior CS or UAE, or current ART pregnancy

75.9

73.9

5.9

99.3

73.9

0.50

Prior CS or UAE, or current placenta previa

55.2

81.2

5.9

98.8

80.6

0.36

Prior CS, or current ART pregnancy or placenta previa

78.2

70.8

2.4

99.3

70.9

0.49

Prior D&C or hysteroscopic surgery or UAE

69.0

68.0

4.4

99.0

68.0

0.37

Prior D&C or hysteroscopic surgery, or current ART pregnancy

80.5

60.5

4.2

99.3

60.9

0.41

Prior D&C or hysteroscopic surgery, or current placenta previa

81.6

65.1

2.5

99.4

65.5

0.47

Prior D&C or UAE, or current ART pregnancy

82.8

60.8

4.3

99.4

61.2

0.44

Prior D&C or UAE, or current placenta previa

83.9

65.6

5.0

99.5

65.9

0.49

Prior D&C, or current ART pregnancy or placenta previa

92.0

58.4

4.5

99.7

59.1

0.50

Prior hysteroscopic surgery or UAE, or current ART pregnancy

51.7

86.0

7.3

98.8

85.3

0.38

Prior hysteroscopic surgery or UAE, or current placenta previa

49.4

94.3

15.7

98.9

93.4

0.44

Prior hysteroscopic surgery, or current ART pregnancy or placenta previa

75.9

82.5

8.5

99.4

82.3

0.58

Prior UAE, or current ART pregnancy or placenta previa

77.0

82.9

8.8

99.4

82.8

0.60

Prior CS or D&C or hysteroscopic surgery or UAE

81.6

58.8

4.1

99.3

59.3

0.40

Prior CS or D&C or hysteroscopic surgery, or current ART pregnancy

94.3

52.3

4.1

99.8

53.2

0.47

Prior CS or D&C or hysteroscopic surgery, or current placenta previa

85.1

56.0

4.0

99.4

56.7

0.41

Prior CS or D&C or UAE, or current ART pregnancy

95.4

52.5

4.1

99.8

53.4

0.48

Prior CS or D&C or UAE, or current placenta previa

85.1

56.5

2.6

99.4

57.1

0.42

Prior CS or D&C, or current ART pregnancy or placenta previa

94.3

50.3

3.9

99.8

51.2

0.45

Prior CS or hysteroscopic surgery or UAE, or current ART pregnancy

75.9

73.4

5.8

99.3

73.4

0.49

Index

Prior CS or hysteroscopic surgery or UAE, or current placenta previa

57.5

80.4

5.9

98.9

79.9

0.38

Prior CS or hysteroscopic surgery, or current ART pregnancy or placenta previa

81.6

70.2

5.6

99.4

70.5

0.52

Prior CS or UAE, or current ART pregnancy or placenta previa

81.6

70.7

5.6

99.4

70.9

0.52

Prior D&C or hysteroscopic surgery or UAE, or current ART pregnancy

83.9

61.4

4.3

99.5

61.8

0.45

Prior D&C or hysteroscopic surgery or UAE, or current placenta previa

85.1

64.9

4.9

99.5

65.4

0.50

Prior D&C or UAE, or current ART pregnancy or placenta previa

95.4

57.9

4.6

99.8

58.7

0.53

Prior D&C or UAE, or current ART pregnancy or placenta previa

97.7

58.2

4.8

99.9

59.0

0.56

Prior hysteroscopic surgery or UAE, or current ART pregnancy or placenta previa

78.2

82.3

8.6

99.4

82.2

0.60

Prior CS or D&C or hysteroscopic surgery or UAE, or current ART pregnancy

95.4

52.2

4.1

99.8

53.1

0.48

Prior CS or D&C or hysteroscopic surgery or UAE, or current placenta previa

86.2

56.0

4.0

99.5

56.6

0.42

Prior CS or D&C or hysteroscopic surgery, or current ART pregnancy or placenta previa

97.7

50.0

4.0

99.9

51.0

0.48

Prior CS or D&C or UAE, or current ART pregnancy or placenta previa

97.7

50.2

4.0

99.9

51.2

0.48

Prior CS or hysteroscopic surgery or UAE, or current ART pregnancy or placenta previa

81.6

70.2

5.5

99.4

70.4

0.52

Prior D&C or hysteroscopic surgery or UAE, or currentART pregnancy or placenta previa

97.7

57.8

4.7

99.9

58.6

0.55

Prior CS or D&C or hysteroscopic surgery or UAE, or current ART pregnancy or placenta previa

97.7

49.9

4.0

99.9

50.9

0.48

Abbreviations: CS, caesarean section; D&C, dilation and curettage; UAE, uterine artery embolization; ART, assisted reproductive technology

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