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The management of abnormally invasive placentation (AIP) is one of the most challenging conditions in obstetrics. This condition is a group of disorders, which has more recently been relabeled as placenta accrete spectrum (PAS), that covers all varieties including placenta accrete, placenta increta, and placenta percreta (1). This update was made so as to include both the abnormal adhesion and invasion of trophoblasts into the uterine wall given that the two conditions may coexist alongside one another (2). Considering the global increase of the cesarean section (CS) rate to 30% of labors over the last 40 years, the incidence of PAS has increased by more than 10-fold (3). In turn, this has led to the emergence of multiple maternalrelated morbidities, including massive hemorrhage and the need for multiple transfusions, hysterectomy, injury to the abdominal organs, and the need for vascular, bowel, or bladder surgery. In addition, the maternal mortality rate attributed to PAS might be as high as 7% (4,5). The PAS management at level III or IV centers by a multidisciplinary team is known to improve maternal morbidity and mortality outcomes (1). To achieve a successful result, the antenatal diagnosis of the condition is of utmost importance to ensure adequate time for referrals to the multidisciplinary team at the time of delivery (4). Other than the clinical anticipation, which is based on the previous history of CS or uterine surgery, maternal age, and the presence of placenta previa, ultrasound (US) is still preferable to other radiological modalities such as magnetic resonance imaging (4,6,7). In spite of being still recommended as the mainstay for the antenatal diagnosis of PAS, the US neither identifies all cases nor relates to the depth of invasion or histopathological findings (3,4,7). In addition, its successful use depends on the expertise of the operator, with an interobserver variation in the diagnosis which is entirely possible (1). Many researchers have suggested adding different serum biomarkers in order to improve the detection of AIP, including pregnancy-associated plasma protein-A (PAPP-A), betahuman gonadotropin (β-hCG), alpha-fetoprotein, and most recently, cell-free fetal deoxyribonucleic acid and micro ribonucleic acid (8, 9). Zinc (Zn) is an essential trace element previously reported to be related to abnormal fetal growth (10), low birth weight (11,12), and preeclampsia in obstetrics (13-15). As new knowledge, the preterm rupture of the membranes is also associated with reduced umbilical cord and maternal serum Zn when compared to spontaneous preterm births (15). Based on previous studies, human trophoblasts and Abstract Objectives: Abnormally invasive placentation (AIP) is a challenging situation capable of complicating childbirth that has recently arisen, imposing a risk on maternal lives and well-being. The optimal management of this complication requires a valid antenatal diagnostic tool other than Doppler ultrasound (US). Of these, a handful of laboratory markers have been so far used for the antenatal detection of invasive placentation. This study sought to establish whether low maternal serum zinc (Zn) is related to AIP in women with placenta previa. Materials and Methods: Over a period of six years, a prospective study was performed, including 168 pregnant ladies with placenta previa of whom, 72 cases were diagnosed with placenta accrete (PA) spectrum using Doppler US. The serum Zn was measured in all participants, and each individual was followed up regarding intraoperative and postoperative outcomes. Results: A significantly lower serum Zn level was found in women having the PA spectrum (P < 0.001). At a level of 68 μg/dL, serum Zn was 79.2% sensitive, 95.8% specific, and had a comparable accuracy (88.7% vs. 89.3%) to color Doppler US in the identification of cases with PAS spectrum among those with placenta previa. Conclusions: Low maternal serum Zn level is associated with AIP among placenta previa cases. Thus, more studies are needed in the future to support the use of this technique in the antenatal detection of the PAS.

Serum Zinc: A Noninvasive Biomarker for the Prediction of Invasive Placentation