Diagnostic ultrasound to inform the surgical approach to cesarean delivery in patients at high risk for placenta accreta spectrum disorders

Background: Uterine-sparing surgery has become an option for patients with placenta accreta spectrum disorders. The decision to perform a cesarean hysterectomy vs uterine-sparing surgery is made intraoperatively. This study was undertaken to assess the value of ultrasound markers in predicting the need for hysterectomy. Objective: This study aimed to describe ultrasound markers associated with the need for cesarean hysterectomy among patients at risk of placenta accreta spectrum. Study Design: This was an analysis of prospectively collected data of high-risk placenta accreta spectrum cases between September 2023 and August 2024. Ultrasound examination was performed by an expert focusing on the diagnosis of placenta accreta spectrum. All patients were counseled regarding the management options available at our center, namely uterine-sparing surgery and hysterectomy. All patients opted for uterine-sparing surgery if safe and technically feasible. The final choice of surgical management approach was solely based on the intraoperative topography, which describes the size and location of the abnormally adherent placenta. The primary outcome was the need for hysterectomy despite a preoperative plan for uterine-sparing surgery. Results: A total of 123 participants were enrolled: 93 placenta accreta spectrum cases and 30 non–placenta accreta scar dehiscence cases. Uterine-sparing surgery was successful in 74 of 93 (79.6%) placenta accreta spectrum cases and in 100% of non–placenta accreta scar dehiscence cases. LASSO (least absolute shrinkage and selection operator) penalized regression revealed intracervical hypervascularity >50%, urinary bladder wall distortion, and parametrial hypervascularity as the most influential predictors for hysterectomy. This best-fitted model achieved an accuracy of 94% (95% confidence interval, 81.3%–99.3%) after model cross-validation. The combination of intracervical hypervascularity >50% and bladder wall distortion had the highest predictive probability for hysterectomy, with a value of 0.87 (95% confidence interval, 0.81–0.93), a sensitivity of 96.0% (95% confidence interval, 89.0%–99.0%), and a specificity of 92.0% (95% confidence interval, 62.0–100.0). Conclusion: Comprehensive preoperative ultrasound can reasonably predict the appropriate surgical approach to placenta accreta spectrum. This can be achieved by assessing intracervical hypervascularity and urinary bladder wall distortion using a combination of transabdominal, transvaginal, and color Doppler ultrasound techniques because these signs have a strong correlation with the need for hysterectomy in a cohort for which the intended treatment was uterine-sparing surgery.