Antenatal Ultrasound Predictors of Urologic Tract Injury in Cesarean Hysterectomy for Placenta Accreta Spectrum: A Multicenter Retrospective Cohort Study.

OBJECTIVES

Placenta accreta spectrum (PAS) is a complex obstetric condition associated with maternal morbidity and mortality. Urologic injuries complicate 15-20% of PAS deliveries during cesarean hysterectomy (CH). This study aimed to evaluate antenatal ultrasound markers for predicting intraoperative urologic tract (UT) injury during CH for PAS.

METHODS

We conducted a multicenter, retrospective cohort analysis of singleton pregnancies with pathology-confirmed PAS delivered at 2 large referral centers. Subjects were excluded if there were incomplete records, delivery outside of the centers, or lack of histopathology PAS confirmation. Ultrasonographic variables assessed included placental location, presence of previa or low-lying placenta, presence of lacunae, loss of retroplacental clear zone, lower segment hypervascularity, bladder and uterine bulge, myometrial thinning, abnormal uterine-bladder interface, and suspected depth of invasion. The primary outcome was the occurrence of any UT injury (ureteral or bladder) during CH. Univariate and multivariate analyses were performed to identify predictive factors for the primary outcome.

RESULTS

Of 358 subjects meeting inclusion criteria, 59 (16.5%) sustained a UT injury. Central previa was the only independent predictor of GU injury on adjusted analysis (aOR 4.08, 95% CI 1.39-12.13; p = .011). A pre-specified central previa × suspected percreta interaction term was not statistically significant, indicating additive rather than synergistic risk. Individual ultrasound markers were not independently associated with GU injury (AUC 0.783).

CONCLUSION

Placental topography, specifically US findings of a central placenta previa and suspicion for percreta, was the main driver in predicting intra-operative genitourinary injury during PAS deliveries. Multimodal imaging remains essential; however, targeted counseling and operative preparedness should be prioritized for patients with central previa and suspected percreta.