Crystal Vue-Estimated Placental Invasion Area as a Novel Predictor of Postpartum Hemorrhage Risk in Placenta Accreta Spectrum Disorders: A Case-Control Study

Abstract Background Postpartum hemorrhage (PPH) represents ​​one of the most frequent and serious​​ complications in placenta accreta spectrum (PAS), making prenatal risk stratification essential for optimizing obstetric management ​​strategies​​ and maternal outcomes. This study aimed to evaluate a novel prenatal ultrasound ​​method​​ for estimating ​​placenta invasion area​​ and to investigate ​​its association​​ with estimated blood loss (​​EBL in mL​​) during delivery and ​​the​​ adverse maternal outcomes ​​in PAS​​. Methods This retrospective study measured PAS area by determinging the length of “tramline sign” obliteration and its distance from the cervical os. Placental invasion was segemented into trapezoidal sections using three-dimensional (3D)-Crystal Vue imaging. Linear and multiple regression analyses were use to assess correlations between estimated PAS area and EBL, PPH, (EBL ≥ 1000 ml), severe PPH (EBL ≥ 2500 ml), post-delivery transfusion need, and maternal ICU admission. Results Among 168 patients, 78 developed PPH and 90 did not. The PPH group > 2-fold higher PAS area vs. non-PPH (17.28 cm² vs. 7.36 cm²; P < 0.001). Linear regression analysis indicated each 1 mm² PAS area increase corresponded to 40.13 mL higher EBL (95% CI, 26.84–53.42; P < 0.001). PAS area independently predicted PPH (adjusted odds ratio (aOR) 1.07, 95% CI 1.03–1.13; P = 0.003) and severe PPH (aOR 1.03, 95% CI 1.01–1.05; P = 0.01). ROC analysis yielded PAS area cutoffs for PPH (10.13 cm²; AUC 0.83 (0.76–0.89); P < 0.001) and severe PPH (10.57cm²; AUC 0.83 (0.76–0.89); P < 0.001). Using these cutoffs, PAS area outperformed classic ultrasound signs in predicting PPH and severe PPH. Conclusion 3D-Crystal Vue-derived PAS area estimation is clinically feasible and correlates with EBL and PPH risk in PAS patients.