Comment on “Diagnostic Ultrasound to Inform the Surgical Approach to Cesarean Delivery in Patients at High Risk for Placenta Accreta Spectrum Disorders”

Placenta accreta spectrum is a complex obstetric condition increasingly managed with techniques besides hysterectomy, such as one-step conservative surgery. This approach can be successful in the majority of cases but depends heavily on lesion characteristics and surgical expertise. Current decision-making relies largely on intraoperative assessment, which limits preoperative planning and patient counseling. Ultrasound is the primary diagnostic tool for placenta accreta, but research on this tool’s effectiveness in guiding surgical management remains limited. This study aimed to evaluate whether preoperative ultrasound can predict the need for cesarean hysterectomy versus uterine-sparing surgery in high-risk placenta accreta cases. This prospective cohort study included patients at high risk for placenta accreta spectrum at a tertiary referral center in Indonesia, defined by prior cesarean delivery with low-lying placenta or placenta previa. All patients received standardized transvaginal and transabdominal ultrasound with Doppler within 2 weeks before surgery. Detailed assessments were performed on vascular and structural features, including bladder wall involvement, cervical and parametrial hypervascularity, placental location, loss of clear zone, myometrial thinning, subplacental hypervascularity, and cervical length or funneling. Imaging was reviewed by multiple experts. Surgical management was planned for uterine conservation in all cases based on patient preference, but ultimately intraoperative findings such as lesion location, depth, and involvement of surrounding structures determined feasibility. Table 1 summarizes the decision-making algorithm. The primary outcome was the need for cesarean hysterectomy. Possible ultrasound predictors of hysterectomy were identified, weighted using LASSO-based feature selection, and assessed using multivariable logistic regression. Among 123 analyzed patients, 93 had placenta accreta spectrum and 30 had uterine scar dehiscence. Of placenta accreta spectrum cases, 79.6% were managed with uterine-sparing surgery and 20.4% required cesarean hysterectomy. Surgical outcomes were strongly associated with lesion topography: all lesions above the bladder trigone were managed conservatively, whereas all lesions involving the cervicovesical trigone required hysterectomy. Ultrasound features most associated with hysterectomy were intracervical hypervascularity >50% (adjusted OR 41.0), bladder wall distortion (adjusted OR 14.3), and parametrial hypervascularity. A multivariable model with weighted incorporation of these features achieved 94.4% accuracy, with the combination of intracervical hypervascularity >50% and bladder wall distortion showing the highest predictive value (probability 0.87, sensitivity 96.0%, specificity 92.0%). Preoperative ultrasound features, particularly intracervical hypervascularity >50%, bladder wall distortion, and parametrial hypervascularity, were strongly associated with the need for cesarean hysterectomy. These sonographic findings have been previously shown to reflect underlying lesion location and extent of placental implantation. These markers carry value beyond traditional diagnostic signs by informing surgical planning. Prior studies focused primarily on diagnosis or lacked standardized surgical intent, whereas all patients in this study were managed with planned uterine conservation except when predefined standardized intraoperative findings were identified. While the resulting model demonstrated high accuracy, findings require external validation and may be limited by expert-level imaging and surgical management. Overall, targeted ultrasound assessment may improve preoperative counseling and resource planning for one-step conservative surgery in pregnancies affected by placenta accreta, though intraoperative flexibility remains essential. (Summarized from Aryananda RA, Adu-Bredu TK, Cininta NI, et al. Diagnostic ultrasound to inform the surgical approach to cesarean delivery in patients at high risk for placenta accreta spectrum disorders. Am J Obstet Gynecol . 2025;233:658.e1–658.e16. doi:10.1016/j.ajog.2025.08.005).