(1103) Antenatal Ultrasound Predictors of Genitourinary Injury in Cesarean Hysterectomy for Placenta Accreta Spectrum

Objective: Placenta accreta spectrum (PAS) is a complex obstetric condition associated with maternal morbidity. Urologic injuries complicate 20-30% of PAS deliveries during cesarean hysterectomy. This study aimed to evaluate ultrasonographic predictors of genitourinary (GU) injury during Cesarean Hysterectomy for PAS from multiple referral centers.

Study Design: We conducted a multicenter, retrospective analysis of singleton pregnancies with pathology-confirmed PAS (accreta, increta, or percreta). 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 GU injury (ureteral or bladder) during cesarean hysterectomy. Comparisons were made using Fisher’s Exact test, and odd ratios were established using logistic regression.

Results: Among 358 patients included in the study, 59 (16%) experienced GU injury during surgery. Patients with GU injury were significantly more likely to have had antenatal suspicion of percreta based on ultrasound findings (OR 2.89, 95% CI: 1.56 – 5.35) and to have complete placenta previa (OR 3.26, 95% CI: 1.71 – 6.21), as seen in Table 1. Conversely, posterior placental location was associated with a lower risk of GU injury (OR 0.31, 95% CI: 0.11 – 0.89). None of the six ultrasonographic markers independently predicted GU injury.

Conclusion: Antenatal suspicion of percreta and complete placenta previa significantly increase the risk of GU injury during Cesarean Hysterectomy for PAS. Conversely, posterior placental location appears to be associated with a lower risk of such injuries. Individual ultrasonographic markers alone do not reliably predict GU injury at the time of cesarean hysterectomy; thus, multimodal imaging may be important for patient counseling and surgical preparation.