The role of the intraplacental fetal artery in predicting the need for cesarean-hysterectomy in women at high risk for placenta accreta spectrum

Introduction: Prenatal determination of placenta accreta spectrum (PAS) and its severity is crucial, as it is a highly morbid condition. The aim was to investigate the intraplacental fetal artery (IFA) as a novel ultrasonographic marker in predicting cesarean-hysterectomy need in PAS. Methods: A prospective observational cohort study was conducted with a total of 62 women with placenta previa and >= 1 previous cesarean-section who were managed for PAS between September 2022 and January 2024. All women were classified according to the ultrasonographic classification system for prenatal PAS, and ultrasonographic assessments for IFA were performed. Odds ratios were calculated to test the association of IFA and other parameters related to PAS with cesarean-hysterectomy need. Receiver operating characteristic analysis was performed to evaluate the ability of maximum diameter (D-max) of IFA to predict cesarean-hysterectomy need. Results: The study was completed with 49 women who underwent a cesarean-section with uterus-sparing surgery (n = 22) and a cesarean-hysterectomy (n = 27). Outer placental-half extension of IFA and each 1 mm increase in IFA D-max >3.5 mm were associated with a 58.82- and 3.52-fold increased risk of cesarean-hysterectomy, respectively. An IFA D-max of >3.5 mm was associated with cesarean-hysterectomy need at any PAS stage [area under the curve (AUC) = 0.845, 95 % CI:0.71-0.93, p < 0.001)] and in PAS 2 patients (AUC = 0.750, 95 % CI:0.56-0.89, p = 0.010), in whom prenatal prediction of cesarean-hysterectomy need is difficult. Discussion: Evaluation of D-max and outer placental-half extension of IFA along with other markers of PAS improved the ability of ultrasonography to predict cesarean-hysterectomy need.