Rethinking placenta accreta spectrum: a topography-based framework for prenatal imaging and individualized surgery

Area of Science:

• Obstetrics and Gynecology
• Maternal-Fetal Medicine
• Surgical Oncology

Background:

• Placenta accreta spectrum (PAS) is a leading cause of severe obstetric hemorrhage and maternal morbidity.
• Abnormal placental adherence in PAS, particularly with scarred myometria, presents significant surgical challenges.
• Current diagnostic and surgical planning methods for PAS often fall short in predicting complexity.

Purpose of the Study:

• To synthesize current evidence on PAS biology, imaging, and surgical management into a unified clinical framework.
• To emphasize the shift from depth of invasion to lesion topography and uterine scar remodeling in understanding PAS.
• To guide clinicians in selecting optimal surgical strategies, including uterine-preserving options.

Main Methods:

• Review and synthesis of emerging evidence on PAS pathogenesis, prenatal imaging, vascular anatomy, and surgical techniques.
• Focus on topography-based ultrasound assessment and surgical staging for improved prediction of operative complexity.
• Integration of biological, imaging, and surgical data into a decision-making framework.

Main Results:

• PAS is increasingly understood as a disorder of uterine scar remodeling, with topography and anatomy being key determinants of complexity.
• Prenatal imaging is evolving beyond diagnosis to defining lesion topography and anticipating surgical challenges.
• Surgical staging and individualized strategies expand options beyond hysterectomy for selected patients.

Conclusions:

• A unified framework integrating PAS biology, advanced imaging, and surgical staging can improve prediction of operative complexity.
• Topography-based ultrasound and surgical staging facilitate multidisciplinary planning for individualized PAS management.
• This integrated approach supports informed selection between uterine-preserving surgery and peripartum hysterectomy, guiding future research and training.