Prenatal predictors of severe maternal outcomes in placenta accreta spectrum: A multicenter cohort study in China

To identify preoperative risk factors and develop predictive models for severe postpartum hemorrhage (PPH) (≥2000 mL) and hysterectomy in patients with placenta accreta spectrum (PAS).

This retrospective multicenter cohort study included 508 patients diagnosed with PAS. Medical history, timing of ultrasound diagnosis (TUD), specific sonographic signs, and pre-delivery laboratory parameters were analyzed. Multivariate logistic regression was employed to identify independent risk factors for severe PPH and hysterectomy. Model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC).

Severe PPH occurred in 138 (27.2%) patients, and 90 (17.7%) underwent hysterectomy. Independent predictors for severe PPH included TUD in the first or second trimester (odds ratio [OR] 9.45 and 5.97, respectively), presence of placental lacunae (OR 1.75), and prolonged preoperative prothrombin time (PT) (OR 1.35). For hysterectomy, independent risk factors included TUD in the first trimester (OR 8.34), placental lacunae feeder vessels (OR 3.07), bladder wall interruption (OR 2.88), and prolonged preoperative activated partial thromboplastin time (APTT) (OR 1.19). The predictive models showed good performance, with an AUC of 0.744 (95% CI 0.696-0.792) for severe PPH and 0.831 (95% CI 0.788-0.875) for hysterectomy.

Preoperative risk stratification for PAS could be improved by integrating routinely available coagulation profiles and specific sonographic findings. Early ultrasound identification of PAS-related signs and prolonged preoperative PT and APTT may indicate an increased risk of severe complications. Placental lacunae feeder vessels, bladder wall interruption may provide additional prognostic value for hysterectomy and severe PPH.