Crystal Vue-Estimated placental invasion area as a novel predictor of postpartum hemorrhage risk in placenta accreta spectrum disorders: a retrospective cohort study

Postpartum hemorrhage (PPH) represents ​​one of the most frequent and serious​​ complications in placenta accreta spectrum (PAS), making prenatal risk stratification essential for optimizing obstetric management ​​strategies​​ and maternal outcomes. This study aimed to evaluate a novel prenatal ultrasound ​​method​​ for estimating ​​placenta invasion area​​ and to investigate ​​its association​​ with estimated blood loss (​​EBL in mL​​) during delivery and ​​the​​ adverse maternal outcomes ​​in PAS​​. This a retrospective cohort study measured PAS area by determining the length of “tramline sign” obliteration and its distance from the cervical os. Placental invasion was segmented into trapezoidal sections using three-dimensional (3D)-Crystal Vue imaging. Linear and multiple regression analyses were used to assess associations between estimated PAS area and EBL, PPH (EBL ≥ 1000 ml), severe PPH (EBL ≥ 2500 ml) and post-delivery transfusion need. Among 168 patients, 78 developed PPH and 90 did not. The PPH group > 2-fold higher PAS area vs. non-PPH (17.28 cm² vs. 7.36 cm²; P < 0.001). Linear regression analysis indicated each 1 cm² PAS area increase corresponded to 42.84 mL higher EBL (95% CI, 27.47–55.77; P < 0.001). PAS area independently predicted PPH (adjusted odds ratio (aOR) 1.08, 95% CI 1.04–1.13; P < 0.001) and severe PPH (aOR 1.03, 95% CI 1.02–1.04; P = 0.03). ROC analysis yielded PAS area cutoffs for PPH (10.13 cm 2 ; AUC 0.83 (0.76–0.89); P < 0.001) and severe PPH (10.57cm 2 ; AUC 0.83 (0.76–0.89); P < 0.001). Using these cutoffs, PAS area outperformed classic ultrasound signs in predicting PPH and severe PPH. 3D-Crystal Vue-derived PAS area estimation is clinically feasible and correlates with EBL and PPH risk in PAS patients.