Transvaginal ultrasound imaging of intracervical hypervascularity grading correlates with maternal outcome in placenta accreta spectrum

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Placenta accreta spectrum (PAS) is the abnormal attachment of the placenta to the uterine wall, frequently after Cesarean section in a previous pregnancy, and the prevalence of this disorder is increasing all over the world.The maternal outcome correlates with the topography of PAS and lower bladder involvement, which present different challenges for surgery 1 .Therefore, PAS topography can determine the surgical strategy and control of the pelvic vascularity and uterine anastomoses.Intraoperative surgical staging has a crucial role in the decision to perform uterine conservative-resective surgery or Cesarean hysterectomy 2,3 .Previous studies highlighted the lack of correlation between diagnosis of PAS and clinical outcome; therefore, future ultrasound studies should not only focus on the uteroplacental interface, but also on correlating ultrasound findings during surgery with maternal outcome 4 .The utilization of three-dimensional (3D) ultrasound rendering techniques, such as Crystal Vue and Realistic Vue, can provide information on uteroplacental interface complexity associated with PAS, by identifying signs such as loss of the clear zone, disruption of the tramline and distorted bladder mucosa [5][6][7] .3D transvaginal ultrasound (TVS) rendering with Crystal-Realistic Vue Flow (Samsung Hera W10; Samsung, Seoul, South Korea) is still not widely used, even though this software may be helpful in predicting maternal outcome during surgery for PAS 8,9 .Intracervical lakes or intracervical hypervascularity are important signs on TVS that can be used to predict the complexity of PAS surgery 9 .This is because they are associated with colpouterine remodeling of lower PAS, which refers to PAS with lower bladder trigone topography, which may be located in the lower anterior uterus or lower parametrium.Vascular structures within the cervix typically originate from the outer cervix and branch towards the internal cervical os.Previous Cesarean section incisions that were too low may cause

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