The advance grading of intracervical hypervascularity in transvaginal ultrasound indicates a significant risk in Placenta Accreta Spectrum

Sir,

We greatly appreciate Sarah P Walker and Mohamed Elhodaiby's contribution in sharing a highly complex case of Placenta Accreta Spectrum (PAS). You have conveyed a powerful message regarding the necessity of routine additional transvaginal ultrasound in high-risk PAS cases.¹ Understanding intracervical hypervascularity grading is essential to effectively prepare for surgeries involving PAS. The surgery's complexity largely depends on its topography, with type 1 PAS, situated 2 cm above the bladder trigone, typically allowing for successful uterine-sparing surgery.^{2, 3} On the other hand, lower PAS topographies involve more complex lower pelvic vascular networks, increasing surgical difficulty.⁴

We acknowledge that changes in cervical hypervascularity are directly related to topography. Intracervical hypervascularity exceeding 50% (grade 2) may be associated with lower uterine-cervix remodeling and local angiogenesis during pregnancy and lead to cervical hypervascularity. Intracervical hypervascularity grade 3 (loss of the clear zone between the placenta and hypervascularized cervix) might result from a low incision during previous caesarean sections, leading to abnormally adherent placental tissue in the lower uterus and massive new vascularity between the cervix and placenta.^{5, 6}

We have previously reported that unexpected vaginal bleeding often occurs in cases of intracervical hypervascularity grade 3, likely due to minor injuries at the cervix-placental interface, which may arise from uterine manipulation, leading to significant vaginal hemorrhage.⁷ This type of hemorrhage is challenging to control, as it requires vascular management in the lower colpo-uterine area following bladder dissection. In such critical situations, internal manual aortic compression proves to be an optimal strategy, as it quickly halts bleeding without necessitating additional maneuvers.⁸

As a significant ultrasound marker associated with a critical situation during surgery, intracervical hypervascularity grade 3 indicates a potential for hysterectomy, unexpected vaginal bleeding, and the need for aortic control. Consequently, it can serve as a guiding parameter for surgical preparation, encompassing surgical strategies such as midline abdominal incision, prophylactic abdominal aortic balloon placement, preparing for joined surgery with a vascular surgeon, and ensuring an adequate blood supply.^{9, 10}