Purpose: To evaluate perioperative outcomes and the prognostic role of the tramline sign in a cohort of women with anterior placenta previa. Materials and Methods: Retrospective analysis of 3D ultrasound volumes from women with anterior placenta previa who underwent ultrasound examination beyond 32 weeks. 3D and 3D color volumes were obtained from a sagittal section of the uterus bisecting a partially full bladder and processed using Crystal Vue and Crystal Vue Flow rendering to look for the tramline sign. Partial obliteration was defined as a loss of some or part of the uterine-serosal interface and full obliteration as when both interfaces were interrupted. Postnatal ascertainment of placenta accreta spectrum (PAS) was confirmed by findings recorded intraoperatively or on a pathology report. Results: 65 cases were included. The tramline sign was partially (17) or fully (19) obliterated in 36 cases (55.4 %), and present in 29 (44.6 %). Obliteration was associated with earlier gestational age at delivery (35 + 1 (26 + 3-38 + 3) vs. 36 + 4 (25 + 3-38 + 0) weeks, p = 0.005), greater estimated blood loss (800 (400-11 000) vs. 600 (300-2100) mls, p = 0.003), longer operative time (155 (60-240) vs. 54 (25-80) minutes, p < 0.001), higher rate of hysterectomy (97.2 % vs. 0.0 %, p < 0.001), longer postoperative admission (7 (3-19) vs. 3Â (1-5) days, p < 0.001) and a 100 % rate of postnatal diagnosis of PAS. The finding of an obliterated tramline sign identified all women that required hysterectomy and all cases of PAS. Conclusion: A partially or fully obliterated tramline sign is strongly associated with indicators of operative complexity, the postnatal confirmation of PAS, and the need for peripartum hysterectomy.
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