Prophylactic use of intravascular balloon catheters in women with placenta accreta, increta and percreta

Clinical evaluation of the effect for prophylactic balloon occlusion in pregnancies complicated with placenta accreta spectrum disorder: A systematic review and meta-analysis

BACKGROUND

Placenta accreta spectrum (PAS) disorder is a critical and severe obstetric condition associated with high risk of intraoperative massive hemorrhage and cesarean hysterectomy. Severe obstetric hemorrhage is currently one of the leading causes of maternal death worldwide. Prophylactic balloon occlusions, including prophylactic balloon occlusion of the abdominal aorta (PBOAA) and prophylactic balloon occlusion of the internal iliac arteries (PBOIIA), are the most common means of controlling hemorrhage in patients with PAS disorder, but their effectiveness is still debated.

OBJECTIVE

A systematic review and meta-analysis were conducted to evaluate the clinical effectiveness of prophylactic balloon occlusion during cesarean section (CS) in improving maternal outcomes for PAS patients.

SEARCH STRATEGY

MEDLINE, EMBASE, OVID, PubMed and the Cochrane Library were systematically searched from the inception dates to June 2022, using the keywords "placenta accreta spectrum disorder/morbidly adherent placenta (placenta previa, placenta accreta, placenta increta, placenta percreta), balloon occlusion, internal iliac arteries, abdominal aorta, hemorrhage, hysterectomy, estimated blood loss (EBL), packed red blood cells (PRBCs)" to identify the systematic reviews or meta-analyses.

SELECTION CRITERIA

All articles regarding PAS disorders and including the application of balloon occlusion were included in the screening.

DATA COLLECTION AND ANALYSIS

Two independent researchers performed the data extraction and assessed study quality. EBL volume and PRBC transfusion volume was regarded as the primary endpoints. Random and fixed effects models were used for the meta-analysis (RRs and 95% CIs), and the Newcastle-Ottawa Scale was used for quality assessments.

MAIN RESULTS

Of 429 studies identified, a total of 35 trials involving the application of balloon occlusion for patients with PAS disorder during CS were included. A total of 19 studies involving 935 patients who underwent PBOIIA were included in the PBOIIA group, and 851 patients were included in control 1 group. Ten studies including 428 patients with PAS who underwent PBOAA were allocated to the PBOAA group, and 324 patients without PBOAA were included in control 2 group. Simultaneously, we compared the effect on PBOAA and PBOIIA including seven studies, which referred to 267 cases in the PBOAA group and 313 cases in the PBOIIA group. The results showed that the PBOIIA group had a reduced EBL volume (MD: 342.06 mL, 95% CI: -509.90 to -174.23 mL, I2 = 77%, P < 0.0001) and PRBC volume (MD: -1.57 U, 95% CI: -2.49 to -0.66 U, I2 = 91%, P = 0.0008) than that in control 1 group. With regard to the EBL volume (MD: -926.42 mL, 95% CI: -1437.07 to -415.77 mL, I2 = 96%, P = 0.0004) and PRBC transfusion volume (MD: -2.42 U, 95% CI: -4.25 to -0.59 U, I2 = 99%, P = 0.009) we found significant differences between the PBOAA group and control 2 group. Prophylactic balloon occlusion (PBOAA and PBOIIA) had a significant effect on reducing intraoperative blood loss and blood transfusion volume in patients with PAS. Moreover, PBOAA was more effective than PBOIIA in reducing intraoperative blood loss (MD: -406.63 mL, 95% CI: -754.12 to -59.13 mL, I2 = 92%, P = 0.020), but no significant difference in controlling PRBCs (MD: -3.48 U, 95% CI: -8.90 to 1.95 U, I2 = 99%, P = 0.210) between the PBOIIA group and the PBOAA group. Hierarchical analysis was conducted by differentiating gestational weeks and maternal age to reduce the high heterogeneity of meta-analysis. Hierarchical analysis results demonstrated the heterogeneities of the study were reduced to some extent, and gestational weeks and maternal age might be the cause of increased heterogeneity.

CONCLUSION

Prophylactic balloon occlusion is a safe and effective method to control hemorrhage and reduce PRBC transfusion volume for patients with PAS, and PBOAA could reduce more intraoperative blood loss than PBOIIA. However, we found no statistical difference in lessening packed red blood cell transfusion volume for PAS patients. Hence, preoperative prophylactic balloon occlusion is the recommended application for PAS patients in obstetric CSs. Furthermore, PBOAA is preferred for controlling intraoperative bleeding in patients with corresponding medical conditions.

Evidence-based surgery for cesarean hysterectomy secondary to placenta accreta spectrum: A systematic review

OBJECTIVE

In this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity.

DATA SOURCES

We conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy.

STUDY ELIGIBILITY CRITERIA

We included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria.

STUDY APPRAISAL AND SYNTHESIS METHODS

Articles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations.

RESULTS

Based on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria).

CONCLUSIONS

Development of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted.

Prophylactic Radiologic Interventions for Postpartum Hemorrhage Control in Women With Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis

OBJECTIVE

To quantify the association between prophylactic radiologic interventions and perioperative blood loss during cesarean delivery in women with placenta accreta spectrum disorder through a systematic review and network meta-analysis.

DATA SOURCES

On January 3, 2023, a literature search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science. We also checked ClinicalTrials.gov retrospectively. Prophylactic radiologic interventions to reduce bleeding during cesarean delivery involved preoperative placement of balloon catheters, distal (internal or common iliac arteries) or proximal (abdominal aorta), or sheaths (uterine arteries). The primary outcome was volume of blood loss; secondary outcomes were the number of red blood cell units transfused and adverse events. Studies including women who received an emergency cesarean delivery were excluded.

METHODS OF STUDY SELECTION

Two authors independently screened citations for relevance, extracted data, and assessed the risk of bias of individual studies with the Cochrane Risk of Bias in Non-randomized Studies of Interventions tool.

TABULTATION, INTEGRATION, AND RESULTS

From a total of 1,332 screened studies, 50 were included in the final analysis, comprising 5,962 women. These studies consisted of two randomized controlled trials and 48 observational studies. Thirty studies compared distal balloon occlusion with a control group, with a mean difference in blood loss of -406 mL (95% CI, -645 to -167). Fourteen studies compared proximal balloon occlusion with a control group, with a mean difference of -1,041 mL (95% CI, -1,371 to -710). Sensitivity analysis excluding studies with serious or critical risk of bias provided similar results. Five studies compared uterine artery embolization with a control group, all with serious or critical risk of bias; the mean difference was -936 mL (95% CI, -1,522 to -350). Reported information on adverse events was limited.

CONCLUSION

Although the predominance of observational studies in the included literature warrants caution in interpreting the findings of this meta-analysis, our findings suggest that prophylactic placement of balloon catheters or sheaths before planned cesarean delivery in women with placenta accreta spectrum disorder may, in some cases, substantially reduce perioperative blood loss. Further study is required to quantify the efficacy according to various severities of placenta accreta spectrum disorder and the associated safety of these radiologic interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022320922.

Outcome evaluation of prophylactic internal iliac balloon occlusion in the management of patients with placenta accreta spectrum

PURPOSE

To evaluate outcomes and complications of prophylactic internal iliac balloon occlusion (PIIBO) in the management of patients with placenta accreta spectrum (PAS) at a large regional referral centre.

MATERIALS AND METHODS

A retrospective review of all PIIBO for PAS performed over a 12-year period (2010-2022). Information for analysis was gathered from the local RIS/PACS and clinical documentation. Collected data included patient demographics, indication for procedure, sheath insertion and removal time, total duration of balloon inflation and complications that occurred.

RESULTS

106 patients underwent temporary internal iliac artery balloon occlusion within the 12-year period. All procedures utilised bilateral common femoral artery punctures, 6Fr sheath and 5Fr Le Maitre occlusion balloons. Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. There was no maternal mortality or foetal morbidity. Twenty patients (18.9%) had some form of complication that required further intervention. Of these, 7(6.6%) had post-operative PPH, which was treated with uterine artery embolisation; and 13 (12.3%) had arterial thrombus which required aspiration thrombectomy. All procedures were technically successful with no long-term sequelae.

CONCLUSION

PIIBO plays an important part in reducing morbidity and mortality in patients with PAS. Clear pathways and multidisciplinary team working is critical in the management of these patients to ensure that any complications are dealt with promptly to avoid long-term sequelae.

Is temporary clamping of the bilateral common iliac artery beneficial in reducing intraoperative blood loss in patients with segmental resected anterior placenta percreta?: A prospective observational study

OBJECTIVE

The aim of our study was to investigate whether temporary clamping of the bilateral common iliac artery (BCIA) has a role in reducing intraoperative blood loss in patients with segmentally resected anterior placenta percreta or not.

METHODS

This prospective observational study included patients with anterior placenta percreta who underwent cesarean segmental resection either with BCIA temporary clamping or without clamping between October 2022 and September 2023.

RESULTS

A comparison of demographic, obstetric, and surgical parameters and the need for transfusion (except for postoperative erythrocyte suspension transfusion) between the two groups revealed no significant difference (P > 0.05). In contrast, the amount of intraoperative blood loss (P = 0.001) (1974 ± 749 mL vs 2702 ± 615 mL) and postoperative erythrocyte suspension transfusion (P = 0.046) in patients who underwent BCIA temporary clamping were significantly lower than in those who did not undergo BCIA temporary clamping.

CONCLUSION

Temporary clamping of BCIA plays a significant favorable role both in reducing blood loss and the need for postoperative transfusion in patients with placenta percreta who underwent segmental uterine resection.

Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study

Background

The placenta accreta spectrum is a complex disorder characterized by abnormal invasion of the placenta into the uterine wall, posing a significant risk of life-threatening haemorrhage for patients. Its incidence is on the rise, largely attributed to the increasing rates of caesarean sections. Management of this spectrum involves a multidisciplinary approach, although standardized protocols are not yet established. While caesarean hysterectomy remains the standard Gold, several adjunctive treatments have emerged in recent years to mitigate bleeding risk and associated morbidity. Among these, prophylactic occlusion balloons placed in the internal iliac arteries have shown promise. The aim of our study is to demonstrate the effect of prophylactic occlusion balloons in both uterine iliac arteries in the management of placental accreta spectrum disorders.

Methods

A retrospective monocentric cohort study was conducted in the Department "C" of Gynaecology and Obstetrics at the Maternity Center of Tunis. The study spanned three years, from January 2nd, 2020, to December 31st, 2022. The study population consisted of two groups: Control Group (CG) comprised patients who underwent caesarean hysterectomy without internal-iliac prophylactic occlusion balloons, and Occlusion balloons of both internal iliac arteries Group (OBIIAG) included patients who underwent caesarean hysterectomy with internal-iliac prophylactic occlusion balloons.

Results

A total of 38 patients were included in the study, all of whom exhibited similar epidemiological characteristics and comparable personal and obstetric histories. The most prevalent risk factor among the patients was a history of caesarean section (92%). On average, patients were diagnosed at 30 weeks of gestation, with third-trimester bleeding being the most common presentation (71% of cases). The median gestational age at delivery was between 36 and 37 weeks. We observed a significant difference in blood loss between the two groups (2888 ml in the control group and 1828 ml in the group with internal-iliac prophylactic occlusion balloons, p < 0.05). Implementation of this technique resulted in a reduced need for massive transfusions (p < 0.01) and shorter operating times (126 min for the control group and 92 min for the group with internal-iliac prophylactic occlusion balloons; p = 0.04). There were no significant differences in morbidity between the two groups.

Conclusion

The intra-iliac prophylactic occlusion balloons can help reduce the risk of hemorrhage and the morbidities that come with the placenta accreta spectrum disorder.

Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach

Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.

Prophylactic radiologic interventions to reduce postpartum hemorrhage in women with risk factors for placenta accreta spectrum disorder: a nationwide cohort study

OBJECTIVE

To quantify the association between prophylactic radiologic interventions and perioperative blood loss in women with risk factors for placenta accreta spectrum disorder (PAS).

METHODS

We conducted a retrospective nationwide cohort study of women with risk factors for placenta accreta spectrum disorder who underwent planned cesarean section in 69 Dutch hospitals between 2008 and 2013. All women had two risk factors for PAS: placenta previa/anterior low-lying placenta and a history of cesarean section(s). Women with and without ultrasonographic signs of PAS were studied as two separate groups. We compared the total blood loss of women with prophylactic radiologic interventions, defined as preoperative placement of balloon catheters or sheaths in the internal iliac or uterine arteries, with that of a control group consisting of women without prophylactic radiologic interventions using multivariable regression. We evaluated maternal morbidity by the number of red blood cell (RBC) units transfused within 24 h following childbirth (categories: 0, 1-3, >4), duration of hospital admission, and need for intensive care unit (ICU) admission.

RESULTS

A total of 350 women with placenta previa/anterior low-lying placenta and history of cesarean section(s) were included: 289 with normal ultrasonography, of whom 21 received prophylactic radiologic intervention, and 61 had abnormal ultrasonography, of whom 22 received prophylactic intervention. Among women with normal ultrasonography without prophylactic intervention (n = 268), the median blood loss was 725 mL (interquartile range (IQR) 500-1500) vs. 1000 mL (IQR 550-1750) in women with intervention (n = 21); the adjusted difference in blood loss was 9 mL (95% confidence interval (CI) -315-513), p = .97). Among women with abnormal ultrasonography, those without prophylactic intervention (n = 39) had a median blood loss of 2500 mL (IQR 1200-5000) vs. 1750 mL (IQR 775-4000) in women with intervention (n = 22); the adjusted difference in blood loss was -1141 mL (95% CI -1694- -219, p = .02). Results of outcomes on maternal morbidity were comparable among women with and without prophylactic intervention.

CONCLUSION

These findings suggest that prophylactic radiologic interventions prior to planned cesarean section may help to limit perioperative blood loss in women with clear signs of placenta accreta spectrum disorder on ultrasonography, but there was no evidence of a difference within the subgroup without such ultrasonographic signs. The use of these interventions should be discussed in a multidisciplinary shared decision-making process, including discussions of potential benefits and possible complications.

TRIAL REGISTRATION

Netherlands Trial Registry, https://onderzoekmetmensen.nl/en/trial/28238, identifier NL4210 (NTR4363).

Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum

PURPOSE

To evaluate the effectiveness and safety of prophylactic multivessel selective embolization (MVSE) compared to those of internal iliac artery occlusion balloon (IIABO) placement in patients undergoing cesarean hysterectomy for placenta accreta spectrum (PAS).

MATERIALS AND METHODS

An institutional review board-approved retrospective series was conducted with consecutive patients with PAS at a single institution between 2010 and 2021. MVSE was performed in a hybrid operating room after cesarean section prior to hysterectomy. IIABO was performed with balloons placed into the bilateral internal iliac arteries, which were inflated during hysterectomy. Median blood loss, transfusion requirements, percentage of cases requiring transfusion, and adverse events were recorded.

RESULTS

A total of 20 patients treated with embolization and 34 patients with balloon placement were included. Placenta percreta and previa were seen in 60% and 90% of patients, respectively. Median blood loss in the MVSE group was 713 mL (interquartile range [IQR], 475-1,000 mL) compared to 2,000 mL (IQR, 1,500-2,425 mL) in the IIABO group (P < .0001). The median total number of units of packed red blood cell transfusions (0 vs 2.5) and percentage of cases requiring a transfusion (20% vs 65%) were less in the MVSE group (P < .01). A median of 4 vessels (IQR, 3-9) were embolized during MVSE. No major adverse events or nontarget embolization consequences were observed.

CONCLUSIONS

Prophylactic MVSE is a safe procedure that reduces operative blood loss and transfusion requirements compared to those of IIABO in patients undergoing cesarean hysterectomy for presumed higher-degree PAS.

General Management Considerations for Placenta Accreta Spectrum

The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.

Emergency Obstetric Hysterectomy after Conservative Management of Placenta Accreta

Background

Obstetric hemorrhage is a frequent and life-threatening complication of either vaginal or cesarean delivery. It can be due to many causes, one of which is placenta accreta, the abnormal invasion of the placenta into the myometrial wall of uterus. Ultrasonography is the first line diagnostic method that can lead to the diagnosis of placenta accreta although, the depth of penetration is estimated by magnetic resonance imaging. Placenta accreta is a life-threatening situation requiring an experienced health care team for its management. Hysterectomy is usually performed although, conservative management might be preferred in carefully selected cases. Case Presentation. A 32-year-old woman (G2, P0) who had an inconsistently monitored pregnancy appeared at a regional hospital with contractions at 39th week of gestation. In her first pregnancy, she was subjected to cesarean section due to delay in second stage of labor and unfortunately her child died due to sudden cardiac death. During C-section, placenta accreta was identified. Given her previous history and her desire to maintain fertility, conservative management was initially planned to preserve her uterus. However, due to persisting vaginal bleeding immediately after delivery an emergency hysterectomy was performed.

Conclusion

Conservative management of placenta accreta can be considered in some special cases with the aim to spare fertility. However, if bleeding cannot be controlled during the immediate postpartum period, emergency hysterectomy is unavoidable. A specialized multidisciplinary medical team is required to optimize management.

Placenta Accreta Spectrum Part II: hemostatic considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality-as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized "centers of excellence," and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.

Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.

Placenta Accreta Spectrum: Prenatal Diagnosis and Management

The incidence of placenta accreta spectrum (PAS) is increasing and is now about 3 per 1000 deliveries, largely due to the rising cesarean section rate. Ultrasound is the preferred method for diagnosis of PAS. Ultrasound markers include multiple vascular lacunae, loss of the hypoechoic retroplacental zone, abnormalities of the uterine serosa-bladder interface, retroplacental myometrial thickness less than 1 mm, increased placental vascularity, and observation of bridging vessels linking the placenta and bladder. Patients with PAS should be managed by experienced multidisciplinary teams. Hysterectomy is the accepted management of PAS and conservative or expectant management of PAS should be considered investigational.

Utilizations and outcomes of intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum

INTRODUCTION

This study examined national-level trends, characteristics, and perioperative outcomes of women who had intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum (PAS).

MATERIAL AND METHODS

This was a population-based retrospective observational study that queried the National Inpatient Sample from October 2015 to December 2018. Study population was women who underwent hysterectomy at cesarean delivery for PAS (n = 6440 in 806 centers). Exposure allocation was the use of intra-arterial balloon occlusion. Main outcome measures were (a) characteristics associated with intra-arterial balloon occlusion use, and (b) perioperative outcome including hemorrhage, blood transfusion, coagulopathy, shock, urinary tract injury, intra-arterial balloon occlusion-related complication (arterial injury, arterial thrombosis, and lower extremities ischemia), and death, assessed in multivariable analysis.

RESULTS

Intra-arterial balloon occlusion was used in 420 (6.5%) women in 64 (7.9%) centers. Utilization of intra-arterial balloon occlusion during cesarean hysterectomy for placenta accreta decreased significantly over time (from 6.3% to 3.1%, p < 0.001), but not in placenta increta (from 12.8% to 9.3%, p = 0.204) or placenta percreta (from 21.3% to 17.5%, p = 0.344). In a multivariable analysis, patient factors (younger age, earlier year, obesity, diabetes mellitus), pregnancy factors (placenta increta/percreta, previous cesarean delivery, placenta previa, and early gestational age), and facility factors (large bed capacity, urban teaching status, and Northeast/West regions) represented the independent characteristics for using the intra-arterial balloon occlusion (all, p < 0.05). In a classification-tree model, the absolute difference in intra-arterial balloon occlusion use among 18 utilization patterns was 48% (range, 0%-48%). In perioperative outcome analysis, women who received intra-arterial balloon occlusion were more likely to have coagulopathy (adjusted odds ratio [aOR] 3.43) and arterial thrombosis (aOR 9.82) in placenta accreta, but less likely to have hemorrhage (aOR 0.25) in placenta increta, and blood transfusion (aOR 0.60) and urinary tract injury (aOR 0.28) in placenta percreta compared with those who did not (all, p < 0.05).

CONCLUSIONS

There is a wide range in the utilization of intra-arterial balloon occlusion at cesarean hysterectomy for PAS based on patient, pregnancy, and facility factors, which implies that there is a lack of universal practice guidelines in this surgical procedure. Whether the use of intra-arterial balloon occlusion in the severe forms of PAS improves surgical outcome merits further investigation.

Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization: the PASTIME protocol

BACKGROUND

Multidisciplinary care of placenta accreta spectrum cases improves pregnancy outcomes, but the specific components of such a multidisciplinary collaboration varies between institutions. As experience with placenta accreta spectrum increases, it is crucial to assess new surgical techniques and protocols to help improve maternal outcomes and to advocate for hospital resources.

OBJECTIVE

This study aimed to assess a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that comprises cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite.

STUDY DESIGN

This was a matched prepost study of placenta accreta spectrum cases managed before (2010-2017) and after implementation of the Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol (2018-2021) at a tertiary medical center. Historical cases were managed with internal iliac artery balloon placement in selected cases with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. Intraoperative Embolization cases were compared with historical cases in a 1:2 ratio matched on the basis of placenta accreta spectrum severity and surgical urgency. The primary outcome was a requirement for transfusion with packed red blood cells. Secondary outcomes included estimated surgical blood loss, operative and postoperative complications, procedural time, length of stay, and neonatal outcomes.

RESULTS

A total of 15 Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization cases and 30 matched historical cases were included in the analysis. There were no demographic differences noted between the groups. A median (interquartile range) of 0 units (0-2 units) of packed red blood cells were transfused in the Intraoperative Embolization group compared with 2 units (0-4.5 units) in the historical group (P=.045); 5 of 15 (33.3%) Intraoperative Embolization cases required blood transfusions compared with 19 of 30 (63.3%) cases in the historical group (P=.11). The estimated blood loss was significantly less in the Intraoperative Embolization group with a median (interquartile range) of 750 mL (450-1050 mL) compared with 1750 mL (1050-2500 mL) in the historical group (P=.003). There were no cases requiring massive transfusion (≥10 red blood cell units in 24 hours) in the Intraoperative Embolization group compared with 5 of 30 (16.7%) cases in the historical group (P=.15). There were no intraoperative deaths from hemorrhagic shock using the Intraoperative Embolization protocol, whereas this occurred in 2 of the historical cases. The mean duration of the interventional radiology procedure was longer in the Intraoperative Embolization group (67.8 vs 34.1 minutes; P=.002). Intensive care unit admission and postpartum length of stay were similar, and surgical and postoperative complications were not significantly different between the groups. The gestational age and neonatal birthweights were similar; however, the neonatal length of stay was longer in the Intraoperative Embolization group (median duration, 32 days vs 15 days; P=.02) with a trend toward low Apgar scores. Incidence of arterial umbilical cord blood pH <7.2 and respiratory distress syndrome and intubation rates were not statistically different between the groups.

CONCLUSION

A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and estimated blood loss with no increase in operative complications. The Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol provides a definitive surgical method that warrants consideration by other centers specializing in placenta accreta spectrum treatment.

Placenta Accreta Spectrum Disorder in a Patient with Six Previous Caesarean Deliveries: Step by Step Management

The definition placenta accreta spectrum disorders (PAS) introduced by FIGO (International Federation of Gynaecology and Obstetrics) indicates an abnormal, pathological adherence or invasion of the placenta. The growing worldwide incidence of this pathological entity, and the possible serious correlated surgical risks, has caused a significant increase in attention among the scientific community. Previous caesarean delivery and presence of placenta previa are the main risk factors for the onset of PAS. Here, we present the intriguing case of a 39-year-old woman, at the 33rd week of gestation, with six previous caesarean sections and with a diagnosis of placenta previa accreta. At our referral center for PAS disorders, we successfully managed this difficult case with the help of a multidisciplinary skilled team.

Intraoperative blood volume loss according to gestational age at delivery among pregnant women with placenta accreta spectrum (PAS): an 11-year experience in Songklanagarind Hospital

A retrospective study was conducted to evaluate the intraoperative blood volume loss in pregnant women with PAS according to gestational age at delivery. A total of 116 women were enrolled, 39 (33.6%) had an intraoperative massive blood loss (>5000 ml). The massive haemorrhage group had statistically significantly higher percentages of increta and percreta type than the non-massive haemorrhage group (94.9 vs. 67.5%, p < .001). Multiple linear regression analysis showed a decreasing trend of intraoperative blood loss after 34 weeks' gestation with the nadir period between 35 and 36⁺⁶ weeks' gestation, especially from 36-36⁺⁶ weeks' gestation which was statistically significant, p <.05. The perinatal morbidities from 36-36⁺⁶weeks were not statistically significantly different from 37 weeks' gestation. Therefore, we recommend that pregnant women with PAS and stable clinical symptoms should be scheduled for caesarean hysterectomy from 36-36⁺⁶ weeks' gestation.Impact statementWhat is already known on this subject? Massive obstetric haemorrhage from PAS disorders is the main concern for caesarean hysterectomy among these patients as it leads to secondary complications including coagulopathy, multisystem organ failure, and death.What do the results of this study add? The amount of intraoperative blood loss in pregnant women who underwent caesarean hysterectomy due to PAS, was lowest from 36-36⁺⁶ weeks' gestation.What are the implications of these findings for clinical practice and/or further research? We recommend that pregnant women with PAS and stable clinical symptoms should be scheduled for caesarean hysterectomy from 36-36⁺⁶ weeks' gestation.

Safer outcomes for placenta accreta spectrum disorders: A decade of quality improvement

OBJECTIVE

To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders.

METHODS

A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization.

RESULTS

Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 ml in the initial period to 1000 ml in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days).

CONCLUSION

These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.

Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis

PURPOSE

To examine the effectiveness and safety of prophylactic internal iliac artery balloon occlusion for hemorrhage control in placenta accreta.

METHOD

EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials data-bases were searched through November 2020. Clinical trials comparing the management of placenta accreta with and without internal iliac artery balloon occlusion were included. The meta-analysis results were expressed as the risk ratio (RR) or mean difference, with 95 % CIs.

RESULTS

Fifteen studies including 1098 women were eligible. No statistically significant difference was found between the internal arterial balloon occlusion group and the control group with respect to estimated blood loss volume (-0.525 mL, [95 % CI, -1.112 to -0.061], p = 0.079.), red blood cells (RBCs) transfused in observational studies (-0.682 mL, [95 % CI, -1.540 to 0.176], p = 0.119.) and in randomized controlled trials (0.134 mL, [95 % CI, -0.214 to 0.482], p = 0.451.), intensive care unit admission (p = 0.197), hysterectomy in observational studies (p = 0.969) and in randomized controlled trials (p = 0.323), urinary system injury in observational studies (p = 0.182) and in randomized controlled trials (p = 0.956), Apgar score at 5 min (p = 0.641), and neonatal intensive care unit admission (p = 0.973).

CONCLUSIONS

The currently available data demonstrate no significant differences between the internal iliac artery balloon occlusion group and the control group in blood loss and packed RBCs transfused for women with placenta accreta. Further large randomized controlled studies are needed to confirm our findings.

Experience of Managing Suspected Placenta Accreta Spectrum with or without Internal Iliac Artery Balloon Occlusion in Two Lithuanian University Hospitals

Background and objectives: Placenta previa and placenta accreta spectrum are considered major causes of massive postpartum hemorrhage. Objective: To determine whether the placement of an occlusion balloon catheter in the internal iliac artery could reduce bleeding and other related complications during cesarean delivery in patients with placenta previa and placenta accreta spectrum. Materials and Methods: A retrospective analysis was conducted at two tertiary obstetric units of Lithuania. From January 2016 to November 2019 patients with placenta previa and antenatally suspected invasive placenta were included in the intervention group and underwent cesarean delivery with endovascular procedure. From January 2014 to December 2015 patients with placenta previa and suspected placenta accreta spectrum were included in the non-intervention group. The primary outcomes were reduction in intraoperative blood loss and transfusion volumes in the intervention group. Secondary outcomes were the incidence of hysterectomy and maternal complications. Results: Nineteen patients underwent cesarean delivery with preoperative endovascular procedure, and 47 women underwent elective cesarean delivery. The median intraoperative blood loss (1000 (400-4500) mL vs. 1000 (400-5000) mL; p = 0.616) and the need for red blood cell transfusion during operation (26% vs. 23%; p = 0.517) did not differ significantly between the patients groups. Seven patients in the intervention group and two patients in the non-intervention group underwent perioperative hysterectomy (p = 0.002). None of the patients had complications related to the endovascular procedure. Conclusion: The use of intermittent balloon occlusion catheter in patients with placenta pathology is a safe method but does not significantly reduce intraoperative blood loss during cesarean delivery.

The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis

BACKGROUND

Placenta previa describes a placenta that extends partially or completely over the internal cervical oss. Placenta previa is one of the leading causes of widespread postpartum hemorrhage and maternal mortality worldwide. Another cause of bleeding in pregnant women is Placenta accreta spectrum. Therefore, the aim of the present systematic review and meta-analysis is to determine the effect of prophylactic balloon occlusion of the internal iliac arteries in patients with placenta previa or placental accreta spectrum (PAS).

METHODS

In this systematic review and meta-analysis, to identify and select relevant studies, the SID, MagIran, ScienceDirect, Embase, Scopus, PubMed, Web of Science, and Google Scholar databases were searched, using the keywords of internal iliac artery balloon, placenta, previa, balloon, accreta, increta and percreta, without a lower time limit and until 2020. The heterogeneity of the studies was examined using the I² index, and subsequently a random effects model was applied. Data analysis was performed within the Comprehensive Meta-Analysis software (version 2).

RESULTS

In the review of 29 articles with a total sample size of 1140 in the control group, and 1225 in the balloon occlusion group, the mean difference between the two groups was calculated in terms of Intraoperative blood loss index (mL) and it was derived as 3.21 ± 0.38; moreover, in 15 studies with a sample size of 887 in the control group, and 760 in the balloon occlusion group, the mean difference between the two groups in terms of gestation index (weeks) was found as 2.84 ± 0.49; and also with regards to hysterectomy balloon occlusion after prophylactic closure of the iliac artery, hysterectomy (%) balloon occlusion was calculated as 8.9 %, and this, in the hysterectomy control group (%) was obtained as 31.2 %; these differences were statistically significant and showed a positive effect of the intervention (P < 0.05).

CONCLUSION

The results of this study show that the use of prophylactic internal iliac artery balloon occlusion in patients with placenta previa or Placenta accreta spectrum has benefits such as reduced intraoperative blood loss, reduced hysterectomy and increased gestation (weeks), which can be considered by midwives and obstetricians.

Postpartum Hemorrhages: Prevention

The strict correlation between abnormal invasive placentation and postpartum hemorrhage suggests that a widespread antenatal diagnosis of placental anomalies would improve the management of these challenging patients; acting preventive solutions at the moment of delivery reduces blood loss and avoid hysterectomies. The role of endovascular procedures in this field has been encouraged by multiple studies reporting prophylactic uterine arteries embolization and iliac/aortic balloon catheters positioning. This paper aims to review the main imaging diagnostic findings of placental implant anomalies and summarize the principal preventive endovascular strategies proposed in literature.

Role of interventional radiology in placenta accreta spectrum (PAS) disorders

Placenta accreta spectrum (PAS) disorders are rare but potentially life-threatening obstetric conditions, which can result in severe post-partum haemorrhage (PPH). Traditional management necessitates peripartum hysterectomy, but this carries high rates of morbidity and mortality. More recently, interventional radiology techniques have been developed in order to reduce morbidity and preserve fertility. This article summarises and compares the various reported interventional radiology techniques. Arterial embolisation performed to treat PPH is the therapeutic option which is supported by the highest degree of evidence. The role of preventative procedures, such as temporary balloon occlusion of the internal iliac arteries or distal aorta, continues to be debated due to conflicting outcome data and concerns regarding associated morbidity. The choice of which, if any, interventional radiological technique is utilised is determined by local expertise, available resources and the planned obstetric approach. The most complex patients are likely to benefit from multidisciplinary management in high-volume centres.

Placenta percreta - a management dilemma: an institutional experience and review of the literature

Objective

Placenta percreta is an extremely high-risk obstetric condition often associated with significant maternal morbidity and mortality. To date, there is no consensus on its management. This article aimed to identify an optimum management option to improve maternal outcomes in patients with placenta percreta.

Material and Methods

This was an observational study conducted at a tertiary care institute from October 2019 to June 2020. A well-defined plan of preoperative, bilateral, uterine artery catheter placement, cesarean delivery (CD) of the baby followed by uterine artery embolization (UAE), and elective delayed hysterectomy after 2-4 weeks, was made by a multidisciplinary team. Demographic variables such as age, parity, period of gestation, presenting complaints, imaging findings, mode of management, intraoperative findings, blood loss, the requirement for blood and blood products, and complications were noted.

Results

We encountered seven cases of placenta percreta over a period of nine months. UAE was performed in 6/7 patients. UAE was not performed in one patient as she presented to the emergency department in shock. Elective delayed hysterectomy was performed after 2-4 weeks in three patients, three patients required emergency hysterectomy (two during CD and one on the seventh postoperative day) and one patient was managed conservatively by leaving the placenta in situ after CD and UAE. Patients who underwent UAE had notably less intraoperative blood loss and requirement of blood and blood products than the patient who could not receive UAE. During cesarean hysterectomy, blood loss was 1,700 mL in embolized (case 4) vs 3,000 mL in unembolized patient (case 7). In embolized patients, the median blood loss during CD (case 1,2,3,5,6) was 200 mL (interquartile range: 165-200 mL) and during delayed elective hysterectomy (case 1,3,5) was 150 mL (range: 125-225 mL). Blood loss in case 2 was 1,000 mL during emergency hysterectomy on the 7^th day of CD and UAE. The blood loss was appreciably higher in patients who underwent immediate cesarean hysterectomy rather than elective delayed hysterectomy.

Conclusion

Placenta percreta, if not managed in a preplanned manner, may lead to disastrous maternal outcomes. Prophylactic devascularization during CD and leaving the placenta in situ followed by elective delayed hysterectomy, might be a reasonable management option in most severe cases of placenta percreta.

A practical FIST maneuver to minimize the bleeding during cesarean hysterectomy for placenta percreta: a retrospective comparative study

BACKGROUND

Placenta percreta (PP) is a life-threatening condition and its surgery poses a very high potential for bleeding. The recommended treatment is a cesarean hysterectomy. There are several techniques reported in the literature to reduce the bleeding during percreta operations.

OBJECTIVE

To show and describe a practical and novel intraoperative maneuver to minimize the hemorrhage during cesarean hysterectomy for PP.

METHODS

The patients who were diagnosed with PP and underwent cesarean hysterectomy (CH) in our unit between 2016 and 2020 were retrospectively evaluated. These patients were divided into two groups. Group A included patients who underwent hysterectomy with intraoperative FIST maneuver. Group B included patients with ordinary cesarean hysterectomy. The groups were compared with regards to the intraoperative bleeding, surgical complications, and perioperative outcomes.

RESULTS

Seventy-two patients who had a cesarean hysterectomy and diagnosed with PP during the study period were included in this retrospective cohort. 22 patients underwent intraoperative FIST maneuver with CH as Group A and 50 patients underwent ordinary CH as Group B. The demographic variables including maternal age, gravida, number of previous cesarean sections, and body-mass index were not statistically different between the two groups. Intraoperative FIST maneuver was significantly associated with reduced operative hemorrhage, the need for transfusion of erythrocyte suspension, admission to intensive care unit, and hospitalization days (p < .005). The operative time was statistically significantly shorter in Group A than Group B, respectively (90 ± 18.6 vs 120 ± 20.5 min) (p < .05).

CONCLUSION

FIST maneuver is a very practical, easy to apply, and effective method that reduces the obstetrical bleeding during cesarean hysterectomy in placenta percreta cases.

Management of massive hemorrhage in pregnant women with placenta previa

Patients with placenta previa are at risk for intra- and postpartum massive blood loss as well as increased risk of placenta accreta, a type of abnormal placental implantation. This condition can lead to serious obstetric complications, including maternal mortality and morbidity. The risk factors for previa include prior cesarean section, multiparity, advanced maternal age, prior placenta previa history, prior uterine surgery, and smoking. The prevalence of previa parturients has increased due to the rising rates of cesarean section and advanced maternal age. For these reasons, we need to identify the risk factors for previa and identify adequate management strategies to respond to blood loss during surgery. This review evaluated the diagnosis of placenta previa and placenta accreta and assessed the risk factors for previa-associated bleeding prior to cesarean section. We then presented intraoperative anesthetic management and other interventions to control bleeding in patients with previa expected to experience massive hemorrhage and require transfusion.

Retrospective review of cesarean hysterectomy outcomes utilizing uterine intravascular interventions in a large, community-based healthcare setting

OBJECTIVE

To explore outcomes of women with planned cesarean hysterectomies, with or without use of internal iliac intravascular occlusive balloon catheter or uterine artery embolization (UAE).

STUDY DESIGN

We retrospectively reviewed adult women who underwent a planned cesarean hysterectomy, 2004-2019. All planned cases were included, regardless of indication. Planned surgeries were divided into three groups: balloon placement, UAE, or no intervention. Patients with balloon placement were further subdivided into: balloons placed but not deployed or balloons placed and deployed intraoperatively. Hemorrhage was defined as estimated blood loss (EBL) ≥1,500 mL. An adverse outcome was defined as one or more of the following: intensive care unit admission, thromboembolism, ureteral stent placement, amputation, or reoperation. Basic descriptive and inferential statistics were used to explore differences among groups and adverse outcomes.

RESULTS

A total of 34 patients underwent planned cesarean hysterectomy. Ten patients (29.4%) had balloons placed, nine (26.5%) had UAE, and 15 (44.1%) had no intervention. Risk of hemorrhage was clinically higher among those with balloon placement (80% vs. 33% UAE vs. 60% no intervention; P = 0.14), with mean EBL (3,605.0 mL vs. 1,488.9 mL vs. 2,289.3 mL; P = 0.05) and mean transfusion requirements (9.3 units vs. 2.8 vs. 4.4; P = 0.01) being significantly higher. Adverse outcomes were also significantly higher among those with balloon placement (80.0% vs. 66.7% UAE vs. 20.0% no intervention; P ≤ 0.01). Of the ten patients with balloons placed, four were deployed. Among those with balloons placed and deployed, mean EBL (5,250.0 mL vs. 2,508.3 mL balloons placed but not deployed vs. 2,289.3 mL no intervention; P=0.04) and mean transfusion requirements (11 units vs. 7.5 units balloons placed but not deployed vs. 4.4 units no intervention; P = 0.05) were significantly higher. Adverse outcomes were also significantly higher among those who had balloons placed and deployed (100.0% vs. 66.7% balloons placed but not deployed vs. 20.0% no intervention; P ≤ 0.01).

CONCLUSIONS

Balloon placement, regardless of deployment, may not be beneficial to women undergoing a planned cesarean hysterectomy. Although UAE was also associated with adverse outcomes, it may be a better option for reducing intraoperative blood loss among patients with a planned cesarean hysterectomy.

Pelvic arterial embolisation with cyanoacrylate during caesarean hysterectomy for placenta accreta

PURPOSE

To compare n-butyl cyanoacrylate (NBCA) and gelatine sponge (GS) as embolic materials for prophylactic pelvic arterial embolisation during caesarean hysterectomy for placenta accreta spectrum (PAS).

MATERIAL AND METHODS

This retrospective study comprised 12 women (age range, 23-42 years; mean, 34.1 years) who underwent caesarean hysterectomy for PAS. Following caesarean delivery, bilateral uterine and non-uterine parasitic arteries were embolized with GS in the first four cases (GS group) and primarily with NBCA mixed with iodized oil in the subsequent eight cases (NBCA group). Procedure time for embolisation and hysterectomy and total blood loss were compared between the two groups using Welch's t-test.

RESULTS

Although procedure time for embolisation tended to be longer in the NBCA group than in the GS group (111 ± 47 min versus 71 ± 32 min, p=.11), that for hysterectomy was significantly reduced in the NBCA group when compared to the GS group (158 ± 42 min versus 236 ± 39 min, p=.02). Total blood loss was significantly lower in the NBCA group than in the GS group (1375 ± 565 mL versus 2668 ± 587 mL, p=.01).

CONCLUSION

Procedure time for hysterectomy and total blood loss during caesarean hysterectomy can be reduced by using NBCA instead of GS in prophylactic pelvic arterial embolisation for PAS.

Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.

Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial

BACKGROUND

Placenta previa remains one of the major causes of massive postpartum hemorrhage and maternal mortality worldwide.

OBJECTIVE

To determine whether internal iliac artery balloon occlusion during cesarean delivery for placenta previa could reduce postpartum hemorrhage and other maternal complications.

STUDY DESIGN

This was a prospective randomized controlled trial conducted at a tertiary university obstetric unit in Hong Kong. Pregnant women who were diagnosed to have placenta previa at 34 weeks (defined as lower placenta edge within 2 cm from the internal os) and required cesarean delivery were invited to participate. Eligible pregnant women were randomized into internal iliac artery balloon occlusion (Occlusion) group or standard management (Control) group. Those randomized to the Occlusion group had internal iliac artery balloon catheter placement performed before cesarean delivery and then balloon inflation after delivery of the baby. The primary outcome was the reduction of postpartum hemorrhage in those with internal iliac artery balloon occlusion. Secondary outcome measures included hemoglobin drop after delivery; amount of blood product transfusion; incidence of hysterectomy; maternal complications including renal failure, ischemic liver, disseminated intravascular coagulation, and adult respiratory distress syndrome; length of stay in hospital; admission to intensive care unit; and maternal death.

RESULTS

Between May 2016 and September 2018, 40 women were randomized (20 in each group). Demographic and obstetric characteristics were similar between the 2 groups. In the Occlusion group, 3 women did not receive the scheduled procedure, as it was preceded by antepartum hemorrhage that required emergency cesarean delivery, and 1 woman had repeated scan at 36 weeks showing the placental edge was slightly more than 2 cm from the internal os. Intention-to-treat analysis found no significant differences between the Occlusion and the Control groups regarding to the median intraoperative blood loss (1451 [1024-2388] mL vs 1454 [888-2300] mL; P = .945), the median length of surgery (49 [30-62] min vs 37 [30-51] min; P = .204), or the need for blood transfusion during operation (57.9% vs 50.0%; P = .621). None of the patients had rebleeding after operation, complication related to internal iliac artery procedure, or any other maternal complications. Reanalyzing the data using on-treatment approach showed the same results.

CONCLUSION

The use of prophylactic internal iliac artery balloon occlusion in placenta previa patients undergoing cesarean delivery did not reduce postpartum hemorrhage or have any effect on maternal or neonatal morbidity.

Prophylactic internal iliac artery ligation versus balloon occlusion for placenta accreta spectrum disorders: A retrospective cohort study

OBJECTIVE

To compare surgical outcomes between women undergoing prophylactic internal iliac artery ligation or preoperative placement of balloon-occlusive devices at cesarean hysterectomy for placenta accreta spectrum (PAS) disorders.

METHODS

A retrospective cohort study was conducted at a tertiary-care referral center for PAS disorders in Ontario, Canada. Eligible electronic records were reviewed of women undergoing cesarean hysterectomy for PAS disorders between November 2012 and June 2018. Outcomes for the ligation and balloon groups were compared primarily on procedure-related complications and secondarily on total procedure time, bleeding and transfusion metrics, and intraoperative and postoperative complications.

RESULTS

Of the 79 cases of cesarean hysterectomy, 47 underwent balloon placement and 32 underwent ligation. Baseline characteristics between the groups were similar except for more emergency procedures in the ligation group (37.5% vs 12.8%, P=0.014). The balloon-related complication rate was 5/47 (10.6%), with no reported complications in the ligation group (P=0.077). Procedural time was longer in the balloon group (353 ± 14 vs 227 ± 13 minutes, P<0.001). Estimated blood loss was similar (1874 ± 245 mL vs 1713 ± 181 mL, P=0.590).

CONCLUSION

Women undergoing prophylactic placement of endovascular balloons at caesarean hysterectomy for PAS disorders had a 10.6% procedure-related complication rate and increased total procedure time, with no decrease in blood loss compared to those undergoing surgical ligation.

The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences

Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.

Control of postpartum hemorrhage in women with placenta accreta spectrum using prophylactic balloon occlusion combined with Pituitrin intra-arterial infusion

OBJECTIVES

The aim of this study is to evaluate the efficacy of prophylactic internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion in the control of postpartum hemorrhage in women with placenta accreta spectrum (PAS).

METHODS

This is a prospective and non-randomized controlled study. The participants were assigned into three groups: without balloon catheterization (non-BC) group, balloon catheterization (BC) group, and Pituitrin combined with balloon catheterization (PBC) group. The primary outcomes were estimated blood loss (EBL) and the units of transfused packed red blood cells (PRBC). The secondary outcome was the incidence of hysterectomy.

RESULTS

A total of 100 participants were recruited between August 2013 and November 2018 and assigned into the respective groups as follows: 27 in the non-BC group, 22 in the BC group, and 51 in the PBC group. No statistical differences were found in demographic characteristics among the three groups. There was a trend of lower EBL, PRBC, and hysterectomy rate in the BC group than those in the non-BC group, while all values showed no significant differences (all p > 0.05). Patients in the PBC group had significantly lower EBL, PRBC, and hysterectomy rate compared with those in the non-BC group (all p < 0.05). Linear regression analysis revealed that the PBC (vs. others) was negatively correlated with EBL and the non-BC (vs. others) independently predicted more EBL.

CONCLUSIONS

Balloon occlusion combined with Pituitrin infusion is an effective treatment method which significantly reduced EBL, PRBC, and hysterectomy rate in patients with PAS.

KEY POINTS

• Internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion can significantly decrease EBL, PRBC, and hysterectomy rate during cesarean section in patients with PAS. • Cesarean section without balloon occlusion and placenta accreta depth are two independent risk factors for EBL in patients with PAS.

Development of placental abnormalities in location and anatomy

Low‐lying placentas, placenta previa and abnormally invasive placentas are the most frequently occurring placental abnormalities in location and anatomy. These conditions can have serious consequences for mother and fetus mainly due to excessive blood loss before, during or after delivery. The incidence of such abnormalities is increasing, but treatment options and preventive strategies are limited. Therefore, it is crucial to understand the etiology of placental abnormalities in location and anatomy. Placental formation already starts at implantation and therefore disorders during implantation may cause these abnormalities. Understanding of the normal placental structure and development is essential to comprehend the etiology of placental abnormalities in location and anatomy, to diagnose the affected women and to guide future research for treatment and preventive strategies. We reviewed the literature on the structure and development of the normal placenta and the placental development resulting in low‐lying placentas, placenta previa and abnormally invasive placentas.

A retrospective analysis of the treatment on abdominal aortic balloon occlusion-related thrombosis by continuous low-flow diluted heparin

Thrombosis is one of the serious complications related to prophylactic balloon occlusion of the abdominal aorta (PBOAA). This study aims to retrospectively analyze the efficacy and safety of continuous low-flow infusion of diluted heparin saline to prevent this complication related to PBOAA and further to provide the theory and evidences for using PBOAA.A study was carried out at our hospital from March 2016 to December 2018. Women with pernicious placenta previa (PPP) were treated PBOAA to prevent massive bleeding during CS. According to whether continuous low-flow infusion of diluted heparin saline was used to prevent catheter-related thrombosis or not, they were divided into 2 groups, the test group and the control group. The incidence of thrombosis between the 2 groups was compared and the effective treatment of thrombosis was also discussed. The comparison of nonparametric values was accomplished by using Fisher exact test. Statistical significance was set at P < .05.There were 31 women with PPP who received PBOAA during CS who were included in our study. Six of 19 women in control group (31.6%) developed thrombotic complications, while none of 12 women in test group. There were statistically significant differences in the incidence of thrombosis between the 2 groups (P = .037). There was no statistically significant difference in the amount of estimated blood loss and blood transfusion during CS between the 2 groups, nor was there statistically significant difference in the hospital days after CS (P > .05). All 6 women with thrombotic complications had no positive symptoms and thrombotic sequelae. The managements of thrombus included systemic anticoagulation, catheter-directed thrombolysis, and catheter-directed anticoagulation. One of the 6 women was lost to follow-up, and the thrombus of the other 5 women were completely dissolved. No other adverse outcomes or complications related to PBOAA were observed in all women in this study.Continuous low-flow infusion of diluted heparin saline is a safe procedure when PBOAA is performed for patients with PPP. It can effectively reduce or even avoid thrombosis without increasing intraoperative blood loss during CS for PPP patients.

Laparoscopic hysterectomy to manage uterine rupture due to placenta percreta in the first trimester: A case report

Placenta percreta causing uterine rupture is a rare complication of pregnancy. It is most commonly diagnosed after the second trimester and can lead to significant morbidity necessitating abdominal hysterectomy of a gravid or immediately postpartum uterus. We describe a patient who presented with abdominal pain at 13 weeks of gestation and was diagnosed with placenta percreta during laparoscopy for presumed appendicitis. Intraoperatively, placenta was seen perforating the uterine fundus and 1 l of hemoperitoneum was evacuated. However, the uterus was hemostatic and the patient was stable, so the procedure was terminated. The patient was then transferred to a tertiary care center, where she ultimately underwent an uncomplicated laparoscopic gravid hysterectomy. We conclude that placenta percreta can occur in the first trimester even in patients without traditional risk factors. In stable patients, it is appropriate to consider minimally invasive hysterectomy with utilization of specific techniques to minimize intraoperative blood loss.

•

Uterine rupture due to placenta percreta can present in the first trimester.

•

Minimally invasive laparoscopic hysterectomy can provide definitive treatment with decreased surgical morbidity and shorter convalescence.

•

Blood loss and allogenic transfusion can be minimized with appropriate hemostatic techniques and surgical planning.

Outcomes of balloon occlusion in the University of California Morbidly Adherent Placenta Registry

BACKGROUND

Morbidly adherent placenta, also known as placenta accreta spectrum, is associated with severe maternal morbidity and mortality. Multiple adjunctive procedures have been proposed to improve outcomes, and at many institutions, interventional radiologists will play a role in assisting obstetricians in these cases.

OBJECTIVE

The objective of the study was to evaluate the outcomes of women with morbidly adherent placenta who underwent cesarean hysterectomy with aortic balloon occlusion or internal iliac artery balloon occlusion catheters, compared with cesarean hysterectomy with surgical ligation of the iliac arteries, or cesarean hysterectomy without adjunctive procedures.

STUDY DESIGN

A retrospective review of women with morbidly adherent placenta treated with cesarean hysterectomy was performed at 5 institutions from May 2014 to April 2018. The balloon occlusion group had either prophylactic aortic or iliac balloons placed prior to cesarean hysterectomy. Comparison groups included those who underwent internal iliac artery ligation prior to hysterectomy or a control group if they underwent cesarean hysterectomy without adjuvant procedures. Evaluated outcomes include estimated blood loss, transfusion requirements, intensive care unit admission, and adverse event rates.

RESULTS

There were 171 women with morbidly adherent placenta included in the study. Twenty-eight had balloon placement prior to cesarean hysterectomy, 18 had intraoperative internal iliac artery ligation, and there were 125 control women who underwent cesarean hysterectomy without any adjunctive procedures. Compared with the women who underwent cesarean hysterectomy without adjunctive procedures, women who underwent aortic or iliac artery balloon occlusion prior to hysterectomy had significantly lower estimated blood loss (30.9% decrease, P < .001), transfusion requirements (76.8% decrease, P < .001), intensive care unit admission rates (0% vs 15.2%, P < .001), and intensive care unit stay lengths (0.0 vs 3.1 days, P < .001). Compared with women who underwent surgical ligation of the internal iliac arteries prior to hysterectomy, women who underwent aortic or iliac artery balloon occlusion prior to cesarean hysterectomy had lower estimated blood loss (54.2% decrease, P < .01), transfusion requirements (90.5% decrease, P < .001), operating room times (40.0% decrease, P < .01), intensive care unit admissions rates (0% vs 77.8%, P < .001), intensive care unit stay lengths (0.0 vs 1.4 days, P < .001), and adverse events (3.6% vs 44.4%, P < .01).

CONCLUSION

Aortic and iliac artery balloon occlusion are associated with lower estimated blood loss, transfusion requirements, intensive care unit admission rates, and adverse event rates compared with women who underwent internal iliac artery ligation prior to cesarean hysterectomy or women who had no adjunctive interventions prior to cesarean hysterectomy for morbidly adherent placenta.

REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery

Catastrophic bleeding is a feared complication of robotic abdominal procedures that involve dissection in close proximity to major vessels. In the event of uncontrollable hemorrhage, standard practice involves emergency undocking with conversion to laparotomy. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapid and life-saving technique gaining acceptance in the trauma setting for the management of catastrophic hemorrhage. The purpose of this study was to evaluate feasibility of REBOA for emergency hemostasis during robotic surgery. The surgical robot was docked to a REBOA mannequin to simulate an upper abdominal surgery. A femoral arterial line was placed in the mannequin. Supplies needed for REBOA insertion were opened and arranged on the surgical back table. The surgeon was seated at the console with an assistant scrubbed. A catastrophic vascular injury was announced. The time it took the surgeon to achieve aortic occlusion by the REBOA was recorded. Four surgeons participated and performed three timed trials each. Each surgeon, irrespective of experience with REBOA or years in surgical practice, was able to obtain aortic occlusion in less than 2 min. The mean time to aortic occlusion for all surgeons was 111 s. No manipulation of the robotic arms was required to perform the procedure. Aortic occlusion was achieved rapidly with REBOA. Ability to achieve prompt aortic control was not associated with surgical experience or prior familiarity with the REBOA device. Prophylactic femoral access and preparation of supplies facilitates prompt placement of the occlusion balloon. REBOA should be considered as a viable alternative to open laparotomy for temporary hemorrhage control during robotic surgery.

Vascular balloon occlusion and planned caesarean hysterectomy for morbidly adherent placenta: A systematic review

BACKGROUND

Morbidly adherent placenta is potentially life-threatening, often requiring technically difficult surgery and large blood loss. Use of intravascular balloon occlusion with or without hysterectomy to reduce blood loss is increasing despite associated morbidity and lack of evidence of efficacy.

AIMS

To evaluate if prophylactic use of vascular balloon occlusion at the time of planned caesarean hysterectomy for antenatally diagnosed morbidly adherent placenta reduces blood loss and transfusion requirements, and determine rate of associated complications.

MATERIALS AND METHODS

A systematic review of PubMed and Medline covering January 1997 to December 2018 was conducted. Key words included placenta accreta, increta, percreta, and morbidly adherent placenta, balloon, interventional radiology, embolization, and caesarean hysterectomy.

RESULTS

Nineteen studies were included. Only three studies had appropriate controls: two with balloon placement in the internal iliac arteries and one in the common iliac arteries. One showed no difference in blood loss or transfusion requirements, the second showed a reduction in cases of percreta only and the third reported reduction in blood loss. Only few studies reported objective measures of blood loss. Blood loss and transfusion were still high (2.26 L and 3.79 units, respectively) despite use of vascular balloons. Balloon catheter use was associated with a 7.5% rate of complications; 4.5% were minor and 3.0% major.

CONCLUSIONS

There is a large body of poor data evaluating efficacy of prophylactic vascular balloon occlusion in cases of planned caesarean hysterectomy for known morbidly adherent placenta. Limited relevant data provide only scant evidence that these techniques are beneficial in reducing blood loss, despite associated significant complications.

Role of interventional radiology in pregnancy complicated by placenta accreta spectrum disorder: systematic review and meta-analysis

OBJECTIVE

To evaluate the potential benefit of interventional radiology (IR) in improving the outcome of women undergoing surgery for a placenta accreta spectrum (PAS) disorder.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched for studies comparing outcomes of women with a prenatal diagnosis of PAS who underwent an IR procedure before surgery vs those who did not, using a robust collection of terms relating to PAS. The primary outcome was intraoperative estimated blood loss (EBL). Secondary outcomes were the number of transfused units of packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets and cryoprecipitate, operation time, length of hospital stay, EBL ≥ 2.5 L, PRBC transfused ≥ 5 units, surgical complications, bladder or ureteral injury, relaparotomy, infection, disseminated intravascular coagulation, and complications related to endovascular catheter placement. Only studies reporting on the incidence of, or the mean difference in, the observed outcomes in women affected by a PAS disorder who had vs those who did not have an IR procedure before surgery were considered for inclusion. All outcomes were explored in the overall population of women with a prenatally diagnosed PAS disorder and in those undergoing hysterectomy. Quality assessment of each included study was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The GRADE methodology was used to assess the quality of the body of retrieved evidence.

RESULTS

Fifteen studies (958 women with PAS) were included. In women who underwent IR before surgery, compared with those who did not, mean EBL (mean difference (MD), -1.02 L; 95% CI, -1.60 to -0.43 L; P < 0.001) and the risk of EBL ≥ 2.5 L (odds ratio (OR), 0.18; 95% CI, 0.04-0.78; P = 0.02) were significantly lower. There was no significant difference between the two groups in the other outcomes explored. On subgroup analysis of pregnancies complicated by PAS undergoing hysterectomy, EBL (MD, -0.68 L; 95% CI, -1.24 to -0.12 L; P = 0.02) and the number of transfused FFP units (MD, -1.66; 95% CI, -2.71 to -0.61; P = 0.02) were significantly lower in women who had an endovascular IR procedure compared with controls. Furthermore, women undergoing IR had a significantly lower risk of EBL ≥ 2.5 L (OR, 0.10; 95% CI, 0.02-0.47; P = 0.004). Overall, complications related to the placement of an endovascular catheter occurred in 5.3% (95% CI, 2.6-8.9; I² , 65.3%) of pregnancies undergoing IR. Overall quality of evidence, as assessed by GRADE, was very low.

CONCLUSIONS

The current available data provide encouraging evidence that IR procedures may be associated with lower EBL and need for transfusion in pregnancies undergoing surgery for a PAS disorder. However, given the overall very low quality of the evidence, further large studies are needed in order to confirm the beneficial role of IR in improving the outcome of these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta

PURPOSE

To evaluate outcomes of patients with placenta accreta spectrum (PAS) disorders who underwent uterine artery embolization (UAE) following cesarean delivery but before hysterectomy.

MATERIALS AND METHODS

A retrospective review of patients with PAS treated with cesarean-hysterectomy (C-hyst) was performed. Patients in the UAE group underwent UAE after cesarean delivery but before hysterectomy; patients in the control group underwent C-hyst alone. Estimated blood loss (EBL), transfusion requirements, length of intensive care unit (ICU) stay, and adverse events were evaluated.

RESULTS

The study included 31 patients, 7 in the UAE group and 24 in the control group. Median EBL, transfusion requirements, and length of ICU stay in the UAE group compared with control group were 1,500 mL (range, 500-2,000 mL) vs 2,000 mL (range, 1,000-4,500 mL) (P = .04), 150 mL (range, 0-650 mL) vs 550 mL (range, 0-3,125 mL) (P = .10), and 0 d (range, 0-1 d) vs 0.5 d (range, 0-2 d) (P = .07). All patients in the UAE group had placenta increta; patients in the control group had placenta accreta (29%), increta (54%), and percreta (17%) (P = .10). Subgroup analysis of patients with placenta increta demonstrated that the UAE group had a significant decrease in median EBL (P = .004), transfusion requirements (P = .009), and length of ICU stay (P = .04). No adverse events following UAE were noted.

CONCLUSIONS

UAE following cesarean delivery but before hysterectomy in patients with placenta increta appears to be safe and effective in decreasing EBL, transfusion requirements, and length of ICU stay compared with C-hyst alone.

Surgical Management of the Placenta Accreta Spectrum: An Institutional Experience

OBJECTIVE

The incidence of placenta accreta spectrum (PAS) has risen over the past decades, primarily in response to increasing Caesarean section rates. The surgical management of PAS is associated with significant morbidity, including hemorrhage and intensive care unit (ICU) admission. This study sought to evaluate the surgical outcomes of a PAS operative approach.

METHODS

A single-centre retrospective chart review of all Caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described (Canadian Task Force Classification II-2).

RESULTS

The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) with placenta accreta, 14 (29.8%) with placenta increta, and 14 (29.8%) with placenta percreta. Mean estimated blood loss was 1416 ± 699 mL, and mean operative time was 112 ± 49 minutes. Overall, 16 patients (34.0%) required blood transfusion, and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2 days, with no re-admission within 30 days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (P > 0.05). Patients with placenta percreta had significantly more blood loss (P = 0.02) and longer operative time (P = 0.007) compared with those with placenta accreta and increta.

CONCLUSION

The current surgical model for planned Caesarean hysterectomy for PAS exhibits a low complication rate. Further research is needed for developing a standardized approach to the management of PAS.

Placenta Accreta Spectrum

Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.