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

Roadmap to safety: a single center study of evidence-informed approach to placenta accreta spectrum

Objective

To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS).

Methods

This was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used t-tests and Mood's Median test.

Results

There were no differences in baseline demographics between the pre- (n = 38) and post-MAPS (n = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, p = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, p = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, p = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, p < 0.001), postoperative complications (32% pre- vs.12% post-MAPS, p = 0.043), hemorrhages >1l (95% pre- vs.65% post-MAPS, p = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, p = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, p = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, p = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, p = 0.007).

Conclusion

An evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.

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).

Timing of intra-abdominal aortic balloon occlusion for prevention of hemorrhage in patients with placenta previa and placenta accreta spectrum

OBJECTIVE

Placenta accreta spectrum (PAS) has been linked to severe negative maternal-fetal pregnancy outcomes, including a high risk of maternal death. The goal of this study was to determine whether an abdominal aortic balloon block performed before fetal birth lowered intraoperative bleeding and the risk of severe bleeding, as opposed to a block performed after fetal birth.

METHODS

In this retrospective cohort study, patients who underwent pre-delivery or post-delivery inflation were compared for intraoperative hemorrhage, transfusion rate, hysterectomy rate, intensive care unit (ICU) hospitalization, and newborn indices. To ensure the robustness of our findings, we applied multivariate logistic regression, propensity score analysis, and an inverse probability-weighting model.

RESULTS

This study included 168 patients who underwent balloon occlusion (62 pre-delivery, 106 post-delivery). The overall probability of major bleeding was 56.5% (95/168), and the pre-delivery and post-delivery probabilities for major bleeding were 64.5% (40/62) and 51.9% (55/106) (P = 0.112), respectively. In the multivariable-adjusted model, post-delivery inflation was associated with a 33% numerically higher probability of massive bleeding (odds ratio 1.33, 95% confidence interval 0.54-3.25, P = 0.535). However, the difference was not statistically significant.

CONCLUSION

According to our findings, pre-delivery inflation did not significantly reduce the risk or amount of severe bleeding.

Placenta Accreta: A Case Report on the Role of Interventional Radiology

Placenta accreta spectrum disorder is a pregnancy-related disorder responsible for important post-partum morbimortality, associated with intractable or massive hemorrhage, leading to uterine loss in up to 64% of women. Despite international recommendations advocating planned preterm cesarean hysterectomy for the management of these patients, uterus preservation management is being continuously reported with the implementation of minimally invasive bleeding reduction strategies, such as prophylactic balloon-assisted occlusion. We present the case of a 40-year-old pregnant woman with a previous cesarean, diagnosed with placenta previa and suspected placenta accreta on magnetic resonance after having second-trimester vaginal bleeding. A peri-operative multidisciplinary panel was involved, in collaboration with the interventional radiologist, and the c-section was scheduled for 36 weeks of gestation. The prophylactic balloon-assisted occlusion was successfully performed, minimizing the blood loss and allowing a uterus-preserving approach.

Current state of interventional procedures to treat pernicious placenta previa accompanied by placenta accreta spectrum: A review

Pernicious placenta previa (PPP) accompanied by placenta accreta spectrum (PAS) is a life-threatening placental implantation that causes a variety of complications, including antepartum hemorrhage, postpartum hemorrhage, hemorrhagic shock, preterm birth, and neonatal asphyxia. Along with continuous improvements in medical technology, interventional procedures have been widely used to prevent intraoperative hemorrhage associated with PPP. The commonly used interventional procedures include abdominal aorta clamping, prophylactic balloon occlusion of the internal or common iliac arteries, and uterine artery embolization. The above-mentioned interventional procedures have their respective advantages and disadvantages. The best procedure for different situations continues to be debated considering the complex pattern of blood supply to the uterus in patients with PPP. The specific choice of interventional procedure depends on the clinical situation of the patient with PPP. For grade III PAS, the need for uterine artery embolization is assessed based on blood loss and preoperative hemostatic effect following abdominal aorta clamping. Repair or hysterectomy may be performed following uterine artery embolization if there is a hybrid operating room for grade III PAS patients with extensive sub-serosal penetration of the uterus and repair difficulty. For grade II PAS (shallow placental implantation), prophylactic balloon occlusion may not be necessary before surgery. Uterine artery embolization can be performed in case of postoperative hemorrhage.

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

A novel approach in the management of placenta accreta spectrum disorders: A single-center multidisciplinary surgical experience at Tu Du Hospital in Vietnam

OBJECTIVE

Placenta accreta spectrum disorders (PASD) are the leading cause which results in highly maternal mortality during pregnancy. Although hysterectomy has been the gold standard for PASD, the recent study along with our experience has been demonstrated that the association between uterine myometrial resection and transverse B-Lynch suture in conservative management might be effective in the appropriate patients, thus we hereby attempted to determine this issue.

MATERIALS AND METHODS

A retrospective observational study enrolled 65 patients at Tu Du Hospital in Vietnam between January 2017 and December 2018. This study included all pregnant women above 28 weeks of gestational age, who had undergone cesarean delivery due to PASD diagnosed preoperatively by ultrasound or upon laparotomy. Additionally, all patients who desired uterine preservation underwent modified one-step conservative uterine surgery (MOSCUS), avoiding peripartum hysterectomy.

RESULTS

Overall, the rate of successful preservation was 93.8%. Other main outcomes such as average operative blood loss was 987 mL, mean blood transfusion was 831 ± 672 mL; mean operative time was 135 ± 31 min and average postoperative time was 5.79 days. Postoperative complications included six out of 65 cases due to intraoperative bleeding and postoperative infection, requiring hysterectomy in 4 patients.

CONCLUSION

MOSCUS was associated with less operative blood loss and blood transfusion amount. Its success rate of uterine preservation was approximately 94% in our study. Thus, this method can be acceptable in PASD management at our maternity health care center. Further studies might be necessary to evaluate the long-term effects of this method in PASD management.

Recurrent postpartum hemorrhage at subsequent pregnancy in patients with prior uterine artery embolization: angiographic findings and outcomes of repeat embolization

OBJECTIVE

To evaluate angiographic findings and outcomes of uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in a subsequent pregnancy in patients with a history of prior UAE.

METHODS

Between March 2004 and February 2021, UAE was performed for PPH with gelatin sponge slurry in 753 patients. Among these, 13 underwent repeat UAE for recurrent PPH after subsequent delivery. The causes of PPH, angiographic findings, hemostasis, and adverse events were evaluated.

RESULTS

The causes of recurrent PPH included retained placental tissue (n = 9) and uterine atony (n = 4). On angiography, unilateral or bilateral uterine arteries were obliterated due to prior UAE in 10 patients (76.9%). The uterine collateral vessels were embolized (anterior division of the internal iliac artery [n = 10], round ligament [n = 5], and ovarian [n = 4] artery). In the remaining three patients with recanalized or patent (not embolized at prior UAE) uterine arteries, both uterine arteries were embolized. Immediate hemostasis was achieved in nine patients (69.2%). The remaining four patients (30.8%) with obliterated uterine arteries required hysterectomy. There were three mild adverse events (pelvic pain [n = 2] and fever [n = 1]).

CONCLUSION

UAE with gelatin sponge slurry frequently causes permanent uterine artery obliteration. In cases of recurrent PPH occurring in subsequent pregnancy, repeat UAE may be less likely to achieve hemostasis (69.2%).

ADVANCES IN KNOWLEDGE

1. UAE with gelatin sponge slurry frequently caused permanent uterine artery obliteration.2. In recurrent PPH occurring in subsequent pregnancy, the repeat UAE may be less likely to achieve hemostasis than initial UAE.

Percreta score to differentiate between placenta accreta and placenta percreta with ultrasound and MR imaging

INTRODUCTION

The objective of this study was to assess the performance of ultrasound and magnetic resonance imaging (MRI) features in helping to classify the type of placenta accreta spectrum (PAS; accreta/increta vs percreta), alone or combined in a predictive score.

MATERIAL AND METHODS

We conducted a retrospective study in 82 pregnant women with PAS who underwent ultrasound and MRI examination of the pelvis before delivery (from an initial cohort of 185 women with PAS). We estimated the sensitivity, specificity and accuracy of MRI and ultrasound in the diagnosis of the type of PAS. We analyzed cesarean and imaging features using univariable logistic regression analysis. We constructed a nomogram to predict the risk of placenta percreta and validated it with bootstrap resampling, then used receiver operating characteristic curves to assess the performance of the model in distinguishing between placenta percreta and placenta accreta/increta.

RESULTS

Among the 82 patients, 29 (35%) had placenta accreta/increta and 53 (65%) had placenta percreta. The best features to discriminate between placenta accreta/increta and placenta percreta with ultrasound were increased vascularization at the uterine serosa-bladder wall interface (odds ratio [OR] 7.93; 95% confidence interval [CI] 2.78-24.99; p < 0.01) and the number of lacunae without a hyperechogenic halo (OR 1.36; 95% CI 1.14-1.67; p = 0.012). Concerning MRI markers, heterogeneous placenta (OR 12.89; 95% CI 3.05-89.16; p = 0.002), dark intraplacental bands (OR 12.89; 95% CI 3.05-89.16; p = 0.002) and bladder wall interruption (OR 15.89; 95% CI 4.78-73.33; p < 0.001) had a higher OR in discriminating placenta accreta/increta from placenta percreta. The nomogram yielded areas under the curve of 0.841 (95% CI 0.754-0.927) and 0.856 (95% CI 0.767-0.945), after bootstrap resampling, for the accurate prediction of placenta percreta.

CONCLUSIONS

The nomogram we developed to predict the risk of placenta percreta among patients with PAS had good discriminative capabilities. This performance and its impact on maternal morbidity should be confirmed by future prospective studies.

Role of Abdominal Aortic Balloon Placement in Planned Conservative Management of Placenta Previa With Placenta Increta or Percreta

Background: We investigated the role of balloon placement in the abdominal aorta (BPAA) in planned conservative management of placenta previa with placenta increta or percreta and the effects of BPAA on perinatal adverse maternal events. Methods: This retrospective case-control study included women with placenta previa (increta or percreta), who underwent pregnancy termination at the Qilu Hospital of Shandong University between January 2016 and June 2019. Patients were categorized into the BPAA and non-BPAA groups based on the BPAA placement before delivery. The Chi-square and non-parametric rank-sum tests were used for the intergroup comparison of patient characteristics. The propensity score matching algorithm was used to minimize the intergroup differences in clinical characteristics. Logistic regression analysis was used to identify the factors associated with a high risk of adverse pregnancy outcomes. The area under the receiver operating characteristic curve [area under the curve (AUC)] was used to evaluate the classification of the selected high-risk factors. Results: The study included 260 patients, and 104 patients were identified after propensity score matching. In the post-matched cohort, intraoperative blood loss was significantly lower in the BPAA than in the non-BPAA group (median 1,000 vs. 2,250 ml, P < 0.001). Intraoperative B-Lynch suture was performed in fewer patients in the BPAA (15.4 vs. 34.6%, P = 0.024) than in the non-BPAA group. The packed red blood cell (PRBC) transfusion rate was lower in the BPAA group (median 4 vs. 8 units, P < 0.001). Overall, 46 (45.1%) patients developed adverse maternal events; however, the rate of adverse maternal events was lower in the BPAA group (19.6 vs. 80.4%, P < 0.001). No ligation of the ascending branch of the uterine artery (P = 0.034), no BPAA (P < 0.001), intraplacental vascular lacunae (P = 0.046), and cervical hypervascularity (P = 0.001) were associated with a high risk of adverse perinatal maternal events. The AUC of the high-risk factors was 0.89 in the post-matched and 0.76 in the pre-matched cohorts. Conclusion: Planned conservative management using BPAA significantly minimized the intraoperative blood loss, the need for a B-Lynch suture, and PRBC transfusion in patients with severe placenta accreta spectrum and placenta previa.

The effect of prophylactic balloon occlusion in patients with placenta accreta spectrum: a Bayesian network meta-analysis

OBJECTIVES

Placenta accreta spectrum (PAS) can induce severe life-threatening obstetric hemorrhage. Herein, we conducted a Bayesian network meta-analysis of previous studies to evaluate the relative benefits of different prophylactic balloon occlusion (PBO) procedures.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to July 2021. Blood loss volume, blood transfusion volume, and hysterectomy rate were regarded as the primary endpoints. The data were pooled using a Bayesian network and traditional pairwise meta-analysis.

RESULTS

Fifty-nine articles with a total sample size of 5150 patients were included. Compared with no PBO (non-PBO) intervention, PBO of the abdominal aorta (PBOAA, mean difference(MD) - 1.02, 95% credible interval (CrI) - 1.4 to - 0.67), common iliac artery (PBOCIA, MD - 0.84; 95%CrI - 1.36 to - 0.06) and internal iliac artery (PBOIIA, MD - 0.42; 95%CrI - 0.72 to - 0.13) significantly lowered blood loss volume, with PBOAA being more effective than PBOIIA (MD - 0.60; 95%CrI - 1.05 to - 0.17). PBOAA and PBOIIA also significantly decreased blood loss volume (MD - 2.33; 95%CrI - 3.74 to - 0.94, MD - 1.57; 95%CrI - 2.77 to - 0.47 respectively) and hysterectomy rate (OR 0.31; 95%CrI 0.16 to 0.54, OR 0.53; 95%CrI 0.29 to 0.92 respectively). PBOAA has the highest probability of being more effective in reducing the blood loss volume, blood transfusion volume, and hysterectomy rate.

CONCLUSIONS

Performing PBOAA, PBOCIA, or PBOIIA in PAS patients is an effective way to minimize blood loss volume, while PBOAA and PBOIIA also reduce blood transfusion volume and hysterectomy rate. PBOAA is a notably more effective strategy to reduce blood loss volume than PBOIIA.

KEY POINTS

• PBOAA, PBOCIA, and PBOIIA procedures can significantly reduce the blood loss volume compared to non-PBO intervention in PAS patients, of which PBOAA was more effective than the PBOIIA procedure. • PBOAA and PBOIIA could significantly reduce the blood transfusion volume and hysterectomy rate in contrast to the non-PBO intervention in patients with PAS. • According to our statistical treatment ranking, PBOAA was statistically superior in reducing blood transfusion volume, blood transfusion volume, and hysterectomy rate than other PBO procedures.

Protocolo para el manejo de placenta percreta con cesárea, embolización uterina e histerectomía diferida

Introducción. El objetivo de este artículo fue dar a conocer el protocolo institucional del manejo de la placenta percreta como un procedimiento varias horas después de la cesárea, con embolización de arterias placentarias de forma selectivas, previo a la práctica de la histerectomía, y presentar los resultados. Métodos. Estudio de serie de casos, donde se evaluaron las pacientes con placenta percreta, manejadas durante un año en un hospital de cuarto nivel de complejidad en la ciudad de Bogotá, D.C., Colombia. Se efectuó cesárea fúndica y se dejó la placenta in situ, 48 a 72 horas después se realizó embolización ultra selectiva y luego de 2 a 3 días se procedió a practicar la histerectomía vía abdominal. Resultados. Se evaluaron 5 pacientes, con paridad de 3,8 embarazos promedio, con diagnóstico de placenta percreta. El tiempo promedio de espera entre la embolización y la histerectomía fue de 1,6 días. No se presentaron complicaciones asociadas a la embolización, ni morbimortalidad materno fetal. Los volúmenes de sangrado en promedio durante la histerectomía de cada paciente fueron de 1160 ml. Conclusión. Existen datos limitados sobre el tratamiento óptimo del acretismo placentario. La sospecha diagnóstica permite planificar de forma favorable el manejo intraparto y, es por ello, que el surgimiento de nuevas técnicas, como la embolización de arterias placentarias, constituyen alternativas para un manejo más seguro de las pacientes.

Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the effectiveness and safety of prophylactic intraoperative uterine artery embolization (UAE) performed immediately after fetal delivery during planned cesarean section or cesarean hysterectomy in patients with placenta accreta spectrum disorder or placenta previa.

METHODS

A systematic search was conducted on Ovid MEDLINE and Embase, PubMed, Web of Science, and Cochrane databases. Studies were selected using the Population/Intervention/Comparison/Outcomes (PICO) strategy. The intraoperative blood loss and the rate of emergent peripartum hysterectomy (EPH) were the primary outcomes, whereas the length of hospital stay and volume of blood transfused were the secondary outcomes. A random-effects model was employed to pool each effect size. The cumulative values of the primary outcomes were calculated using the generic inverse variance method.

RESULTS

Eleven retrospective cohort studies and five case series were included, recruiting 421 women who underwent prophylactic intraoperative UAE (UAE group) and 374 women who did not (control group). Compared with the control group, the UAE group had significantly reduced intraoperative blood loss (p = 0.020) during cesarean section or cesarean hysterectomy. Furthermore, the EPH rate was also significantly decreased (p = 0.020; cumulative rate: 19.65%), but not the length of hospital stay (p = 0.850) and volume of pRBC transfused (p = 0.140), after cesarean section in the UAE group. The incidence of major complications was low (3.33%), despite two patients with uterine necrosis.

CONCLUSION

The currently available data provides encouraging evidence that prophylactic intraoperative UAE may contribute to hemorrhage control and fertility preservation in women with abnormal placentation.

REGISTRATION

PROSPERO registration code: CRD42021230581. https://clinicaltrials.gov/ct2/show/CRD42021230581 LEVEL OF EVIDENCE: Level 2a, systematic review of retrospective cohort studies.

Accurate prenatal discrimination of placenta accreta spectrum from uterine dehiscence is necessary to ensure optimal management

Uterine scar dehiscence with underlying placenta is often misdiagnosed as placenta accreta spectrum both prenatally and intraoperatively due to the absence of myometrial tissue in the area. Misdiagnosis generates obstetric anxiety and results in overtreatment which carries a risk of iatrogenic injury. We present a case of the antenatal diagnosis of uterine dehiscence in a 36-year-old woman with a history of two caesarean deliveries and a low-lying placenta. We further describe the sonographic features useful for differentiating this condition from placenta accreta spectrum in instances where the placenta lies under an area of full thickness uterine scar dehiscence.

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.

Vascular control by infrarenal aortic cross-clamping in placenta accreta spectrum disorders: description of technique

We describe a novel surgical technique in 31 women with histopathologically confirmed placenta accreta spectrum (PAS) disorders managed by a multidisciplinary team using a prophylactic infrarenal abdominal aortic cross-clamping technique during caesarean hysterectomy. We conclude that this new surgical procedure is a relatively safe technique to potentially control operative blood loss. Our work may stimulate others to develop protocols assessing this innovative technique to improve the surgical outcome of PAS disorders.