John C. Kingdom, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada. Electronic address: john.kingdom@sinaihealthsystem.ca
Sebastian R. Hobson, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
Ally Murji, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
Lisa Allen, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
Rory C. Windrim, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Ontario, Canada
Evelyn Lockhart, Department of Pathology, University of New Mexico Health Science Center, Albuquerque, NM
Sally L. Collins, Department of Obstetrics & Gynaecology, University of Oxford NHS Foundation Trust, England, United Kingdom
Hooman Soleymani Majd, Department of Obstetrics & Gynaecology, University of Oxford NHS Foundation Trust, England, United Kingdom
Moiad Alazzam, Department of Obstetrics & Gynaecology, University of Oxford NHS Foundation Trust, England, United Kingdom
Feras Naaisa, Department of Gynaecology, South Bristol NHS Trust, Bristol, England, United Kingdom
Alireza A. Shamshirsaz, Maternal-Fetal Medicine Division, Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX
Michael A. Belfort, Maternal-Fetal Medicine Division, Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX
Karin A. Fox, Maternal-Fetal Medicine Division, Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX

Document Type

Article

Publication Date

9-1-2020

Abstract

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.

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