Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: A retrospective hospital-based study

Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: A retrospective hospital-based study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: A retrospective hospital-based study Yongchi Zhan, Enfan Lu, Tingting Xu, Guiqiong Huang, Chunyan Deng, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4659404/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Oct, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 11 You are reading this latest preprint version Abstract Background Placenta previa accreta (PPA) is a severe obstetric condition that can cause massive postpartum hemorrhage and transfusion. Cesarean hysterectomy is necessary in some severe cases of PPA to stop the life-threatening bleeding, but cesarean hysterectomy can be associated with significant surgical blood loss and major complications. The current study is conducted to investigate the potential risk factors of excessive blood loss during cesarean hysterectomy in women with PPA. Methods This is a retrospective study including singleton pregnancies after 28 weeks of gestation in women with placenta previa and pathologically confirmed placenta accreta spectrum who received hysterectomy during cesarean sections. A total of 199 women from January 2012 to August 2023 were included in this study and were divided into Group 1 (estimated surgical blood loss (EBL) ≤ 3500 mL, n=103) and Group 2 (EBL > 3500 mL, n=96). The primary outcome was defined as an EBL over 3500 mL. Baseline characteristics and surgical outcomes were compared between the two groups. A multivariate logistic regression model was applied to find potential risk factors of the primary outcome. Results Massive surgical blood loss was prevalent in our study group, with a median EBL of 3500 mL. The multivariate logistic analysis showed that emergency surgery (OR 2.18, 95% CI 1.08-4.41, p = 0.029), cervical invasion of the placenta (OR 2.70, 95% CI 1.43-5.10, p = 0.002), and intraoperative bladder injury (OR 5.18, 95% CI 2.02-13.28, p = 0.001) were all associated with the primary outcome. Bilateral internal iliac arteries balloon occlusion (OR 0.57, 95% CI 0.34-0.97) and abdominal aortic balloon occlusion (OR 0.33, 95% CI 0.19-0.56) were negatively associated with the primary outcome. Conclusions Emergency surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for additional EBL during cesarean hysterectomy in women with PPA. Future prospective studies are needed to confirm the effect of intra-arterial balloon occlusion in cesarean hysterectomy of PPA. Placenta previa Hemorrhage Cesarean hysterectomy Balloon occlusion Figures Figure 1 Background Placenta accreta spectrum (PAS) is a severe gestational complication. Prior cesarean section and placenta previa are risk factors for PAS. The risk of PAS increased significantly with the increasing number of previous cesarean deliveries. 1 According to a systematic review of 20 original studies, the median prevalence of placenta previa with PAS was 0.07%. 2 Placenta previa and placenta accreta are two leading causes of postpartum hemorrhage (PPH). 3 From a nationwide study in the United States, prior cesarean section with placenta previa or PAS brought significantly increased risk of PPH, blood transfusion, and peripartum hysterectomy. 4 The principles of surgical management of placenta previa accreta (PPA) are keeping the safe delivery of the fetus and surgical hemostasis. According to the current guidelines, cesarean hysterectomy with the placenta left in situ is preferable in the peripartum management of women with PAS 5–7 , especially for those severe cases of placenta previa percreta. Cesarean hysterectomy in women with PPA is considered a difficult surgical procedure that should be managed by experienced multidisciplinary teams and may cause severe bleeding and significant complications. 8 In primary health care institutions, cesarean hysterectomy may be uncommon, large-scale studies about cesarean hysterectomy in women with PPA are lacking. Therefore, we performed this retrospective study to investigate the clinical characteristics of cesarean hysterectomy in women with PPA. In addition, we hope to find possible risk factors of additional surgical blood loss in those cases that can help with perinatal management and improve perinatal outcomes in PPA. Methods This retrospective study was conducted from January 2012 to August 2023 in West China Second University Hospital, a tertiary referral center for maternal and children’s health in Western China. The study was approved by the Ethics Committee of the West China Second University Hospital, Sichuan University. In our hospital, PPA is managed by multidisciplinary expertise, including experienced obstetricians, gynecologic oncologists, anesthesiologists, interventional radiologists, and surgical nurses. In our hospital, a cesarean hysterectomy was conducted to stop life-threatening hemorrhage only in case of severe PPA without an attempt to separate the placenta and in cases that had a failure of conservative management after removing the placenta. Women with placenta previa and pathologically confirmed PAS who underwent hysterectomy during cesarean section after 28 weeks of gestation were included in the current study. Patients with twin pregnancies, severe prenatal uterine rupture before surgery, and who underwent relaparotomy for hysterectomy were excluded. Clinical and demographic characteristics were obtained from the electronic medical records. A total of 199 women with PPA who received cesarean hysterectomy were included in the current study. PPA is a major cause of life-threatening PPH. 4 The rate of PPH was extremely high in our study group. The median EBL of the study group was 3500 mL (2500, 5000) (interquartile range), and about 96.48% (192/199) of women were diagnosed with PPH which had EBL ≥ 1000 mL. In addition, there is no consensus on the severity classification of PPH. Therefore, the cases were divided into two similarly sized groups to investigate the potential risk factors of additional EBL in women with PPA who received cesarean hysterectomy. We defined Group 1 (G1) = EBL ≤ 3500 mL (n = 103), Group 2 (G2) = EBL > 3500 mL (n = 96). (Fig. 1 ) Maternal information included demographic characteristics, obstetric history, perinatal complications, ultrasonic findings, and placental pathology. Perioperative outcomes included estimated blood loss (EBL), gestational age (GA) at delivery, intra-arterial balloons, surgical time, hysterectomy types, intraoperative consultation, cervical invasion of placenta, intraoperative bladder injury, infusion, blood products transfusion, and maternal postsurgical hospital stay. Neonatal outcomes included neonatal intensive care unit (NICU) admission and birth weight. The primary outcome was defined as an EBL > 3500 mL. Placenta previa is defined as placenta implanting within the lower uterine segment, and the lower placental edge partially or entirely covers the cervical internal os. 5 PAS is defined as three types of placenta adherenta, increta, and percreta, based on pathological examination of the hysterectomy specimens according to the International Federation of Gynecology and Obstetrics (FIGO) PAS classification. Placenta adherenta is where placental villi are attached directly to the superficial myometrium and extended absence of decidua. Placenta increta is where the villi penetrate into the uterine myometrium, and placenta percreta is defined as villous tissue within or breaching the uterine serosa. 9 According to recent studies, the effectiveness of intraoperative internal iliac artery balloon occlusion in women with PAS was not reliable. 10,11 Therefore, most of the women in our study who had bilateral internal iliac artery balloon occlusion were delivered before the year 2020. After 2020, prophylactic balloon occlusion of the internal iliac artery was not routinely conducted in our hospital, and prophylactic abdominal aortic balloon was performed in some severe cases of PPA at the multidisciplinary team’s discretion. Written informed consents were obtained from all women who received intra-arterial balloon catheters. The procedure for balloon occlusion was as follows. For internal iliac arteries occlusion, under X-ray guidance, the catheters (low profile PTA dilatation catheter PTA5-35-80-8-6.0, Cook Medical Inc., Bloomington, USA) were inserted via the femoral arteries and placed at the anterior division of the internal iliac arteries. For abdominal aortic occlusion, the catheter (dilatation catheter AT75164, Bard Peripheral Vascular Inc., Arizona, USA) was inserted via the right femoral artery and placed in the abdominal aorta below the level of renal arteries. After the placement of catheters, cesarean delivery was conducted immediately, and the balloons were inflated after the cord was clamped. During the surgery, the abdominal aortic balloons were deflated every ten minutes, and oxygen saturation of the left great toe was monitored. EBL was based on the amount of blood collected in the suction canister, excluding amniotic fluid and saline for irrigation. The number of laparotomy pads used during the surgery and blood on other surfaces were also calculated. The final EBL was confirmed by the judgment of surgeons, nurses, and anesthetists. The surgical time was defined as the duration between incision for cesarean and wound closure. The final decision of cesarean hysterectomy and the procedure of hysterectomy were made by experienced obstetricians and with consultation from gynecologic oncologists in some cases. Cervical invasion of the placenta was confirmed by laparotomic finding that part of the placenta penetrated the cervical canal or abnormally attached to the cervical tissue. If an intraoperative bladder injury occurred, urologists were consulted to repair the bladder. The Kolmogorov–Smirnov test was performed to determine the normality of continuous variables. Non-normally distributed data were shown as median (interquartile range), and the Mann–Whitney U test was used for the analysis. Categorical variables are presented as number/proportion (%) and were analyzed by the chi-square test. A stepwise backward elimination multivariate logistic regression model was applied to ascertain independent risk factors of the primary outcome. All statistical analyses and data processing were conducted using SPSS 24.0 statistical software (IBM, Armonk, NY, USA). P < 0.05 was considered as statistically significant. Odds ratio (OR) and 95% confidence intervals (CI) are used to show the effect of potential risk factors. Results From January 2012 to August 2023, a total of 205 women received cesarean hysterectomy after 28 weeks of gestation in West China Second University Hospital, Sichuan University. After the exclusion of four cases of twin pregnancy, one case of severe prenatal uterine rupture, and one case of relaparotomy for hemostasis, 199 women diagnosed with PPA and received cesarean hysterectomy were included in the study. Baseline characteristics, including maternal age, gravidity, parity, prior uterine curettage, prior cesarean section, rate of the anterior placenta, and classification of pathological examination, were not significantly different between G1 and G2 (p > 0.05). (Table 1) The proportion of placenta increta (67.0% vs. 57.3%) and placenta percreta (30.1% vs. 37.5%) were comparable between G1 and G2. A slightly higher rate of gestational diabetes mellitus (GDM) was diagnosed in G1 (31.1% vs. 18.8%, p = 0.045). For neonatal outcomes, the gestational age at delivery, birth weight, and rate of NICU admission were not significantly different between the two groups. According to the division of the two study groups, the EBL was higher in G2 than G1, as well as perioperative blood products transfusion and infusion volume. The infusion volumes were 7100 (5906.25, 8700) mL in G2 and 4300 (3000, 5200) mL in G1 (p < 0.001). The transfusion of packed red blood cells (PRBCs), fresh frozen plasma, fibrinogen, and cryoprecipitate during surgery were 10.5 (6, 15.5) U, 1000 (800, 1562.5) mL, 2 (0, 4) g, and 0 (0, 9.5) U in G2 respectively. In G1, the numbers were 3 (1.5, 6) U, 600 (0, 600) mL, 0 (0, 0) g, and 0 (0, 0) U, respectively (all p < 0.001). The autologous blood transfusion volumes were comparable between the two groups (G1: 220 (0, 463) mL vs. G2: 0 (0, 1098) mL, p = 0.101). For perioperative period characteristics, the postsurgical hospital stays (six days vs. seven days), surgical time (131 min vs. 185.5 min), emergency surgery rate (21.4% vs. 41.7%), intraoperative gynecologic oncology consultation (74.8% vs. 88.5%), cervical invasion of the placenta (41.7% vs. 59.4%), and bladder injury rate (6.8% vs. 25.0%) were all significantly lower in G1 than G2 (all p < 0.05). The intra-arterial ball balloon proportion differed between G1 and G2 (p = 0.022). 12.6% (13/103) women had abdominal aortic balloon occlusion, 48.5% (50/103) had bilateral internal iliac arteries balloon occlusion in G1. At the same time, the rate of bilateral internal iliac arteries balloon occlusion was 44.8% (43/96), but the abdominal aortic balloon occlusion rate was only 3.1% (3/96) in G2. There was no difference in the rate of total hysterectomy vs. supracervical hysterectomy in G1 and G2 (p = 0.979). (Details shown in Table 2) Maternal age, prior uterine curettage, prior cesarean section, GDM, anterior placenta, pathological classification, gestational age at delivery, neonatal birth weight, emergency surgery, intraoperative gynecologic oncology consultation, cervical invasion of placenta, bladder injury, total/supracervical hysterectomy, and intra-arterial balloons were included in the stepwise backward elimination multivariate logistic regression analysis and five variables were included in the final model. (Table 3) Emergency surgery (OR 2.18, 95% CI 1.08-4.41, p = 0.029), cervical invasion of placenta (OR 2.70, 95% CI 1.43-5.10, p = 0.002), and intraoperative bladder injury (OR 5.18, 95% CI 2.02-13.28, p = 0.001) were all associated with an EBL > 3500 mL. Bilateral internal iliac arteries occlusion (OR 0.57, 95% CI 0.34-0.97) and abdominal aortic occlusion (OR 0.33, 95% CI 0.19-0.56) were negatively associated with the primary outcome, and intraoperative gynecologic oncology consultation was not associated with it (OR 2.20, 95% CI 0.99-5.32, p = 0.054). Discussion In the current study, a large case series of 199 women with PPA who underwent cesarean hysterectomy from an over ten-year period were investigated to find risk factors of excessive surgical blood loss. Our findings revealed that emergency surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for an EBL over 3500 mL. Surprisingly, our study found that abdominal aortic balloon occlusion and bilateral internal iliac artery balloon occlusion can reduce the EBL during cesarean hysterectomy in women with PPA. Women with PPA should be transferred to experienced centers and managed by multidisciplinary teams. In our hospital, a cesarean hysterectomy was conducted in cases of severe PPA without the attempt to separate the placenta and in cases that had failed conservative management after removing the placenta. Usually, cesarean hysterectomy for PAS is a rare surgical procedure, that conducted in a hospital with higher surgical volume may be associated with improved surgical outcomes. 12 A well-established multidisciplinary team performing 2–3 cases per month can improve perinatal outcomes over time with increasing experience. 13 In a retrospective study conducted in the United States, which included 77 women with PAS who underwent peripartum hysterectomy, the median blood loss was 3000 mL, and the median transfusion of PRBCs was five units 14 , similar to the current study. However, the placenta increta/percreta rate was only 32.47% (25/77), and the rate was as high as 95.98% (191/199) in our study. Unplanned delivery with emergency cesarean hysterectomy in women with PPA may be associated with adverse peripartum outcomes. Our study included all the planned or unplanned cesarean hysterectomies and revealed emergency surgery was a potential risk factor for additional surgical blood loss. A multicenter retrospective study showed patients who had planned cesarean hysterectomy had a significantly lower rate of blood loss, less need for blood transfusion, and fewer surgical complications. 15 Similar results were shown in other studies. Antenatal vaginal bleeding and preterm labor were risk factors for emergent delivery. Individualized management and planned delivery at optimal gestational age are recommended. 16,17 Placenta invading the cervical canal may cause additional surgical blood loss. In our study, cervical invasion of the placenta was a clinical finding during surgery. The histological examination of cervical specimens was lacking. Studies focused on pathologically confirmed cervical placenta accreta are scarce. Cervical, parametrial, and bladder invasion of the placenta were considered severe PAS conditions. In a retrospective study including 55 cases of placenta percreta, nine of them had cervical invasion diagnosed antenatally, and all of the nine women received cesarean hysterectomy. 18 Theoretically, when the placenta invades the cervix in women with PPA, total hysterectomy is required. In the current study, total or supracervical hysterectomy were not significantly associated with an EBL over 3500 mL. Similarly, there was no difference in surgical time or complications between total or supracervical hysterectomy in a retrospective study, including 78 cases of placenta accreta in 150 cases of emergent cesarean hysterectomy. 19 However, in a recent small sample-sized study, supracervical hysterectomy had better perinatal outcomes than total hysterectomy, and supracervical hysterectomy was suggested for the first-line approach in cases of abnormally invasive placenta. 20 Our study revealed that intraoperative bladder injury was potentially associated with additional EBL. When placenta previa percreta involves the maternal bladder, intraoperative bladder injury may be inevitable. 21 For this severe condition, timely consultation with experienced urologists may be necessary. Our findings suggest individualized surgical procedures may be more reasonable in patients with PPA. Which surgical procedure should be selected is based on which can stop the bleeding and minimize the surgical complications. For example, some scholars suggested a kind of modified supracervical hysterectomy in PAS patients with cervical-trigonal fibrosis, which resulted in a significant improvement in surgical outcomes. 22 Whether intra-arterial balloon occlusion during cesarean hysterectomy can improve perinatal outcomes in women with PPA is debated, especially using internal iliac artery balloon occlusion. Randomized controlled studies about using intra-arterial balloons in cesarean hysterectomy were lacking. Randomized trials with small samples in women with PAS or placenta previa revealed that prophylactic internal iliac artery balloon occlusion was not associated with improved perinatal outcomes. 23–25 A systematic review including 15 original studies showed the same results that internal iliac artery balloons cannot reduce blood loss or PRBC transfusion in PAS women. 26 So recently, the use of internal iliac artery balloons was not routinely recommended, and abdominal aorta balloon occlusion has become preferable in severe cases of PPA. Abundant evidence suggested that abdominal aorta balloons were safe and effective in patients with PAS, which was associated with reduced blood loss volume, transfusion volume, and hysterectomy rate. 27,28 Surprisingly, our study revealed that both the internal iliac artery balloon and the abdominal aortic balloon were potentially associated with an EBL ≤ 3500 mL in cesarean hysterectomy of PPA, and the effect of the abdominal aortic balloon was more significant. In another retrospective study conducted in our hospital, which included 114 cases of planned deliveries with PPA underwent cesarean hysterectomy, intraoperative internal iliac artery balloon occlusion was not associated with an EBL greater or equal to 3000 mL, or transfusion of ten or more units of PRBCs. 10 This study excluded emergent deliveries and chose a different primary outcome, which may explain the different results. The main strength of the current study is that we included a large case series. A total of 199 cases of cesarean hysterectomy in women with PPA were analyzed, and the cesarean hysterectomy is a relatively rare surgical procedure. In addition, the diagnosis of PAS was confirmed pathologically in all the cases. Secondly, our study included all the cases of planned or emergent deliveries, total or supracervical cesarean hysterectomy to find potential risk factors of additional EBL in the severe condition of PPA. Our study also had some limitations. Firstly, this is a retrospective study, and possible bias may exist in data collection. However, randomized controlled studies may be difficult to conduct for cesarean hysterectomy. Secondly, our data could not differentiate the cases that conducted cesarean hysterectomy instantly without an attempt to separate the placenta and the cases that failed conservative management after removing the placenta. In China, the cesarean hysterectomy is usually decided during the surgery because most of the patients are eager to keep their fertility. Separation of the placenta in PPA is a potentially significant risk factor that can lead to massive hemorrhage before hysterectomy. Conclusions In conclusion, our study reviewed a large case series, including 199 cases of cesarean hysterectomy in women with PPA. Life-threatening hemorrhage was very common, with the median EBL of the study group as high as 3500 mL. Emergent surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for additional EBL. Both the internal iliac artery balloon occlusion and abdominal aorta balloon occlusion were potentially associated with fewer EBL. Future prospective studies are needed to confirm the effect of intra-arterial balloon occlusion in cesarean hysterectomy of women with PPA. Abbreviations CI, Confidence intervals; EBL, Estimated surgical blood loss; FIGO, International Federation of Gynecology and Obstetrics; GA, Gestational age; GDM, Gestational diabetes mellitus; NICU, Neonatal intensive care unit; OR, Odds ratio; PPA, Placenta previa accreta; PPH, Postpartum hemorrhage; PRBCs, Packed red blood cells; Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of the West China Second University Hospital, Sichuan University. Informed consent was obtained from the patients. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by the Science Foundation of Sichuan Province (grant number 2022YF0042). Authors’ contributions YC Zhan, TT Xu, and XD Wang initiated and designed the present study. YC Zhan, TT Chen, and YX Ren collected the data. X Wu performed the pathological diagnosis. YC Zhan, EF Lu, CY Deng, and GQ Huang performed data analysis. YC Zhan wrote the first draft of the manuscript. TT Xu, HY Yu, and XD Wang reviewed, completed, and supervised the manuscript writing. All authors contributed to its interpretation and contributed to the article and approved the submitted version. Acknowledgements We are grateful to the staff who have been involved in this work. All persons that contributed to this study are listed as authors and meet the criteria for authorship. References Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226–32. 10.1097/01.AOG.0000219750.79480.84 . Jauniaux E, Grønbeck L, Bunce C, Langhoff-Roos J, Collins SL. Epidemiology of placenta previa accreta: a systematic review and meta-analysis. BMJ Open. 2019;9(11):e031193. 10.1136/bmjopen-2019-031193 . Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186. 10.1097/AOG.0000000000002351 . Corbetta-Rastelli CM, Friedman AM, Sobhani NC, Arditi B, Goffman D, Wen T. Postpartum Hemorrhage Trends and Outcomes in the United States, 2000–2019. Obstet Gynecol. 2023;141(1):152–61. 10.1097/AOG.0000000000004972 . Jauniaux E, Alfirevic Z, Bhide A, et al. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. BJOG Int J Obstet Gynaecol. 2019;126(1). 10.1111/1471-0528.15306 . Committee on Obstetric Practice. Committee opinion 529: placenta accreta. Obstet Gynecol. 2012;120(1):207–11. 10.1097/AOG.0b013e318262e340 . Publications Committee, Society for Maternal-Fetal Medicine, Belfort MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430–9. 10.1016/j.ajog.2010.09.013 . Kingdom JC, Hobson SR, Murji A, et al. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020. Am J Obstet Gynecol. 2020;223(3):322–9. 10.1016/j.ajog.2020.01.044 . Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S. FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;146(1):20–4. 10.1002/ijgo.12761 . Chen M, Lv B, He G, Liu X. Internal iliac artery balloon occlusion during cesarean hysterectomy in women with placenta previa accreta. Int J Gynaecol Obstet. 2019;145(1):110–5. 10.1002/ijgo.12763 . Chen D, Xu J, Tian Y, et al. Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta. BMC Pregnancy Childbirth. 2021;21(1):640. 10.1186/s12884-021-04103-x . Matsuo K, Youssefzadeh AC, Mandelbaum RS, et al. Hospital surgical volume-outcome relationship in caesarean hysterectomy for placenta accreta spectrum. BJOG Int J Obstet Gynaecol. 2022;129(6):986–93. 10.1111/1471-0528.16993 . Shamshirsaz AA, Fox KA, Erfani H, et al. Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time. Am J Obstet Gynecol. 2017;216(6):612e. 10.1016/j.ajog.2017.02.016 . Wright JD, Pri-Paz S, Herzog TJ, et al. Predictors of massive blood loss in women with placenta accreta. Am J Obstet Gynecol. 2011;205(1):e381–6. 10.1016/j.ajog.2011.01.040 . Briery CM, Rose CH, Hudson WT, et al. Planned vs emergent cesarean hysterectomy. Am J Obstet Gynecol. 2007;197(2):e1541–5. 10.1016/j.ajog.2007.03.026 . Thang NM, Anh NTH, Thanh PH, Linh PT, Cuong TD. Emergent versus planned delivery in patients with placenta accreta spectrum disorders: A retrospective study. Med (Baltim). 2021;100(51):e28353. 10.1097/MD.0000000000028353 . Oge T, Tokgoz VY, Cakmak Y, Velipasaoglu M. Peripartum Hysterectomy: Is There Any Difference Between Emergency and Planned Surgeries? Rev Bras Ginecol E Obstet Rev Fed Bras Soc Ginecol E Obstet. 2022;44(1):3–9. 10.1055/s-0041-1736303 . Chen X, Shan R, Song Q, Wei X, Liu W, Wang G. Placenta percreta evaluated by MRI: correlation with maternal morbidity. Arch Gynecol Obstet. 2020;301(3):851–7. 10.1007/s00404-019-05420-5 . Imudia AN, Hobson DTG, Awonuga AO, Diamond MP, Bahado-Singh RO. Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy. Am J Obstet Gynecol. 2010;203(3):e2211–5. 10.1016/j.ajog.2010.04.007 . Levin G, Rottenstreich A, Benshushan A, et al. The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: a case-control study. J Matern-Fetal Neonatal Med. 2020;33(15):2522–6. 10.1080/14767058.2018.1554049 . Murji A, Kingdom J. Placenta Percreta Involving Maternal Bladder. N Engl J Med. 2019;381(7):e12. 10.1056/NEJMicm1900978 . Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2023;36(1):2183741. 10.1080/14767058.2023.2183741 . Salim R, Chulski A, Romano S, Garmi G, Rudin M, Shalev E. Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol. 2015;126(5):1022–8. 10.1097/AOG.0000000000001113 . Chen M, Liu X, You Y, et al. Internal Iliac Artery Balloon Occlusion for Placenta Previa and Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol. 2020;135(5):1112–9. 10.1097/AOG.0000000000003792 . Yu SCH, Cheng YKY, Tse WT, et al. Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial. Am J Obstet Gynecol. 2020;223(1):117e. 1-117.e13. Liang D, Zhao H, Liu D, Lin Y. Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis. Eur J Radiol. 2021;139:109711. 10.1016/j.ejrad.2021.109711 . Shahin Y, Pang CL. Endovascular interventional modalities for haemorrhage control in abnormal placental implantation deliveries: a systematic review and meta-analysis. Eur Radiol. 2018;28(7):2713–26. 10.1007/s00330-017-5222-0 . Chen L, Wang X, Wang H, Li Q, Shan N, Qi H. Clinical evaluation of prophylactic abdominal aortic balloon occlusion in patients with placenta accreta: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2019;19(1):30. 10.1186/s12884-019-2175-0 . Tables Table 1. Demographics and baseline characteristics between two groups Group 1 (n=103) Group 2 (n=96) P value Age, years 33 (29, 37) 32 (30, 37) 0.828 Gravidity 4 (3, 5) 4 (3, 5) 0.917 Parity 1 (1, 2) 1 (1, 2) 0.887 Prior uterine curettage 2 (1, 3) 2 (1, 3) 0.733 Prior cesarean sections 1 (1, 1) 1 (1, 1) 0.577 GDM No 71 (68.9) 78 (81.3) 0.045 Yes 32 (31.1) 18 (18.8) Anterior placenta No 24 (23.3) 19 (19.8) 0.548 Yes 79 (76.7) 77 (80.2) Pathology Adherenta 3 (2.9) 5 (5.2) 0.331 Increta 69 (67.0) 55 (57.3) Percreta 31 (30.1) 36 (37.5) GDM, Gestational diabetes mellitus Table 2. Perioperative period characteristics between two groups Group 1 (n=103) Group 2 (n=96) P value Estimate surgical blood loss, mL 2500 (1700, 3000) 5060.5 (4025, 7000) <0.001 Gestational age at delivery, weeks 36 (34.7, 36.7) 36.14 (34.18, 37) 0.827 Postsurgical hospital stay, days 6 (5, 7) 7 (5, 10) 0.001 Surgical time, min 131 (113, 159) 185.5 (137, 246) <0.001 Emergency surgery No 81 (78.6) 56 (58.3) 0.002 Yes 22 (21.4) 40 (41.7) Intra-arterial balloons None 40 (38.8) 50 (52.1) 0.022 Bilateral internal iliac arteries 50 (48.5) 43 (44.8) Abdominal aorta 13 (12.6) 3 (3.1) Intraoperative gynecologic oncology consultation No 26 (25.2) 11 (11.5) 0.013 Yes 77 (74.8) 85 (88.5) Cervical invasion of the placenta No 60 (58.3) 39 (40.6) 0.013 Yes 43 (41.7) 57 (59.4) Hysterectomy Supracervical 13 (12.6) 12 (12.5) 0.979 Total 90 (87.4) 84 (87.5) Bladder injury No 96 (93.2) 72 (75.0) <0.001 Yes 7 (6.8) 24 (25.0) Infusion volume, mL 4300 (3000, 5200) 7100 (5906.25, 8700) <0.001 Transfusion PRBCs, U 3 (1.5, 6) 10.5 (6, 15.5) <0.001 Autologous blood transfusion, mL 220 (0, 463) 0 (0, 1098) 0.101 FFP, mL 600 (0, 600) 1000 (800, 1562.5) <0.001 Fibrinogen, g 0 (0, 0) 2 (0, 4) <0.001 Cryoprecipitate, U 0 (0, 0) 0 (0, 9.5) <0.001 NICU No 65 (63.1) 53 (55.2) 0.257 Yes 38 (36.9) 43 (44.8) Birth weight, g 2650 (2290, 2970) 2635 (2132.5, 2850) 0.241 FFP, Fresh frozen plasma; NICU, Neonatal intensive care unit; PRBC, Packed red blood cells Table 3. Multivariate logistic analysis (stepwise backward elimination) OR (95% CI) P value Intraoperative gynecologic oncology consultation No 1 Yes 2.29 (0.99, 5.32) 0.054 Emergency surgery No 1 Yes 2.18 (1.08, 4.41) 0.029 Cervical invasion of the placenta No 1 Yes 2.70 (1.43, 5.10) 0.002 Intra-arterial balloons None 1 Bilateral internal iliac arteries 0.57 (0.34, 0.97) 0.039 Abdominal aorta 0.33 (0.19, 0.56) Bladder injury No 1 Yes 5.18 (2.02, 13.28) 0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Oct, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 15 Jul, 2024 Reviews received at journal 12 Jul, 2024 Reviewers agreed at journal 10 Jul, 2024 Reviewers agreed at journal 10 Jul, 2024 Reviews received at journal 09 Jul, 2024 Reviewers agreed at journal 06 Jul, 2024 Reviewers invited by journal 06 Jul, 2024 Editor invited by journal 03 Jul, 2024 Editor assigned by journal 02 Jul, 2024 Submission checks completed at journal 02 Jul, 2024 First submitted to journal 29 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4659404","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":327289206,"identity":"ebf18326-a6e5-49c5-a265-72f9e9f8209f","order_by":0,"name":"Yongchi Zhan","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yongchi","middleName":"","lastName":"Zhan","suffix":""},{"id":327289207,"identity":"901fdabb-ad7c-43a8-b49f-3a167497135a","order_by":1,"name":"Enfan Lu","email":"","orcid":"","institution":"Operation Management Office, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Enfan","middleName":"","lastName":"Lu","suffix":""},{"id":327289208,"identity":"87426de0-0bfa-475b-8f70-1fcd0a17f9d0","order_by":2,"name":"Tingting Xu","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Tingting","middleName":"","lastName":"Xu","suffix":""},{"id":327289209,"identity":"126bd526-484f-42a8-a4fe-148916a0af38","order_by":3,"name":"Guiqiong Huang","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Guiqiong","middleName":"","lastName":"Huang","suffix":""},{"id":327289210,"identity":"ce036dee-9caf-4bc1-a166-404e1e12aa21","order_by":4,"name":"Chunyan Deng","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Chunyan","middleName":"","lastName":"Deng","suffix":""},{"id":327289211,"identity":"e4a2adcb-4f34-4b75-943c-f3eb56f21bde","order_by":5,"name":"Tiantian Chen","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Tiantian","middleName":"","lastName":"Chen","suffix":""},{"id":327289212,"identity":"827a3711-732a-43ec-a526-1d5b1917b43f","order_by":6,"name":"Yuxin Ren","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yuxin","middleName":"","lastName":"Ren","suffix":""},{"id":327289213,"identity":"baabb4f9-cf2f-44a7-b3ca-3edbb8dec8b5","order_by":7,"name":"Xia Wu","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xia","middleName":"","lastName":"Wu","suffix":""},{"id":327289214,"identity":"38ced874-e65c-409c-bf91-7e505ae2d045","order_by":8,"name":"Haiyan Yu","email":"","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Haiyan","middleName":"","lastName":"Yu","suffix":""},{"id":327289215,"identity":"585b9038-449d-4fff-813b-f68e86324ea8","order_by":9,"name":"Xiaodong Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYNACNhDBfIAhgUQtbAkka+ExIE6xwfGzh1/zlDHY88/I+fzh4Q47Bv72bvyWGZzJS7OccY4hccaN3G0SiWeSGSTOnN2AV4vZgRwzg49tDAkGErnbGBLbmBmADAJazr8xM0hsY7A3kMh5/CGxrZ4ILTdyjB8AbWHcIJHDIJHYdpiwFvsbb8wYwX4588wMqOU4D0G/SPbnGH8Gh1h78uOPP9uq5fjbe/FrAQI2CQaG/3AeDyHlIMD8gRhVo2AUjIJRMIIBAN+dRjARnXpiAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"Xiaodong","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-06-29 12:59:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4659404/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4659404/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-024-06834-z","type":"published","date":"2024-10-02T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61011179,"identity":"e52ede84-b6e3-453f-a3be-008ae1f5f331","added_by":"auto","created_at":"2024-07-24 14:35:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":293914,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4659404/v1/e1da7019778bd5d8fd450dd3.png"},{"id":66096968,"identity":"7ce5b6fc-3135-4748-b30f-5295d70f5d89","added_by":"auto","created_at":"2024-10-07 16:12:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":770764,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4659404/v1/829bf87a-7ed2-4698-a04b-316feb378a67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: A retrospective hospital-based study","fulltext":[{"header":"Background","content":"\u003cp\u003ePlacenta accreta spectrum (PAS) is a severe gestational complication. Prior cesarean section and placenta previa are risk factors for PAS. The risk of PAS increased significantly with the increasing number of previous cesarean deliveries.\u003csup\u003e1\u003c/sup\u003e According to a systematic review of 20 original studies, the median prevalence of placenta previa with PAS was 0.07%.\u003csup\u003e2\u003c/sup\u003e Placenta previa and placenta accreta are two leading causes of postpartum hemorrhage (PPH).\u003csup\u003e3\u003c/sup\u003e From a nationwide study in the United States, prior cesarean section with placenta previa or PAS brought significantly increased risk of PPH, blood transfusion, and peripartum hysterectomy.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe principles of surgical management of placenta previa accreta (PPA) are keeping the safe delivery of the fetus and surgical hemostasis. According to the current guidelines, cesarean hysterectomy with the placenta left in situ is preferable in the peripartum management of women with PAS\u003csup\u003e5\u0026ndash;7\u003c/sup\u003e, especially for those severe cases of placenta previa percreta. Cesarean hysterectomy in women with PPA is considered a difficult surgical procedure that should be managed by experienced multidisciplinary teams and may cause severe bleeding and significant complications.\u003csup\u003e8\u003c/sup\u003e In primary health care institutions, cesarean hysterectomy may be uncommon, large-scale studies about cesarean hysterectomy in women with PPA are lacking. Therefore, we performed this retrospective study to investigate the clinical characteristics of cesarean hysterectomy in women with PPA. In addition, we hope to find possible risk factors of additional surgical blood loss in those cases that can help with perinatal management and improve perinatal outcomes in PPA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective study was conducted from January 2012 to August 2023 in West China Second University Hospital, a tertiary referral center for maternal and children\u0026rsquo;s health in Western China. The study was approved by the Ethics Committee of the West China Second University Hospital, Sichuan University. In our hospital, PPA is managed by multidisciplinary expertise, including experienced obstetricians, gynecologic oncologists, anesthesiologists, interventional radiologists, and surgical nurses. In our hospital, a cesarean hysterectomy was conducted to stop life-threatening hemorrhage only in case of severe PPA without an attempt to separate the placenta and in cases that had a failure of conservative management after removing the placenta.\u003c/p\u003e \u003cp\u003eWomen with placenta previa and pathologically confirmed PAS who underwent hysterectomy during cesarean section after 28 weeks of gestation were included in the current study. Patients with twin pregnancies, severe prenatal uterine rupture before surgery, and who underwent relaparotomy for hysterectomy were excluded. Clinical and demographic characteristics were obtained from the electronic medical records.\u003c/p\u003e \u003cp\u003eA total of 199 women with PPA who received cesarean hysterectomy were included in the current study. PPA is a major cause of life-threatening PPH.\u003csup\u003e4\u003c/sup\u003e The rate of PPH was extremely high in our study group. The median EBL of the study group was 3500 mL (2500, 5000) (interquartile range), and about 96.48% (192/199) of women were diagnosed with PPH which had EBL\u0026thinsp;\u0026ge;\u0026thinsp;1000 mL. In addition, there is no consensus on the severity classification of PPH. Therefore, the cases were divided into two similarly sized groups to investigate the potential risk factors of additional EBL in women with PPA who received cesarean hysterectomy. We defined Group 1 (G1)\u0026thinsp;=\u0026thinsp;EBL\u0026thinsp;\u0026le;\u0026thinsp;3500 mL (n\u0026thinsp;=\u0026thinsp;103), Group 2 (G2)\u0026thinsp;=\u0026thinsp;EBL\u0026thinsp;\u0026gt;\u0026thinsp;3500 mL (n\u0026thinsp;=\u0026thinsp;96). (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMaternal information included demographic characteristics, obstetric history, perinatal complications, ultrasonic findings, and placental pathology. Perioperative outcomes included estimated blood loss (EBL), gestational age (GA) at delivery, intra-arterial balloons, surgical time, hysterectomy types, intraoperative consultation, cervical invasion of placenta, intraoperative bladder injury, infusion, blood products transfusion, and maternal postsurgical hospital stay. Neonatal outcomes included neonatal intensive care unit (NICU) admission and birth weight. The primary outcome was defined as an EBL\u0026thinsp;\u0026gt;\u0026thinsp;3500 mL.\u003c/p\u003e \u003cp\u003ePlacenta previa is defined as placenta implanting within the lower uterine segment, and the lower placental edge partially or entirely covers the cervical internal os.\u003csup\u003e5\u003c/sup\u003e PAS is defined as three types of placenta adherenta, increta, and percreta, based on pathological examination of the hysterectomy specimens according to the International Federation of Gynecology and Obstetrics (FIGO) PAS classification. Placenta adherenta is where placental villi are attached directly to the superficial myometrium and extended absence of decidua. Placenta increta is where the villi penetrate into the uterine myometrium, and placenta percreta is defined as villous tissue within or breaching the uterine serosa.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccording to recent studies, the effectiveness of intraoperative internal iliac artery balloon occlusion in women with PAS was not reliable.\u003csup\u003e10,11\u003c/sup\u003e Therefore, most of the women in our study who had bilateral internal iliac artery balloon occlusion were delivered before the year 2020. After 2020, prophylactic balloon occlusion of the internal iliac artery was not routinely conducted in our hospital, and prophylactic abdominal aortic balloon was performed in some severe cases of PPA at the multidisciplinary team\u0026rsquo;s discretion. Written informed consents were obtained from all women who received intra-arterial balloon catheters.\u003c/p\u003e \u003cp\u003eThe procedure for balloon occlusion was as follows. For internal iliac arteries occlusion, under X-ray guidance, the catheters (low profile PTA dilatation catheter PTA5-35-80-8-6.0, Cook Medical Inc., Bloomington, USA) were inserted via the femoral arteries and placed at the anterior division of the internal iliac arteries. For abdominal aortic occlusion, the catheter (dilatation catheter AT75164, Bard Peripheral Vascular Inc., Arizona, USA) was inserted via the right femoral artery and placed in the abdominal aorta below the level of renal arteries. After the placement of catheters, cesarean delivery was conducted immediately, and the balloons were inflated after the cord was clamped. During the surgery, the abdominal aortic balloons were deflated every ten minutes, and oxygen saturation of the left great toe was monitored.\u003c/p\u003e \u003cp\u003eEBL was based on the amount of blood collected in the suction canister, excluding amniotic fluid and saline for irrigation. The number of laparotomy pads used during the surgery and blood on other surfaces were also calculated. The final EBL was confirmed by the judgment of surgeons, nurses, and anesthetists. The surgical time was defined as the duration between incision for cesarean and wound closure. The final decision of cesarean hysterectomy and the procedure of hysterectomy were made by experienced obstetricians and with consultation from gynecologic oncologists in some cases. Cervical invasion of the placenta was confirmed by laparotomic finding that part of the placenta penetrated the cervical canal or abnormally attached to the cervical tissue. If an intraoperative bladder injury occurred, urologists were consulted to repair the bladder.\u003c/p\u003e \u003cp\u003eThe Kolmogorov\u0026ndash;Smirnov test was performed to determine the normality of continuous variables. Non-normally distributed data were shown as median (interquartile range), and the Mann\u0026ndash;Whitney U test was used for the analysis. Categorical variables are presented as number/proportion (%) and were analyzed by the chi-square test. A stepwise backward elimination multivariate logistic regression model was applied to ascertain independent risk factors of the primary outcome. All statistical analyses and data processing were conducted using SPSS 24.0 statistical software (IBM, Armonk, NY, USA). P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered as statistically significant. Odds ratio (OR) and 95% confidence intervals (CI) are used to show the effect of potential risk factors.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom January 2012 to August 2023, a total of 205 women received cesarean hysterectomy after 28 weeks of gestation in West China Second University Hospital, Sichuan University. After the exclusion of four cases of twin pregnancy, one case of severe prenatal uterine rupture, and one case of relaparotomy for hemostasis, 199 women diagnosed with PPA and received cesarean hysterectomy were included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBaseline characteristics, including maternal age, gravidity, parity, prior uterine curettage, prior cesarean section, rate of the anterior placenta, and classification of pathological examination, were not significantly different between G1 and G2 (p \u0026gt; 0.05). (Table 1) The proportion of placenta increta (67.0% vs. 57.3%) and placenta percreta (30.1% vs. 37.5%) were comparable between G1 and G2. A slightly higher rate of gestational diabetes mellitus (GDM) was diagnosed in G1 (31.1% vs. 18.8%, p = 0.045). For neonatal outcomes, the gestational age at delivery, birth weight, and rate of NICU admission were not significantly different between the two groups.\u003c/p\u003e\n\u003cp\u003eAccording to the division of the two study groups, the EBL was higher in G2 than G1, as well as perioperative blood products transfusion and infusion volume. The infusion volumes were 7100 (5906.25, 8700) mL in G2 and 4300 (3000, 5200) mL in G1 (p \u0026lt; 0.001). The transfusion of packed red blood cells (PRBCs), fresh frozen plasma, fibrinogen, and cryoprecipitate during surgery were 10.5 (6, 15.5) U, 1000 (800, 1562.5) mL, 2 (0, 4) g, and 0 (0, 9.5) U in G2 respectively. In G1, the numbers were 3 (1.5, 6) U, 600 (0, 600) mL, 0 (0, 0) g, and 0 (0, 0) U, respectively (all p \u0026lt; 0.001). The autologous blood transfusion volumes were comparable between the two groups (G1: 220 (0, 463) mL vs.\u0026nbsp; \u0026nbsp;G2: 0 (0, 1098) mL, p = 0.101).\u003c/p\u003e\n\u003cp\u003eFor perioperative period characteristics, the postsurgical hospital stays (six days vs. seven days), surgical time (131 min vs. 185.5 min), emergency surgery rate (21.4% vs. 41.7%), intraoperative gynecologic oncology consultation (74.8% vs. 88.5%), cervical invasion of the placenta (41.7% vs. 59.4%), and bladder injury rate (6.8% vs. 25.0%) were all significantly lower in G1 than G2 (all p \u0026lt; 0.05). The intra-arterial ball balloon proportion differed between G1 and G2 (p = 0.022). 12.6% (13/103) women had abdominal aortic balloon occlusion, 48.5% (50/103) had bilateral internal iliac arteries balloon occlusion in G1. At the same time, the rate of bilateral internal iliac arteries balloon occlusion was 44.8% (43/96), but the abdominal aortic balloon occlusion rate was only 3.1% (3/96) in G2. There was no difference in the rate of total hysterectomy vs. supracervical hysterectomy in G1 and G2 (p = 0.979). (Details shown in Table 2)\u003c/p\u003e\n\u003cp\u003eMaternal age, prior uterine curettage, prior cesarean section, GDM, anterior placenta, pathological classification, gestational age at delivery, neonatal birth weight, emergency surgery, intraoperative gynecologic oncology consultation, cervical invasion of placenta, bladder injury, total/supracervical hysterectomy, and intra-arterial balloons were included in the stepwise backward elimination multivariate logistic regression analysis and five variables were included in the final model. (Table 3) Emergency surgery (OR 2.18, 95% CI 1.08-4.41, p = 0.029), cervical invasion of placenta (OR 2.70, 95% CI 1.43-5.10, p = 0.002), and intraoperative bladder injury (OR 5.18, 95% CI 2.02-13.28, p = 0.001) were all associated with an EBL \u0026gt; 3500 mL. Bilateral internal iliac arteries occlusion (OR 0.57, 95% CI 0.34-0.97) and abdominal aortic occlusion (OR 0.33, 95% CI 0.19-0.56) were negatively associated with the primary outcome, and intraoperative gynecologic oncology consultation was not associated with it (OR 2.20, 95% CI 0.99-5.32, p = 0.054).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the current study, a large case series of 199 women with PPA who underwent cesarean hysterectomy from an over ten-year period were investigated to find risk factors of excessive surgical blood loss. Our findings revealed that emergency surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for an EBL over 3500 mL. Surprisingly, our study found that abdominal aortic balloon occlusion and bilateral internal iliac artery balloon occlusion can reduce the EBL during cesarean hysterectomy in women with PPA.\u003c/p\u003e \u003cp\u003eWomen with PPA should be transferred to experienced centers and managed by multidisciplinary teams. In our hospital, a cesarean hysterectomy was conducted in cases of severe PPA without the attempt to separate the placenta and in cases that had failed conservative management after removing the placenta. Usually, cesarean hysterectomy for PAS is a rare surgical procedure, that conducted in a hospital with higher surgical volume may be associated with improved surgical outcomes.\u003csup\u003e12\u003c/sup\u003e A well-established multidisciplinary team performing 2\u0026ndash;3 cases per month can improve perinatal outcomes over time with increasing experience.\u003csup\u003e13\u003c/sup\u003e In a retrospective study conducted in the United States, which included 77 women with PAS who underwent peripartum hysterectomy, the median blood loss was 3000 mL, and the median transfusion of PRBCs was five units\u003csup\u003e14\u003c/sup\u003e, similar to the current study. However, the placenta increta/percreta rate was only 32.47% (25/77), and the rate was as high as 95.98% (191/199) in our study.\u003c/p\u003e \u003cp\u003eUnplanned delivery with emergency cesarean hysterectomy in women with PPA may be associated with adverse peripartum outcomes. Our study included all the planned or unplanned cesarean hysterectomies and revealed emergency surgery was a potential risk factor for additional surgical blood loss. A multicenter retrospective study showed patients who had planned cesarean hysterectomy had a significantly lower rate of blood loss, less need for blood transfusion, and fewer surgical complications.\u003csup\u003e15\u003c/sup\u003e Similar results were shown in other studies. Antenatal vaginal bleeding and preterm labor were risk factors for emergent delivery. Individualized management and planned delivery at optimal gestational age are recommended.\u003csup\u003e16,17\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePlacenta invading the cervical canal may cause additional surgical blood loss. In our study, cervical invasion of the placenta was a clinical finding during surgery. The histological examination of cervical specimens was lacking. Studies focused on pathologically confirmed cervical placenta accreta are scarce. Cervical, parametrial, and bladder invasion of the placenta were considered severe PAS conditions. In a retrospective study including 55 cases of placenta percreta, nine of them had cervical invasion diagnosed antenatally, and all of the nine women received cesarean hysterectomy.\u003csup\u003e18\u003c/sup\u003e Theoretically, when the placenta invades the cervix in women with PPA, total hysterectomy is required. In the current study, total or supracervical hysterectomy were not significantly associated with an EBL over 3500 mL. Similarly, there was no difference in surgical time or complications between total or supracervical hysterectomy in a retrospective study, including 78 cases of placenta accreta in 150 cases of emergent cesarean hysterectomy.\u003csup\u003e19\u003c/sup\u003e However, in a recent small sample-sized study, supracervical hysterectomy had better perinatal outcomes than total hysterectomy, and supracervical hysterectomy was suggested for the first-line approach in cases of abnormally invasive placenta.\u003csup\u003e20\u003c/sup\u003e Our study revealed that intraoperative bladder injury was potentially associated with additional EBL. When placenta previa percreta involves the maternal bladder, intraoperative bladder injury may be inevitable.\u003csup\u003e21\u003c/sup\u003e For this severe condition, timely consultation with experienced urologists may be necessary. Our findings suggest individualized surgical procedures may be more reasonable in patients with PPA. Which surgical procedure should be selected is based on which can stop the bleeding and minimize the surgical complications. For example, some scholars suggested a kind of modified supracervical hysterectomy in PAS patients with cervical-trigonal fibrosis, which resulted in a significant improvement in surgical outcomes.\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhether intra-arterial balloon occlusion during cesarean hysterectomy can improve perinatal outcomes in women with PPA is debated, especially using internal iliac artery balloon occlusion. Randomized controlled studies about using intra-arterial balloons in cesarean hysterectomy were lacking. Randomized trials with small samples in women with PAS or placenta previa revealed that prophylactic internal iliac artery balloon occlusion was not associated with improved perinatal outcomes.\u003csup\u003e23\u0026ndash;25\u003c/sup\u003e A systematic review including 15 original studies showed the same results that internal iliac artery balloons cannot reduce blood loss or PRBC transfusion in PAS women.\u003csup\u003e26\u003c/sup\u003e So recently, the use of internal iliac artery balloons was not routinely recommended, and abdominal aorta balloon occlusion has become preferable in severe cases of PPA. Abundant evidence suggested that abdominal aorta balloons were safe and effective in patients with PAS, which was associated with reduced blood loss volume, transfusion volume, and hysterectomy rate.\u003csup\u003e27,28\u003c/sup\u003e Surprisingly, our study revealed that both the internal iliac artery balloon and the abdominal aortic balloon were potentially associated with an EBL\u0026thinsp;\u0026le;\u0026thinsp;3500 mL in cesarean hysterectomy of PPA, and the effect of the abdominal aortic balloon was more significant. In another retrospective study conducted in our hospital, which included 114 cases of planned deliveries with PPA underwent cesarean hysterectomy, intraoperative internal iliac artery balloon occlusion was not associated with an EBL greater or equal to 3000 mL, or transfusion of ten or more units of PRBCs.\u003csup\u003e10\u003c/sup\u003e This study excluded emergent deliveries and chose a different primary outcome, which may explain the different results.\u003c/p\u003e \u003cp\u003eThe main strength of the current study is that we included a large case series. A total of 199 cases of cesarean hysterectomy in women with PPA were analyzed, and the cesarean hysterectomy is a relatively rare surgical procedure. In addition, the diagnosis of PAS was confirmed pathologically in all the cases. Secondly, our study included all the cases of planned or emergent deliveries, total or supracervical cesarean hysterectomy to find potential risk factors of additional EBL in the severe condition of PPA. Our study also had some limitations. Firstly, this is a retrospective study, and possible bias may exist in data collection. However, randomized controlled studies may be difficult to conduct for cesarean hysterectomy. Secondly, our data could not differentiate the cases that conducted cesarean hysterectomy instantly without an attempt to separate the placenta and the cases that failed conservative management after removing the placenta. In China, the cesarean hysterectomy is usually decided during the surgery because most of the patients are eager to keep their fertility. Separation of the placenta in PPA is a potentially significant risk factor that can lead to massive hemorrhage before hysterectomy.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, our study reviewed a large case series, including 199 cases of cesarean hysterectomy in women with PPA. Life-threatening hemorrhage was very common, with the median EBL of the study group as high as 3500 mL. Emergent surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for additional EBL. Both the internal iliac artery balloon occlusion and abdominal aorta balloon occlusion were potentially associated with fewer EBL. Future prospective studies are needed to confirm the effect of intra-arterial balloon occlusion in cesarean hysterectomy of women with PPA.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCI, Confidence intervals; EBL, Estimated surgical blood loss; FIGO, International Federation of Gynecology and Obstetrics; GA, Gestational age; GDM, Gestational diabetes mellitus; NICU, Neonatal intensive care unit; OR, Odds ratio; PPA, Placenta previa accreta; PPH, Postpartum hemorrhage; PRBCs, Packed red blood cells;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the West China Second University Hospital, Sichuan University. Informed consent was obtained from the patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Science Foundation of Sichuan Province (grant number 2022YF0042).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYC Zhan, TT Xu, and XD Wang initiated and designed the present study. YC Zhan, TT Chen, and YX Ren collected the data. X Wu performed the pathological diagnosis. YC Zhan, EF Lu, CY Deng, and GQ Huang performed data analysis. YC Zhan wrote the first draft of the manuscript. TT Xu, HY Yu, and XD Wang reviewed, completed, and supervised the manuscript writing. All authors contributed to its interpretation and contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the staff who have been involved in this work. All persons that contributed to this study are listed as authors and meet the criteria for authorship.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSilver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.AOG.0000219750.79480.84\u003c/span\u003e\u003cspan address=\"10.1097/01.AOG.0000219750.79480.84\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, Gr\u0026oslash;nbeck L, Bunce C, Langhoff-Roos J, Collins SL. Epidemiology of placenta previa accreta: a systematic review and meta-analysis. BMJ Open. 2019;9(11):e031193. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2019-031193\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2019-031193\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCommittee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0000000000002351\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0000000000002351\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorbetta-Rastelli CM, Friedman AM, Sobhani NC, Arditi B, Goffman D, Wen T. Postpartum Hemorrhage Trends and Outcomes in the United States, 2000\u0026ndash;2019. Obstet Gynecol. 2023;141(1):152\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0000000000004972\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0000000000004972\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, Alfirevic Z, Bhide A, et al. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. BJOG Int J Obstet Gynaecol. 2019;126(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1471-0528.15306\u003c/span\u003e\u003cspan address=\"10.1111/1471-0528.15306\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCommittee on Obstetric Practice. Committee opinion 529: placenta accreta. Obstet Gynecol. 2012;120(1):207\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0b013e318262e340\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0b013e318262e340\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePublications Committee, Society for Maternal-Fetal Medicine, Belfort MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2010.09.013\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2010.09.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKingdom JC, Hobson SR, Murji A, et al. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020. Am J Obstet Gynecol. 2020;223(3):322\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2020.01.044\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2020.01.044\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S. FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;146(1):20\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijgo.12761\u003c/span\u003e\u003cspan address=\"10.1002/ijgo.12761\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen M, Lv B, He G, Liu X. Internal iliac artery balloon occlusion during cesarean hysterectomy in women with placenta previa accreta. Int J Gynaecol Obstet. 2019;145(1):110\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijgo.12763\u003c/span\u003e\u003cspan address=\"10.1002/ijgo.12763\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen D, Xu J, Tian Y, et al. Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta. BMC Pregnancy Childbirth. 2021;21(1):640. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-021-04103-x\u003c/span\u003e\u003cspan address=\"10.1186/s12884-021-04103-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsuo K, Youssefzadeh AC, Mandelbaum RS, et al. Hospital surgical volume-outcome relationship in caesarean hysterectomy for placenta accreta spectrum. BJOG Int J Obstet Gynaecol. 2022;129(6):986\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1471-0528.16993\u003c/span\u003e\u003cspan address=\"10.1111/1471-0528.16993\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShamshirsaz AA, Fox KA, Erfani H, et al. Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time. Am J Obstet Gynecol. 2017;216(6):612e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2017.02.016\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2017.02.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright JD, Pri-Paz S, Herzog TJ, et al. Predictors of massive blood loss in women with placenta accreta. Am J Obstet Gynecol. 2011;205(1):e381\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2011.01.040\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2011.01.040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriery CM, Rose CH, Hudson WT, et al. Planned vs emergent cesarean hysterectomy. Am J Obstet Gynecol. 2007;197(2):e1541\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2007.03.026\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2007.03.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThang NM, Anh NTH, Thanh PH, Linh PT, Cuong TD. Emergent versus planned delivery in patients with placenta accreta spectrum disorders: A retrospective study. Med (Baltim). 2021;100(51):e28353. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MD.0000000000028353\u003c/span\u003e\u003cspan address=\"10.1097/MD.0000000000028353\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOge T, Tokgoz VY, Cakmak Y, Velipasaoglu M. Peripartum Hysterectomy: Is There Any Difference Between Emergency and Planned Surgeries? Rev Bras Ginecol E Obstet Rev Fed Bras Soc Ginecol E Obstet. 2022;44(1):3\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0041-1736303\u003c/span\u003e\u003cspan address=\"10.1055/s-0041-1736303\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen X, Shan R, Song Q, Wei X, Liu W, Wang G. Placenta percreta evaluated by MRI: correlation with maternal morbidity. Arch Gynecol Obstet. 2020;301(3):851\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00404-019-05420-5\u003c/span\u003e\u003cspan address=\"10.1007/s00404-019-05420-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImudia AN, Hobson DTG, Awonuga AO, Diamond MP, Bahado-Singh RO. Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy. Am J Obstet Gynecol. 2010;203(3):e2211\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2010.04.007\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2010.04.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevin G, Rottenstreich A, Benshushan A, et al. The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: a case-control study. J Matern-Fetal Neonatal Med. 2020;33(15):2522\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14767058.2018.1554049\u003c/span\u003e\u003cspan address=\"10.1080/14767058.2018.1554049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurji A, Kingdom J. Placenta Percreta Involving Maternal Bladder. N Engl J Med. 2019;381(7):e12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMicm1900978\u003c/span\u003e\u003cspan address=\"10.1056/NEJMicm1900978\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalacios-Jaraquemada JM, Nieto-Calvache \u0026Aacute;J, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet. 2023;36(1):2183741. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14767058.2023.2183741\u003c/span\u003e\u003cspan address=\"10.1080/14767058.2023.2183741\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalim R, Chulski A, Romano S, Garmi G, Rudin M, Shalev E. Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol. 2015;126(5):1022\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0000000000001113\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0000000000001113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen M, Liu X, You Y, et al. Internal Iliac Artery Balloon Occlusion for Placenta Previa and Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol. 2020;135(5):1112\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AOG.0000000000003792\u003c/span\u003e\u003cspan address=\"10.1097/AOG.0000000000003792\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu SCH, Cheng YKY, Tse WT, et al. Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial. Am J Obstet Gynecol. 2020;223(1):117e. 1-117.e13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang D, Zhao H, Liu D, Lin Y. Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis. Eur J Radiol. 2021;139:109711. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejrad.2021.109711\u003c/span\u003e\u003cspan address=\"10.1016/j.ejrad.2021.109711\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahin Y, Pang CL. Endovascular interventional modalities for haemorrhage control in abnormal placental implantation deliveries: a systematic review and meta-analysis. Eur Radiol. 2018;28(7):2713\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00330-017-5222-0\u003c/span\u003e\u003cspan address=\"10.1007/s00330-017-5222-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen L, Wang X, Wang H, Li Q, Shan N, Qi H. Clinical evaluation of prophylactic abdominal aortic balloon occlusion in patients with placenta accreta: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2019;19(1):30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12884-019-2175-0\u003c/span\u003e\u003cspan address=\"10.1186/s12884-019-2175-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"504\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"98.41269841269842%\" colspan=\"4\" style=\"width: 74.8821%;\"\u003e\n \u003cp\u003eTable 1. Demographics and baseline characteristics between two groups\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003eGroup 1 (n=103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003eGroup 2 (n=96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e33 (29, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e32 (30, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e0.828\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eGravidity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e4 (3, 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e4 (3, 5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e0.917\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eParity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e1 (1, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e1 (1, 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e0.887\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003ePrior uterine curettage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e2 (1, 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e2 (1, 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e0.733\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003ePrior cesarean sections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e1 (1, 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e1 (1, 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e0.577\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eGDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e71 (68.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e78 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e32 (31.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e18 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eAnterior placenta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e24 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e19 (19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e0.548\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e79 (76.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e77 (80.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003ePathology\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eAdherenta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e3 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e5 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e0.331\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e69 (67.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e55 (57.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.944444444444443%\" style=\"width: 24.3025%;\"\u003e\n \u003cp\u003ePercreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" style=\"width: 19.8977%;\"\u003e\n \u003cp\u003e31 (30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.404761904761905%\" style=\"width: 18.5307%;\"\u003e\n \u003cp\u003e36 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.46031746031746%\" style=\"width: 13.5183%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" style=\"width: 76.401%;\"\u003e\n \u003cp\u003eGDM, Gestational diabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"629\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\"\u003e\n \u003cp\u003eTable 2. Perioperative period characteristics between two groups\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003eGroup 1 (n=103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003eGroup 2 (n=96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eEstimate surgical blood loss, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e2500 (1700, 3000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e5060.5 (4025, 7000)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eGestational age at delivery, weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e36 (34.7, 36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e36.14 (34.18, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.827\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003ePostsurgical hospital stay, days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e6 (5, 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e7 (5, 10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eSurgical time, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e131 (113, 159)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e185.5 (137, 246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eEmergency surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e81 (78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e56 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e22 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e40 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eIntra-arterial balloons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e40 (38.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e50 (52.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.022\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eBilateral internal iliac arteries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e50 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e43 (44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eAbdominal aorta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e13 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e3 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eIntraoperative gynecologic oncology consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e26 (25.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e11 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.013\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e77 (74.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e85 (88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eCervical invasion of the placenta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e60 (58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e39 (40.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.013\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e43 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e57 (59.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eSupracervical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e13 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e12 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.979\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e90 (87.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e84 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eBladder injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e96 (93.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e72 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e7 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e24 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eInfusion volume, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e4300 (3000, 5200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e7100 (5906.25, 8700)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eTransfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003ePRBCs, U\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e3 (1.5, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e10.5 (6, 15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eAutologous blood transfusion, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e220 (0, 463)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e0 (0, 1098)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.101\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eFFP, mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e600 (0, 600)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e1000 (800, 1562.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eFibrinogen, g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e0 (0, 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e2 (0, 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eCryoprecipitate, U\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e0 (0, 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e0 (0, 9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eNICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e65 (63.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e53 (55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.257\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\" valign=\"bottom\"\u003e\n \u003cp\u003e38 (36.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\" valign=\"bottom\"\u003e\n \u003cp\u003e43 (44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.54054054054054%\"\u003e\n \u003cp\u003eBirth weight, g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.575516693163753%\"\u003e\n \u003cp\u003e2650 (2290, 2970)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.006359300476948%\"\u003e\n \u003cp\u003e2635 (2132.5, 2850)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.492845786963434%\"\u003e\n \u003cp\u003e0.241\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"97.61526232114467%\" colspan=\"4\"\u003e\n \u003cp\u003eFFP, Fresh frozen plasma; NICU, Neonatal intensive care unit; PRBC, Packed red blood cells\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.384737678855326%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"533\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\"\u003e\n \u003cp\u003eTable 3. Multivariate logistic analysis (stepwise backward elimination)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eIntraoperative gynecologic oncology consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e2.29 (0.99, 5.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\n \u003cp\u003e0.054\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eEmergency surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e2.18 (1.08, 4.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.029\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eCervical invasion of the placenta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e2.70 (1.43, 5.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eIntra-arterial balloons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eBilateral internal iliac arteries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e0.57 (0.34, 0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.039\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eAbdominal aorta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e0.33 (0.19, 0.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eBladder injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.53658536585366%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.080675422138835%\"\u003e\n \u003cp\u003e5.18 (2.02, 13.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.382739212007504%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Placenta previa, Hemorrhage, Cesarean hysterectomy, Balloon occlusion","lastPublishedDoi":"10.21203/rs.3.rs-4659404/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4659404/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlacenta previa accreta (PPA) is a severe obstetric condition that can cause massive postpartum hemorrhage and transfusion. Cesarean hysterectomy is necessary in some severe cases of PPA to stop the life-threatening bleeding, but cesarean hysterectomy can be associated with significant surgical blood loss and major complications. The current study is conducted to investigate the potential risk factors of excessive blood loss during cesarean hysterectomy in women with PPA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a retrospective study including singleton pregnancies after 28 weeks of gestation in women with placenta previa and pathologically confirmed placenta accreta spectrum who received hysterectomy during cesarean sections. A total of 199 women from January 2012 to August 2023 were included in this study and were divided into Group 1 (estimated surgical blood loss (EBL) ≤ 3500 mL, n=103) and Group 2 (EBL \u0026gt; 3500 mL, n=96). The primary outcome was defined as an EBL over 3500 mL. Baseline characteristics and surgical outcomes were compared between the two groups. A multivariate logistic regression model was applied to find potential risk factors of the primary outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMassive surgical blood loss was prevalent in our study group, with a median EBL of 3500 mL. The multivariate logistic analysis showed that emergency surgery (OR 2.18, 95% CI 1.08-4.41, p = 0.029), cervical invasion of the placenta (OR 2.70, 95% CI 1.43-5.10, p = 0.002), and intraoperative bladder injury (OR 5.18, 95% CI 2.02-13.28, p = 0.001) were all associated with the primary outcome. Bilateral internal iliac arteries balloon occlusion (OR 0.57, 95% CI 0.34-0.97) and abdominal aortic balloon occlusion (OR 0.33, 95% CI 0.19-0.56) were negatively associated with the primary outcome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmergency surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for additional EBL during cesarean hysterectomy in women with PPA. Future prospective studies are needed to confirm the effect of intra-arterial balloon occlusion in cesarean hysterectomy of PPA.\u003c/p\u003e","manuscriptTitle":"Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: A retrospective hospital-based study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-24 14:35:00","doi":"10.21203/rs.3.rs-4659404/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-15T18:00:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-12T16:21:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58730807633089719320086147803904600783","date":"2024-07-11T00:23:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247547818018664932684048287048605567819","date":"2024-07-10T10:21:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-09T10:52:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289454261446474178804281738140423431013","date":"2024-07-06T16:16:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-06T16:09:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-03T15:59:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-02T12:53:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-02T12:52:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-06-29T12:57:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d08b4104-9e01-4a21-a290-ea6647084b71","owner":[],"postedDate":"July 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-07T16:03:46+00:00","versionOfRecord":{"articleIdentity":"rs-4659404","link":"https://doi.org/10.1186/s12884-024-06834-z","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2024-10-02 15:57:00","publishedOnDateReadable":"October 2nd, 2024"},"versionCreatedAt":"2024-07-24 14:35:00","video":"","vorDoi":"10.1186/s12884-024-06834-z","vorDoiUrl":"https://doi.org/10.1186/s12884-024-06834-z","workflowStages":[]},"version":"v1","identity":"rs-4659404","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4659404","identity":"rs-4659404","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}