Intraoperative Contact Duplex Ultrasonography in Navigation of Prophylactic Balloon Occlusion of the Abdominal Aorta in Patients With Placenta Percreta

Intraoperative Contact Duplex Ultrasonography in Navigation of Prophylactic Balloon Occlusion of the Abdominal Aorta in Patients With Placenta Percreta | 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 Intraoperative Contact Duplex Ultrasonography in Navigation of Prophylactic Balloon Occlusion of the Abdominal Aorta in Patients With Placenta Percreta Tamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8264156/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Prophylactic balloon occlusion of the abdominal aorta (PBOAA) is the most effective vascular control strategy in surgical treatment of patients with placenta accreta spectrum (PAS) disorders. Intraoperative contact duplex ultrasonography (ICDUS) can be used for PBOAA navigation in the absence of opportunities for traditional X-ray imaging. Methods This retrospective observational study was conducted using medical records of patients with PAS who gave birth from January 1st, 2020, to October 30th, 2025. Inclusion criteria : singleton pregnancy; cesarean delivery; PAS types T3 or T4. Exclusion criteria : multiple pregnancy; vaginal delivery; no clinical signs of PAS at delivery; PAS types T0, T1, T2, and T5. The study cohort was divided into two groups based on the primary method of bleeding prevention. Group 1 – using distal complex compression hemostasis. Group 2 – using PBOAA under ICDUS navigation. The primary outcome was total blood loss of ≥ 2500 ml. The secondary outcomes were: operation time ≥ 120 minutes, bladder injury, need for additional intraoperative methods of hemostasis, postpartum hemorrhage, relaparotomy, hysterectomy, and PBOAA-related complications. Results Of the total cohort, 62 (80.5%) patients were assigned to Group 1 and 15 (19.5%) patients to Group 2; in all cases, ICDUS allowed direct real-time control of the introducer movement and precise positioning of the balloon in zone 3 of the abdominal aorta. The only PBOAA-associated complications were hematomas at the site of femoral artery puncture, which were reported in 2 (13.3%) patients and did not require surgical intervention. A total blood loss volume of ≥ 2500 ml. was seen in 25 cases (40.3%) in Group 1 but in only 1 case (6.7%) in Group 2 (p=0.014). In Group 1, additional methods of blood flow reduction were used in almost all (95.1%) cases, while in Group 2 they were not required (p<0.0001). Average total blood loss (1850 ml vs 980 ml), duration of the operation (126.5 min vs 112 min), and postoperative hospitalization (7 vs 5 days) of women were also significantly higher in Group 1 in comparison to Group 2 (p<0.05). Conclusion ICDUSappears to be a safe and effective form of navigation for PBOAA during Caesarean section in placenta percreta cases. Prophylactic balloon occlusion of the abdominal aorta placenta accreta spectrum (PAS) disorders placenta percreta massive intraoperative blood loss peripartum hemorrhage intraoperative contact duplex ultrasonography Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The iatrogenic epidemic of placenta accreta spectrum (PAS) disorders, associated with a significant increase in maternal morbidity and mortality, remains a concern for public health officials worldwide [ 1 ]. According to a U.S. national study, the reported incidence of PAS disorders increases by 2.1% every three months [ 2 ]. The current level of antenatal visual diagnostics and a multidisciplinary treatment approach have significantly reduced maternal mortality rates from baseline values of 7%–30% to 0.05%–0.25% [ 2 – 5 ]. However, the problem has not yet been completely solved: a multivariate analysis of 2,727,477 cesarean sections demonstrated a significant increase in the incidence of surgical complications (78.3% versus 10.6%) in the presence and absence of PAS, respectively. In particular, in PAS and non-PAS cesarean deliveries, bleeding was recorded in 54.1% versus 3.9%, hemorrhagic shock in 5.0% versus 0.1%, and lethal complications in 0.25% versus 0.01% of deliveries, in which in the overwhelming majority (≥ 88%) of fatalities were a consequence of massive bleeding followed by the development of coagulopathy and multiple organ failure [ 2 , 6 ]. It has been shown that, despite the availability of various methods for intraoperative vascular control, in reality most medical clinics use only one method for all PAS cases regardless of the grade, type, and localization of abnormal invasion [ 7 ]. Lack of readiness to use various methods of bleeding prevention complicates the response of the medical team, who may not be comfortable deviating from the initial surgical plan, and significantly increases the time required for decision-making in the event of complications [ 7 ]. The highest risk of intraoperative complications includes cases of placenta percreta, increasing the odds ratio (OR) of maternal mortality by 32.1 (95% CI 9.61–107.4) compared with cases of normal placentation [ 2 , 8 ]. Among cases of placenta percreta, the highest surgical complexity is typical for cases with multiple vascular collaterals in the lower uterine segment, the cervix, and the bladder trigone. There is a demand for the most reliable methods of vascular control, related to types T3 (invasion of the posterior wall of the bladder and cervix) and T4 (invasion into the posterior wall of the bladder with severe fibrosis) of the topographic classification responsible for 82.7% (95% CI 71.4–91.6) of all near-miss cases [ 9 – 11 ]. To date, prophylactic balloon occlusion of the abdominal aorta (PBOAA) – used either prophylactically before operative delivery or after intraoperative PAS confirmation – has been shown to be a significantly more effective strategy for reducing blood loss, transfusion volume, and hysterectomy rates than other methods of proximal or distal vascular control [ 12 , 13 ]. Despite the clear effectiveness of PBOAA, the alternative method of X-ray navigation has a number of disadvantages, the most important of these being that it is an expensive, time-consuming procedure and that it results in fetal radiation exposure [ 14 , 15 ]. Ultrasound navigation appears to be a potentially promising, but understudied, tool for expanding the application of PBOAA for delivery in patients with PAS in low- and middle-income clinical settings [ 16 – 20 ]. Intraoperative contact ultrasound with Doppler guidance is already widely used in various medical fields, but has not yet been studied for PBOAA navigation in PAS cases [ 21 ]. Currently, in the Russian Federation, the X-ray endovascular method of arterial balloon occlusion is not available in most public clinics, and was used only in 12.2% of severe PAS cases; therefore, distal vascular control techniques are the main methods of hemorrhage prevention [ 22 ]. In December 2024, a multidisciplinary team from the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky began a study aimed at analyzing data on the efficacy and safety of prophylactic balloon occlusion of the abdominal aorta under intraoperative contact duplex ultrasonography (ICDUS) navigation during caesarean section. Inclusion criteria for patient records is PAS type T3-T4 of the topographic classification, which partially corresponds to grade 3B of the International Federation of Gynecology and Obstetrics (FIGO) classification [ 23 – 25 ]. Taking into account the null hypothesis of an expected tenfold (from 20% to 2%) reduction in the incidence of massive (more than 2500 ml) intraoperative blood loss when using PBOAA, a total of 30 cases are planned to be included in a two-year study framework. In this publication, we present preliminary results of the application of this methodology. Materials and methods This retrospective observational study was conducted using medical records of patients with PAS seen from January 1st, 2020, to October 30th 2025 at a tertiary maternal and child healthcare hospital Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky, Moscow, Russia. The inclusion criteria were as follows: (1) singleton pregnancy, (2) cesarean delivery, (3) T3 or T4 PAS types of intraoperative topographic classification as confirmed at surgery [ 7 ], and (4) complete maternal, neonatal, and delivery records. The exclusion criteria included: (1) multiple pregnancies, (2) vaginal delivery, (3) no clinical signs of PAS at delivery, (4) T0, T1, T2, or T5 PAS types of intraoperative topographic classification as confirmed at surgery [ 7 ], and (5) incomplete baseline data. The entire study cohort was divided into two groups: Group 1 – using distal complex compression hemostasis as the primary method of bleeding prevention (delivery before December 2024). Complex compression hemostasis was carried out in the following steps: 1) dissection of the peritoneum of the vesicoureteral fold, 2) bringing down the bladder and, in some cases, its partial resection, 3) targeted coagulation of blood vessels, 4) the formation of artificial ‘windows’ in broad ligaments of the uterus and through them, 5) the bilateral application of tourniquets on the cervical-interstitial region. For the following two tourniquets, 6) the ovaries were displaced laterally of the tourniquets. Then, 7) loops were created to place a tourniquet around the fallopian tubes, mesosalpinx, and the ovary ligaments. As a result, the tubal and communicative branches of the ovarian and uterine arteries were occluded. Next, the part of the anterior uterine wall with an abnormally adherent placenta was excised, followed by metroplasty using a controlled intrauterine balloon tamponade with subsequent resection of the uterine wall with abnormal placental invasion, evacuation of placenta from the uterine cavity, and closure of the uterine wall defect with a double suture. At the end, the tourniquets were removed with the simultaneous injection of uterotonic agents [ 26 ]. Group 2 – proximal vascular control with prophylactic balloon occlusion of the abdominal aorta (PBOAA) under intraoperative contact duplex ultrasonography (ICDUS) navigation (delivery after December 2024). Prevention of bleeding was achieved by PBOAA, performed according to the generally accepted technique using an endo-MIT balloon (Minimally Invasive Technologies LLC, Russia), compatible with a 6 Fr. introducer. The balloon was inserted after fetal extraction, and the umbilical cord was tied and cut without attempting to remove the placenta. Ultrasound navigation was performed using a BK5000 ultrasound system (GE Healthcare, USA) with a 13 − 4 MH (z13L4w (9011) broadband linear probe for endovascular access to the femoral artery. A 12 − 5 MHz I12C5b (9024) sterile biplane probe for intraoperative contact scanning of the uterus was used when 1) selecting an incision site outside the placental site, as well as for 2) intraoperative contact ultrasound duplex scanning (Figs. 1–3) of the abdominal aorta and its branches during PBOAA to control an introducer movement, and 3) during balloon placement in zone 3 of abdominal aorta between the renal arteries and aorta bifurcation. The balloon was then opened with Doppler guidance of distal blood flow blocking. Postoperatively, at 2, 6, 12, and 24 hours after the PBOAA intervention, an ultrasound examination of the abdominal aorta and its branches was performed to exclude possible complications using a broadband linear probe 13 − 4 MH (z13L4w (9011), as well as an ultrasound examination of the kidneys using a convex probe 6 − 2 MH (6C2 (9040)). Apart from that, the perioperative management of Groups 1 and 2 was similar. Organ-preserving techniques were the method of choice in all cases [ 27 ]. Hysterectomy was performed only in the event of complications that precluded preservation of the uterus. Gravimetric analysis was used for estimation of the amount of blood loss. The primary outcome was total blood loss of ≥ 2500 ml. The secondary outcomes were operation time ≥ 120 minutes, bladder injury, need for additional intraoperative methods of hemostasis, postpartum hemorrhage, relaparotomy, hysterectomy, and PBOAA-related complications. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [ 28 ], was conducted in accordance with the Declaration of Helsinki, and was approved by the Ethics Committee of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky (number No. 1 of the minutes of the meeting No. 7, 27. 11.2024). All patients provided written informed consent for caesarean delivery and caesarean delivery with PBOAA in Group 1 and Group 2, respectively. Maternal clinical and anamnestic data, intra- and postoperative data, and neonatal data were collected from hospital electronic records. All patient data was anonymized to maintain the patients’ privacy prior to the analysis. Statistical analysis Data was analyzed by MedCalc Statistical Software version 16.4.3 (MedCalc Software by Ostend, Belgium). Quantitative variables were presented as a median (Me) and interquartile range (Q1-Q3) and qualitative variables are presented as frequencies and percentages. The Wilcoxon rank-sum test for independent samples and the χ2 test (or Fisher’s exact test if appropriate) were performed to compare variables between groups. Univariate and multivariate analysis of the entire cohort was used to establish the PBOAA association with primary and secondary outcomes. A post-hoc power analysis was used to determine the power of the retrospective study. P < 0.05 was regarded as indicating statistical significance. Results Our multidisciplinary team operated on 424 patients with PAS between January 1st, 2020, and October 30th, 2025. Five (1.2%) of these pregnancies were multiples and 342 (80.6%) cases were intraoperatively classified as PAS types T0, T1, T2, and T5 and were hence excluded from the study. 77 (18.2%) cases with PAS types T3 and T4 formed our study cohort (Fig. 4). Of the total cohort, 62 (80.5%) patients were assigned to Group 1, and 15 (19.5%) patients to Group 2, with baseline maternal characteristics presented in Table 1 . Table 1 Baseline maternal and neonatal characteristics of two study groups Variable Group 1 (n = 62) Group 2 (n = 15) P-value Maternal characteristics Age, years, Me (Q1-Q3) 35 (33–37) 38 (35,5–38,5) 0,278 Body mass index, kg/m², Me (Q1-Q3) 26,4 (24,4–30,4) 30,1 (25,6–35,5) 0,098 Body mass index ≥ 30, n (%) 19 (30,6) 8 (53,3) 0,13 Parity, Me (Q1-Q3) 4,5 (3–6) 3 (2–5) 0,136 Pregnancy > 4, n (%) 31 (50%) 4 (26,7%) 0,149 Number of previous cesarean sections, Me (Q1-Q3) 3 (2–3) 3 (2–3) 0,849 Year from previous cesarean sections ≤ 2, n (%) 22 (35,5%) 0 (0%) 0,004 Number of previous vaginal deliveries, Me (Q1-Q3) 0 (0–1) 3 (2–3) 0,0001 Interpregnancy interval, years, Me (Q1-Q3) 3 (2–4) 5 (3,5–7) 0,048 Curettage of the uterine cavity: 1, n (%) 12 (19,4) 2 (13,3) 0,72 ≥2, n (%) 19 (30,6) 3 (20) 0,53 Intrauterine procedures > = 4, n (%) 18 (29%) 4 (26,6%) 1 Preoperative hemoglobin level, g/l, Me (Q1-Q3) 105,5 (97,25–114,75) 109 (101–116) 0,49 Preoperative hemoglobin level < 100, g/l, n (%) 20 (32,2%) 2 (13,3%) 0,021 Gestational age at delivery, weeks, Me (Q1-Q3) 35,1 (33,5–35,9) 36,0 (35,15–36,1) 0,06 Neonatal characteristics Gender male, n (%) 27 (43.5) 4 (26.7) 0,26 female, n (%) 35 (56.5) 11 (73.3) 0,26 Birth weight, gram, Me (Q1-Q3) 2455 (2255–2802) 2830 (2635–3005) 0,046 5-min Apgar score < 7, n (%) 1 (1,6) 0 (0) 1 Data are given as n (%) or median (Me) (interquartile range(Q1-Q3). A statistically significant difference was found in the median number of previous vaginal deliveries and the interpregnancy interval, which were larger in Group 2 with PBOAA compared to Group 1: 3 versus 0 (p = 0.0001) and 5 versus 3 (p = 0.048), respectively. The number of patients with a preoperative hemoglobin level < 100 g/l was significantly higher in the Group 1 accounting for 32,2% compared to 13,3% in Group 1 (p = 0,021). Maternal age, body mass index, presence of obesity, the number of previous cesarean sections, median preoperative hemoglobin levels, and gestational age at delivery were not significantly different. Emergency cesarean delivery was performed due to the onset of bleeding in 21 (33.9%) and 2 (13.3%) cases in Group 1 and Group 2, respectively (p = 0.02) (Table 2 ). Table 2 Surgical and postoperative indicators of two study groups Variable Group 1 (n = 62) Group 2 (n = 15) P-value Operation time, minutes, Me (Q1-Q3) 126,5 (113,5–158,75) 112 (98,5–124,5) 0,025 Operation time ≥ 120 minutes, n (%) 41 (66,1) 4 (26,7) 0,008 Emergency cesarean delivery, n (%) 21 (33.9) 2 (13,3) 0,2 Elective cesarean delivery, n (%) 41 (66,1) 13 (86,7) 0,2 Laparotomy Pfannenstiel incision, n (%) 4 (6,5) 1 (6,7) 1 midline vertical incision, n (%) 58 (93,5) 14 (93,3) 1 Cesarean section fundal, n (%) 52 (83,8) 6 (40) 0,001 transvers (OSCS), n (%) 10 (16,2) 9 (60) 0,001 Bladder injury, n (%) 21 (33,9) 4 (26,7) 0,761 Additional intraoperative methods of hemostasis, total number, n (%) 59 (95,1) 0 (0) < 0,0001 Internal iliac artery ligation n (%) 15 (24,2) 0 (0) 0,03 Uterine artery ligation, n (%) 10 (16,1) 0 (0) 0,195 Intraoperative uterine compression suture, n (%) 18 (29) 0 (0) 0,016 Intrauterine balloon tamponade, n (%) 52 (83,9) 0 (0) < 0,0001 Intraoperative estimated blood loss, ml, Me (Q1-Q3) 1700 (1100–2712) 980 (689–1472) 0,005 Postpartum hemorrhage, n (%) 6 (9,7) 0 (0) 0,59 Postpartum estimated blood loss, ml, Me (Q1-Q3) 1000 (600–1700) 0 0,57 Total estimated blood loss, ml, Me (Q1-Q3) 1850 (1125–2800) 980 (689–1472) 0,002 Total estimated blood loss ≥ 2500 ml, n (%) 25 (40,3) 1 (6.7) 0,014 Relaparotomy, n (%) 7 (11,3) 0 (0) 0,33 Hysterectomy, total number, n (%) 7 (11,3) 0 (0) 0,33 Primary hysterectomy, n (%) 4 (6,5) 0 (0) 0,58 Delayed hysterectomy, n (%) 3 (4,8) 0 (0) 1 PBOAA - related complications, total number, n (%) 0 (0) 2 (13,3) 0,03 vascular access site complications, n (%) 0 (0) 2 (13,3) 0,03 other complications, n (%) 0 (0) 0 (0) 1 Postoperative hospitalization, days, Me (Q1-Q3) 7 (5–7,75) 5 (5–6) 0,028 Postoperative hospitalization, ≥ 7 days, n (%) 35 (56,4) 4 (26,7) 0,047 Notes: PBOAA - prophylactic balloon occlusion of the abdominal aorta OSCS – one step conservative surgery Continuous variables are presented as median (Q1 – Q3) Categorical variables are presented as number(percentage) In Group 2, in all cases, intraoperative contact duplex ultrasonography allowed direct real-time continued visualization of the introducer movement and precise positioning of the balloon in zone 3 of the abdominal aorta between the renal arteries and the aortic bifurcation. Doppler guidance of distal blood flow blockage allowed for monitoring of the correct position for balloon opening, with the time for aortic occlusion ranging from 15 to 30 minutes in 14 (93.3%) cases. In one (6.7%) case, occlusion was performed intermittently for a total of 40 minutes (30 minutes + 10 other minutes after temporary deflation of the balloon). There were no cases of balloon migration or malposition. The primary outcome - a total blood loss volume of ≥ 2500 ml. - was recorded in 25 (40.3%) patients in Group 1, which was significantly higher than in Group 2 with PBOAA, which had only 1 such case (6.7%) (p = 0.014). A comparative analysis of the parameters in patients of the entire cohort, divided depending on the volume of total blood loss with a threshold of ≥ 2500 ml, is presented in Supplementary table 1. Taking into account the obtained frequency of the primary outcome equal to 40.3% in Group 1 and 6.7% in Group 2, post-hoc power analysis determined the power of this pilot part of retrospective study of 78% with a probability of type I error of 0.05. In Group 2, a single transverse uterine incision was used more often than in Group 2 (60.0% vs. 16.2%, p = 0.001), as the one step conservative surgery technique was initiated by our surgical team in only 2024. In Group 1, additional methods of blood flow reduction were used in almost all cases, while in Group 2 they were not required (p < 0.0001) (Table 2 ). Total estimated blood loss, duration of the operation and the number of cases with operation time ≥ 120 minutes, duration of postoperative hospitalization of women were also significantly higher in Group 1, where distal methods of blood flow reduction were used, compared with Group 2 (Table 2 ). In Group 2, complications associated with PBOAA were represented only by hematomas at the site of femoral artery puncture in 2 (13.3%) patients (p = 0.03), which did not require surgical intervention. There were no injuries from balloon overinflation, ischemic renal or limb damage (Table 2 ). It should be noted that all cases of postpartum hemorrhage, relaparotomy and hysterectomy were noted only in Group 1; however, statistical significance was not achieved due to the insufficient number of observations at the time of submission. Univariate analysis of the entire cohort established that only PBOAA was inversely associated with the estimated blood loss ≥ 2.500 ml (odds ratio 0.106, 95% confidence interval 0.013–0.856, p = 0.029) (Table 3 ). Table 3 Odds Ratios for the primary outcome (total estimated blood loss ≥ 2500) Variables OUTCOME: Total estimated blood loss ≥ 2500 Odds Ratio* 95% confidence interval p-value PBOAA 0.106 0.013–0.856 0.029 Year from previous cesarean sections < = 2 0.884 0.308–2.54 0.819 Preoperative hemoglobin level < 100, g/l 1.175 0.417–3.308 0.76 Fundal uterine incision 2.514 0.743–8.514 0.138 Transvers uterine incision (OSCS) 0.398 0.118–1.345 0.173 Notes: PBOAA - prophylactic balloon occlusion of the abdominal aorta OSCS – one step conservative surgery * univariate analysis Multivariate analysis confirmed significant decreasing of massive hemorrhage risk in PBOAA cases (Table 4 ). Table 4 Odds Ratios for the primary outcome (total estimated blood loss ≥ 2500)* OUTCOME: Total estimated blood loss ≥ 2500 Adjusted Odds Ratios 95% confidence interval Model 1 PBOAA + Year from previous cesarean sections ≤ 2 + Preoperative hemoglobin level < 100 g/l 0.088 0.0105–0.737 Model 2 PBOAA + Year from previous cesarean sections ≤ 2 0.087 0.0104–0.728 Model 3 PBOAA + Preoperative hemoglobin level < 100 g/l 0.104 0.012–0.854 Notes: PBOAA - prophylactic balloon occlusion of the abdominal aorta * multivariate analysis Moreover, balloon occlusion inversely associated with the operation duration of ≥ 120 minutes (odds ratio 0.186, 95% confidence interval 0.053–0.656, p = 0.012), and the necessity for additional intraoperative methods of hemostasis (odds ratio 0.0 95% confidence interval 0.0–0.0, p = 0.00) (Table 5 ). Table 5 Odds Ratios for the secondary outcomes depending on the use of PBOAAunivariate analysis Odds Ratio* 95% confidence interval p-value Operation time ≥ 120 minutes 0.186 0.053–0.656 0.012 The need for additional intraoperative methods of hemostasis 0.000 0.0000 0.000 Postoperative hospitalization ≥ 7 days 0.280 0.08–0.978 0.074 Notes: PBOAA - prophylactic balloon occlusion of the abdominal aorta * univariate analysis Discussion In this publication, we present the primary results of an ongoing study investigating the efficacy and safety of temporary prophylactic balloon occlusion of the aorta, performed under the guidance of contact ultrasound examination during cesarean section in patients with intraoperatively confirmed types of placenta percreta, strictly associated with the highest risk of hemorrhagic complications (FIGO Grade 3B, types T3 or T4). As in many previously published results, in the group with balloon aortic occlusion, a significant reduction in the median volume of blood loss, the incidence of major bleeding, the duration of surgery, and length of hospital stay were noted [ 12 , 13 ]. However, our study has several distinctive features. Firstly, we selectively used endovascular techniques only in patients with an intraoperatively confirmed high risk of major bleeding, aimed at minimizing the likelihood of complications associated with vascular access and aortic occlusion [ 23 , 24 , 29 , 30 ]. Secondly, our study is unique for the use of intraoperative navigation using ultrasound, which is a generally available method commonly practiced in any clinic. Endovascular techniques have not yet been widely adopted in our country, primarily due to the lack of X-ray operating rooms in a significant number of hospitals [ 14 ]. At the same time, the current medical need for endovascular procedures has prompted the search for and development of non-X-ray balloon positioning methods [ 16 – 20 , 31 ], including empirical determination of the required delivery catheter length [ 31 ] and studies with echo-contrast agents in the femoral artery puncture zone [ 16 ]. Monitoring the introducer position using a convex ultrasound probe placed on the patient's skin, as described in a number of publications, produces extremely poor visualization in real-life practice, as confirmed by images provided by the authors [ 16 , 17 , 19 , 20 ]. This is due to the significant distance between the patient's skin and aorta. When choosing an ultrasound approach, it is necessary to consider the clinical and anthropometric characteristics of women with PAS disorders. The overwhelming majority of these patients are multiparous, with cicatricial changes in the anterior abdominal wall following repeat cesarean sections. Within our study, 25 women (37%) from both groups combined (Table 1 ) were overweight or obese, reflecting a standard clinical presentation for many PAS patients. This, in addition to the limited area for probe movements during surgery, virtually precludes a high-quality assessment of the balloon position and inflation, as well as Doppler monitoring of blood flow in the distal and proximal aorta and its branches relative to the occlusion site. The use of intravascular ultrasound provides a unique opportunity to evaluate the aorta in a more direct way. However, this technique requires specialized equipment and specialist training, and has only been presented in a single report to date [ 18 ]. Diagnostic and procedural intraoperative ultrasound is widely used in kidney, liver, pancreas, and pelvic surgery in non-pregnant patients for real-time assessment of lesion topography and blood flow in the area of interest [ 21 ]. To our knowledge, this is the first study on evaluation of abdominal aorta contact duplex ultrasound. This technique utilizes a sterile probe positioned in close proximity to the aortic wall, allowing for a detailed and easy assessment of the origins of the abdominal aorta, aortic branches, and their diameter. Due to the minimal distance from the transducer to the lumen of the aorta and iliac arteries, it is possible to continuously and accurately track the movement of the introducer, as well as the position and opening of the balloon. Clear blood flow imaging using color Doppler allows for correct assessment of where best to induce blockage. All of this makes this technique a potential method of choice for non-X-ray guidance during endovascular blood flow reduction procedures. Continuing our study with a larger number of patients will provide reliable data on the safety of this type of navigation during cesarean section in patients with PAS disorders requiring proximal vascular control. Conclusion Intraoperative contact duplex ultrasound navigation of temporary prophylactic balloon occlusion of the aorta during Caesarean section in placenta percreta cases ensures precise balloon positioning in zone 3 of the abdominal aorta, significantly reducing intraoperative blood loss, surgical time, and postoperative hospital stay. Abbreviations ICDUS intraoperative contact duplex ultrasonography FIGO International Federation of Gynecology and Obstetrics OR odds ratio PAS placenta accreta spectrum PBOAA Prophylactic balloon occlusion of the abdominal aorta STROBE Strengthening the Reporting of Observational Studies in Epidemiology Declarations Ethics approval The study was conducted in accordance with the Declaration of Helsinki, and was approved by the Internal Review Board (IRB) of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky (number No. 1 of the minutes of the meeting No. 7, 27. 11.2024). Consent for publication All patients provided informed consent for data publication. Availability of data and materials The datasets used or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding The study conducted without addition financial support. Author`s contributions Tamara Yarygina, Roman Shmakov - designed this study. Tamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Aleksandr Spassky obtained, analyzed or interpreted the data. Tamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Konstantin Lebedev drafted the manuscript. Roman Shmakov revised the manuscript. All the authors read and approved the final manuscript for publication. Acknowledgments Leonid Kokov, Sergey Petrikov for supporting the new method. Anton Fedorov, Irina Krasnopolskaya, Pavel Petrov, and the entire staff of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky for their shared work in treating such complex patients. Ethics approval The study was conducted in accordance with the Declaration of Helsinki, and was approved by the Internal Review Board of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky (number No. 1 of the minutes of the meeting No. 7, 27. 11.2024). Consent for publication All patients provided written informed consent for consent to participate in the study. All patients provided written informed consent for caesarean delivery and caesarean delivery with PBOAA in Group 1 and Group 2, respectively. All patients provided informed consent for data publication. Availability of data and materials The datasets used or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding The study conducted without addition financial support. Author`s contributions Tamara Yarygina, Roman Shmakov - designed this study. Tamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Aleksandr Spassky obtained, analyzed or interpreted the data. Tamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Konstantin Lebedev drafted the manuscript. Roman Shmakov revised the manuscript. All the authors read and approved the final manuscript for publication. Acknowledgments Leonid Kokov, Sergey Petrikov for supporting the new method. Anton Fedorov, Irina Krasnopolskaya, Pavel Petrov, and the entire staff of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky for their shared work in treating such complex patients. References Fonseca A, Ayres de Campos D. Maternal morbidity and mortality due to placenta accreta spectrum disorders. Best Pract Res Clin Obstet Gynaecol. 2021;72:84–91. https://doi.org/10.1016/j.bpobgyn.2020.07.011 . 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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Vergara-Galliadi LM, Matera L, Sanín-Blair JE, Rivera EP, Rozo-Rangel AP, Burgos-Luna JM, Latin American Group for the Study of Placenta Accreta Spectrum. All maternal deaths related to placenta accreta spectrum are preventable: a difficult-to-tell reality. AJOG Glob Rep. 2021;1(3):100012. https://doi.org/10.1016/j.xagr.2021.100012 . Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N. Advantages of individualizing the placenta accreta spectrum management. Front Reprod Health. 2023;4:1096175. https://doi.org/10.3389/frph.2022.1096175 . Palacios-Jaraquemada JM, D'Antonio F, Buca D, Fiorillo A, Larraza P. Systematic review on near miss cases of placenta accreta spectrum disorders: correlation with invasion topography, prenatal imaging, and surgical outcome. J Matern Fetal Neonatal Med. 2020;33(19):3377–84. https://doi.org/10.1080/14767058.2019.1570494 . Palacios-Jaraquemada JM, Basanta N, Nieto-Calvache Á, Aryananda RA. Comprehensive surgical staging for placenta accreta spectrum. J Matern Fetal Neonatal Med. 2022;35(26):10660–6. https://doi.org/10.1080/14767058.2022.2154572 . Palacios-Jaraquemada JM, Nieto-Calvache Á, Aryananda RA, Basanta N. Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location. J Maternal-fetal Neonatal Med. 2023;36(1):2183764. https://doi.org/10.1080/14767058.2023.2183764 . 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: Cervical-trigonal placenta invasion. J Maternal-Fetal. 2023;36(1). https://doi.org/10.1080/14767058.2023.2183741 . Chen D, Xu J, Tian Y, Ling Q, Peng B. Clinical evaluation of the effect for prophylactic balloon occlusion in pregnancies complicated with placenta accreta spectrum disorder: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2024;167(1):109–27. Epub 2024 Jun 20. PMID: 38899567. Dai M, Zhang F, Li K, Jin G, Chen Y, Zhang X. The effect of prophylactic balloon occlusion in patients with placenta accreta spectrum: a Bayesian network meta-analysis. Eur Radiol. 2022;32(5):3297–308. 10.1007/s00330-021-08423-6 . Epub 2021 Nov 30. PMID: 34846565. Wu X, He J, Bai Y, Gan Y, Xu H, Qi H. Xinyang Yu Risk factors for severe postpartum hemorrhage in placenta accreta spectrum patients undergoing prophylactic resuscitative endovascular balloon occlusion of the aorta during cesarean delivery. Ann Med. 2025;57(1):2442065. Akter S, Sharmin T, Ikram S, Parvine E, Akhter R, Begum A, Abedin ES. Assessing the Risks of Prenatal Radiation: Effects on Pregnancy and Neonatal Development. J Pharm Bioallied Sci. 2025;17(Suppl 3):S2434–8. 10.4103/jpbs.jpbs_1675_24 . Chaudery M, Clark J, Morrison JJ, Wilson MH, Bew D, Darzi A. Can contrast-enhanced ultrasonography improve Zone III REBOA placement for prehospital care? J Trauma Acute Care Surg. 2016;80(1):89–94. https://doi.org/10.1097/TA.0000000000000863 . Riazanova OV, Reva VA, Fox KA, Romanova LA, Kulemin ES, Riazanov AD, Ioscovich A. Open versus endovascular REBOA control of blood loss during cesarean delivery in the placenta accreta spectrum: A single-center retrospective case control study. Eur J Obstet Gynecol Reprod Biol. 2021;258:23–8. https://doi.org/10.1016/j.ejogrb.2020.12.022 . Bartels HC, Brophy DP, Moriarty JM, Geoghegan T, McMahon G, Donnelly J, Thompson C, Brennan DJ. Use of an aortic balloon to achieve uterine conservation in a case of placenta accreta spectrum: A case report. Case Rep Womens Health. 2023;37:e00497. 10.1016/j.crwh.2023.e00497 . Chen K, Zhang G, Li F, Liu J, Xie K, Zhu E, Li W, Zhang M, Gen C, Wang A. Application of ultrasound-guided balloon occlusion in cesarean section in 130 cases of sinister placenta previa. J Interv Med. 2020;3(1):41–4. https://doi.org/10.1016/j.jimed.2020.01.006 . Grewal M, Magro M, Premnath KPB, Bologa S, Otigbah C. Ultrasound-guided prophylactic abdominal aortic balloon occlusion for placenta accreta spectrum disorder: A case series. J Clin Imaging Sci. 2023;13:9. 10.25259/JCIS_141_2022 . Meghan G, Lubner LM, Gettle DH, Kim TJ, Ziemlewicz N, Dahiya P, Pickhardt. Diagnostic and procedural intraoperative ultrasound: technique, tips and tricks for optimizing results. Br J Radiol. May 2021;94(1121):20201406. https://doi.org/10.1259/bjr.20201406 . Sukhikh GT, Shmakov RG, Kurtser MA et al. Surgical management of placenta accreta spectrum in the Russian Federation (a pilot multicenter study). Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2024; (1): 50–66 (In Russian). https://dx.doi.org/10.18565/aig.2023.306 = 9. Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, Rodriguez F, Ordoñez CA, Messa Bryon A, Calvache JPB, Lopez J, Campos CI, Mejia M, Rengifo M, Galliadi LMV, Maya J, Zambrano MA, Aguayo IP, Carabalí IG, Burgos JM. How to identify patients who require aortic vascular control in placenta accreta spectrum disorders? Am J Obstet Gynecol MFM. 2022;4(1):100498. https://doi.org/10.1016/j.ajogmf.2021.100498 . Albaro José Nieto-Calvache, Rodriguez-Holguin F. María Camila López-Girón & Carlos Ordoñez. REBOA only for selected cases of placenta accreta spectrum. J Maternal-Fetal Neonatal Med 2020 Nov;35(21):4095–6. https://doi.org/10.1080/14767058.2020.1846710 Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S, et al. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet. 2019;146(1):20–4. https://doi.org/10.1002/ijgo.12761 . Barinov, S. V., Shmakov, R. G., Medyannikova, I. V., Tirskaya, Yu. I., Kadtsyna,T. V., Lazareva, O. V., … Stepanov, S. S. (2021). Efficacy of distal haemostasis during caesarean delivery in women with placenta accreta spectrum disorders. The Journal of Maternal-Fetal & Neonatal Medicine, 35(25), 8778–8785. https://doi.org/10.1080/14767058.2021.2005019. Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda R, Basanta N, Aguilera R, Benavides JP, López J, Campos C, Valencia L, Arboleda K, Cabrera V, Cabrera J, Tavera-Martinez GM, Sinisterra S, Maya J, Peña T, Burgos-Luna JM, Messa A. How to perform the one-step conservative surgery for placenta accreta spectrum move by move. Am J Obstet Gynecol MFM. 2023;5(2):100802. 10.1016/j.ajogmf.2022.100802 . Epub 2022 Nov 11. PMID: 36372188. Lee H, Cashin AG, Lamb SE, Hopewell S, Vansteelandt S, VanderWeele TJ, et al. A Guideline for Reporting Mediation Analyses of Randomized Trials and Observational Studies: The AGReMA Statement. JAMA. 2021;326(11):1045–56. Nieto-Calvache AJ, Hidalgo-Cardona A, Lopez-Girón MC, Rodriguez F, Ordoñez C, Garcia AF, Mejia M, Pabón-Parra MG, Burgos-Luna JM. Arterial thrombosis after REBOA use in placenta accreta spectrum: a case series. J Matern Fetal Neonatal Med. 2022;35(21):4031–4. Epub 2020 Nov 18. PMID: 33207992. Whittington JR, Pagan ME, Nevil BD, Kalkwarf KJ, Sharawi NE, Hughes DS, Sandlin AT. Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum. J Matern Fetal Neonatal Med. 2022;35(16):3049–3052. doi: 10.1080/14767058.2020.1802717. Epub 2020 Aug 11. PMID: 32781879. Van de Voort JC, Verbeek BB, van der Burg BLSB, Hoencamp R. Exploring aortic morphology and determining variable-distance insertion lengths for fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta (REBOA). World J Emerg Surg. 2024;19(1):29. https://doi.org/10.1186/s13017-024-00557-4 . Additional Declarations No competing interests reported. Supplementary Files Supplementarytable1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 07 May, 2026 Reviews received at journal 17 Apr, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviews received at journal 27 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers invited by journal 21 Jan, 2026 Editor assigned by journal 08 Dec, 2025 Submission checks completed at journal 05 Dec, 2025 First submitted to journal 05 Dec, 2025 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. 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Percreta\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe iatrogenic epidemic of placenta accreta spectrum (PAS) disorders, associated with a significant increase in maternal morbidity and mortality, remains a concern for public health officials worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to a U.S. national study, the reported incidence of PAS disorders increases by 2.1% every three months [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current level of antenatal visual diagnostics and a multidisciplinary treatment approach have significantly reduced maternal mortality rates from baseline values of 7%\u0026ndash;30% to 0.05%\u0026ndash;0.25% [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, the problem has not yet been completely solved: a multivariate analysis of 2,727,477 cesarean sections demonstrated a significant increase in the incidence of surgical complications (78.3% versus 10.6%) in the presence and absence of PAS, respectively. In particular, in PAS and non-PAS cesarean deliveries, bleeding was recorded in 54.1% versus 3.9%, hemorrhagic shock in 5.0% versus 0.1%, and lethal complications in 0.25% versus 0.01% of deliveries, in which in the overwhelming majority (\u0026ge;\u0026thinsp;88%) of fatalities were a consequence of massive bleeding followed by the development of coagulopathy and multiple organ failure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt has been shown that, despite the availability of various methods for intraoperative vascular control, in reality most medical clinics use only one method for all PAS cases regardless of the grade, type, and localization of abnormal invasion [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Lack of readiness to use various methods of bleeding prevention complicates the response of the medical team, who may not be comfortable deviating from the initial surgical plan, and significantly increases the time required for decision-making in the event of complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe highest risk of intraoperative complications includes cases of placenta percreta, increasing the odds ratio (OR) of maternal mortality by 32.1 (95% CI 9.61\u0026ndash;107.4) compared with cases of normal placentation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Among cases of placenta percreta, the highest surgical complexity is typical for cases with multiple vascular collaterals in the lower uterine segment, the cervix, and the bladder trigone.\u003c/p\u003e \u003cp\u003eThere is a demand for the most reliable methods of vascular control, related to types T3 (invasion of the posterior wall of the bladder and cervix) and T4 (invasion into the posterior wall of the bladder with severe fibrosis) of the topographic classification responsible for 82.7% (95% CI 71.4\u0026ndash;91.6) of all near-miss cases [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To date, prophylactic balloon occlusion of the abdominal aorta (PBOAA) \u0026ndash; used either prophylactically before operative delivery or after intraoperative PAS confirmation \u0026ndash; has been shown to be a significantly more effective strategy for reducing blood loss, transfusion volume, and hysterectomy rates than other methods of proximal or distal vascular control [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the clear effectiveness of PBOAA, the alternative method of X-ray navigation has a number of disadvantages, the most important of these being that it is an expensive, time-consuming procedure and that it results in fetal radiation exposure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Ultrasound navigation appears to be a potentially promising, but understudied, tool for expanding the application of PBOAA for delivery in patients with PAS in low- and middle-income clinical settings [\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Intraoperative contact ultrasound with Doppler guidance is already widely used in various medical fields, but has not yet been studied for PBOAA navigation in PAS cases [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, in the Russian Federation, the X-ray endovascular method of arterial balloon occlusion is not available in most public clinics, and was used only in 12.2% of severe PAS cases; therefore, distal vascular control techniques are the main methods of hemorrhage prevention [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In December 2024, a multidisciplinary team from the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky began a study aimed at analyzing data on the efficacy and safety of prophylactic balloon occlusion of the abdominal aorta under intraoperative contact duplex ultrasonography (ICDUS) navigation during caesarean section. Inclusion criteria for patient records is PAS type T3-T4 of the topographic classification, which partially corresponds to grade 3B of the International Federation of Gynecology and Obstetrics (FIGO) classification [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTaking into account the null hypothesis of an expected tenfold (from 20% to 2%) reduction in the incidence of massive (more than 2500 ml) intraoperative blood loss when using PBOAA, a total of 30 cases are planned to be included in a two-year study framework. In this publication, we present preliminary results of the application of this methodology.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e This retrospective observational study was conducted using medical records of patients with PAS seen from January 1st, 2020, to October 30th 2025 at a tertiary maternal and child healthcare hospital Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky, Moscow, Russia.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe inclusion criteria\u003c/b\u003e were as follows: (1) singleton pregnancy, (2) cesarean delivery, (3) T3 or T4 PAS types of intraoperative topographic classification as confirmed at surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and (4) complete maternal, neonatal, and delivery records.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe exclusion criteria\u003c/b\u003e included: (1) multiple pregnancies, (2) vaginal delivery, (3) no clinical signs of PAS at delivery, (4) T0, T1, T2, or T5 PAS types of intraoperative topographic classification as confirmed at surgery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and (5) incomplete baseline data.\u003c/p\u003e \u003cp\u003eThe entire study cohort was divided into two groups:\u003c/p\u003e \u003cp\u003e \u003cb\u003eGroup 1\u003c/b\u003e \u0026ndash; using distal complex compression hemostasis as the primary method of bleeding prevention (delivery before December 2024).\u003c/p\u003e \u003cp\u003eComplex compression hemostasis was carried out in the following steps: 1) dissection of the peritoneum of the vesicoureteral fold, 2) bringing down the bladder and, in some cases, its partial resection, 3) targeted coagulation of blood vessels, 4) the formation of artificial \u0026lsquo;windows\u0026rsquo; in broad ligaments of the uterus and through them, 5) the bilateral application of tourniquets on the cervical-interstitial region. For the following two tourniquets, 6) the ovaries were displaced laterally of the tourniquets. Then, 7) loops were created to place a tourniquet around the fallopian tubes, mesosalpinx, and the ovary ligaments. As a result, the tubal and communicative branches of the ovarian and uterine arteries were occluded.\u003c/p\u003e \u003cp\u003eNext, the part of the anterior uterine wall with an abnormally adherent placenta was excised, followed by metroplasty using a controlled intrauterine balloon tamponade with subsequent resection of the uterine wall with abnormal placental invasion, evacuation of placenta from the uterine cavity, and closure of the uterine wall defect with a double suture. At the end, the tourniquets were removed with the simultaneous injection of uterotonic agents [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eGroup 2\u003c/b\u003e \u0026ndash; proximal vascular control with prophylactic balloon occlusion of the abdominal aorta (PBOAA) under intraoperative contact duplex ultrasonography (ICDUS) navigation (delivery after December 2024).\u003c/p\u003e \u003cp\u003ePrevention of bleeding was achieved by PBOAA, performed according to the generally accepted technique using an endo-MIT balloon (Minimally Invasive Technologies LLC, Russia), compatible with a 6 Fr. introducer. The balloon was inserted after fetal extraction, and the umbilical cord was tied and cut without attempting to remove the placenta.\u003c/p\u003e \u003cp\u003eUltrasound navigation was performed using a BK5000 ultrasound system (GE Healthcare, USA) with a 13\u0026thinsp;\u0026minus;\u0026thinsp;4 MH (z13L4w (9011) broadband linear probe for endovascular access to the femoral artery. A 12\u0026thinsp;\u0026minus;\u0026thinsp;5 MHz I12C5b (9024) sterile biplane probe for intraoperative contact scanning of the uterus was used when 1) selecting an incision site outside the placental site, as well as for 2) intraoperative contact ultrasound duplex scanning (Figs.\u0026nbsp;1\u0026ndash;3) of the abdominal aorta and its branches during PBOAA to control an introducer movement, and 3) during balloon placement in zone 3 of abdominal aorta between the renal arteries and aorta bifurcation. The balloon was then opened with Doppler guidance of distal blood flow blocking.\u003c/p\u003e \u003cp\u003ePostoperatively, at 2, 6, 12, and 24 hours after the PBOAA intervention, an ultrasound examination of the abdominal aorta and its branches was performed to exclude possible complications using a broadband linear probe 13\u0026thinsp;\u0026minus;\u0026thinsp;4 MH (z13L4w (9011), as well as an ultrasound examination of the kidneys using a convex probe 6\u0026thinsp;\u0026minus;\u0026thinsp;2 MH (6C2 (9040)).\u003c/p\u003e \u003cp\u003eApart from that, the perioperative management of Groups 1 and 2 was similar.\u003c/p\u003e \u003cp\u003eOrgan-preserving techniques were the method of choice in all cases [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Hysterectomy was performed only in the event of complications that precluded preservation of the uterus.\u003c/p\u003e \u003cp\u003eGravimetric analysis was used for estimation of the amount of blood loss.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe primary outcome\u003c/b\u003e was total blood loss of \u0026ge;\u0026thinsp;2500 ml.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThe secondary outcomes were\u003c/strong\u003e \u003cp\u003eoperation time\u0026thinsp;\u0026ge;\u0026thinsp;120 minutes, bladder injury, need for additional intraoperative methods of hemostasis, postpartum hemorrhage, relaparotomy, hysterectomy, and PBOAA-related complications.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], was conducted in accordance with the Declaration of Helsinki, and was approved by the Ethics Committee of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky (number No. 1 of the minutes of the meeting No. 7, 27. 11.2024).\u003c/p\u003e \u003cp\u003e All patients provided written informed consent for caesarean delivery and caesarean delivery with PBOAA in Group 1 and Group 2, respectively.\u003c/p\u003e \u003cp\u003eMaternal clinical and anamnestic data, intra- and postoperative data, and neonatal data were collected from hospital electronic records. All patient data was anonymized to maintain the patients\u0026rsquo; privacy prior to the analysis.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData was analyzed by MedCalc Statistical Software version 16.4.3 (MedCalc Software by Ostend, Belgium). Quantitative variables were presented as a median (Me) and interquartile range (Q1-Q3) and qualitative variables are presented as frequencies and percentages. The Wilcoxon rank-sum test for independent samples and the χ2 test (or Fisher\u0026rsquo;s exact test if appropriate) were performed to compare variables between groups. Univariate and multivariate analysis of the entire cohort was used to establish the PBOAA association with primary and secondary outcomes. A post-hoc power analysis was used to determine the power of the retrospective study. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was regarded as indicating statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur multidisciplinary team operated on 424 patients with PAS between January 1st, 2020, and October 30th, 2025. Five (1.2%) of these pregnancies were multiples and 342 (80.6%) cases were intraoperatively classified as PAS types T0, T1, T2, and T5 and were hence excluded from the study. 77 (18.2%) cases with PAS types T3 and T4 formed our study cohort (Fig.\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOf the total cohort, 62 (80.5%) patients were assigned to Group 1, and 15 (19.5%) patients to Group 2, with baseline maternal characteristics presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline maternal and neonatal characteristics of two study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMaternal characteristics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (33\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (35,5\u0026ndash;38,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, kg/m\u0026sup2;,\u003c/p\u003e \u003cp\u003eMe (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26,4\u003c/p\u003e \u003cp\u003e(24,4\u0026ndash;30,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30,1\u003c/p\u003e \u003cp\u003e(25,6\u0026ndash;35,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index\u0026thinsp;\u0026ge;\u0026thinsp;30, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (30,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (53,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,5 (3\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnancy\u0026thinsp;\u0026gt;\u0026thinsp;4, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26,7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,149\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of previous cesarean sections,\u003c/p\u003e \u003cp\u003eMe (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,849\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear from previous cesarean sections\u0026thinsp;\u0026le;\u0026thinsp;2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (35,5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of previous vaginal deliveries,\u003c/p\u003e \u003cp\u003eMe (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpregnancy interval, years, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (3,5\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,048\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurettage of the uterine cavity:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (19,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (30,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntrauterine procedures\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;4, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26,6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative hemoglobin level, g/l, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105,5\u003c/p\u003e \u003cp\u003e(97,25\u0026ndash;114,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109 (101\u0026ndash;116)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative hemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;100, g/l, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (32,2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13,3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age at delivery, weeks, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35,1\u003c/p\u003e \u003cp\u003e(33,5\u0026ndash;35,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36,0\u003c/p\u003e \u003cp\u003e(35,15\u0026ndash;36,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeonatal characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (43.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth weight, gram, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2455\u003c/p\u003e \u003cp\u003e(2255\u0026ndash;2802)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2830\u003c/p\u003e \u003cp\u003e(2635\u0026ndash;3005)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5-min Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eData are given as n (%) or median (Me) (interquartile range(Q1-Q3).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA statistically significant difference was found in the median number of previous vaginal deliveries and the interpregnancy interval, which were larger in Group 2 with PBOAA compared to Group 1: 3 versus 0 (p\u0026thinsp;=\u0026thinsp;0.0001) and 5 versus 3 (p\u0026thinsp;=\u0026thinsp;0.048), respectively. The number of patients with a preoperative hemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;100 g/l was significantly higher in the Group 1 accounting for 32,2% compared to 13,3% in Group 1 (p\u0026thinsp;=\u0026thinsp;0,021).\u003c/p\u003e \u003cp\u003eMaternal age, body mass index, presence of obesity, the number of previous cesarean sections, median preoperative hemoglobin levels, and gestational age at delivery were not significantly different.\u003c/p\u003e \u003cp\u003eEmergency cesarean delivery was performed due to the onset of bleeding in 21 (33.9%) and 2 (13.3%) cases in Group 1 and Group 2, respectively (p\u0026thinsp;=\u0026thinsp;0.02) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical and postoperative indicators of two study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 2\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time, minutes, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126,5 (113,5\u0026ndash;158,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (98,5\u0026ndash;124,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time\u0026thinsp;\u0026ge;\u0026thinsp;120 minutes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (66,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency cesarean delivery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (33.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective cesarean delivery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (66,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (86,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePfannenstiel incision, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (6,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emidline vertical incision, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (93,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (93,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efundal, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (83,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etransvers (OSCS), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (16,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder injury, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (33,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,761\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdditional intraoperative methods of hemostasis, total number, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (95,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal iliac artery ligation n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (24,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterine artery ligation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (16,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,195\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative uterine compression suture, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntrauterine balloon tamponade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (83,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative estimated blood loss, ml,\u003c/p\u003e \u003cp\u003eMe (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1700\u003c/p\u003e \u003cp\u003e(1100\u0026ndash;2712)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e980\u003c/p\u003e \u003cp\u003e(689\u0026ndash;1472)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostpartum hemorrhage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (9,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostpartum estimated blood loss, ml, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1000\u003c/p\u003e \u003cp\u003e(600\u0026ndash;1700)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal estimated blood loss, ml, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1850\u003c/p\u003e \u003cp\u003e(1125\u0026ndash;2800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e980\u003c/p\u003e \u003cp\u003e(689\u0026ndash;1472)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal estimated blood loss\u0026thinsp;\u0026ge;\u0026thinsp;2500 ml, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (40,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelaparotomy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (11,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysterectomy, total number, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (11,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary hysterectomy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (6,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed hysterectomy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (4,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBOAA - related complications, total number, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evascular access site complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (13,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eother complications, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospitalization, days, Me (Q1-Q3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5\u0026ndash;7,75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospitalization, \u0026ge; 7 days, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (56,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0,047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eNotes:\u003c/p\u003e \u003cp\u003ePBOAA - prophylactic balloon occlusion of the abdominal aorta\u003c/p\u003e \u003cp\u003eOSCS \u0026ndash; one step conservative surgery\u003c/p\u003e \u003cp\u003eContinuous variables are presented as median (Q1 \u0026ndash; Q3)\u003c/p\u003e \u003cp\u003eCategorical variables are presented as number(percentage)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn Group 2, in all cases, intraoperative contact duplex ultrasonography allowed direct real-time continued visualization of the introducer movement and precise positioning of the balloon in zone 3 of the abdominal aorta between the renal arteries and the aortic bifurcation. Doppler guidance of distal blood flow blockage allowed for monitoring of the correct position for balloon opening, with the time for aortic occlusion ranging from 15 to 30 minutes in 14 (93.3%) cases. In one (6.7%) case, occlusion was performed intermittently for a total of 40 minutes (30 minutes\u0026thinsp;+\u0026thinsp;10 other minutes after temporary deflation of the balloon). There were no cases of balloon migration or malposition.\u003c/p\u003e \u003cp\u003eThe primary outcome - a total blood loss volume of \u0026ge;\u0026thinsp;2500 ml. - was recorded in 25 (40.3%) patients in Group 1, which was significantly higher than in Group 2 with PBOAA, which had only 1 such case (6.7%) (p\u0026thinsp;=\u0026thinsp;0.014).\u003c/p\u003e \u003cp\u003eA comparative analysis of the parameters in patients of the entire cohort, divided depending on the volume of total blood loss with a threshold of \u0026ge;\u0026thinsp;2500 ml, is presented in Supplementary table 1.\u003c/p\u003e \u003cp\u003eTaking into account the obtained frequency of the primary outcome equal to 40.3% in Group 1 and 6.7% in Group 2, post-hoc power analysis determined the power of this pilot part of retrospective study of 78% with a probability of type I error of 0.05.\u003c/p\u003e \u003cp\u003eIn Group 2, a single transverse uterine incision was used more often than in Group 2 (60.0% vs. 16.2%, p\u0026thinsp;=\u0026thinsp;0.001), as the one step conservative surgery technique was initiated by our surgical team in only 2024.\u003c/p\u003e \u003cp\u003eIn Group 1, additional methods of blood flow reduction were used in almost all cases, while in Group 2 they were not required (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Total estimated blood loss, duration of the operation and the number of cases with operation time\u0026thinsp;\u0026ge;\u0026thinsp;120 minutes, duration of postoperative hospitalization of women were also significantly higher in Group 1, where distal methods of blood flow reduction were used, compared with Group 2 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Group 2, complications associated with PBOAA were represented only by hematomas at the site of femoral artery puncture in 2 (13.3%) patients (p\u0026thinsp;=\u0026thinsp;0.03), which did not require surgical intervention. There were no injuries from balloon overinflation, ischemic renal or limb damage (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt should be noted that all cases of postpartum hemorrhage, relaparotomy and hysterectomy were noted only in Group 1; however, statistical significance was not achieved due to the insufficient number of observations at the time of submission.\u003c/p\u003e \u003cp\u003eUnivariate analysis of the entire cohort established that only PBOAA was inversely associated with the estimated blood loss\u0026thinsp;\u0026ge;\u0026thinsp;2.500 ml (odds ratio 0.106, 95% confidence interval 0.013\u0026ndash;0.856, p\u0026thinsp;=\u0026thinsp;0.029) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOdds Ratios for the primary outcome (total estimated blood loss\u0026thinsp;\u0026ge;\u0026thinsp;2500)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003cp\u003eOUTCOME: Total estimated blood loss\u0026thinsp;\u0026ge;\u0026thinsp;2500\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds Ratio*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003cp\u003econfidence interval\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBOAA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.013\u0026ndash;0.856\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear from previous cesarean sections\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.308\u0026ndash;2.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative hemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;100, g/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.417\u0026ndash;3.308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFundal uterine incision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.743\u0026ndash;8.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransvers uterine incision (OSCS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.118\u0026ndash;1.345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eNotes: PBOAA - prophylactic balloon occlusion of the abdominal aorta\u003c/p\u003e \u003cp\u003eOSCS \u0026ndash; one step conservative surgery\u003c/p\u003e \u003cp\u003e* univariate analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariate analysis confirmed significant decreasing of massive hemorrhage risk in PBOAA cases (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOdds Ratios for the primary outcome (total estimated blood loss\u0026thinsp;\u0026ge;\u0026thinsp;2500)*\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOUTCOME:\u003c/p\u003e \u003cp\u003eTotal estimated blood loss\u0026thinsp;\u0026ge;\u0026thinsp;2500\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted Odds Ratios\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003cp\u003econfidence interval\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 1\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePBOAA +\u003c/p\u003e \u003cp\u003eYear from previous cesarean sections\u0026thinsp;\u0026le;\u0026thinsp;2\u0026thinsp;+\u0026thinsp;Preoperative hemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;100 g/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0105\u0026ndash;0.737\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 2\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePBOAA +\u003c/p\u003e \u003cp\u003eYear from previous cesarean sections\u0026thinsp;\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0104\u0026ndash;0.728\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eModel 3\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePBOAA +\u003c/p\u003e \u003cp\u003ePreoperative hemoglobin level\u0026thinsp;\u0026lt;\u0026thinsp;100 g/l\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.012\u0026ndash;0.854\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNotes: PBOAA - prophylactic balloon occlusion of the abdominal aorta\u003c/p\u003e \u003cp\u003e* multivariate analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMoreover, balloon occlusion inversely associated with the operation duration of \u0026ge;\u0026thinsp;120 minutes (odds ratio 0.186, 95% confidence interval 0.053\u0026ndash;0.656, p\u0026thinsp;=\u0026thinsp;0.012), and the necessity for additional intraoperative methods of hemostasis (odds ratio 0.0 95% confidence interval 0.0\u0026ndash;0.0, p\u0026thinsp;=\u0026thinsp;0.00) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOdds Ratios for the secondary outcomes depending on the use of PBOAAunivariate analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds Ratio*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003cp\u003econfidence interval\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time\u0026thinsp;\u0026ge;\u0026thinsp;120 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.053\u0026ndash;0.656\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe need for additional intraoperative methods of hemostasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospitalization\u0026thinsp;\u0026ge;\u0026thinsp;7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08\u0026ndash;0.978\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eNotes: PBOAA - prophylactic balloon occlusion of the abdominal aorta\u003c/p\u003e \u003cp\u003e* univariate analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this publication, we present the primary results of an ongoing study investigating the efficacy and safety of temporary prophylactic balloon occlusion of the aorta, performed under the guidance of contact ultrasound examination during cesarean section in patients with intraoperatively confirmed types of placenta percreta, strictly associated with the highest risk of hemorrhagic complications (FIGO Grade 3B, types T3 or T4).\u003c/p\u003e \u003cp\u003eAs in many previously published results, in the group with balloon aortic occlusion, a significant reduction in the median volume of blood loss, the incidence of major bleeding, the duration of surgery, and length of hospital stay were noted [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, our study has several distinctive features. Firstly, we selectively used endovascular techniques only in patients with an intraoperatively confirmed high risk of major bleeding, aimed at minimizing the likelihood of complications associated with vascular access and aortic occlusion [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecondly, our study is unique for the use of intraoperative navigation using ultrasound, which is a generally available method commonly practiced in any clinic. Endovascular techniques have not yet been widely adopted in our country, primarily due to the lack of X-ray operating rooms in a significant number of hospitals [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. At the same time, the current medical need for endovascular procedures has prompted the search for and development of non-X-ray balloon positioning methods [\u003cspan additionalcitationids=\"CR17 CR18 CR19\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], including empirical determination of the required delivery catheter length [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and studies with echo-contrast agents in the femoral artery puncture zone [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMonitoring the introducer position using a convex ultrasound probe placed on the patient's skin, as described in a number of publications, produces extremely poor visualization in real-life practice, as confirmed by images provided by the authors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This is due to the significant distance between the patient's skin and aorta. When choosing an ultrasound approach, it is necessary to consider the clinical and anthropometric characteristics of women with PAS disorders. The overwhelming majority of these patients are multiparous, with cicatricial changes in the anterior abdominal wall following repeat cesarean sections. Within our study, 25 women (37%) from both groups combined (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were overweight or obese, reflecting a standard clinical presentation for many PAS patients. This, in addition to the limited area for probe movements during surgery, virtually precludes a high-quality assessment of the balloon position and inflation, as well as Doppler monitoring of blood flow in the distal and proximal aorta and its branches relative to the occlusion site.\u003c/p\u003e \u003cp\u003eThe use of intravascular ultrasound provides a unique opportunity to evaluate the aorta in a more direct way. However, this technique requires specialized equipment and specialist training, and has only been presented in a single report to date [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiagnostic and procedural intraoperative ultrasound is widely used in kidney, liver, pancreas, and pelvic surgery in non-pregnant patients for real-time assessment of lesion topography and blood flow in the area of interest [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo our knowledge, this is the first study on evaluation of abdominal aorta contact duplex ultrasound. This technique utilizes a sterile probe positioned in close proximity to the aortic wall, allowing for a detailed and easy assessment of the origins of the abdominal aorta, aortic branches, and their diameter. Due to the minimal distance from the transducer to the lumen of the aorta and iliac arteries, it is possible to continuously and accurately track the movement of the introducer, as well as the position and opening of the balloon. Clear blood flow imaging using color Doppler allows for correct assessment of where best to induce blockage. All of this makes this technique a potential method of choice for non-X-ray guidance during endovascular blood flow reduction procedures. Continuing our study with a larger number of patients will provide reliable data on the safety of this type of navigation during cesarean section in patients with PAS disorders requiring proximal vascular control.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntraoperative contact duplex ultrasound navigation of temporary prophylactic balloon occlusion of the aorta during Caesarean section in placenta percreta cases ensures precise balloon positioning in zone 3 of the abdominal aorta, significantly reducing intraoperative blood loss, surgical time, and postoperative hospital stay.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICDUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintraoperative contact duplex ultrasonography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFIGO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Federation of Gynecology and Obstetrics\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eodds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eplacenta accreta spectrum\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePBOAA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProphylactic balloon occlusion of the abdominal aorta\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTROBE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki, and was approved by the Internal Review Board (IRB) of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky (number No. 1 of the minutes of the meeting No. 7, 27. 11.2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients provided informed consent for data publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used or analyzed during the current study are available from the\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ecorresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study conducted without addition financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor`s contributions \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTamara Yarygina, Roman Shmakov - designed this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Aleksandr Spassky obtained, analyzed or interpreted the data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Konstantin Lebedev drafted the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRoman Shmakov revised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the authors read and approved the final manuscript for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeonid Kokov, Sergey Petrikov for supporting the new method. Anton Fedorov, Irina Krasnopolskaya, Pavel Petrov, and the entire staff of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky for their shared work in treating such complex patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki, and was approved by the Internal Review Board of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky (number No. 1 of the minutes of the meeting No. 7, 27. 11.2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients provided written informed consent for consent to participate in the study. \u0026nbsp;All patients provided written informed consent for caesarean delivery and caesarean delivery with PBOAA in Group 1 and Group 2, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll patients provided informed consent for data publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used or analyzed during the current study are available from the corresponding author on reasonable request. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study conducted without addition financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor`s contributions \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTamara Yarygina, Roman Shmakov - designed this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Aleksandr Spassky obtained, analyzed or interpreted the data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTamara Yarygina, Tatiana Zabelina, Sabina Gadjieva, Daniil Kotsuba, Konstantin Lebedev drafted the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRoman Shmakov revised the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the authors read and approved the final manuscript for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeonid Kokov, Sergey Petrikov for supporting the new method. Anton Fedorov, Irina Krasnopolskaya, Pavel Petrov, and the entire staff of the Moscow Regional Research Institute of Obstetrics and Gynecology named after academician V. I. Krasnopolsky for their shared work in treating such complex patients.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFonseca A, Ayres de Campos D. Maternal morbidity and mortality due to placenta accreta spectrum disorders. Best Pract Res Clin Obstet Gynaecol. 2021;72:84\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bpobgyn.2020.07.011\u003c/span\u003e\u003cspan address=\"10.1016/j.bpobgyn.2020.07.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsuzaki S, Mandelbaum RS, Sangara RN, McCarthy LE, Vestal NL, Klar M, Matsushima K, Amaya R, Ouzounian JG, Matsuo K. 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J Maternal-Fetal Neonatal Med 2020 Nov;35(21):4095\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/14767058.2020.1846710\u003c/span\u003e\u003cspan address=\"10.1080/14767058.2020.1846710\" 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, et al. 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\"\u003ehttps://doi.org/10.1002/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\u003eBarinov, S. V., Shmakov, R. G., Medyannikova, I. V., Tirskaya, Yu. I., Kadtsyna,T. V., Lazareva, O. V., \u0026hellip; Stepanov, S. S. (2021). Efficacy of distal haemostasis during caesarean delivery in women with placenta accreta spectrum disorders. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine, 35(25), 8778\u0026ndash;8785. https://doi.org/10.1080/14767058.2021.2005019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda R, Basanta N, Aguilera R, Benavides JP, L\u0026oacute;pez J, Campos C, Valencia L, Arboleda K, Cabrera V, Cabrera J, Tavera-Martinez GM, Sinisterra S, Maya J, Pe\u0026ntilde;a T, Burgos-Luna JM, Messa A. How to perform the one-step conservative surgery for placenta accreta spectrum move by move. Am J Obstet Gynecol MFM. 2023;5(2):100802. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajogmf.2022.100802\u003c/span\u003e\u003cspan address=\"10.1016/j.ajogmf.2022.100802\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Nov 11. PMID: 36372188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee H, Cashin AG, Lamb SE, Hopewell S, Vansteelandt S, VanderWeele TJ, et al. A Guideline for Reporting Mediation Analyses of Randomized Trials and Observational Studies: The AGReMA Statement. JAMA. 2021;326(11):1045\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNieto-Calvache AJ, Hidalgo-Cardona A, Lopez-Gir\u0026oacute;n MC, Rodriguez F, Ordo\u0026ntilde;ez C, Garcia AF, Mejia M, Pab\u0026oacute;n-Parra MG, Burgos-Luna JM. Arterial thrombosis after REBOA use in placenta accreta spectrum: a case series. J Matern Fetal Neonatal Med. 2022;35(21):4031\u0026ndash;4. Epub 2020 Nov 18. PMID: 33207992.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhittington JR, Pagan ME, Nevil BD, Kalkwarf KJ, Sharawi NE, Hughes DS, Sandlin AT. Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum. J Matern Fetal Neonatal Med. 2022;35(16):3049\u0026ndash;3052. doi: 10.1080/14767058.2020.1802717. Epub 2020 Aug 11. PMID: 32781879.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan de Voort JC, Verbeek BB, van der Burg BLSB, Hoencamp R. Exploring aortic morphology and determining variable-distance insertion lengths for fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta (REBOA). World J Emerg Surg. 2024;19(1):29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13017-024-00557-4\u003c/span\u003e\u003cspan address=\"10.1186/s13017-024-00557-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"Prophylactic balloon occlusion of the abdominal aorta, placenta accreta spectrum (PAS) disorders, placenta percreta, massive intraoperative blood loss, peripartum hemorrhage, intraoperative contact duplex ultrasonography","lastPublishedDoi":"10.21203/rs.3.rs-8264156/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8264156/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\u003eProphylactic balloon occlusion of the abdominal aorta (PBOAA) is the most effective vascular control strategy in surgical treatment of patients with placenta accreta spectrum (PAS) disorders. Intraoperative contact duplex ultrasonography (ICDUS) can be used for PBOAA navigation in the absence of opportunities for traditional X-ray imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective observational study was conducted using medical records of patients with PAS who gave birth from January 1st, 2020, to October 30th, 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e: singleton pregnancy; cesarean delivery; PAS types T3 or T4. \u003cstrong\u003eExclusion criteria\u003c/strong\u003e: multiple pregnancy; vaginal delivery; no clinical signs of PAS at delivery; PAS types T0, T1, T2, and T5.\u003c/p\u003e\n\u003cp\u003eThe study cohort was divided into two groups based on the primary method of bleeding prevention. \u003cstrong\u003eGroup 1\u003c/strong\u003e – using distal complex compression hemostasis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup 2\u003c/strong\u003e – using PBOAA under ICDUS navigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe primary outcome\u003c/strong\u003e was total blood loss of ≥ 2500 ml. \u003cstrong\u003eThe secondary outcomes\u003c/strong\u003e were: operation time ≥ 120 minutes, bladder injury, need for additional intraoperative methods of hemostasis, postpartum hemorrhage, relaparotomy, hysterectomy, and PBOAA-related complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the total cohort, 62 (80.5%) patients were assigned to Group 1 and 15 (19.5%) patients to Group 2; in all cases, ICDUS allowed direct real-time control of the introducer movement and precise positioning of the balloon in zone 3 of the abdominal aorta. The only PBOAA-associated complications were hematomas at the site of femoral artery puncture, which were reported in 2 (13.3%) patients and did not require surgical intervention.\u003c/p\u003e\n\u003cp\u003eA total blood loss volume of ≥ 2500 ml. was seen in 25 cases (40.3%) in Group 1 but in only 1 case (6.7%) in Group 2 (p=0.014). In Group 1, additional methods of blood flow reduction were used in almost all (95.1%) cases, while in Group 2 they were not required (p\u0026lt;0.0001). Average total blood loss (1850 ml vs 980 ml), duration of the operation (126.5 min vs 112 min), and postoperative hospitalization (7 vs 5 days) of women were also significantly higher in Group 1 in comparison to Group 2 (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eICDUSappears to be a safe and effective form of navigation for PBOAA during Caesarean section in placenta percreta cases.\u003c/p\u003e","manuscriptTitle":"Intraoperative Contact Duplex Ultrasonography in Navigation of Prophylactic Balloon Occlusion of the Abdominal Aorta in Patients With Placenta Percreta","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 00:10:50","doi":"10.21203/rs.3.rs-8264156/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"74498986645835649180051948334652114208","date":"2026-05-08T03:03:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T03:00:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134834668098316478685769619151998072014","date":"2026-04-18T02:45:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T23:01:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294709910599885612748641099491949132560","date":"2026-01-22T22:15:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T03:36:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T18:07:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-05T20:04:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-12-05T19:59:19+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":"509bfbcf-b20f-4c60-8ffb-02cc2816c88f","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"74498986645835649180051948334652114208","date":"2026-05-08T03:03:28+00:00","index":77,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-27T00:10:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 00:10:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8264156","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8264156","identity":"rs-8264156","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}