Internal Iliac Artery Balloon Occlusion for Placenta Accreta Spectrum Disorder: Outcomes and Factors influencing Efficacy

Internal Iliac Artery Balloon Occlusion for Placenta Accreta Spectrum Disorder: Outcomes and Factors influencing Efficacy | 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 Internal Iliac Artery Balloon Occlusion for Placenta Accreta Spectrum Disorder: Outcomes and Factors influencing Efficacy Wright Ann, Toh Luke Han Wei, Sivanathan Chandramohan, Tan Bien Soo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8121877/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: Placenta accreta spectrum disorder (PASD) is a major obstetric complication associated with life-threatening haemorrhage. Prophylactic internal iliac artery balloon occlusion (IIABO) is used in many centres to reduce intraoperative blood loss but success rate is variable. Methods: We reviewed 20 consecutive patients with PASD over a twenty-one-month period stratified by procedure type [total abdominal hysterectomy (TAH) versus conservative myometrial repair (MR)] and balloon occlusion use. Estimated blood loss (EBL) was recorded. Welch’s t-tests compared groups, and a two-way analysis of variance (ANOVA) assessed the effects of balloon use and procedure type. Effect sizes were expressed as Cohen’s d and η². Results: Mean EBL was significantly lower with balloon use than without (1660 ± 676 mL vs 3260 ± 2021 mL, p = 0.034, Cohen’s d = − 1.15). Two-way ANOVA confirmed a main effect of balloon use (η² = 0.28), while procedure type showed no independent effect (p = 0.504). However, EBL values were widely dispersed— with balloons: median 1500 mL (interquartile range {IQR} 1200–1850), range 800–3000; without balloons: median 3000 mL (IQR 1600–5000), range 900–6000—highlighting variable efficacy at the individual level. Conclusion: Prophylactic balloon occlusion reduces blood loss overall in both TAH and conservative MR for PASD, but its efficacy is highly variable. Collateral circulation and scar defect morphology likely underpin this variability, and further research should focus on refining preoperative risk stratification to guide individualised surgical planning with the aid of available imaging techniques. Placenta accreta spectrum disorders Caesarean scar defect Internal iliac artery occlusion Myometrial Repair Conservative management Placenta praevia Figures Figure 1 Figure 2 Introduction Placenta accreta spectrum disorder (PASD), previously attributed to abnormal placental adherence or invasion into the myometrium, is increasingly being recognized as a Caesarean scar disorder in which the placenta is intimately related to a muscular dehiscence at the site of a previous uterine scar associated with fibrinoid deposition and neo-angiogenesis, with the appearance of large immature vessels on the residual myometrium over the isthmocele. ( 1 – 5 ). The primary risk associated with delivery in cases of PASD is severe, potentially life-threatening haemorrhage. The principal surgical challenge lies in achieving rapid source control over the blood loss from an extensive and variable neovascular network within the myometrial defect, often further complicated by fibrosis resulting from prior surgical interventions. Traditionally, total abdominal hysterectomy (TAH) has been regarded as the first-line treatment for PASD, but this procedure carries considerable surgical morbidity related to blood loss and visceral injury often exacerbated by adhesions from previous surgeries. It also requires significant surgical expertise. Nonetheless, even with vascular occlusion, whether by surgical ligation or radiologically guided, TAH does not fully prevent massive bleeding; instances of up to four liters of blood loss during caesarean hysterectomy have been reported despite interventional guided bilateral common iliac occlusion ( 6 ). More recently, conservative techniques such as myometrial repair (MR) after placental delivery ( 3 , 7 – 9 ) have been developed in efforts to preserve fertility. However, these approaches also carry a high risk of significant peri-operative blood loss and demand advanced surgical skills. Approaches to minimizing blood loss in PASD have been adapted from management strategies for major trauma patients, yielding variable degrees of success but carrying inherent risks. These methods include both permanent and temporary occlusion of the main arterial supplies to the uterus. While targeted endovascular occlusion does not eliminate blood loss due to collateral circulation altogether, it does significantly reduce the rate of hemorrhage. The larger the vessel occluded, the greater the haemostatic effect, with aortic balloon occlusion substantially decreasing the necessity for hysterectomy and embolisation in placenta praevia major (PPM)/PASD cases ( 10 – 14 ). Endovascular balloon occlusion of pelvic vessels, including the internal iliac arteries limits intraoperative blood loss by reducing pelvic arterial inflow thereby facilitating surgical haemostasis. Reported outcomes of the intervention vary between dramatic reductions in estimated blood loss (EBL) to minimal benefit raising concerns about the variable efficacy of balloon occlusion. At our institution, the established practice is internal iliac artery balloon occlusion (IIABO) over larger vessel occlusion for PASD. We present a case series of 20 consecutive patients with PASD and compare the blood loss during TAH with that during MR, both with and without IIABO. We review the current evidence and highlight how vascular anatomy and scar defect morphology influence the variable efficacy of balloon occlusion. Methods The authors previously described the technique of MR as a possible conservative approach for PASD and compared various operating parameters with TAH ( 3 ). Here, we have focused on the difference in EBL in women undergoing TAH and those undergoing MR with and without IIABO. This was a heterogeneous group of elective and emergency cases. The elective cases had protocolised care coordinated by the ‘accreta team’. After the diagnosis of PASD was made women were seen in the obstetric high risk antenatal clinic to formulate a plan of care for the remainder of the pregnancy. About half of the patients underwent magnetic resonance imaging (MRI) at 28–32 weeks to delineate the retracted muscle edges, relationship of the placenta to the internal os and to identify any aberrations in the uterine blood supply. Surgical options, with inherent risks, were discussed and the patient was listed for her preferred choice of surgery at 34 weeks, regardless of the suspected grade of placenta accreta, usually under general anaesthesia, which was immediately preceded by percutaneous insertion of occlusion balloon catheters in the angiography suite, the technical details about which have been described previously ( 15 ). The balloons were inflated after delivery of the baby, prior to removal of the placenta and removed at the end of surgery unless there were concerns of ongoing bleeding. Blood loss was estimated jointly by the surgeons and anaesthetists from the amount collected from the surgical field by suction and cell salvage, number of swabs used and on occasion point of care haemoglobin measurement compared to preoperative level. Four units of packed cells were available on standby for the surgery and cell salvage was routinely used. Even for emergency cases the protocol was followed as far as possible, time permitting. This retrospective study of consecutive cases performed between December 2019 and September 2021 and was conducted in accordance with the Declaration of Helsinki. It was approved and reviewed by Singhealth institutional review board (IRB Approval Reference number – 2020/2966/D) and all participants provided informed consent. Statistical Analysis EBL was compared according to procedure type [TAH versus conservative MR] and IIABO (yes versus no). Continuous variables are presented as mean ± standard deviation (SD). Primary analysis used a two-way ANOVA (factors procedure type x balloon use) to assess main and interaction effects. Where appropriate, Welch’s independent-samples t-tests, which do not assume equal variances, were applied for pair-wise comparisons I) balloon vs no balloon (collapsed across procedure type) and ii) TAH vs MR (collapsed across balloon use). Effect sizes were calculated as Cohen’s d for pairwise tests (0.2 = small, 0.5 = medium, 0.8 = large) and η²for ANOVA effects (0.01 = small, 0.06 = medium, 0.14 = large). Results Twenty consecutive patients with PASD were included, 10 of whom had a Caesarean section (CS) with peripartum TAH and 10, a Caesarean section and MR using the previously described technique. There was a fairly even mix of grades of PASD across the 2 groups as shown by preceding MRI or subsequent histopathology (h/p) or both. Histopathological results were available for 8 cases who had TAH with 2 showing accreta, 4 increta and 2 percreta. Among these, 4 had a preceding MRI with results correlating with histopathology(h/p) apart from 1 which suggested accreta when h/p suggested increta. Among the MR group, 5 had a pre-operative MRI, 2 suggesting accreta, 2 increta and 1 percreta. Five patients in each group underwent elective surgery between 34 and 36 weeks and the remainder required emergency delivery for an intervening complication. None of the patients had a TAH for failed conservative management. All patients were offered pre-operative endovascular placement, time permitting. The groups were similar with respect to age and gestational age at delivery (Table 1). The 20 women were stratified into 4 groups by procedure type and prophylactic balloon use: TAH with IIABO (n=5), TAH without IIABO (n=5), MR with IIABO (n=6), and MR without IIABO (n=4). Tables 1 & 2 show the demographics for each group and blood losses. Group Comparisons Mean EBL was lower in patients managed with IIABO. For TAH, mean EBL was 1660 +/-780ml with IIABO versus 3480 +/-2032ml without. For MR mean EBL was 1550 +/-629ml with IIABO compared to 2900 +/-1908ml without balloons. EBL values were widely dispersed—with IIABO: median 1500 mL (IQR 1200–1850), range 800–3000; without IIABO: median 3000 mL (IQR 1600–5000), range 900–6000. Pooled Comparisons When analysed by IIABO use, irrespective of procedure, mean EBL was significantly reduced with IIABO (1660 +/-676ml) compared to without IIABO (3260+/-2021ml). Welch’s t (12.6) = -2.4, p = 0.034. Cohen’s d = -1.15 (large effect). By contrast, there was no significant difference between TAH (2570 +/-1780ml) and MR (2113 +/-1446ml): Welch’s t (16.9) =0.68, p=0.504. Cohen’s d =0.31 (small effect). ANOVA Two-way ANOVA confirmed a significant effect of IIABO use on EBL (F (1.16) =6.22, p =0.024. η² = 0.28 (large effect) but no significant effect of procedure type (F (1.16) = 0.26, P =0.620, η²= 0.01) and no interaction (F (1.16) =0.14, p=0.717, n 2 0.006) (Table 3). Discussion & Review Our series shows that IIABO significantly reduced blood loss in PASD. The effect was consistent across both TAH and MR, but procedure type itself did not independently influence EBL. However, the ranges in blood loss were large and the benefit of IIABO use was not uniform across all patients. Published series and meta-analyses, have reported variable outcomes with vascular occlusive methods for both PPM and PASD since the 2000’s, with reductions in EBL ranging from >50% to negligible (16-20). Nankali et al. in a systematic review and meta-analysis of 29 studies comparing 1140 controls with 1225 IIABO cases, found a positive intervention effect on EBL and reduced hysterectomy rate with increasing gestational age (21). Picel et al. described it as a safe, minimally invasive technique to limit blood loss and transfusion requirements in PASD patients undergoing CS (22). Other studies have shown different results (23,24,25) and there have been no previous studies specifically looking at the effect of IIABO in cases managed by TAH compared with myometrial repair. Our series shows that IIABO significantly reduced blood loss in PASD in both approaches (TAH and MR). EBL values were widely dispersed in our study — with or without IIABO. While part of the heterogeneity in effect of IIABO relates to surgical expertise and protocols, a more fundamental explanation lies in the vascular and anatomical variability of the caesarean scar defect which has to be addressed for the treatment to be successful. Mechanisms of Variable Efficacy We suggest that the variable efficacy may be explained by the following mechanisms: 1.Collateral and Extrauterine Vascular Supply The uterus mainly receives blood from paired uterine arteries, typically branching from the internal iliac artery, though variations in origin do exist. The uterine artery passes under the broad ligament, splits at the isthmus, and crosses the ureter, with ascending branches supplying the myometrium and descending branches serving the cervix and vagina, connecting with other pelvic arteries. Spiral arteries reach the endometrium, and the ovarian artery arises from the abdominal aorta to supply the ovary. During pregnancy, uterine blood flow increases significantly, from 50 millilitres per minute to more than 1 litre per minute by term. Approximately 90% of this flow reaches inter-villous spaces within the placenta for fetal exchange. Around 200 spiral arteries from the uterine artery support the developing placenta. In pregnancy, pelvic blood flow shifts, increasing common iliac and uterine artery perfusion while decreasing external iliac flow (16-18,22,26 - 29) (Figure 1). External iliac and ovarian artery anastomoses contribute to collateral flow. These pathways explain persistent bleeding despite technically successful occlusion of the internal iliac arteries (30,31). 2. Anatomical Changes at the Scar Defect When considering which haemostatic techniques to use during surgery and to explain the variable IIABO effectiveness, it is crucial to understand the development and anatomy of the caesarean scar defect (CSD) and the unique placental blood supply found in PASD. CSDs typically form at the lower anterior uterine wall after a previous lower segment CS due to incomplete healing resulting in a thinned myometrium. Factors influencing CSD formation include number and type of prior CS procedures, incision location, labour duration, cervical dilatation, closure technique, adhesions, and uterine retroversion (32). The CSD itself is measured by depth, residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT). Large CSDs are often defined as defects with a 50%-80% reduction in wall thickness or an RMT <2.2 mm by transvaginal ultrasound scan (TVUS); an RMT <2 mm in early pregnancy is linked to PASD at delivery. A thin RMT impairs myometrial contractility which affects vessel constriction postpartum (33). At repeat CS, vessels may be visible through the thin wall which does not respond to uterotonics. One complication following CS is a Caesarean scar pregnancy which typically implants near the scar defect, and, if allowed to progress, is often associated with future development of PASD with a high hysterectomy rate. ‘On the scar’ implantations with measurable myometrial thickness generally have better outcomes than ‘in the niche’ implantations with minimal intervening myometrium (34 - 37). Vascular remodelling depends on scar location, defect size, muscle involvement, proximity to the internal os, placental distance to vasculature, and associated fibrosis—nearly half of CSDs show fibrosis involving angiogenesis which can complicate bladder dissection (38,39). Arterial remodelling produces low-resistance, high-flow vessels, boosting blood flow into intervillous spaces. Which arteries are affected depends on the extent of endometrial and myometrial loss, with affected vessels seen as lacunae on ultrasound, sometimes indicating invasion (4,5). Remodelling is linked with increased fibrinoid on the residual myometrium which hinders placental separation (4,5); minimal myometrium and scarring may make separation easier although ultrasound is not always able to distinguish these cases. Low anterior scars involve the bladder and fibrosis, mimicking invasion on imaging, while peritoneal vessel remodelling can give the appearance of peritoneal invasion. Larger CSDs are associated with a higher risk of haemorrhage due to impaired myometrial contractility from markedly reduced residual myometrial thickness (RMT) and proximity to the remodelled and collateral vascular channels (Figure 2). 3.Differential Effect in Hysterectomy vs Myometrial Repair Balloon occlusion reduces the rate of blood flow to the surgical field allowing more time to complete the surgery regardless of whether the PASD is managed by TAH or MR. In hysterectomy, IIABO globally reduces pelvic organ perfusion facilitating vascular control during uterine devascularisation while in MR, although bleeding may persist from the isthmocele and adjacent muscle edges which are supplied by external iliac collaterals, the inflated balloons primarily reduce high-pressure uterine inflow to the uterine scar defect which is being repaired which could be tackled by more proximal occlusion including bilateral occlusion of the common iliac arteries or even the aorta. These subtle differences in mode of action may explain why efficacy is variable between procedures even though average blood loss is lower with balloon occlusion in both groups. 4. Imaging Insights Doppler ultrasound, computerised tomographic (CT) angiography, and MRI angiography are all helpful in delineating scar defect morphology and aberrant vascular channels. Therefore, preoperative imaging has the potential to aid in stratification of patients, predicting which are most likely to benefit from balloon occlusion and which may require adjunctive or alternative haemostatic strategies (40-45). Strengths and Limitations This study is limited by its small sample size, single-centre design, and heterogeneous mix of elective and emergency cases. One strength is operator variability which was limited to a single team managing all the cases ensuring consistency of care as far as possible. Larger, prospective studies integrating imaging-guided risk stratification and looking at anatomical differences in the scar linked to factors associated with previous surgeries are needed. Clinical Implications This review and case series have three major implications: Efficacy across procedures: It suggests that prophylactic IIABO appear to be beneficial in reducing blood loss during both TAH and conservative MR for PASD and we advocate its use in all cases, time permitting. Risk stratification: It highlights the importance of preoperative assessment of the CSD morphology and how detailed vascular mapping can help identify patients most likely to benefit from balloon occlusion although with the tools available this is still not easy. Individualised planning: In patients with extensive extrauterine anastomoses or anticipated persistent collateral supply, alternative or adjunctive measures (e.g. stepwise uterine devascularisation, consideration of more proximal occlusion techniques, selective vessel ligation, or hysterectomy) should be incorporated into the surgical plan. Conclusion Prophylactic IIABO reduces blood loss in many—but not all—cases of PASD. Its variable efficacy may be best explained by underlying scar defect anatomy and collateral circulation, which influence whether haemorrhage can be controlled by IIABO alone. Incorporating scar defect assessment and vascular imaging into preoperative planning may improve patient selection, optimise haemostatic efficacy and reduce the risk of catastrophic haemorrhage. Our data highlight that despite overall benefit, blood loss values are highly variable underscoring the need for individualised surgical planning. Abbreviations CS Caesarean section CSD Caesarean scar defect CT Computerised Tomography MRI Magnetic resonance imaging MR Myometrial repair PASD Placenta accreta spectrum disorders RMT Residual myometrial thickness AMT Adjacent myometrial thickness TAH Total abdominal Hysterectomy IIABO Internal iliac artery balloon occlusion IIA Internal iliac artery EIA External Iliac artery UA Uterine artery PPM Placenta previa major EBL Estimated blood loss Declarations Data Availability The datasets generated and analysed during the current study are not publicly available due to reasons for non-disclosure of data but are available from the corresponding author on reasonable request. Conflict of interest: The authors report no conflict of interest Financial support and sponsorship : Nil Precise : Internal Iliac Artery Balloon Occlusion in Placenta Accreta Spectrum: Outcomes and Efficacy Factors Funding The study is supported by Singapore Duke-NUS Benjamin Henry Sheares Professorship in Obstetrics & Gynecology and Integrated Platform for Research in Advancing Metabolic Health Outcomes of Women & Children (IPRAMHO) Study Group (NMRC CGAug16C008). The funding was used to cover the open access submission. Authors information and affiliation Wright Ann 1 MRCP(I),FRCOG, Toh Luke Han Wei 2 FRCR Sivanathan Chandramohan 2 FRCR Tan Bien Soo 2 FRCR, Lee Yien Sien 2 FRCR, Tay Kiang Hiong 2 FRCR Williams Ian 3 MD, FRCS Tan Kok Hian 4 FRCOG, Mohamed Siraj 5 FRCOG 1 Department of Maternal Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital 2. Department of Diagnostic and Interventional Imaging, KK Women’s and Children’s Hospital 3.Vascular Unit, University Hospital of Wales, Health PK Cardiff CF 14 4XN 4.Department of Maternal Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore OBGYN Academic Clinical Programme, DUKE-NUS Medical School, 8 College Road, Singapore, 169857, Singapore 5. Minimally Invasive Surgery Unit, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital Authors contribution MS and AMW performed background literature review, summarised, and synthesised the cases in the light of literature review. They were also involved in the surgical technique of myometrial repair and hysterectomy of PASD. IW advised on vascular and LT, SC, TBS, LYS and TKH on radiological aspects and supervised and contributed to writing the paper. KH reviewed the concept and statistical analysis and edited. All authors commented on the final paper and approved final version Corresponding Author : SHM Siraj, Minimally Invasive Surgery Unit, Division of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore 229899 Email: [email protected] Ethics declaration Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. It was approved and reviewed by Singhealth institutional review board (IRB Approval Reference number – 2020/2966/D) and all participants provided informed consent. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Einerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum. Obstet Gynecol. 2023 Jul 1;142(1):31-50. doi: 10.1097/AOG.0000000000005229. Epub 2023 Jun 7. PMID: 37290094; PMCID: PMC10491415. Einerson BD, Comstock J, Silver RM, Branch DW, Woodward PJ, Kennedy A. Placenta accreta spectrum disorder: uterine dehiscence. Not Placental Invasion Obstet Gynecol. 2020;135(5):1104–11. Mohamed Siraj, S.H., Tan, K.H. & Wright, A.M. Conservative surgical approach towards placenta accreta spectrum disorders for uterine preservation. BMC Pregnancy Childbirth23, 28 (2023). https://doi.org/10.1186/s12884-023-05370-6 Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol. 2022 Sep;227(3):384-391. doi: 10.1016/j.ajog.2022.02.038. Epub 2022 Mar 3. PMID: 35248577. Jauniaux E, Hussein AM, Elbarmelgy RM, Elbarmelgy RA, Burton GJ. Failure of placental detachment in accreta placentation is associated with excessive fibrinoid deposition at the utero-placental interface. Am J Obstet Gynecol. 2022 Feb;226(2):243.e1-243.e10. doi: 10.1016/j.ajog.2021.08.026. Epub 2021 Aug 28. PMID: 34461077. Takahashi H, Ohkuchi A, Usui R, Suzuki H, Baba Y, Matsubara S. Factors Contributing to Massive Blood Loss on Peripartum Hysterectomy for Abnormally Invasive Placenta: Who Bleeds More? Obstet Gynecol Int. 2016;2016:5349063. doi: 10.1155/2016/5349063. Epub 2016 Aug 17. PMID: 27630716; PMCID: PMC5005569. Piñas-Carrillo A, Chandraharan E. Conservative surgical approach: The Triple P procedure. Best Pract Res Clin Obstet Gynaecol. 2021 Apr;72:67-74. doi: 10.1016/j.bpobgyn.2020.07.009. Epub 2020 Jul 20. PMID: 32771462. Palacios-Jaraquemada JM, Fiorillo A, Hamer J, Martínez M, Bruno C. Placenta accreta spectrum: a hysterectomy can be prevented in almost 80% of cases using a resective-reconstructive technique. J Matern Fetal Neonatal Med. 2022 Jan;35(2):275-282.doi:10.1080/14767058.2020.1716715. Epub 2020 Jan 26. PMID: 31984808. Mappa I, Espuelas Malon S, D'Antonio F, Chandraharan E. Effectiveness of the Triple P Procedure and its modifications on reducing the blood loss and peripartum hysterectomy rates in women with Placenta Accreta Spectrum (PAS): a review of published literature. J Matern Fetal Neonatal Med. 2025 Dec;38(1):2452920. doi: 10.1080/14767058.2025.2452920. Epub 2025 Jan 15. PMID: 39814467. Hong L, Chen A, Chen J, Li X, Zhuang W, Shen Y, Dai Q, Zhang L. The clinical evaluation of IIA balloon occlusion in caesarean delivery for patients with PAS: a retrospective study. BMC Pregnancy Childbirth. 2022 Feb 5;22(1):103. doi: 10.1186/s12884-022-04434-3. PMID: 35123442; PMCID: PMC8817511. Senapati A, Browse NL. Gluteal necrosis and paraplegia following postoperative bilateral internal iliac artery occlusion. J Cardiovasc Surg (Torino). 1990 Mar-Apr;31(2):194-6. PMID: 2341478. Ono Y, Murayama Y, Era S, Matsunaga S, Nagai T, Osada H, Takai Y, Baba K, Takeda S, Seki H. Study of the utility and problems of common iliac artery balloon occlusion for placenta previa with accreta. J Obstet Gynaecol Res. 2018 Mar;44(3):456-462. doi: 10.1111/jog.13550. Epub 2018 Jan 3. PMID: 29297951; PMCID: PMC5873444. Kidney DD, Nguyen AM, Ahdoot D, Bickmore D, Deutsch LS, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. AJR Am J Roentgenol. 2001 Jun;176(6):1521-4. doi: 10.2214/ajr.176.6.1761521. PMID: 11373225. Huang J, Zhang X, Liu L, Duan S, Pei C, Zhao Y, Liu R, Wang W, Jian Y, Liu Y, Liu H, Wu X, Zhang W. Placenta Accreta Spectrum Outcomes Using Tourniquet and Forceps for Vascular Control. Front Med (Lausanne). 2021 Oct 18;8:557678. doi: 10.3389/fmed.2021.557678. PMID: 34733857; PMCID: PMC8558214. Tan CH, Tay KH, Sheah K, Kwek K, Wong K, Tan HK, Tan BS. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta. AJR Am J Roentgenol. 2007 Nov;189(5):1158-63. doi: 10.2214/AJR.07.2417. PMID: 17954654. Chen M, Liu X, You Y, Wang X, Li T, Luo H, Qu H, Xu L. Internal Iliac Artery Balloon Occlusion for Placenta Previa and Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol. 2020 May;135(5):1112-1119. doi: 10.1097/AOG.0000000000003792. PMID: 32282608. Rosner-Tenerowicz A, Fuchs T, Pomorski M, Sliwa J, Zimmer-Stelmach A, Zimmer M. The clinical evaluation of internal iliac arteries balloon occlusion for placenta accreta spectrum. Ginekol Pol. 2021;92(3):210-215. doi: 10.5603/GP.a2020.0180. Epub 2021 Jan 15. PMID: 33448010. Peng Y, Jiang L, Peng C, Wu D, Chen L. The application of prophylactic balloon occlusion of the internal iliac artery for the treatment of placenta accreta spectrum with placenta previa: a retrospective case-control study. BMC Pregnancy Childbirth. 2020 Jun 8;20(1):349. doi: 10.1186/s12884-020-03041-4. PMID: 32513127; PMCID: PMC7282070. Liang D, Zhao H, Liu D, Lin Y. Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis. Eur J Radiol. 2021 Jun;139:109711. doi: 10.1016/j.ejrad.2021.109711. Epub 2021 Apr 20. PMID: 33910145. Clausen C, Stensballe J, Albrechtsen CK, Hansen MA, Lönn L, Langhoff-Roos J. Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta. Acta Obstet Gynecol Scand. 2013 Apr;92(4):386-91. doi: 10.1111/j.1600-0412.2012.01451.x. Epub 2012 Jun 27. PMID: 22574880 Nankali A, Salari N, Kazeminia M, Mohammadi M, Rasoulinya S, Hosseinian-Far M. The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis. Reprod Biol Endocrinol. 2021 Mar 4;19(1):40. doi: 10.1186/s12958-021-00722-3. PMID: 33663536; PMCID: PMC7931359. Picel AC, Wolford B, Cochran RL, Ramos GA, Roberts AC. Prophylactic Internal Iliac Artery Occlusion Balloon Placement to Reduce Operative Blood Loss in Patients with Invasive Placenta. J Vasc Interv Radiol. 2018 Feb;29(2):219-224. doi: 10.1016/j.jvir.2017.08.015. Epub 2017 Nov 9. PMID: 29128157. 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 Oct;167(1):109-127. doi: 10.1002/ijgo.15704. 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 May;32(5):3297-3308. doi: 10.1007/s00330-021-08423-6. Epub 2021 Nov 30. PMID: 34846565. Chen D, Xu J, Tian Y, Ye P, Zhao F, Liu X, Wang X, Peng B. Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta. BMC Pregnancy Childbirth. 2021 Sep 21;21(1):640. doi: 10.1186/s12884-021-04103-x. PMID: 34548060; PMCID: PMC8456564. Liapis K, Tasis N, Tsouknidas I, Tsakotos G, Skandalakis P, Vlasis K, Filippou D. Anatomic variations of the Uterine Artery. Review of the literature and their clinical significance. Turk J Obstet Gynecol. 2020 Mar;17(1):58-62. doi: 10.4274/tjod.galenos.2020.33427. Epub 2020 Apr 6. PMID: 32341832; PMCID: PMC7171538. Pijnenborg R, Vercruysse L, Hanssens M. The uterine spiral arteries in human pregnancy: facts and controversies. Placenta. 2006 Sep-Oct;27(9-10):939-58. doi: 10.1016/j.placenta.2005.12.006. Epub 2006 Feb 20. PMID: 16490251. Espinoza J, Romero R, Mee Kim Y, Kusanovic JP, Hassan S, Erez O, Gotsch F, Than NG, Papp Z, Jai Kim C. Normal and abnormal transformation of the spiral arteries during pregnancy. J Perinat Med. 2006;34(6):447-58. doi: 10.1515/JPM.2006.089. PMID: 17140293; PMCID: PMC7062302. Palmer SK, Zamudio S, Coffin C, Parker S, Stamm E, Moore LG. Quantitative estimation of human uterine artery blood flow and pelvic blood flow redistribution in pregnancy. Obstet Gynecol. 1992 Dec;80(6):1000-6. PMID: 1448242. Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, Basanta N, Burgos-Luna JM, Rodriguez F, Ordoñez C, Sarria-Ortiz D, Muñoz-Córdoba L, Quintero JC, Galindo-Velasco V, Messa-Bryon A. Ligation or Occlusion of the Internal Iliac Arteries for the Treatment of Placenta Accreta Spectrum: Why Is This Technique Still Performed? Matern Fetal Med. 2023 Jul;5(3):131-136. doi: 10.1097/FM9.0000000000000195. Epub 2023 Jul 21. PMID: 40416858; PMCID: PMC12096400. Lukies M, Han Wei LT, Chandramohan S. Collateral Round Ligament Arterial Supply of Placenta Accreta Spectrum and Considerations for Prophylactic Balloon Occlusion Catheter Placement. J Vasc Interv Radiol. 2024 Jun;35(6):895-899. doi: 10.1016/j.jvir.2024.03.008. Epub 2024 Mar 14. PMID: 38492660. Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, Brölmann HA, Mol BW, Huirne JA. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod 2015;30:2695-702. Wang J, Pang Q, Wei W, Cheng L, Huang F, Cao Y, et al. Definition of large niche after Cesarean section based on prediction of postmenstrual spotting: Chinese cohort study in non-pregnant women. Ultrasound Obstet Gynecol 2022;59:450-6. Kaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche”. Am J Obstet Gynecol 2017;216:510.e1- 510.e6. Zosmer N, Fuller J, Shaikh H, Johns J, Ross JA. Natural history of early first-trimester pregnancies implanted in Cesarean scars. Ultrasound Obstet Gynecol 2015;46:367-75. Noël L, Thilaganathan B. Caesarean scar pregnancy: Diagnosis, natural history and treatment. Curr Opin Obstet Gynecol 2022;34:279-86. Pomorski M, Fuchs T, Budny-Winska J, Zimmer A, Zimmer M. Natural history of caesarean scar pregnancy. Ginekol Pol 2019;90:351-2 Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern Fetal Neonatal Med. 2023 Dec;36(1):2183741. doi: 10.1080/14767058.2023.2183741. PMID: 37193605. Palacios-Jaraquemada JM, Nieto-Calvache Á, Aryananda RA, Basanta N. Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location. J Matern Fetal Neonatal Med. 2023 Dec;36(1):2183764. doi: 10.1080/14767058.2023.2183764. PMID: 36966802. Expert Panel on Women’s Imaging; Poder L, Weinstein S, Maturen KE, Feldstein VA, Mackenzie DC, Oliver ER, Shipp TD, Strachowski LM, Sussman BL, Wang EY, Weber TM, Whitcomb BP, Glanc P. ACR Appropriateness Criteria® Placenta Accreta Spectrum Disorder. J Am Coll Radiol. 2020 May;17(5S):S207-S214. doi: 10.1016/j.jacr.2020.01.031. PMID: 32370965. Patel-Lippmann KK, Planz VB, Phillips CH, Ohlendorf JM, Zuckerwise LC, Moshiri M. Placenta Accreta Spectrum Disorders: Update and Pictorial Review of the SAR-ESUR Joint Consensus Statement for MRI. Radiographics. 2023 May;43(5):e220090. doi: 10.1148/rg.220090. PMID: 37079459. Jha P, Pōder L, Bourgioti C, Bharwani N, Lewis S, Kamath A, Nougaret S, Soyer P, Weston M, Castillo RP, Kido A, Forstner R, Masselli G. Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) joint consensus statement for MR imaging of placenta accreta spectrum disorders. Eur Radiol. 2020 May;30(5):2604-2615. doi: 10.1007/s00330-019-06617-7. Epub 2020 Feb 10. PMID: 32040730. Familiari A, Liberati M, Lim P, Pagani G, Cali G, Buca D, Manzoli L, Flacco ME, Scambia G, D'antonio F. Diagnostic accuracy of magnetic resonance imaging in detecting the severity of abnormal invasive placenta: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2018 May;97(5):507-520. doi: 10.1111/aogs.13258. Epub 2017 Dec 13. PMID: 29136274. Kapoor H, Hanaoka M, Dawkins A, Khurana A. Review of MRI imaging for placenta accreta spectrum: Pathophysiologic insights, imaging signs, and recent developments. Placenta. 2021 Jan 15;104:31-39. doi: 10.1016/j.placenta.2020.11.004. Epub 2020 Nov 13. PMID: 33238233. Patel-Lippmann KK, Planz VB, Phillips CH, Ohlendorf JM, Zuckerwise LC, Moshiri M. Placenta Accreta Spectrum Disorders: Update and Pictorial Review of the SAR-ESUR Joint Consensus Statement for MRI. Radiographics. 2023 May;43(5):e220090. doi: 10.1148/rg.220090. PMID: 37079459. Tables Table 1 Patients with Hysterectomy for Placenta accrete spectrum disorders (PASD) Status Non occlusion of IIA Occlusion of IIA Case 1 2 3 4 5 6 7 8 9 10 Age 33 38 30 32 34 35 39 38 33 39 BMI 24.3 35.4 31 30.7 29.2 20.6 26 28.5 34.9 24.9 GA 34 6 24 6 34 6 33 4 34 1 35 5 34 35 5 36 2 36 Previous number of CS 2 1 0 (previous myomectomy) 1 2 3 3 4 3 2 Pre op US Accreta Placenta low lying Placenta upper Increta Accreta Accreta Increta Accreta Not done Accrete Pre op MRI Accreta Not done Not done Percreta Not done Not done Not done Increta Accreta Not done Histology Accreta Increta Increta Percreta Not done Not done Percreta Increta Accreta Increta EBL (ml) 900 5000 2500 6000 3000 1200 3000 1200 1200 1700 Transfused PCV 1 12 2 5 4 1 16 1 2 2 Surgical time 101 103 144 151 109 135 248 255 118 163 Visceral injuries Nil Nil Nil Nil nil bladder Nil nil nil nil ICU admission No Yes Yes Yes yes yes Yes yes yes Yes IIA – internal iliac artery occlusion, CS -caesarean section ,US – ultrasound ,MRI – magnetic resonance image, ICU – intensive care unit, EBL – estimated blood loss; PCV - packed cell volume Table 2. Patients with conservative surgery for PASD – Myometrial repair Status Non occlusion of IIA Occlusion of IIA Case 1 2 3 4 5 6 7 8 9 10 Age (years) 33 30 31 33 30 40 32 34 39 36 BMI (kg/m 2 ) 31 35 19.3 25.9 24.6 24 25 24.5 21 29 GA (week/day) 34 6 35 6 31 2 34 4 36 1 36 3 35 4 36 2 35 2 27 2 Previous no of CS 2 1 2 4 2 1 1 2 1 2 Pre op US Not available Low lying placenta Not available Increta Accreta Accreta Accreta Low lying placenta but possible accreta Accreta accreta Pre op MRI Increta Not done Increta Not done Accreta Not done Not done Not done percreta EBL(ml) 5000 1600 1000 4000 1500 800 2500 1500 2000 1000 Transfused PCV 6 3 0 9 2 0 4 2 3 3 Visceral injuries nil Nil nil nil Nil nil nil nil Nil nil Surgical time (min) 119 100 75 148 140 98 143 139 144 81 ICU admission yes No no yes No yes yes yes yes Yes IIA – internal iliac artery occlusion, CS -caesarean section ,US – ultrasound ,MRI – magnetic resonance image, ICU – intensive care unit, EBL – estimated blood loss; PCV - packed cell volume Table 3. Estimated blood loss (EBL) in patients with PASD stratified by procedure type and balloon occlusion use. Group Procedure Balloon Use N EBL Values (mL) Mean ± SD (mL) A TAH Yes 5 1200, 3000, 1200, 1200, 1700 1660 ± 780 B TAH No 5 900, 5000, 2500, 6000, 3000 3480 ± 2032 C MR Yes 6 1500, 800, 2500, 1500, 2000, 1000 1550 ± 629 D MR No 4 5000, 1600, 1000, 4000 2900 ± 1908 Across all procedures, balloon use was associated with significantly reduced blood loss compared with no balloons (t(12.6) = –2.47, p = 0.034). The effect size was large (Cohen’s d = –1.15). In contrast, there was no significant difference in EBL between TAH and MR overall (t(16.9) = 0.68, p = 0.504; d = 0.31). A factorial ANOVA confirmed a significant main effect of balloon use (F(1,16) = 6.22, p = 0.024, η² = 0.28). There was no significant main effect of procedure type (F(1,16) = 0.26, p = 0.620, η² = 0.01) and no interaction between balloon use and procedure type (F(1,16) = 0.14, p = 0.717, η² = 0.006). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 31 Dec, 2025 Reviews received at journal 25 Dec, 2025 Reviews received at journal 21 Dec, 2025 Reviewers agreed at journal 16 Dec, 2025 Reviewers agreed at journal 10 Dec, 2025 Reviewers invited by journal 08 Dec, 2025 Editor assigned by journal 18 Nov, 2025 Submission checks completed at journal 18 Nov, 2025 First submitted to journal 15 Nov, 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8121877","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":557274600,"identity":"8b1ceba3-4bc7-4096-9ba3-b29d6ef37151","order_by":0,"name":"Wright Ann","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wright","middleName":"","lastName":"Ann","suffix":""},{"id":557274601,"identity":"167d5fa8-173b-4789-acc4-ad910615ce2f","order_by":1,"name":"Toh Luke Han Wei","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Toh","middleName":"Luke Han","lastName":"Wei","suffix":""},{"id":557274602,"identity":"7fcb4d87-fbc8-4eb3-89b7-fd0b0efaa4e6","order_by":2,"name":"Sivanathan Chandramohan","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sivanathan","middleName":"","lastName":"Chandramohan","suffix":""},{"id":557274603,"identity":"af947b40-1d83-484e-8504-b436953900fd","order_by":3,"name":"Tan Bien Soo","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tan","middleName":"Bien","lastName":"Soo","suffix":""},{"id":557274604,"identity":"fc1ea7b3-509b-486a-9b95-475434c86a9d","order_by":4,"name":"Lee Yien Sien","email":"","orcid":"","institution":"KK Women's and Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lee","middleName":"Yien","lastName":"Sien","suffix":""},{"id":557274605,"identity":"91e71b7e-f90d-45a7-ad29-717df28433aa","order_by":5,"name":"Tay Kiang Hiong","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tay","middleName":"Kiang","lastName":"Hiong","suffix":""},{"id":557274606,"identity":"794c40e5-5bcf-44eb-8b78-7c62f02a30e3","order_by":6,"name":"Williams Ian","email":"","orcid":"","institution":"University Hospital of Wales","correspondingAuthor":false,"prefix":"","firstName":"Williams","middleName":"","lastName":"Ian","suffix":""},{"id":557274607,"identity":"74627697-83d4-4be7-b1f8-5951d996afae","order_by":7,"name":"Tan Kok Hian","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tan","middleName":"Kok","lastName":"Hian","suffix":""},{"id":557274608,"identity":"097f1155-4ad8-49e5-93ae-cb4915d8b1b9","order_by":8,"name":"Mohamed Siraj","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYDCCAwxsQFICiA8fYGBsIE3LsQSStIAAjwFxWvhuH3/26MYfi3z+xjPfJH7usJFjYD98dAM+LZLncsyNc9skLGccOLtNsvdMmjEDT1raDXxaDM7wsEnnNkgYMAC1SPC2HU5skOAxI6CF/Zl0zh8JA/kDZ55J/iVOC4OZdA6bhIHBgTNs0kTZInmGx0wa6BcDwwPHjK1l29KM2Qj5hQ/isDoDuRuHH95822Yjx89++BheLQggcYAFFKHwaCIC8DcwfyBe9SgYBaNgFIwkAACAZE0OIgj3AQAAAABJRU5ErkJggg==","orcid":"","institution":"KK Women's and Children's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Siraj","suffix":""}],"badges":[],"createdAt":"2025-11-15 12:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8121877/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8121877/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98423754,"identity":"fdfec750-61b8-4ba4-b75d-1b4a1df93bea","added_by":"auto","created_at":"2025-12-17 16:32:34","extension":"jpeg","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":559130,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/04474cb21937fe78b7dabd28.jpeg"},{"id":97992576,"identity":"487659ea-516d-4bb2-b78a-4c956d2462b6","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":561971,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/f25b1b80a548f9ccb23d5509.jpg"},{"id":97992584,"identity":"c06bd1f8-950d-4a5d-893a-7c862059018d","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2480570,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/fdade15cf5c848c1caf8f7b3.docx"},{"id":98424102,"identity":"8c89dd0d-6f80-4d44-a0fa-f46740f39c7e","added_by":"auto","created_at":"2025-12-17 16:32:58","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23337,"visible":true,"origin":"","legend":"","description":"","filename":"Table2myometrialrepair.docx","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/f28636b24ea1e9063b9830e6.docx"},{"id":98423473,"identity":"8f51f53f-53b1-4c66-ab14-bf5fe5a8c01e","added_by":"auto","created_at":"2025-12-17 16:32:16","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15449,"visible":true,"origin":"","legend":"","description":"","filename":"Table3proceduretypeEBL.docx","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/45f70aa5876771a096c794cf.docx"},{"id":98425787,"identity":"e325f91e-3a52-4524-88c8-e162fbafd671","added_by":"auto","created_at":"2025-12-17 16:35:14","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":24690,"visible":true,"origin":"","legend":"","description":"","filename":"Table1Hysterectomy.docx","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/33fadb6f57a87209c0a3ce24.docx"},{"id":97992573,"identity":"2fcf25a6-3a10-4f45-9447-c0be546b15b9","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"json","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10156,"visible":true,"origin":"","legend":"","description":"","filename":"b9d7cddd6f68465fb41466a64d082ff5.json","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/6c1d86496236b10994981948.json"},{"id":97992592,"identity":"652ce321-8d74-4f75-8e8a-26ebf4d0db40","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":176724,"visible":true,"origin":"","legend":"","description":"","filename":"b9d7cddd6f68465fb41466a64d082ff51enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/220e6c1930febbd7853e49e5.xml"},{"id":98424712,"identity":"eb2524a0-66e4-45c1-bae8-a9b4d6fec572","added_by":"auto","created_at":"2025-12-17 16:33:43","extension":"jpeg","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":559130,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/0e28d68c0e99afbe1d128522.jpeg"},{"id":97992581,"identity":"d912758e-be65-40ae-be31-84f7b59bcfc2","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"jpg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":561971,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/2ff47e3bd9225457fb7c1e1c.jpg"},{"id":98424699,"identity":"331dbc05-98b8-4271-af6b-8667e7585ccf","added_by":"auto","created_at":"2025-12-17 16:33:42","extension":"jpeg","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":163066,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/07948b02164d20edf0308fc3.jpeg"},{"id":98423643,"identity":"4fd5ff1e-fba4-4007-b6ee-0ce3698d0f02","added_by":"auto","created_at":"2025-12-17 16:32:28","extension":"jpeg","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82326,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage10.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/ca08baa4bed29b7863f7501b.jpeg"},{"id":97992587,"identity":"92d34ddd-a007-4dab-94fa-79ed36e57169","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"jpeg","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":138129,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage11.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/a6ab3af8fb2dc7bc9eb7e76f.jpeg"},{"id":97992589,"identity":"c4c4d49e-4c6a-45d2-a669-b0d210d15b2c","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"jpeg","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/62c75f6b9152c10da4e9ba52.jpeg"},{"id":98425019,"identity":"110bf2e7-a98f-460a-8f15-667f1ba04d1a","added_by":"auto","created_at":"2025-12-17 16:34:11","extension":"jpeg","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/7c031e432718c4a0f74aff9e.jpeg"},{"id":98424434,"identity":"7ed1164e-21ca-4100-9d3d-c4625acabac9","added_by":"auto","created_at":"2025-12-17 16:33:20","extension":"jpeg","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":162156,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/30a33ea26788451a2c6e9b56.jpeg"},{"id":97992597,"identity":"1808a8c7-02de-4893-9448-38b1d8435162","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"jpeg","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":139827,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/7e6409d5568dc65e3a9a0b00.jpeg"},{"id":98423839,"identity":"994e8663-ff3a-4b40-8da2-5bc4a5551d4f","added_by":"auto","created_at":"2025-12-17 16:32:41","extension":"jpeg","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1074,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/e0b4a308b745400847929c84.jpeg"},{"id":98425601,"identity":"c2e815e2-6da6-41d9-92af-48f80092c0f0","added_by":"auto","created_at":"2025-12-17 16:34:57","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2185091,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/069ae15d1f73ffefd9294f32.png"},{"id":97992608,"identity":"f9d3f42b-1a26-476a-b8f5-6769dac45527","added_by":"auto","created_at":"2025-12-11 14:45:31","extension":"jpeg","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":220104,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/c3e7744dacac2d91fb998cbe.jpeg"},{"id":97992598,"identity":"50692904-e87a-43bc-8e1d-0e90a3ed7e8b","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"jpeg","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92158,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage9.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/f3d87f9b41da5cba2e1414fe.jpeg"},{"id":98425784,"identity":"3ebc54bb-2af8-4ba0-9725-659bac4dbf0e","added_by":"auto","created_at":"2025-12-17 16:35:14","extension":"png","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":246185,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/488fcf12881ce8a3c3c247c4.png"},{"id":97992611,"identity":"2eddbeb3-6c00-4ba2-95ba-2af07983a0f5","added_by":"auto","created_at":"2025-12-11 14:45:31","extension":"png","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":246410,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/fcadd8726d16b76f44c7ea9a.png"},{"id":98424341,"identity":"1362d1ed-f27a-4373-93a7-08e082b3d7ee","added_by":"auto","created_at":"2025-12-17 16:33:14","extension":"png","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":30158,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/9d7a111d8690bfa200edc0d8.png"},{"id":98425102,"identity":"2d81462c-8bbd-4a92-b49b-649a61e640ed","added_by":"auto","created_at":"2025-12-17 16:34:19","extension":"png","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28508,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage10.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/716f8861682f5e425f4a2b8f.png"},{"id":98424577,"identity":"b7cf937f-2417-4bbc-8e3b-f69921705b59","added_by":"auto","created_at":"2025-12-17 16:33:31","extension":"png","order_by":26,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67568,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage11.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/682ca49ead6e38a97d9eafa5.png"},{"id":97992594,"identity":"fb13e161-beee-4d22-8bae-5d0bbcc44e8c","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"png","order_by":27,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/8a105c011bb4f19b5e9ce99f.png"},{"id":97992601,"identity":"7649aaa8-7274-41c0-a0c0-46870a1b6e1d","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"png","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/953fa2cec1ecf7701a1956dc.png"},{"id":98424093,"identity":"9d6d6a77-07a7-472c-bba2-3eb87da5c923","added_by":"auto","created_at":"2025-12-17 16:32:55","extension":"png","order_by":29,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":29940,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/a6ef6a6148fbf3600b66f8d1.png"},{"id":97992606,"identity":"0ec44cbf-d56f-4cd4-92ad-8a96fd771c2e","added_by":"auto","created_at":"2025-12-11 14:45:31","extension":"png","order_by":30,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":27243,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/4a8e36705ef3b390a85ada6c.png"},{"id":97992604,"identity":"e13da9fb-23bc-471a-8394-e1f9317b1ebe","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"png","order_by":31,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":935,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/65a3470199790447c819b56b.png"},{"id":97992602,"identity":"8e6f2a2a-9a3f-441a-9dc2-16ab76076474","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"png","order_by":32,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":241366,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/55fd000a719ff4798b518625.png"},{"id":97992603,"identity":"137fdfd5-fe5e-4d6c-9d9a-8f54f4782b00","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"png","order_by":33,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":87665,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/72f14e87360fd32e809a26e9.png"},{"id":98423779,"identity":"7955746f-2a61-4ae3-86dc-64a3b910eb77","added_by":"auto","created_at":"2025-12-17 16:32:35","extension":"png","order_by":34,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28018,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/c8b26d70c77bebb065bd9d56.png"},{"id":98424686,"identity":"d40674ed-b82e-4ec0-bfa4-687268b003cb","added_by":"auto","created_at":"2025-12-17 16:33:41","extension":"xml","order_by":35,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":176328,"visible":true,"origin":"","legend":"","description":"","filename":"b9d7cddd6f68465fb41466a64d082ff51structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/38a4b3ebec9268b5e594ec55.xml"},{"id":97992609,"identity":"e89bbeef-88c6-4add-b3f5-010281b36e2f","added_by":"auto","created_at":"2025-12-11 14:45:31","extension":"html","order_by":36,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":187896,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/ed2567fa8a9bdaa5f3402391.html"},{"id":98424407,"identity":"a9e63c74-01a8-4708-bd61-9271628a8870","added_by":"auto","created_at":"2025-12-17 16:33:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":267162,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic illustration showing balloon occlusion of the internal iliac arteries and the extensive collateral circulation of the uterus. Despite occlusion, uterine perfusion may persist through collateral vessels, including contributions from the ovarian arteries, contralateral and accessory uterine arteries, and branches of the external iliac arteries.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCIA – common iliac artery, EIA – external iliac artery, IIA – internal iliac artery, AD IIA – Anterior division of internal iliac artery, PD IIA – posterior division of internal iliac artery, UA – uterine artery, UA* - Variation of the origin of the uterine artery from the external iliac artery, OA – Ovarian artery, ** - Occlusion of the balloon in the internal iliac artery\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/b56d48a11b8329e413e4c839.png"},{"id":97992572,"identity":"127117ba-31f4-4d36-ae2a-966c85b9e0f6","added_by":"auto","created_at":"2025-12-11 14:45:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":277631,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSeverity of the caesarean scar defect. Larger caesarean scar defects are associated with a higher risk of haemorrhage due to impaired myometrial contractility from markedly reduced residual myometrial thickness (RMT) and proximity to remodelled and collateral vascular channels.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea – defect involves loss of endometrium. b, c, d – varying degrees of myometrium defect.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/a6c32578556d28cbd783eb6d.png"},{"id":98443754,"identity":"19137a4f-0da2-49c1-a9fa-fa70d451ee73","added_by":"auto","created_at":"2025-12-17 17:14:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1820889,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8121877/v1/1017e012-6e52-47fd-bcb0-0f18063f9379.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Internal Iliac Artery Balloon Occlusion for Placenta Accreta Spectrum Disorder: Outcomes and Factors influencing Efficacy","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePlacenta accreta spectrum disorder (PASD), previously attributed to abnormal placental adherence or invasion into the myometrium, is increasingly being recognized as a Caesarean scar disorder in which the placenta is intimately related to a muscular dehiscence at the site of a previous uterine scar associated with fibrinoid deposition and neo-angiogenesis, with the appearance of large immature vessels on the residual myometrium over the isthmocele. (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe primary risk associated with delivery in cases of PASD is severe, potentially life-threatening haemorrhage. The principal surgical challenge lies in achieving rapid source control over the blood loss from an extensive and variable neovascular network within the myometrial defect, often further complicated by fibrosis resulting from prior surgical interventions.\u003c/p\u003e\u003cp\u003eTraditionally, total abdominal hysterectomy (TAH) has been regarded as the first-line treatment for PASD, but this procedure carries considerable surgical morbidity related to blood loss and visceral injury often exacerbated by adhesions from previous surgeries. It also requires significant surgical expertise. Nonetheless, even with vascular occlusion, whether by surgical ligation or radiologically guided, TAH does not fully prevent massive bleeding; instances of up to four liters of blood loss during caesarean hysterectomy have been reported despite interventional guided bilateral common iliac occlusion (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). More recently, conservative techniques such as myometrial repair (MR) after placental delivery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) have been developed in efforts to preserve fertility. However, these approaches also carry a high risk of significant peri-operative blood loss and demand advanced surgical skills.\u003c/p\u003e\u003cp\u003eApproaches to minimizing blood loss in PASD have been adapted from management strategies for major trauma patients, yielding variable degrees of success but carrying inherent risks. These methods include both permanent and temporary occlusion of the main arterial supplies to the uterus. While targeted endovascular occlusion does not eliminate blood loss due to collateral circulation altogether, it does significantly reduce the rate of hemorrhage. The larger the vessel occluded, the greater the haemostatic effect, with aortic balloon occlusion substantially decreasing the necessity for hysterectomy and embolisation in placenta praevia major (PPM)/PASD cases (\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Endovascular balloon occlusion of pelvic vessels, including the internal iliac arteries limits intraoperative blood loss by reducing pelvic arterial inflow thereby facilitating surgical haemostasis. Reported outcomes of the intervention vary between dramatic reductions in estimated blood loss (EBL) to minimal benefit raising concerns about the variable efficacy of balloon occlusion.\u003c/p\u003e\u003cp\u003eAt our institution, the established practice is internal iliac artery balloon occlusion (IIABO) over larger vessel occlusion for PASD. We present a case series of 20 consecutive patients with PASD and compare the blood loss during TAH with that during MR, both with and without IIABO. We review the current evidence and highlight how vascular anatomy and scar defect morphology influence the variable efficacy of balloon occlusion.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe authors previously described the technique of MR as a possible conservative approach for PASD and compared various operating parameters with TAH (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Here, we have focused on the difference in EBL in women undergoing TAH and those undergoing MR with and without IIABO.\u003c/p\u003e\u003cp\u003eThis was a heterogeneous group of elective and emergency cases. The elective cases had protocolised care coordinated by the \u0026lsquo;accreta team\u0026rsquo;. After the diagnosis of PASD was made women were seen in the obstetric high risk antenatal clinic to formulate a plan of care for the remainder of the pregnancy. About half of the patients underwent magnetic resonance imaging (MRI) at 28\u0026ndash;32 weeks to delineate the retracted muscle edges, relationship of the placenta to the internal os and to identify any aberrations in the uterine blood supply.\u003c/p\u003e\u003cp\u003eSurgical options, with inherent risks, were discussed and the patient was listed for her preferred choice of surgery at 34 weeks, regardless of the suspected grade of placenta accreta, usually under general anaesthesia, which was immediately preceded by percutaneous insertion of occlusion balloon catheters in the angiography suite, the technical details about which have been described previously (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The balloons were inflated after delivery of the baby, prior to removal of the placenta and removed at the end of surgery unless there were concerns of ongoing bleeding. Blood loss was estimated jointly by the surgeons and anaesthetists from the amount collected from the surgical field by suction and cell salvage, number of swabs used and on occasion point of care haemoglobin measurement compared to preoperative level. Four units of packed cells were available on standby for the surgery and cell salvage was routinely used. Even for emergency cases the protocol was followed as far as possible, time permitting.\u003c/p\u003e\u003cp\u003e This retrospective study of consecutive cases performed between December 2019 and September 2021 and was conducted in accordance with the Declaration of Helsinki. It was approved and reviewed by Singhealth institutional review board (IRB Approval Reference number \u0026ndash; 2020/2966/D) and all participants provided informed consent.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eEBL was compared according to procedure type [TAH versus conservative MR] and IIABO (yes versus no). Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD).\u003c/p\u003e\u003cp\u003ePrimary analysis used a two-way ANOVA (factors procedure type x balloon use) to assess main and interaction effects. Where appropriate, Welch\u0026rsquo;s independent-samples t-tests, which do not assume equal variances, were applied for pair-wise comparisons I) balloon vs no balloon (collapsed across procedure type) and ii) TAH vs MR (collapsed across balloon use). Effect sizes were calculated as Cohen\u0026rsquo;s d for pairwise tests (0.2\u0026thinsp;=\u0026thinsp;small, 0.5\u0026thinsp;=\u0026thinsp;medium, 0.8\u0026thinsp;=\u0026thinsp;large) and η\u0026sup2;for ANOVA effects (0.01\u0026thinsp;=\u0026thinsp;small, 0.06\u0026thinsp;=\u0026thinsp;medium, 0.14\u0026thinsp;=\u0026thinsp;large).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty consecutive patients with PASD were included, 10 of whom had a Caesarean section (CS) with peripartum TAH and 10, a Caesarean section and MR using the previously described technique. \u0026nbsp;There was a fairly even mix of grades of PASD across the 2 groups as shown by preceding MRI or subsequent histopathology (h/p) or both. Histopathological results were available for 8 cases who had TAH with 2 showing accreta, 4 increta and 2 percreta. \u0026nbsp;Among these, 4 had a preceding MRI with results correlating with histopathology(h/p) apart from 1 which suggested accreta when h/p suggested increta. Among the MR group, 5 had a pre-operative MRI, 2 suggesting accreta, 2 increta and 1 percreta. \u0026nbsp;Five patients in each group underwent elective surgery between 34 and 36 weeks and the remainder required emergency delivery for an intervening complication. None of the patients had a TAH for failed conservative management. \u0026nbsp;All patients were offered pre-operative endovascular placement, time permitting. \u0026nbsp;The groups were similar with respect to age and gestational age at delivery (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 20 women were stratified into 4 groups by procedure type and prophylactic balloon use: TAH with IIABO (n=5), TAH without IIABO (n=5), MR with IIABO (n=6), and MR without IIABO (n=4). Tables 1 \u0026amp; 2 show the demographics for each group and blood losses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGroup Comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean EBL was lower in patients managed with IIABO. \u0026nbsp; For TAH, mean EBL was 1660 +/-780ml with IIABO versus 3480 +/-2032ml without. \u0026nbsp;For MR mean EBL was 1550 +/-629ml with IIABO compared to 2900 +/-1908ml without balloons.\u003c/p\u003e\n\u003cp\u003eEBL values were widely dispersed—with IIABO: median 1500 mL (IQR 1200–1850), range 800–3000; without IIABO: median 3000 mL (IQR 1600–5000), range 900–6000.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePooled Comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen analysed by IIABO use, irrespective of procedure, mean EBL was significantly reduced with IIABO (1660 +/-676ml) compared to without IIABO (3260+/-2021ml). \u0026nbsp;Welch’s t (12.6) = -2.4, p = 0.034. Cohen’s d = -1.15 (large effect). By contrast, there was no significant difference between TAH (2570 +/-1780ml) and MR (2113 +/-1446ml): Welch’s t (16.9) =0.68, p=0.504. \u0026nbsp;Cohen’s d =0.31 (small effect).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eANOVA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo-way ANOVA confirmed a significant effect of IIABO use on EBL (F (1.16) =6.22, p =0.024. η² = 0.28 (large effect) but no significant effect of procedure type (F (1.16) = 0.26, P =0.620, η²= 0.01) and no interaction (F (1.16) =0.14, p=0.717, n\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e0.006) (Table 3).\u003c/p\u003e"},{"header":"Discussion \u0026 Review","content":"\u003cp\u003eOur series shows that IIABO significantly reduced blood loss in PASD. \u0026nbsp;The effect was consistent across both TAH and MR, but procedure type itself did not independently influence EBL. \u0026nbsp;However, the ranges in blood loss were large and the benefit of IIABO use was not uniform across all patients.\u003c/p\u003e\n\u003cp\u003ePublished series and meta-analyses, have reported variable outcomes with vascular occlusive methods for both PPM and PASD since the 2000’s, with reductions in EBL ranging from \u0026gt;50% to negligible (16-20). \u0026nbsp;Nankali et al. in a systematic review and meta-analysis of 29 studies comparing 1140 controls with 1225 IIABO cases, found a positive intervention effect on EBL and reduced hysterectomy rate with increasing gestational age (21).\u0026nbsp;\u0026nbsp;Picel et al. described it as a safe, minimally invasive technique to limit blood loss and transfusion requirements in PASD patients undergoing CS (22). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther studies have shown different results (23,24,25) and there have been no previous studies specifically looking at the effect of IIABO in cases managed by TAH compared with myometrial repair. Our series shows that IIABO significantly reduced blood loss in PASD in both approaches (TAH and MR).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEBL values were widely dispersed in our study — with or without IIABO. While part of the heterogeneity in effect of IIABO relates to surgical expertise and protocols, a more fundamental explanation lies in the vascular and anatomical variability of the caesarean scar defect which has to be addressed for the treatment to be successful.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMechanisms of Variable Efficacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe suggest that the variable efficacy may be explained by the following mechanisms:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.Collateral and Extrauterine Vascular Supply\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe uterus mainly receives blood from paired uterine arteries, typically branching from the internal iliac artery, though variations in origin do exist. \u0026nbsp;The uterine artery passes under the broad ligament, splits at the isthmus, and crosses the ureter, with ascending branches supplying the myometrium and descending branches serving the cervix and vagina, connecting with other pelvic arteries. \u0026nbsp;Spiral arteries reach the endometrium, and the ovarian artery arises from the abdominal aorta to supply the ovary. \u0026nbsp;During pregnancy, uterine blood flow increases significantly, from 50 millilitres per minute to more than 1 litre per minute by term. \u0026nbsp;Approximately 90% of this flow reaches inter-villous spaces within the placenta for fetal exchange. \u0026nbsp;Around 200 spiral arteries from the uterine artery support the developing placenta. \u0026nbsp;In pregnancy, pelvic blood flow shifts, increasing common iliac and uterine artery perfusion while decreasing external iliac flow (16-18,22,26 - 29) (Figure 1). External iliac and ovarian artery anastomoses contribute to collateral flow. These pathways explain persistent bleeding despite technically successful occlusion of the internal iliac arteries (30,31).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e2. Anatomical Changes at the Scar Defect\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen considering which haemostatic techniques to use during surgery and to explain the variable IIABO effectiveness, it is crucial to understand the development and anatomy of the caesarean scar defect (CSD) and the unique placental blood supply found in PASD. \u0026nbsp;CSDs typically form at the lower anterior uterine wall after a previous lower segment CS due to incomplete healing resulting in a thinned myometrium. Factors influencing CSD formation include number and type of prior CS procedures, incision location, labour duration, cervical dilatation, closure technique, adhesions, and uterine retroversion (32).\u003c/p\u003e\n\u003cp\u003eThe CSD itself is measured by depth, residual myometrial thickness (RMT) and adjacent myometrial thickness (AMT). \u0026nbsp;Large CSDs are often defined as defects with a 50%-80% reduction in wall thickness or an RMT \u0026lt;2.2 mm by transvaginal ultrasound scan (TVUS); an RMT \u0026lt;2 mm in early pregnancy is linked to PASD at delivery. \u0026nbsp;A thin RMT impairs myometrial contractility which affects vessel constriction postpartum (33). \u0026nbsp;At repeat CS, vessels may be visible through the thin wall which does not respond to uterotonics.\u003c/p\u003e\n\u003cp\u003eOne complication following CS is a Caesarean scar pregnancy which typically implants near the scar defect, and, if allowed to progress, is often associated with future development of PASD with a high hysterectomy rate. \u0026nbsp;‘On the scar’ implantations with measurable myometrial thickness generally have better outcomes than ‘in the niche’ implantations with minimal intervening myometrium (34 - 37).\u003c/p\u003e\n\u003cp\u003eVascular remodelling depends on scar location, defect size, muscle involvement, proximity to the internal os, placental distance to vasculature, and associated fibrosis—nearly half of CSDs show fibrosis involving angiogenesis which can complicate bladder dissection (38,39). \u0026nbsp;Arterial remodelling produces low-resistance, high-flow vessels, boosting blood flow into intervillous spaces. \u0026nbsp;Which arteries are affected depends on the extent of endometrial and myometrial loss, with affected vessels seen as lacunae on ultrasound, sometimes indicating invasion (4,5).\u003c/p\u003e\n\u003cp\u003eRemodelling is linked with increased fibrinoid on the residual myometrium which hinders placental separation (4,5); minimal myometrium and scarring may make separation easier although ultrasound is not always able to distinguish these cases. \u0026nbsp;Low anterior scars involve the bladder and fibrosis, mimicking invasion on imaging, while peritoneal vessel remodelling can give the appearance of peritoneal invasion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLarger CSDs are associated with a higher risk of haemorrhage due to impaired myometrial contractility from markedly reduced residual myometrial thickness (RMT) and proximity to the remodelled and collateral vascular channels (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.Differential Effect in Hysterectomy vs Myometrial Repair \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBalloon occlusion reduces the rate of blood flow to the surgical field allowing more time to complete the surgery regardless of whether the PASD is managed by TAH or MR. In hysterectomy, IIABO globally reduces pelvic organ perfusion facilitating vascular control during uterine devascularisation while in MR, although bleeding may persist from the isthmocele and adjacent muscle edges which are supplied by external iliac collaterals, the inflated balloons primarily reduce high-pressure uterine inflow to the uterine scar defect which is being repaired which could be tackled by more proximal occlusion including bilateral occlusion of the common iliac arteries or even the aorta. \u0026nbsp;These subtle differences in mode of action may explain why efficacy is variable between procedures even though average blood loss is lower with balloon occlusion in both groups. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Imaging Insights\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDoppler ultrasound, computerised tomographic (CT) angiography, and MRI angiography are all helpful in delineating scar defect morphology and aberrant vascular channels. Therefore, preoperative imaging has the potential to aid in stratification of patients, predicting which are most likely to benefit from balloon occlusion and which may require adjunctive or alternative haemostatic strategies (40-45).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is limited by its small sample size, single-centre design, and heterogeneous mix of elective and emergency cases. \u0026nbsp;One strength is operator variability which was limited to a single team managing all the cases ensuring consistency of care as far as possible. \u0026nbsp;Larger, prospective studies integrating imaging-guided risk stratification and looking at anatomical differences in the scar linked to factors associated with previous surgeries are needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review and case series have three major implications:\u003c/p\u003e\n\u003cp\u003eEfficacy across procedures: \u0026nbsp;It suggests that prophylactic IIABO appear to be beneficial in reducing blood loss during both TAH and conservative MR for PASD and we advocate its use in all cases, time permitting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk stratification:\u003c/strong\u003e\u0026nbsp; It highlights the importance of preoperative assessment of the CSD morphology and how detailed vascular mapping can help identify patients most likely to benefit from balloon occlusion although with the tools available this is still not easy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndividualised planning:\u003c/strong\u003e In patients with extensive extrauterine anastomoses or anticipated persistent collateral supply, alternative or adjunctive measures (e.g. stepwise uterine devascularisation, consideration of more proximal occlusion techniques, selective vessel ligation, or hysterectomy) should be incorporated into the surgical plan.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eProphylactic IIABO reduces blood loss in many—but not all—cases of PASD. Its variable efficacy may be best explained by underlying scar defect anatomy and collateral circulation, which influence whether haemorrhage can be controlled by IIABO alone. \u0026nbsp;Incorporating scar defect assessment and vascular imaging into preoperative planning may improve patient selection, optimise haemostatic efficacy and reduce the risk of catastrophic haemorrhage. \u0026nbsp;Our data highlight that despite overall benefit, blood loss values are highly variable underscoring the need for individualised surgical planning.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCaesarean section\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCaesarean scar defect\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputerised Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMyometrial repair\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePASD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePlacenta accreta spectrum disorders\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRMT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResidual myometrial thickness\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAMT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdjacent myometrial thickness\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTAH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTotal abdominal Hysterectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIIABO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternal iliac artery balloon occlusion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIIA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternal iliac artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEIA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExternal Iliac artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUterine artery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePlacenta previa major\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEBL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEstimated blood loss\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to reasons for non-disclosure of data but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e The authors \u0026nbsp;report \u0026nbsp;no conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship\u003c/strong\u003e: Nil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrecise\u003c/strong\u003e: Internal Iliac Artery Balloon Occlusion in Placenta Accreta Spectrum: Outcomes and Efficacy Factors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is supported by Singapore Duke-NUS Benjamin Henry Sheares Professorship in Obstetrics \u0026amp;\u0026nbsp;Gynecology\u0026nbsp;and Integrated Platform for Research in Advancing Metabolic Health Outcomes of Women \u0026amp; Children (IPRAMHO) Study Group (NMRC CGAug16C008). The funding was used to cover the open access submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors information and affiliation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWright Ann\u003csup\u003e1\u003c/sup\u003e MRCP(I),FRCOG, Toh Luke Han Wei\u003csup\u003e2\u003c/sup\u003e FRCR Sivanathan Chandramohan\u003csup\u003e2\u003c/sup\u003e FRCR Tan Bien Soo\u003csup\u003e2\u003c/sup\u003e FRCR, Lee Yien Sien\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eFRCR, Tay Kiang Hiong\u003csup\u003e2\u003c/sup\u003e FRCR Williams Ian\u003csup\u003e3\u003c/sup\u003e MD, FRCS \u0026nbsp;Tan Kok Hian\u003csup\u003e4\u003c/sup\u003e FRCOG, Mohamed Siraj\u003csup\u003e5 \u0026nbsp;\u003c/sup\u003e FRCOG\u003c/p\u003e\n\u003cp\u003e1 Department of Maternal Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women\u0026rsquo;s and Children\u0026rsquo;s Hospital\u003c/p\u003e\n\u003cp\u003e2. Department of Diagnostic and Interventional Imaging, KK Women\u0026rsquo;s and Children\u0026rsquo;s Hospital\u003c/p\u003e\n\u003cp\u003e3.Vascular Unit, University Hospital of Wales, Health PK Cardiff CF 14 4XN\u003c/p\u003e\n\u003cp\u003e4.Department of Maternal Fetal Medicine, Division of Obstetrics and Gynaecology, KK Women\u0026rsquo;s and Children\u0026rsquo;s Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore\u003c/p\u003e\n\u003cp\u003eOBGYN Academic Clinical Programme, DUKE-NUS Medical School, 8 College Road, Singapore, 169857, Singapore\u003c/p\u003e\n\u003cp\u003e5. Minimally Invasive Surgery Unit, Division of Obstetrics and Gynaecology, KK Women\u0026rsquo;s and Children\u0026rsquo;s Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMS and AMW performed background literature review, summarised, and synthesised the cases in the light of literature review. They were also involved in the surgical technique of myometrial repair and hysterectomy of PASD. IW advised on vascular and LT, SC, TBS, LYS and TKH on radiological aspects and supervised and contributed to writing the paper. KH reviewed the concept and statistical analysis and edited. \u0026nbsp;All authors commented on the final paper and approved final version\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding Author\u003c/strong\u003e: SHM Siraj,\u0026nbsp;Minimally Invasive Surgery Unit, Division of Obstetrics and Gynaecology, KK Women\u0026rsquo;s and Children\u0026rsquo;s Hospital, 100 Bukit Timah Road, Singapore 229899\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. It was approved and reviewed \u0026nbsp; by Singhealth institutional review board (IRB Approval Reference number \u0026ndash; 2020/2966/D) and all participants provided informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEinerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum. Obstet Gynecol. 2023 Jul 1;142(1):31-50. doi: 10.1097/AOG.0000000000005229. Epub 2023 Jun 7. PMID: 37290094; PMCID: PMC10491415.\u003c/li\u003e\n \u003cli\u003eEinerson BD, Comstock J, Silver RM, Branch DW, Woodward PJ, Kennedy A. Placenta accreta spectrum disorder: uterine dehiscence. Not Placental Invasion Obstet Gynecol. 2020;135(5):1104\u0026ndash;11.\u003c/li\u003e\n \u003cli\u003eMohamed Siraj, S.H., Tan, K.H. \u0026amp; Wright, A.M. Conservative surgical approach towards placenta accreta spectrum disorders for uterine preservation.\u0026nbsp;BMC Pregnancy Childbirth23, 28 (2023). https://doi.org/10.1186/s12884-023-05370-6\u003c/li\u003e\n \u003cli\u003eJauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol. 2022 Sep;227(3):384-391. doi: 10.1016/j.ajog.2022.02.038. Epub 2022 Mar 3. PMID: 35248577.\u003c/li\u003e\n \u003cli\u003eJauniaux E, Hussein AM, Elbarmelgy RM, Elbarmelgy RA, Burton GJ. Failure of placental detachment in accreta placentation is associated with excessive fibrinoid deposition at the utero-placental interface. Am J Obstet Gynecol. 2022 Feb;226(2):243.e1-243.e10. doi: 10.1016/j.ajog.2021.08.026. Epub 2021 Aug 28. PMID: 34461077.\u003c/li\u003e\n \u003cli\u003eTakahashi H, Ohkuchi A, Usui R, Suzuki H, Baba Y, Matsubara S. Factors Contributing to Massive Blood Loss on Peripartum Hysterectomy for Abnormally Invasive Placenta: Who Bleeds More? Obstet Gynecol Int. 2016;2016:5349063. doi: 10.1155/2016/5349063. Epub 2016 Aug 17. PMID: 27630716; PMCID: PMC5005569.\u003c/li\u003e\n \u003cli\u003ePi\u0026ntilde;as-Carrillo A, Chandraharan E. Conservative surgical approach: The Triple P procedure. Best Pract Res Clin Obstet Gynaecol. 2021 Apr;72:67-74. doi: 10.1016/j.bpobgyn.2020.07.009. Epub 2020 Jul 20. PMID: 32771462.\u003c/li\u003e\n \u003cli\u003ePalacios-Jaraquemada JM, Fiorillo A, Hamer J, Mart\u0026iacute;nez M, Bruno C. Placenta accreta spectrum: a hysterectomy can be prevented in almost 80% of cases using a resective-reconstructive technique. J Matern Fetal Neonatal Med. 2022 Jan;35(2):275-282.doi:10.1080/14767058.2020.1716715. Epub 2020 Jan 26. PMID: 31984808.\u003c/li\u003e\n \u003cli\u003eMappa I, Espuelas Malon S, D\u0026apos;Antonio F, Chandraharan E. Effectiveness of the Triple P Procedure and its modifications on reducing the blood loss and peripartum hysterectomy rates in women with Placenta Accreta Spectrum (PAS): a review of published literature. J Matern Fetal Neonatal Med. 2025 Dec;38(1):2452920. doi: 10.1080/14767058.2025.2452920. Epub 2025 Jan 15. PMID: 39814467.\u003c/li\u003e\n \u003cli\u003eHong L, Chen A, Chen J, Li X, Zhuang W, Shen Y, Dai Q, Zhang L. The clinical evaluation of IIA balloon occlusion in caesarean delivery for patients with PAS: a retrospective study. BMC Pregnancy Childbirth. 2022 Feb 5;22(1):103. doi: 10.1186/s12884-022-04434-3. PMID: 35123442; PMCID: PMC8817511.\u003c/li\u003e\n \u003cli\u003eSenapati A, Browse NL. Gluteal necrosis and paraplegia following postoperative bilateral internal iliac artery occlusion. J Cardiovasc Surg (Torino). 1990 Mar-Apr;31(2):194-6. PMID: 2341478.\u003c/li\u003e\n \u003cli\u003eOno Y, Murayama Y, Era S, Matsunaga S, Nagai T, Osada H, Takai Y, Baba K, Takeda S, Seki H. Study of the utility and problems of common iliac artery balloon occlusion for placenta previa with accreta. J Obstet Gynaecol Res. 2018 Mar;44(3):456-462. doi: 10.1111/jog.13550. Epub 2018 Jan 3. PMID: 29297951; PMCID: PMC5873444.\u003c/li\u003e\n \u003cli\u003eKidney DD, Nguyen AM, Ahdoot D, Bickmore D, Deutsch LS, Majors C. Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation. AJR Am J Roentgenol. 2001 Jun;176(6):1521-4. doi: 10.2214/ajr.176.6.1761521. PMID: 11373225.\u003c/li\u003e\n \u003cli\u003eHuang J, Zhang X, Liu L, Duan S, Pei C, Zhao Y, Liu R, Wang W, Jian Y, Liu Y, Liu H, Wu X, Zhang W. Placenta Accreta Spectrum Outcomes Using Tourniquet and Forceps for Vascular Control. Front Med (Lausanne). 2021 Oct 18;8:557678. doi: 10.3389/fmed.2021.557678. PMID: 34733857; PMCID: PMC8558214.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTan CH, Tay KH, Sheah K, Kwek K, Wong K, Tan HK, Tan BS. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta. AJR Am J Roentgenol. 2007 Nov;189(5):1158-63. doi: 10.2214/AJR.07.2417. PMID: 17954654.\u003c/li\u003e\n \u003cli\u003eChen M, Liu X, You Y, Wang X, Li T, Luo H, Qu H, Xu L. Internal Iliac Artery Balloon Occlusion for Placenta Previa and Suspected Placenta Accreta: A Randomized Controlled Trial. Obstet Gynecol. 2020 May;135(5):1112-1119. doi: 10.1097/AOG.0000000000003792. PMID: 32282608.\u003c/li\u003e\n \u003cli\u003eRosner-Tenerowicz A, Fuchs T, Pomorski M, Sliwa J, Zimmer-Stelmach A, Zimmer M. The clinical evaluation of internal iliac arteries balloon occlusion for placenta accreta spectrum. Ginekol Pol. 2021;92(3):210-215. doi: 10.5603/GP.a2020.0180. Epub 2021 Jan 15. PMID: 33448010.\u003c/li\u003e\n \u003cli\u003ePeng Y, Jiang L, Peng C, Wu D, Chen L. The application of prophylactic balloon occlusion of the internal iliac artery for the treatment of placenta accreta spectrum with placenta previa: a retrospective case-control study. BMC Pregnancy Childbirth. 2020 Jun 8;20(1):349. doi: 10.1186/s12884-020-03041-4. PMID: 32513127; PMCID: PMC7282070.\u003c/li\u003e\n \u003cli\u003eLiang D, Zhao H, Liu D, Lin Y. Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis. Eur J Radiol. 2021 Jun;139:109711. doi: 10.1016/j.ejrad.2021.109711. Epub 2021 Apr 20. PMID: 33910145.\u003c/li\u003e\n \u003cli\u003eClausen C, Stensballe J, Albrechtsen CK, Hansen MA, L\u0026ouml;nn L, Langhoff-Roos J. Balloon occlusion of the internal iliac arteries in the multidisciplinary management of placenta percreta. Acta Obstet Gynecol Scand. 2013 Apr;92(4):386-91. doi: 10.1111/j.1600-0412.2012.01451.x. Epub 2012 Jun 27. PMID: 22574880\u003c/li\u003e\n \u003cli\u003eNankali A, Salari N, Kazeminia M, Mohammadi M, Rasoulinya S, Hosseinian-Far M. The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis. Reprod Biol Endocrinol. 2021 Mar 4;19(1):40. doi: 10.1186/s12958-021-00722-3. PMID: 33663536; PMCID: PMC7931359.\u003c/li\u003e\n \u003cli\u003ePicel AC, Wolford B, Cochran RL, Ramos GA, Roberts AC. Prophylactic Internal Iliac Artery Occlusion Balloon Placement to Reduce Operative Blood Loss in Patients with Invasive Placenta. J Vasc Interv Radiol. 2018 Feb;29(2):219-224. doi: 10.1016/j.jvir.2017.08.015. Epub 2017 Nov 9. PMID: 29128157.\u003c/li\u003e\n \u003cli\u003eChen 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 Oct;167(1):109-127. doi: 10.1002/ijgo.15704. Epub 2024 Jun 20. PMID: 38899567.\u003c/li\u003e\n \u003cli\u003eDai 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 May;32(5):3297-3308. doi: 10.1007/s00330-021-08423-6. Epub 2021 Nov 30. PMID: 34846565.\u003c/li\u003e\n \u003cli\u003eChen D, Xu J, Tian Y, Ye P, Zhao F, Liu X, Wang X, Peng B. Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta. BMC Pregnancy Childbirth. 2021 Sep 21;21(1):640. doi: 10.1186/s12884-021-04103-x. PMID: 34548060; PMCID: PMC8456564.\u003c/li\u003e\n \u003cli\u003eLiapis K, Tasis N, Tsouknidas I, Tsakotos G, Skandalakis P, Vlasis K, Filippou D. Anatomic variations of the Uterine Artery. Review of the literature and their clinical significance. Turk J Obstet Gynecol. 2020 Mar;17(1):58-62. doi: 10.4274/tjod.galenos.2020.33427. Epub 2020 Apr 6. PMID: 32341832; PMCID: PMC7171538.\u003c/li\u003e\n \u003cli\u003ePijnenborg R, Vercruysse L, Hanssens M. The uterine spiral arteries in human pregnancy: facts and controversies. Placenta. 2006 Sep-Oct;27(9-10):939-58. doi: 10.1016/j.placenta.2005.12.006. Epub 2006 Feb 20. PMID: 16490251.\u003c/li\u003e\n \u003cli\u003eEspinoza J, Romero R, Mee Kim Y, Kusanovic JP, Hassan S, Erez O, Gotsch F, Than NG, Papp Z, Jai Kim C. Normal and abnormal transformation of the spiral arteries during pregnancy. J Perinat Med. 2006;34(6):447-58. doi: 10.1515/JPM.2006.089. PMID: 17140293; PMCID: PMC7062302.\u003c/li\u003e\n \u003cli\u003ePalmer SK, Zamudio S, Coffin C, Parker S, Stamm E, Moore LG. Quantitative estimation of human uterine artery blood flow and pelvic blood flow redistribution in pregnancy. Obstet Gynecol. 1992 Dec;80(6):1000-6. PMID: 1448242.\u003c/li\u003e\n \u003cli\u003eNieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, Basanta N, Burgos-Luna JM, Rodriguez F, Ordo\u0026ntilde;ez C, Sarria-Ortiz D, Mu\u0026ntilde;oz-C\u0026oacute;rdoba L, Quintero JC, Galindo-Velasco V, Messa-Bryon A. Ligation or Occlusion of the Internal Iliac Arteries for the Treatment of Placenta Accreta Spectrum: Why Is This Technique Still Performed? Matern Fetal Med. 2023 Jul;5(3):131-136. doi: 10.1097/FM9.0000000000000195. Epub 2023 Jul 21. PMID: 40416858; PMCID: PMC12096400.\u003c/li\u003e\n \u003cli\u003eLukies M, Han Wei LT, Chandramohan S. Collateral Round Ligament Arterial Supply of Placenta Accreta Spectrum and Considerations for Prophylactic Balloon Occlusion Catheter Placement. J Vasc Interv Radiol. 2024 Jun;35(6):895-899. doi: 10.1016/j.jvir.2024.03.008. Epub 2024 Mar 14. PMID: 38492660.\u003c/li\u003e\n \u003cli\u003eVervoort AJ, Uittenbogaard LB, Hehenkamp WJ, Brölmann HA, Mol BW, Huirne JA. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod 2015;30:2695-702.\u003c/li\u003e\n \u003cli\u003eWang J, Pang Q, Wei W, Cheng L, Huang F, Cao Y, et al. Definition of large niche after Cesarean section based on prediction of postmenstrual spotting: Chinese cohort study in non-pregnant women. Ultrasound Obstet Gynecol 2022;59:450-6.\u003c/li\u003e\n \u003cli\u003eKaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I. The clinical outcome of cesarean scar pregnancies implanted \u0026ldquo;on the scar\u0026rdquo; versus \u0026ldquo;in the niche\u0026rdquo;. Am J Obstet Gynecol 2017;216:510.e1- 510.e6.\u003c/li\u003e\n \u003cli\u003eZosmer N, Fuller J, Shaikh H, Johns J, Ross JA. Natural history of early first-trimester pregnancies implanted in Cesarean scars. Ultrasound Obstet Gynecol 2015;46:367-75.\u003c/li\u003e\n \u003cli\u003eNoël L, Thilaganathan B. Caesarean scar pregnancy: Diagnosis, natural history and treatment. Curr Opin Obstet Gynecol 2022;34:279-86.\u003c/li\u003e\n \u003cli\u003ePomorski M, Fuchs T, Budny-Winska J, Zimmer A, Zimmer M. Natural history of caesarean scar pregnancy. Ginekol Pol 2019;90:351-2\u003c/li\u003e\n \u003cli\u003ePalacios-Jaraquemada JM, Nieto-Calvache \u0026Aacute;J, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern Fetal Neonatal Med. 2023 Dec;36(1):2183741. doi: 10.1080/14767058.2023.2183741. PMID: 37193605.\u003c/li\u003e\n \u003cli\u003ePalacios-Jaraquemada JM, Nieto-Calvache \u0026Aacute;, Aryananda RA, Basanta N. Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location. J Matern Fetal Neonatal Med. 2023 Dec;36(1):2183764. doi: 10.1080/14767058.2023.2183764. PMID: 36966802.\u003c/li\u003e\n \u003cli\u003eExpert Panel on Women\u0026rsquo;s Imaging; Poder L, Weinstein S, Maturen KE, Feldstein VA, Mackenzie DC, Oliver ER, Shipp TD, Strachowski LM, Sussman BL, Wang EY, Weber TM, Whitcomb BP, Glanc P. ACR Appropriateness Criteria\u0026reg; Placenta Accreta Spectrum Disorder. J Am Coll Radiol. 2020 May;17(5S):S207-S214. doi: 10.1016/j.jacr.2020.01.031. PMID: 32370965.\u003c/li\u003e\n \u003cli\u003ePatel-Lippmann KK, Planz VB, Phillips CH, Ohlendorf JM, Zuckerwise LC, Moshiri M. Placenta Accreta Spectrum Disorders: Update and Pictorial Review of the SAR-ESUR Joint Consensus Statement for MRI. Radiographics. 2023 May;43(5):e220090. doi: 10.1148/rg.220090. PMID: 37079459.\u003c/li\u003e\n \u003cli\u003eJha P, Pōder L, Bourgioti C, Bharwani N, Lewis S, Kamath A, Nougaret S, Soyer P, Weston M, Castillo RP, Kido A, Forstner R, Masselli G. Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) joint consensus statement for MR imaging of placenta accreta spectrum disorders. Eur Radiol. 2020 May;30(5):2604-2615. doi: 10.1007/s00330-019-06617-7. Epub 2020 Feb 10. PMID: 32040730.\u003c/li\u003e\n \u003cli\u003eFamiliari A, Liberati M, Lim P, Pagani G, Cali G, Buca D, Manzoli L, Flacco ME, Scambia G, D\u0026apos;antonio F. Diagnostic accuracy of magnetic resonance imaging in detecting the severity of abnormal invasive placenta: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2018 May;97(5):507-520. doi: 10.1111/aogs.13258. Epub 2017 Dec 13. PMID: 29136274.\u003c/li\u003e\n \u003cli\u003eKapoor H, Hanaoka M, Dawkins A, Khurana A. Review of MRI imaging for placenta accreta spectrum: Pathophysiologic insights, imaging signs, and recent developments. Placenta. 2021 Jan 15;104:31-39. doi: 10.1016/j.placenta.2020.11.004. Epub 2020 Nov 13. PMID: 33238233.\u003c/li\u003e\n \u003cli\u003ePatel-Lippmann KK, Planz VB, Phillips CH, Ohlendorf JM, Zuckerwise LC, Moshiri M. Placenta Accreta Spectrum Disorders: Update and Pictorial Review of the SAR-ESUR Joint Consensus Statement for MRI. Radiographics. 2023 May;43(5):e220090. doi: 10.1148/rg.220090. PMID: 37079459.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 \u0026nbsp;Patients with Hysterectomy for Placenta accrete spectrum disorders (PASD)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"835\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eStatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eNon occlusion of IIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 343px;\"\u003e\n \u003cp\u003eOcclusion of IIA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e24.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e35.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e34.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e34\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e24\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e34\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e33\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e34\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e35\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e35\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e36\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003ePrevious number of CS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0 (previous myomectomy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003ePre op US\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003ePlacenta low lying\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ePlacenta upper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccrete\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003ePre op MRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003ePercreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eHistology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003ePercreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003ePercreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eEBL (ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e6000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1700\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eTransfused \u0026nbsp;PCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eSurgical time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eVisceral injuries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ebladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIIA \u0026ndash; internal iliac artery occlusion, CS -caesarean section ,US \u0026ndash; ultrasound ,MRI \u0026ndash; magnetic resonance image, ICU \u0026ndash; intensive care unit, EBL \u0026ndash; estimated blood loss; PCV - packed cell volume\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Patients with conservative surgery for PASD \u0026ndash; Myometrial repair\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"736\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eStatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 257px;\"\u003e\n \u003cp\u003eNon occlusion of IIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 394px;\"\u003e\n \u003cp\u003eOcclusion of IIA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e19.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eGA (week/day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e34\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e35\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e31\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e34\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e36\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e36\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e35\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e36\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e35\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e27\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ePrevious no of CS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ePre op US\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eNot available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eLow lying placenta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eNot available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eLow lying placenta but possible accreta \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eaccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ePre op MRI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eIncreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eAccreta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNot done\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003epercreta\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eEBL(ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e5000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e1600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e4000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTransfused PCV \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eVisceral injuries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003enil\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSurgical time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003eno\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 73px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003eyes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;IIA \u0026ndash; internal iliac artery occlusion, CS -caesarean section ,US \u0026ndash; ultrasound ,MRI \u0026ndash; magnetic resonance image, ICU \u0026ndash; intensive care unit, EBL \u0026ndash; estimated blood loss; PCV - packed cell volume\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Estimated blood loss (EBL) in patients with PASD stratified by procedure type and balloon occlusion use.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eProcedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBalloon Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eEBL Values (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eTAH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1200, 3000, 1200, 1200,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1660 \u0026plusmn; 780\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eTAH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e900,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5000, 2500, 6000,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e3480 \u0026plusmn; 2032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1500,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e800,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2500, 1500, 2000,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1550 \u0026plusmn; 629\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e5000, 1600, 1000,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2900 \u0026plusmn; 1908\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAcross all procedures, balloon use was associated with significantly reduced blood loss compared with no balloons (t(12.6) = \u0026ndash;2.47, p = 0.034). The effect size was large (Cohen\u0026rsquo;s d = \u0026ndash;1.15). In contrast, there was no significant difference in EBL between TAH and MR overall (t(16.9) = 0.68, p = 0.504; d = 0.31). A factorial ANOVA confirmed a significant main effect of balloon use (F(1,16) = 6.22, p = 0.024, \u0026eta;\u0026sup2; = 0.28). There was no significant main effect of procedure type (F(1,16) = 0.26, p = 0.620, \u0026eta;\u0026sup2; = 0.01) and no interaction between balloon use and procedure type (F(1,16) = 0.14, p = 0.717, \u0026eta;\u0026sup2; = 0.006).\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Placenta accreta spectrum disorders, Caesarean scar defect, Internal iliac artery occlusion, Myometrial Repair, Conservative management, Placenta praevia","lastPublishedDoi":"10.21203/rs.3.rs-8121877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8121877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003ePlacenta accreta spectrum disorder (PASD) is a major obstetric complication associated with life-threatening haemorrhage. Prophylactic internal iliac artery balloon occlusion (IIABO) is used in many centres to reduce intraoperative blood loss but success rate is variable.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe reviewed 20 consecutive patients with PASD over a twenty-one-month period stratified by procedure type [total abdominal hysterectomy (TAH) versus conservative myometrial repair (MR)] and balloon occlusion use. Estimated blood loss (EBL) was recorded. Welch\u0026rsquo;s t-tests compared groups, and a two-way analysis of variance (ANOVA) assessed the effects of balloon use and procedure type. Effect sizes were expressed as Cohen\u0026rsquo;s d and η\u0026sup2;.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eMean EBL was significantly lower with balloon use than without (1660\u0026thinsp;\u0026plusmn;\u0026thinsp;676 mL vs 3260\u0026thinsp;\u0026plusmn;\u0026thinsp;2021 mL, p\u0026thinsp;=\u0026thinsp;0.034, Cohen\u0026rsquo;s d = \u0026minus;\u0026thinsp;1.15). Two-way ANOVA confirmed a main effect of balloon use (η\u0026sup2; = 0.28), while procedure type showed no independent effect (p\u0026thinsp;=\u0026thinsp;0.504). However, EBL values were widely dispersed\u0026mdash; with balloons: median 1500 mL (interquartile range {IQR} 1200\u0026ndash;1850), range 800\u0026ndash;3000; without balloons: median 3000 mL (IQR 1600\u0026ndash;5000), range 900\u0026ndash;6000\u0026mdash;highlighting variable efficacy at the individual level.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eProphylactic balloon occlusion reduces blood loss overall in both TAH and conservative MR for PASD, but its efficacy is highly variable. Collateral circulation and scar defect morphology likely underpin this variability, and further research should focus on refining preoperative risk stratification to guide individualised surgical planning with the aid of available imaging techniques.\u003c/p\u003e","manuscriptTitle":"Internal Iliac Artery Balloon Occlusion for Placenta Accreta Spectrum Disorder: Outcomes and Factors influencing Efficacy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-11 14:45:24","doi":"10.21203/rs.3.rs-8121877/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-31T16:20:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-25T19:22:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T01:57:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128003604305944862156225535656378213630","date":"2025-12-16T16:34:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62500521569006014383267278154267166396","date":"2025-12-11T01:00:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-09T00:20:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-18T10:03:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-18T10:02:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-11-15T12:02:26+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":"813ff705-31d0-4895-bae1-4d56238204a9","owner":[],"postedDate":"December 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T19:24:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-11 14:45:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8121877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8121877","identity":"rs-8121877","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}