Expert Review ajog.

org

Minimizing surgical blood loss at cesarean

hysterectomy for placenta previa with
evidence of placenta increta or placenta
percreta: the state of play in 2020
John C. Kingdom, MD; Sebastian R. Hobson, MB, MPH, PhD; Ally Murji, MD, MPH;
Lisa Allen, MD; Rory C. Windrim, MB, MSc; Evelyn Lockhart, MD; Sally L. Collins, MD, DPhil;
Hooman Soleymani Majd, MD; Moiad Alazzam, MD; Feras Naaisa, MBBS;
Alireza A. Shamshirsaz, MD; Michael A. Belfort, MD, PhD; Karin A. Fox, MD, MMed

O ver the past 20 years, the changing

landscape of pregnancy risk fac-
tors and care has created several
The evolution of multidisciplinary team-based care for women with placenta accreta
spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to
increasingly challenging scenarios to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable bal-
obstetricianegynecologists. Few are loons within the pelvic arteries, most commonly in the anterior divisions of the internal
greater than the surgical risks associated iliac arteries, became popular in many centers, at the expense of prolonging surgical care
with placenta accreta spectrum (PAS) and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall
disorders, particularly when placenta anatomy to safely identify the course of the ureters re-popularized the alternative strategy
previa is associated with evidence of of ligating the same anterior divisions of the internal iliac arteries. With incremental gains
placenta increta and/or placenta per- in surgical expertise, described in 5 steps in this review, our teams have witnessed a
creta. As the incidence of PAS disorders steady decline in surgical blood loss. Nevertheless, a subset of women has the most
has risen and the accuracy of prenatal severe form of placenta accreta spectrum, namely placenta previa-percreta. Such
diagnosis has improved,1 the evolution women are at risk of major hemorrhage during surgery from vessels arising outside the
of a range of multidisciplinary team- territories of the internal iliac arteries. These additional blood supplies, mostly from the
external iliac arteries, pose significant risks of major blood loss even in experienced
hands. To address this risk, some centers, principally in China, have adopted an
From the Department of Obstetrics &
approach of routinely placing an infrarenal aortic balloon, with both impressively low
Gynaecology, Mount Sinai Hospital, University of rates of blood loss and an ability to conserve the uterus by resecting the placenta with the
Toronto, Ontario, Canada (Drs Kingdom, affected portion of the uterine wall. We review these literature developments in the
Hobson, Murji, Allen, and Windrim); Department context of safely performing elective cesarean hysterectomy for placenta previa-
of Pathology, University of New Mexico Health percreta, the most severe placenta accreta spectrum disorder.
Science Center, Albuquerque, NM (Dr
Lockhart); Department of Obstetrics & Key words: cesarean hysterectomy, hemorrhage, infrarenal aortic balloon, internal iliac
Gynaecology, University of Oxford NHS artery ligation, interventional radiology, magnetic resonance imaging, placenta accreta
Foundation Trust, England, United Kingdom
(Drs Collins, Soleymani Majd, Alazzam);
spectrum disorder
Department of Gynaecology, South Bristol NHS
Trust, Bristol, England, United Kingdom (Dr
Naaisa); and the Maternal-Fetal Medicine based skills and practices has improved Placenta.7e10 Ultimately, the major un-
Division, Department of Obstetrics &
clinical outcomes.2 Advances in the derlying cause of severe morbidity or
Gynecology, Baylor College of Medicine,
Houston, TX (Drs Shamshirsaz, Belfort, and development of effective screening pro- mortality is the extent of surgical blood
Fox). grams will further increase the propor- loss during surgery. The key objectives at
Received Oct. 23, 2019; revised Jan. 16, 2020; tion of affected women who will benefit surgery are (1) the safe delivery of the
accepted Jan. 23, 2020. from team-based care and planned fetus and (2) surgical measures to secure
The authors report no conflict of interest. elective surgery.3 Many of the lessons surgical hemostasis. For many women
Corresponding author: John C. Kingdom, MD. learned in the past decade are now with less severe forms of PAS, especially
[email protected] or embedded within national-level guide- in the absence of major placenta previa,
[email protected] lines in the United Kingdom,4 Canada,5 surgical hemostasis can be safely ach-
0002-9378/$36.00 and the United States6; these comple- ieved without recourse to hysterectomy.
ª 2020 Elsevier Inc. All rights reserved. ment the recent guideline series issued This goal is achieved via resection of the
https://doi.org/10.1016/j.ajog.2020.01.044
by the International Federation of Gy- focally embedded placental tissue fol-
necology and Obstetrics and the Inter- lowed by repair of the uterus.7,8 For
national Society for Abnormally Invasive women with more extensive PAS,

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especially those with intraoperative surgical outcomes using this classifica- ligation; the principal risk of bleeding is
confirmation at delivery of placenta tion system at the time of delivery, and from excessive upward traction on the
previa with evidence of extensive that authors use this system in future uterus by lateral straight clamps, rather
placenta percreta, directly resorting to a studies to facilitate subsequent system- than by manual elevation.
cesarean hysterectomy is a definitive atic review and meta-analysis of in-
strategy to secure hemostasis. As many terventions. This discussion will focus Step 3: retroperitoneal dissection
elements of multidisciplinary care on the surgical management of Inter- The uterus is skeletonized down to the
continue to improve for women with national Federation of Gynecology and cardinal ligaments and the para-vesical
PAS disorders, especially in surgical Obstetrics Class 2 and 3 (a-c) cases of spaces are opened, using electro-
strategy and expertise, they challenge the placenta previa with evidence of dissection. This step may also include a
relevance of 2 key approaches to limit abnormal placental invasion, which cephalad pelvic sidewall dissection,
blood loss at cesarean hysterectomy, encompasses focal placenta increta (eg, medial to the psoas muscles, to locate the
namely the use of interventional radi- invasion of the cervix) and placenta bifurcation of the common iliac arteries,
ology techniques and ligation of the percreta (complete loss of myometrium the external iliac vein and the medially
anterior divisions of the internal iliac in areas of the anterior lower segment, located proximal ureters. This adjunct
arteries. with or without bladder and/or para- step leads to exposure of the anterior
metrial involvement). divisions of the internal iliac arteries as
Surgical Difficulty Based on Placental shown in Figure 1 and Video 1, and can
Location Risk of Hemorrhage During Cesarean be followed by ureterolysis in a distal
Placental adherence and invasion pre- Hysterectomy for Placenta Previa- direction to establish the spatial rela-
sent as a disease spectrum rather than as Percreta tionship of the ureters to the cardinal
a singular common pathology. Varying The procedure of cesarean hysterectomy ligaments.
degrees of invasion may be found in the for placenta previa-percreta can be
individual placenta, and the areas of divided into 5 key steps, with varying Step 4: bladder dissection
involvement varies widely between risks of major hemorrhage. Separation of the hypervascular
cases. Low placental implantation and bladder wall away from the extremely
invasion such as that which occurs in Step 1: midline access and hysterotomy thin lower uterine segment often is
the setting of placenta previa poses First, gently expose the entire gravid prolonged. It is here that protracted
distinct technical surgical challenges. uterus and visually confirm the venous bleeding may be first encoun-
Specifically, the placental bulk lies in the external features of this disease. Hys- tered by experienced surgeons if
narrowest portion of the bony pelvis; terotomy is then made to deliver the inadvertent injury to the thin lower
extrauterine invasion within this tech- fetus, avoiding the placenta using an uterine segment occurs. Meticulous
nically challenging region potentially incision placed to avoid the placenta, lateral-to-medial dissection of this
obscures or envelopes critical struc- usually toward the fundus. This inci- plane on each side, including dividing
tures, including both the origin of the sion may be placed vertically and the the engorged blood vessels and adipose
uterine arteries from the internal iliac placenta localized by ultrasound, if not layer down with the bladder, may
arteries, and the distal portions of the already known. Blood loss may be as exceed 30e60 minutes. It is at this
ureters. Even though these structures low as 20 cc at this stage by using a stage that significant blood collection
may not actually be invaded by uterine stapler if the myometrium is often begins when using a cell salvage
trophoblast, their proximity to the suitably thin13; if opened by knife system. Step 4 is concluded when there
highly perfused placental tissue, and incision, elevating the uterine edges is sufficient inferior dissection of the
surrounding neovascularization that with a series of clamps followed by an bladder wall down to the level of the
accompanies placental invasion, greatly efficient single layer closure will also anterior vaginal fornix. Filling the
increases the risk of severe maternal minimize blood loss.6 bladder with 100e300 mL of methy-
morbidity from hemorrhage or uro- lene blue colored saline also may be
logic injury.9,10 To more accurately Step 2: superior devascularization helpful in identifying the superior
categorize and compare cases, including Release and ligation of the round liga- bladder wall margin, especially in
those managed conservatively, mem- ments and utero-ovarian pedicles bilat- difficult cases. In rare instances with
bers of the International Society for erally. This may be achieved using bladder invasion, confirmation and
Abnormally Invasive Placenta devel- traditional methods or with a bipolar localization by cystoscopy is advised14;
oped a clinically-based grading sys- sealing device, taking care to advance this step is then modified to include
tem,11 which was subsequently adopted incrementally, perpendicular to the ves- intentional cystotomy and resection of
by the International Federation of Gy- sels, within the optimal sealing width of the affected portion of the posterior
necology and Obstetrics.12 It is recom- the blades. Blood loss at this step again is bladder wall with the uterus, followed
mended that clinicians prospectively often minimal and is normally not by bladder repair.15 In rare instances
report their imaging findings and excessive using traditional suture in which parametrial placental

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FIGURE 1
Exposing the branches of the left common iliac artery during Cesarean hysterectomy

Illustration by Dr Evelyn Lockhart, University of New Mexico, Albuquerque, New Mexico.

Kingdom et al. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020. Am J Obstet Gynecol
2020.

invasion is found, more extensive likely to be minimal, and easily with considerable bleeding. Inferior
retroperitoneal dissection is required controlled, such that the risk of intra- dissection of the paravesical spaces,
to excise the specimen and secure he- operative hemorrhage has largely passed. below the vault, risks injury to the
mostasis,16 or alternatively a subtotal Steps 4 and 5 represent periods of surrounding venous plexus supplied
hysterectomy is performed, thereby much greater risks of hemorrhage than by the external iliac artery territory.
omitting the final step. in steps 1e3. Furthermore, if the placenta extends
In the context of blood loss control into the cervix or parametrial tissues,
Step 5: colpotomy across steps 4 and 5, several points the vault margins may be extremely
Once adequate exposure for vault entry deserve consideration. First, the arte- vascular. Clear identification of the
is created, the main uterine artery pedi- rial blood supply relevant to steps 4 anterior and posterior vault margins
cles are ligated, followed by securing the and 5 may involve the territories of may be facilitated either using an EEA-
vaginal angles, each containing well- both the internal and the external iliac Sizer for posterior entry13 or a Breisky
developed branches of the vaginal and arteries, and may even involve the retractor for anterior entry, as shown
internal pudendal arteries.17 Colpotomy, aorta. Consequently, the predominant in Figure 2 and Video 2. Both ap-
followed by a circumferential incision internal iliac arterial blood supply to proaches afford greater control during
around the cervicovaginal margin, re- the nonpregnant uterus may switch, in colpotomy, without sacrificing vaginal
sults in removal of the uterus. The the presence of placenta previa- length. In the context of limiting
incised edges are clamped incrementally percreta, to one in which substantial blood loss, there is no substitute for a
as the vault is opened, to minimize blood contributions arise from branches of slow, meticulous execution of each of
loss from the margins, followed by su- the external iliac arteries. Second, step these steps as the principal strategy.
turing of the vault. Once step 5 is 5 gives the illusion of being straight- Each of these steps take time, with
completed, any ongoing bleeding is forward; however, it may be associated skin-to-skin surgery typically taking

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FIGURE 2
Use of the Breisky retractor to identify the upper margin of the anterior fornix, opened using electro-cautery (A).
Saggital view of the retractor (B).

Illustration by Dr Evelyn Lockhart, University of New Mexico, Albuquerque, New Mexico.

Kingdom. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020. Am J Obstet Gynecol 2020.

2e3 hours, even in experienced a subsequent publication that distin- short mean operating time (84 mi-
teams.2 guished a subset of patients with PAS nutes) in each arm.
and placenta percreta demonstrated a With evolving team-based surgical
Percutaneous Internal Iliac Artery statistically significant reduction in operating expertise, especially with
(IIA) Balloons mean blood loss (933 vs 1507 cc).20 In being patient during the steps of
Previously, the preoperative percuta- both reports, mean operating time was bladder dissection (step 4) and colpot-
neous placement of IIA balloons 2.5e3 hours. The more recent publi- omy (step 5), the overall risk of major
before surgery for PAS, to be inflated cation of a pilot randomized blood loss (>2 L) has diminished.
following delivery of the fetus, gained controlled trial, involving 27 subjects, Consequently, it is not surprising that
popularity as a safety measure to avoid found no reduction in mean estimated preoperative IIA balloon placement has
massive blood loss.18 The literature is blood loss (1600 cc in both arms) in not been shown to improve outcomes,
challenging to assess due the inclusion women undergoing cesarean delivery yet this intervention extends resource
of all stages of suspected PAS, for suspected PAS with balloon place- use and overall costs and is not without
including those not pathologically ment and routine inflation.21 These serious potential risks to pelvic struc-
confirmed and false-positive cases. As data are difficult to interpret in the tures and blood supply to the lower
examples, an early caseecontrol series specific context of surgery for mag- limbs.19,22
of patients with PAS demonstrated netic resonance imaging (MRI)e
no significant reduction in mean confirmed placenta previa-percreta. Surgical Ligation of the IIAs
blood loss with the use of internal iliac Only one half of the subjects had a An alternative to IIA balloon place-
artery ligation balloons compared with hysterectomy (which was always sub- ment, surgical exposure and ligation of
controls (2700 vs 3000 cc),19 whereas total), which may explain the relatively the anterior divisions of each IIA, as an

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extension of step 3, typically requires massive blood loss during surgery for bulging vascular placenta previa un-
only 20 minutes to perform bilaterally. placenta previa-percreta. Clearly this is disturbed, then performing surgery in
This technique is illustrated in Figure 1 a highly undesirable and stressful a controlled and meticulous 5-step
and Video 1. Care must be taken to experience. No method of limiting fashion. Reassuringly, these Chinese
avoid injury to the laterally adjacent blood flow to the anterior divisions of groups reported minimal rates of
external iliac vein. Ligating the vessel at the IIAs is effective in these acute sit- vascular complications,26 and in 1 se-
least 3e5 cm distal to its separation uations. Fluoroscopic placement of a ries, 53% (105/197) of women fol-
from the posterior division will avoid balloon in the infrarenal portion of the lowed up had return of normal
inadvertent ligation of posterior divi- descending aorta in theory will permit menses.27 The utility of routine aortic
sion branches that arise as anatomical temporary occlusion of arterial perfu- balloon placement for placenta previa-
variants.23 The exposed anterior divi- sion from most sources to the pelvis percreta surgery in our settings is
sion arteries may either be sutured or during surgery for placenta previa- questionable, since predicted mean
left exposed with a suture loop, for percreta. However, this scenario is not blood loss is reduced to an acceptable
later rapid ligation if excessive bleeding readily predicted, and thus balloon level (<1.5 L) via our 5-step approach
is encountered. Alternatively, they may placement may be performed electively to cesarean hysterectomy. One recent
be occluded using a vessel clip. Classic directly before surgery commences. A North American publication in this
experiments observed that bilateral recent meta-analysis of 7 comparative context compared blood loss in 16
ligation of the IIAs (in 17 nonpregnant cohort studies of more than 500 cases with an aortic balloon with 19
women undergoing laparotomy) women with a range of suspected PAS cases without a balloon over a 7-year
immediately reduced mean arterial disorders reported on outcomes with period and found no significant dif-
pressure in the distal iliac artery elective infrarenal aortic temporary ference in mean blood loss,28 con-
segment by 24%, accompanied by a placement and intra-operative occlu- firming our view. A variant of this
48% reduction in blood flow.24 Aorto- sion.26 These studies are impressive for strategy, originally described in
grams demonstrated that the low im- their reduced blood loss (mean reduc- Taiwan,29 and subsequently adopted
mediate effectiveness of this type of tion 1495 cc) and their significantly both in Denmark30 and in Japan31
vascular ligation was substantially lower rates of hysterectomy (odds ratio, with favorable initial results, is bilat-
diminished by the presence of ilio- 0.3; 95% confidence interval, eral placement of balloons in the
lumbar, sacral, and hemorrhoidal 0.19e0.48). In 1 series of 230 women common iliac arteries. More recently,
anastomoses to the distal iliac vascula- undergoing delivery for placenta previa a Chinese group has compared out-
ture24; consequently, any clinically with suspected PAS and preoperative comes between all 3 levels of balloons
meaningful benefit of this intervention aortic balloon placement, no woman (infrarenal aortic, common iliac, and
is only likely to be short term and less required a hysterectomy, despite 88 anterior divisions of the IIAs) in a
than 20 minutes in duration of effect. having a final diagnosis of placenta retrospective cohort of 112 women
Therefore, if ligation is performed early previa percreta, among whom 29 had delivered with suspected PAS, where
on during the procedure, any benefit bladder wall penetration.27 only 11.6% had confirmed placenta
may be greatly diminished should sig- This literature is challenging to percreta at delivery.32 Surgery with
nificant bleeding be encountered dur- interpret and apply widely for 2 rea- balloons placed in the infrarenal aorta
ing the prolonged meticulous step of sons. First, a common surgical strategy or common iliac arteries had signifi-
bladder dissection, during uterine ar- in these publications was to attempt cantly lower mean blood loss (mean
tery and cardinal ligament ligation, or removal of the placenta even in the 1000 cc) that surgery with IIA bal-
finally during colpotomy. It is of in- context of a severe PAS disorder loons (mean 2900 cc), and cases with
terest that a recent Egyptian pilot ran- (placenta previa percreta). Second, these higher-level balloons had
domized control trial found no benefit mean reported operating times are significantly lower rates of hysterec-
of routine vessel ligation during cesar- remarkably short—only 64 minutes in tomy. Only 2 procedure-related com-
ean hysterectomy for placenta increta the largest series reported to date.27 plications were described, namely
or percreta.25 The need for an aortic balloon, to thrombosis in the IIAs, without long-
control blood loss in the context of term complications.32
Percutaneous Aortic Balloon attempting placental removal for an Our interpretation of this literature is
Placement intraoperative clinical diagnosis of that a subset of women with placenta
The fear of encountering complex placenta previa percreta, may indeed previa and features of either placenta
blood supplies to the uterus persis- be an essential life-saving approach. increta or percreta are at risk of excessive
tently lurks in the minds of even the Combining this approach with a fast blood loss at cesarean delivery of their
most experienced PAS surgical teams. operative technique is in stark contrast baby, despite well-developed team-based
Each of our respective teams have had to our approach, along with that surgical skills. However, contemporary
to resort to occasional infrarenal aortic described in current international outcomes for such women in large cen-
compression, or clamping, to control guidelines, which is to leave the ters does not justify the routine use of an

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ultrasound.3 In the context of placenta

FIGURE 3
previa-percreta, MRI has additional
MR angiogram of the abdominal arterial tree at 36 weeks gestation capabilities that are relevant to uterine
demonstrating the renal arteries (R) and bifurcation of the common iliac vascularization. MRI may be com-
arteries (B). bined with intravenous gadolinium
enhancement to improve diagnostic
accuracy.40 Due to concerns with
gadolinium vehicle stability, this
contrast agent is not commonly used,
although newer agents are under
development.41 In addition to imaging
of the uterus and placenta, advances in
the time of flight modality of MRI
may provide a window into delin-
eating the major arterial vessel seg-
ments supplying the pelvis in
pregnancies complicated by placenta
previa-percreta,42 as shown in
Figure 3. These MR sequences can be
Courtesy of Dr Mike Seed, Department of Medical Imaging, SickKids Hospital, University of Toronto,
combined with standard T2- and T1-
Canada.
weighted imaging protocols presently
Kingdom. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or
placenta percreta: the state of play in 2020. Am J Obstet Gynecol 2020. used to confirm and stage the disease34
and is presently under further inves-
tigation in pregnant women in an
attempt to detect a subset of women
aortic balloon. Further advances in resuscitation of victims with major with PAS that have a substantial
vascular imaging are needed in order lower-body trauma. At a recently re- parasitic blood supply beyond the
that a subset of women, with a more ported robotic surgery training course territories of the anterior divisions of
extensive and complex pelvic arterial of para-aortic node dissection, incor- the IIAs.
blood supply (especially where extra- porating arterial monitoring via the
uterine placental tissue invasion is femoral artery, each level of surgeon The State of Play in 2020
demonstrated), may be identified to from resident to experienced surgeon In each of our respective PAS pro-
potentially derive significant benefit could achieve effective infrarenal aortic grams, we have either always used se-
from this type of device. occlusion in less than 2 minutes.36 A lective vessel ligation (Bristol, Houston,
recent systematic review of 8 studies Oxford) or have evolved from balloon
Emergency Infrarenal Aortic Balloon using aortic balloons in 392 women placement through routine to selective
Placement with PAS included a small subset vessel ligation (Toronto). As our team-
Recent developments provide insight describing the experience of using the based surgical skills have evolved as
into overcoming this challenge. By REBOA device, which reported favor- described in steps 1-5, our centers have
moving these surgeries to hybrid surgical able results and no major complica- seen mean surgical blood losses stabi-
suites,33 with bedside interventional tions.37 A multicenter registry (www. lize at around 1200 cc and in tandem
radiology and digital imaging, the pro- obgynreboa.com) has recently been have evolved to dissection and exposure
cess of selective aortic balloon placement developed to address the utility of this of the IIAs at step 3, such that vessel
may become a time-efficient option, so selective vascular intervention in ligation can be performed rapidly as
long as arterial pressure surveillance is Obstetrics. needed during steps 4 or 5. At these
switched from radial to femoral surgical blood loss levels, combined
monitoring. MRI of the Pelvic Arteries with a more proactive preoperative
A variant of this approach, without Although multimodal ultrasound in hemoglobin optimization, we are left
recourse to a hybrid fluoroscopy surgi- experienced hands can provide accu- questioning the justification for the
cal suite, is the alternative method of rate diagnostic information in the staff and equipment costs incurred to
rapid infrarenal aortic balloon occlu- context of a suspected PAS disorder,38 return low volumes (<500 cc) of blood
sion.34,35 This strategy uses the ER- MRI (T1- and T2-weighted imaging) collected via cell salvage. In summary,
REBOhybA system (Prytime Medical, can provide important diagnostic and there is no substitute for achieving a
Boerne, TX), a device that was origi- staging information39 for women dedicated and experienced surgical
nally designed for military battlefield identified as screen positive by team approach to this disease. The

6 American Journal of Obstetrics & Gynecology MONTH 2020

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importance of nurturing such teams, 11. Collins SL, Stevenson GN, Al-Khan A, et al. Anatomic variations and clinical applications.
including the careful mentoring of our Three-dimensional power Doppler ultrasonography Am J Obstet Gynecol 2007;197:658.e1–5.
for diagnosing abnormally invasive placenta 24. Burchell RC. Arterial blood flow into the
next generation of PAS surgeons, is and quantifying the risk. Obstet Gynecol human intervillous space. Am J Obstet Gynecol
key to advancing our ability to tackle 2015;126:645–53. 1967;98:303–11.
this evolving problem in a safe and 12. Jauniaux E, Ayres-de-Campos D, Langhoff- 25. Hussein AM, Dakhly DMR, Raslan AN,
expert fashion. - Roos J, Fox KA, Collins S. FIGO Placenta et al. The role of prophylactic internal iliac
Accreta Diagnosis and Management Expert artery ligation in abnormally invasive
Consensus Panel. FIGO classification for the placenta undergoing caesarean hysterec-
ACKNOWLEDGMENTS clinical diagnosis of placenta accreta spectrum tomy: a randomized control trial. J Matern
E.M. wishes to thank Dr Michael Corrin, MSc, disorders. Int J Gynaecol Obstet 2019;146: Fetal Neonatal Med 2018;32:3386–92.
Associate Professor of Biology & Associate Di- 20–4. 26. Chen L, Wang X, Wang H, Li Q, Shan N,
rector, Biomedical Communications Graduate 13. Belfort MA, Shamshirsaz AA, Fox KA. Qi H. Clinical evaluation of prophylactic
Program, Department of Biology, University of A technique to positively identify the vaginal abdominal aortic balloon occlusion in patients
Toronto at Mississauga, Canada for his guid- fornices during complicated postpartum hys- with placenta accreta: a systematic review and
ance in preparing her illustrations. terectomy. Am J Obstet Gynecol 2017;217:222. meta-analysis. BMC Pregnancy Childbirth
e1–3. 2019;19:30–8.
14. Murji A, Kingdom J. Placenta percreta 27. Wu Q, Liu Z, Zhao X, et al. Outcome of
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