Control of postpartum hemorrhage in women with placenta accreta spectrum using prophylactic balloon occlusion combined with Pituitrin intra-arterial infusion.

OBJECTIVES: The aim of this study is to evaluate the efficacy of prophylactic internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion in the control of postpartum hemorrhage in women with placenta accreta spectrum (PAS). METHODS: This is a prospective and non-randomized controlled study. The participants were assigned into three groups: without balloon catheterization (non-BC) group, balloon catheterization (BC) group, and Pituitrin combined with balloon catheterization (PBC) group. The primary outcomes were estimated blood loss (EBL) and the units of transfused packed red blood cells (PRBC). The secondary outcome was the incidence of hysterectomy. RESULTS: A total of 100 participants were recruited between August 2013 and November 2018 and assigned into the respective groups as follows: 27 in the non-BC group, 22 in the BC group, and 51 in the PBC group. No statistical differences were found in demographic characteristics among the three groups. There was a trend of lower EBL, PRBC, and hysterectomy rate in the BC group than those in the non-BC group, while all values showed no significant differences (all p > 0.05). Patients in the PBC group had significantly lower EBL, PRBC, and hysterectomy rate compared with those in the non-BC group (all p < 0.05). Linear regression analysis revealed that the PBC (vs. others) was negatively correlated with EBL and the non-BC (vs. others) independently predicted more EBL. CONCLUSIONS: Balloon occlusion combined with Pituitrin infusion is an effective treatment method which significantly reduced EBL, PRBC, and hysterectomy rate in patients with PAS. KEY POINTS: • Internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion can significantly decrease EBL, PRBC, and hysterectomy rate during cesarean section in patients with PAS. • Cesarean section without balloon occlusion and placenta accreta depth are two independent risk factors for EBL in patients with PAS.

Preoperative Prophylactic Balloon-Assisted Occlusion of the Internal Iliac Arteries in the Management of Placenta Increta/Percreta.

Background and Objectives: Preoperative prophylactic balloon-assisted occlusion (PBAO) of the internal iliac arteries minimizes blood loss and facilitates surgery performance, through reductions in the rate of uterine perfusion, which allow for better control in hysterectomy performance, with decreased rates of bleeding and surgical complications. We aimed to investigate the maternal and fetal outcomes associated with PBAO use in women with placenta increta or percreta. Material and Methods: The records of 42 consecutive patients with a diagnosis of placenta increta or percreta were retrospectively reviewed. Of 42 patients, 17 patients (40.5%) with placenta increta or percreta underwent cesarean delivery after prophylactic balloon catheter placement in the bilateral internal iliac artery (balloon group). The blood loss volume, transfusion volume, postoperative hemoglobin changes, rates of hysterectomy and hospitalization, and infant Apgar score in this group were compared to those of 25 similar women who underwent cesarean delivery without balloon placement (surgical group). Results: The mean intraoperative blood loss volume in the balloon group (2319 ± 1191 mL, range 1000-4500 mL) was significantly lower than that in the surgical group (4435 ± 1376 mL, range 1500-10,500 mL) (p = 0.037). The mean blood unit volume transfused in the balloon group (2060 ± 1154 mL, range 1200-8000 mL) was significantly lower than that in the surgical group (3840 ± 1464 mL, range 1800-15,200 mL) (p = 0.043). There was no significant difference in the postoperative hemoglobin change, hysterectomy rates, length of hospitalization, or infant Apgar score between the groups. Conclusion: PBAO of the internal iliac artery prior to cesarean delivery in patients with placenta increta or percreta is a safe and minimally invasive technique that reduces the rate of intraoperative blood loss and transfusion requirements.

Impact of placenta previa with placenta accreta spectrum disorder on fetal growth.

OBJECTIVES: To evaluate fetal growth in pregnancies complicated by placenta previa with or without placenta accreta spectrum (PAS) disorder, compared with in pregnancies with a low-lying placenta. METHODS: This was a multicenter retrospective cohort study of singleton pregnancies complicated by placenta previa with or without PAS disorder, for which maternal characteristics, ultrasound-estimated fetal weight and birth weight were available. Four maternal-fetal medicine units participated in data collection of diagnosis, treatment and outcome. The control group comprised singleton pregnancies with a low-lying placenta (0.5-2 cm from the internal os). The diagnosis of PAS and depth of invasion were confirmed at delivery using both a predefined clinical grading score and histopathological examination. For comparison of pregnancy characteristics and fetal growth parameters, the study groups were matched for smoking status, ethnic origin, fetal sex and gestational age at delivery. RESULTS: The study included 82 women with placenta previa with PAS disorder, subdivided into adherent (n = 35) and invasive (n = 47) PAS subgroups, and 146 women with placenta previa without PAS disorder. There were 64 controls with a low-lying placenta. There was no significant difference in the incidence of small-for-gestational age (SGA) (birth weight ≤ 10th percentile) and large-for-gestational age (LGA) (birth weight ≥ 90th  percentile) between the study groups. Median gestational age at diagnosis was significantly lower in pregnancies with placenta previa without PAS disorder than in the low-lying placenta group (P = 0.002). No significant difference was found between pregnancies complicated by placenta previa with PAS disorder and those without for any of the variables. Median estimated fetal weight percentile was significantly lower in the adherent compared with the invasive previa-PAS subgroup (P = 0.047). Actual birth weight percentile at delivery did not differ significantly between the subgroups (P = 0.804). CONCLUSIONS: No difference was seen in fetal growth in pregnancies complicated by placenta previa with PAS disorder compared with those without and compared with those with a low-lying placenta. There was also no increased incidence of either SGA or LGA neonates in pregnancies with placenta previa and PAS disorder compared with those with placenta previa with spontaneous separation of the placenta at birth. Adverse neonatal outcome in pregnancies complicated by placenta previa and PAS disorder is linked to premature delivery and not to impaired fetal growth. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Interpregnancy interval and abnormally invasive placentation.

INTRODUCTION: The presence of a previous uterine scar is a strong risk factor for developing abnormally invasive placentation (AIP). We sought to determine whether a short interpregnancy interval predisposes to AIP. We hypothesized that a short interpregnancy interval after a previous cesarean delivery increases the risk of AIP in comparison with a longer interpregnancy interval. MATERIAL AND METHODS: We performed a retrospective cohort study of women with a histological diagnosis of AIP and a history of a previous cesarean section. Women were included in the control group if they had a previous cesarean section with a placenta underlying the previous uterine scar or an anterior previa. The time interval between pregnancy and AIP data was analyzed using the chi-square test and two-tailed Fisher's exact test. RESULTS: There was no statistical difference in the interpregnancy interval between women who had AIP vs the control group. Gravidity and parity were found to be significantly higher in the women with AIP vs the controls. CONCLUSIONS: These results suggest that a short interpregnancy interval may not increase the risk of developing AIP.

Placenta percreta into the urinary bladder: the importance of the urologist.

The incidence of placenta accreta spectrum is on the rise. The most serious entity within this spectrum is percreta: extension beyond the uterus. The bladder is most commonly involved in these cases and is especially relevant for the urologist. Important sequelae include hemorrhage, massive transfusion, maternal mortality and urinary tract injury. Approaching this disorder as well as associated urinary tract involvement in a standardized and multi-disciplinary fashion significantly improves outcomes and reduces morbidity. Herein, we present a case of complete placenta percreta involving the bladder that was successfully managed with minimal obstetrical and genitourinary morbidity.

Multidisciplinary Approach to Placenta Percreta: An Observational Case Study.

Abnormal placental implantations can result in postpartum hemorrhage and poor outcomes. With proper diagnosis and preplanning, complications can be minimized and aligned with maternal wishes of abstaining from blood and blood product transfusions.

Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging.

Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. When first described 80 years ago, it mainly occurred after manual removal of the placenta, uterine curettage, or endometritis. Superficial damage leads primarily to an abnormally adherent placenta, and is diagnosed as the complete or partial absence of the decidua on histology. Today, the main cause of placenta accreta spectrum is uterine surgery and, in particular, uterine scar secondary to cesarean delivery. In the absence of endometrial reepithelialization of the scar area the trophoblast and villous tissue can invade deeply within the myometrium, including its circulation, and reach the surrounding pelvic organs. The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium. Placenta accreta spectrum was separated by pathologists into 3 categories: placenta creta when the villi simply adhere to the myometrium, placenta increta when the villi invade the myometrium, and placenta percreta where the villi invade the full thickness of the myometrium. Several prenatal ultrasound signs of placenta accreta spectrum were reported over the last 35 years, principally the disappearance of the normal uteroplacental interface (clear zone), extreme thinning of the underlying myometrium, and vascular changes within the placenta (lacunae) and placental bed (hypervascularity). The pathophysiological basis of these signs is due to permanent damage of the uterine wall as far as the serosa, with placental tissue reaching the deep uterine circulation. Adherent and invasive placentation may coexist in the same placental bed and evolve with advancing gestation. This may explain why no single, or set combination of, ultrasound sign(s) was found to be specific for the depth of abnormal placentation, and accurate for the differential diagnosis between adherent and invasive placentation. Correlation of pathological and clinical findings with prenatal imaging is essential to improve screening, diagnosis, and management of placenta accreta spectrum, and standardized protocols need to be developed.

Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis.

BACKGROUND: General anesthesia (GA) is often selected for cesarean deliveries (CD) with placenta previa and suspected morbidly adherent placenta (MAP) due to increased risk of hemorrhage and hysterectomy. We reviewed maternal outcomes and risk factors for conversion to GA in a cohort of patients undergoing CD and hysterectomy under neuraxial anesthesia (NA). METHODS: We performed a single-center, retrospective cohort study of parturients undergoing nonemergent CD for placenta previa with suspected MAP from 1997 to 2015. Patients were classified according to whether they received GA, NA, or intraoperative conversion from NA to GA. The primary outcome measure was postoperative acuity, defined as the need for intensive care unit admission, arterial embolization, reoperation, or ongoing transfusion with ≥3 units packed red blood cells. We additionally identified variables positively associated with intraoperative conversion from NA to GA during hysterectomy. Confounding was controlled with logistic regression models. RESULTS: Of 129 patients undergoing nonemergent CD for placenta previa with suspected MAP, 122 (95%) received NA as the primary anesthetic. NA was selected in the majority of patients with a body mass index ≥40 kg/m (9 of 10, 90%), a history of ≥3 prior CDs (18 of 20, 90%), suspected placenta increta or percreta (29 of 35, 83%), and Mallampati classification ≥3 (19 of 21, 90%). Of 72 patients with NA at the time of delivery who required hysterectomy, 15 (21%) required conversion to GA intraoperatively. Converted patients had a higher rate of major packed red blood cell transfusion (60% vs 25%; P = .01), with similar rates of massive transfusion (9% vs 7%; P = 1.0). Converted patients also had a higher incidence of postoperative acuity (47% vs 4%; P < .0001), including 5 intensive care unit admissions for airway management after large-volume resuscitation. After adjusting for multiple confounders, the only independent predictors of conversion among hysterectomy patients were longer surgical duration (adjusted odds ratio 1.54, 95% CI, 1.01-2.42) and a history of ≥3 prior CDs (adjusted odds ratio, 6.45; 95% CI, 1.12-45.03). CONCLUSIONS: NA was applied to and successfully used in the majority of patients with suspected MAP. Our findings support selective conversion to GA during hysterectomy in these patients, focusing on those with the highest levels of surgical complexity.

Pathophysiology of Placenta Accreta Spectrum Disorders: A Review of Current Findings.

Current findings continue to support the concept of a biologically defective decidua rather than a primarily abnormally invasive trophoblast. Prior cesarean sections increase the risk of placenta previa and both adherent and invasive placenta accreta, suggesting that the endometrial/decidual defect following the iatrogenic creation of a uterine myometrium scar has an adverse effect on early implantation. Preferential attachment of the blastocyst to scar tissue facilitates abnormally deep invasion of trophoblastic cells and interactions with the radial and arcuate arteries. Subsequent high velocity maternal arterial inflow into the placenta creates large lacunae, destroying the normal cotyledonary arrangement of the villi.

Comparison of temporary abdominal aortic occlusion with internal iliac artery occlusion for patients with placenta accreta - a non-randomised prospective study.

BACKGROUND: To compare the efficacy of temporary abdominal aortic occlusion with internal iliac artery occlusion for the management of placenta accreta. PATIENTS AND METHODS: 105 patients with placenta accreta were selected for treatment with temporary abdominal aortic occlusion (n = 57, group A) or bilateral iliac artery occlusion (n = 48, group B). Temporary abdominal aortic and internal iliac artery balloon occlusions were performed during caesarean sections. Data regarding the clinical success, blood loss, blood transfusion, balloon insertion time, fluoroscopy time, balloon occlusion time, foetal radiation dose, and complications were collected. RESULTS: Temporary abdominal aortic occlusion and bilateral internal iliac artery occlusion were technically successful in all patients. The amount of blood loss (P < 0.001), amount of blood transfusion (P < 0.001), balloon insertion time (P < 0.001), foetal radiation dose (P < 0.001) and fluoroscopy time (P < 0.01) in group A were significantly lower than those of patients in group B. No marked differences were found between these 2 groups with respect to age, mean postoperative hospital stay, balloon occlusion time, and Apgar score (p > 0.05). CONCLUSIONS: Temporary abdominal aortic balloon occlusion resulted in better clinical outcomes with less blood loss, blood transfusion, balloon insertion time, fluoroscopy time and foetal radiation dose than those in bilateral internal iliac balloon occlusion.
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[Placenta percreta as a cause of massive intraabdominal bleeding]. / Placenta percreta a její atypická lokalizace jako prícina silného nitrobrisního krvácení.

OBJECTIVE: To inform about a rare cause of massive intraabdominal bleeding due to perforation of uterine corner by unrecognized placenta percreta. DESIGN: Case report. SETTING: Department of Gynecology and Obstetrics, University Hospital Ostrava. CASE REPORT: We report a case of acute haemoperitoneum in pregnant woman at 34th week of gestation. We have detected the cause of the bleeding during emergency caesarean section - perforation of left uterine corner by placenta percreta. CONCLUSION: Placenta percreta is the most severe form of abnormal placental villous adherence. In rare cases, chorionic villi may penetrate surrounding organs and cause acute intraabdominal bleeding. Due to increasing number of surgical interventions on uterus, these disorders are on the rise. It is crucial to anticipate an abnormal placental villous adherence in women with atypical placenta localization. These women should be thoroughly observed and referred to perinatal center with intermediary or intensive care for further management before delivery.

[Severe Adverse Pregnancy Outcomes in Placenta Previa and Prior Cesarean Delivery].

OBJECTIVE: To investigate the severe adverse pregnancy outcomes in pregnancies with placenta previa and prior cesarean delivery and its risk factors. METHODS: This retrospective casecontrol study reviewed all pregnancies with placenta previa and prior cesarean delivery delivered by repeat cesarean section in our institution between January 2005 and June 2015,and investigated the incidence of severe adverse pregnancy outcome. A composite of severe adverse pregnancy outcomes (including transfusion of 10 units or more red blood cells,maternal ICU admission,unanticipated injuries,repeat operation,hysterectomy,and maternal death) and other maternal and neonatal outcomes were described. Univariate and multivariable logistic regression analysis were used to quantify the effects of risk factors on severe adverse pregnancy outcomes. RESULTS: There were 478 women with placenta previa and prior cesarean delivery in our hospital over the last decade. The average age of them was 32.5±4.8 years old,most women were beyond 30 years old,the average gravidity and parity were 4 and 1,131 cases (27.4%) had severe adverse pregnancy outcomes. Transfusion of 10 units or more red blood cells happened in 75 cases (15.7%,75/478); 44 cases (9.2%,44/478) necessitated maternal ICU admission; unanticipated bladder injury occurred in 11 cases,but non ureter or bowel injury happened; All 4 repeat operations were due to delayed hemorrhage after conservative management during cesarean delivery,and an emergent hysterectomy was performed for all of the 4 cases. Hysterectomy (107 cases,22.4%) was the most common severe adverse pregnancy outcome. Among all 311 morbidly adherent placenta cases finally confirmed by pathological or surgical findings or both,only 172 (55.3%) were suspected before delivery. Multivariable logistic regression analysis showed that the risk of severe adverse pregnancy outcomes was significantly increased by pernicious placenta previa (i.e. anterior placenta overlying the prior cesarean scar),suspicion of morbidly adherent placenta before delivery and hemoglobin before delivery lower than 100 g/L,and the corresponding odds ratios and 95% confidence intervals were 2.4 (1.5-3.8),3.6 (2.3-5.6) and 2.5 (1.6-3.9),respectively. CONCLUSION: Pernicious placenta previa,suspicion of morbidly adherent placenta before delivery and hemoglobin before delivery lower than 100 g/L were associated with severe adverse pregnancy outcomes in women with placenta previa and prior cesarean delivery .

The urologist's role in multidisciplinary management of placenta percreta.

OBJECTIVE: To evaluate urological interventions in patients with placental adhesive disorders in our collaborative experience at a tertiary referral centre. PATIENTS AND METHODS: We performed a retrospective analysis of a prospectively collected data set, consisting of all women that presented with placental adhesive disorders at the Royal Women's Hospital from August 2009 to September 2013. Patients who required urological intervention were identified and perioperative details were retrieved. RESULTS: Of the 49 women that presented with placental adhesive disorders, 36 (73.5%) underwent urological interventions. The patients were divided into three groups: planned hysterectomy (37 patients), planned conservative management (five) and undiagnosed placenta percreta (seven). In the planned hysterectomy group, 29 patients underwent preoperative cystoscopy and ureteric catheter placement. In 10 patients (34%), the placenta partially invaded the bladder and/or ureter, requiring urological repair. In the conservative management group, four underwent preoperative cystoscopy and ureteric catheter placement, and one case required closure of a cystotomy. Of the seven patients with undiagnosed percreta, two were noted to have bladder involvement requiring repair at the time of Caesarean hysterectomy. CONCLUSION: Patients with placental adhesive disorders frequently require urological intervention to prevent or repair injury to the urinary tract. These cases are best managed in specialist centres with multidisciplinary expertise including urologists and interventional radiologists.

Does the presence of placental basal plate myometrial fibres increase the risk of subsequent morbidly adherent placenta: a case-control study.

OBJECTIVE: Antenatal diagnosis of morbidly adherent placenta has been shown to improve outcomes, but existing predictors lack sensitivity. Our objective was to determine whether the presence of myometrial fibres attached to the placental basal plate (BPMYO) in an antecedent pregnancy is associated with subsequent morbidly adherent placenta. DESIGN: A case-control study. SETTING: Departments of Obstetrics and Gynecology and Pathology, Northwestern University, Chicago, IL, USA. SAMPLE: Women who had at least two pregnancies with placental pathological evaluation. METHODS: Cases were defined as women with evidence of morbidly adherent placenta (both clinically and pathologically) in their most recent pregnancy whereas women without evidence of morbidly adherent placenta served as controls. Pathological specimens of placentas from previous pregnancies were evaluated for BPMYO. The presence of BPMYO on a previous placenta was evaluated to determine whether it could be used to improve the antenatal diagnosis of morbidly adherent placenta. RESULTS: Of the 25 cases of morbidly adherent placenta, 19 (76%) had BPMYO present on their previous placenta compared with 41 (41%) of controls (odds ratio 4.8, 95% CI 1.8-13.0). Adding BPMYO to a regression including other risk factors for morbidly adherent placenta (i.e. maternal age, number of previous caesarean sections, placenta praevia, previous multiple gestation, any previous curettage, and ultrasonographic suspicion of placenta accreta) significantly improved the sensitivity of antenatal diagnosis of morbidly adherent placenta (61% versus 39%, P < 0.001) without a change in specificity (97% versus 97%, P = 1.00). CONCLUSION: BPMYO on previous placental pathology is associated with an increased risk of morbidly adherent placenta in a subsequent pregnancy. These findings may shed light on the pathophysiology of accreta and inform future research on predictors of accreta. TWEETABLE ABSTRACT: Previous basal plate myometrium improves the ability to detect subsequent morbidly adherent placenta.

Spontaneous uterine rupture at 28 weeks: A case report.

Spontaneous Uterine rupture is associated with massive intra-peritoneal bleed which can be fatal if not recognized. We report a case of 32 year old multigravida at 28 weeks of gestation with history of liver cysts, previous caesarean and uterine curettage, who presented with acute abdominal pain and tenderness; ultrasound revealed placenta percreta. CT abdomen showed haemoperitoneum. The patient underwent emergency caesarean hysterectomy due to uterine rupture at the cornual site.

Massive haemorrhage secondary to placenta percreta in the first trimester: a case report.

Placenta percreta detected in the first trimester is a very rare condition. It is a known obstetric condition leading to serious maternal morbidity and mortality. High index of clinical suspicion and anticipation of placenta percreta is highly essential in early pregnancy as it is difficult to diagnose. The authors report on a patient who presented with heavy pervaginal bleeding in week 9 of pregnancy. Pelvic examination showed a 12-week sized uterus. Ultrasonography revealed a non-viable fetus. The subsequent emergency curettage performed was complicated by massive haemorrhage which required an abdominal hysterectomy performed as a life-saving procedure.

Peri-operative management of hysterostomy in a parturient with complete heart block, placenta accreta and intrauterine death.

BACKGROUND: Complete heart block in pregnancy has serious implications particularly during the period of delivery. This is more so if the delivery is an operative one as the presence of heart block may produce haemodynamic instability in the intra operative period. We report a unique case of a pregnant mother with complete heart block undergoing hysterostomy, complicated by placenta accreta and intrauterine death. CASE PRESENTATION: A 37 year old Malaysian Chinese parturient was admitted at 25 weeks gestation following a scan which suggested intrauterine death and placenta accreta. She was diagnosed to have congenital complete heart block after her first delivery eight years previously but a pacemaker was never inserted. These medical conditions make her extremely likely to experience massive bleeding and haemodynamic instability. Among the measures taken to optimise her pre-operatively were the insertion of a temporary intravenous pacemaker and embolization of the uterine arteries to minimize peri-operative blood loss. She successfully underwent surgery under general anesthesia, which was relatively uneventful and was discharged well on the fourth post-operative day. CONCLUSION: Congenital heart block in pregnancies in the presence of potential massive bleeding is best managed by a team, with meticulous pre-operative optimization. Suggested strategies would include insertion of a temporary pacemaker and embolization of the uterine arteries to reduce the risk of the patient getting into life threatening situations.

[Efficacy and safety of intrauterine Bakri balloon tamponade in the treatment of postpartum hemorrhage: a multicenter analysis of 109 cases].

OBJECTIVE: To evaluate the efficacy and safety of the Bakri balloon in the treatment of postpartum hemorrhage (PPH). METHODS: A total of 109 patients with PPH who underwent Bakri balloon insertion after unsuccessful first- line medication from thirteen hospitals in Guangdong from Apr. 2013 to Oct. 2013 were recruited in this study. Bakri balloons were applied via vagina or abdomen depending on the delivery mode. The high risk factors and the causes of the PPH were analyzed. The bleeding volume of before and after placing Bakri balloon, the hemoglobin drop-out value, the interval time between the delivery and applying Bakri, the placement mode, staying time, and the complications were recorded. To stratified analyze the Bakri balloon hemostasis success rate and evaluate its safety. RESULTS: (1) The average amount of 24 hours PPH of all 109 cases was 1 523 ml. Successful hemostasis was achieved in 102 cases after Bakri balloon placement, defined as success group. In the other 7 cases, bleeding were not controlled, defined as failure group (six patients underwent hysterectomy). The overall Bakri balloon hemostasis successful rate was 93.6% (102/109), and the failure rate was 6.4% (7/109). The successful rate in cesarean section group was 94% (93/99), and in vaginal delivery group was 9/10. In the patients with placenta previa, placenta increta or scar uterus, the successful rate of Bakri balloon hemostasis was 88% (45/51), 13/16 and 95% (19/20), respectively, and were slightly below the overall successful rate. (2) Data showed that PPH volume after Bakri balloon placement was significantly lower in the success group (364 ml) than that in the failure group (1 533 ml, P < 0.05). However, the hemoglobin drop-off value and the case number that need blood transfusion had no statistically significant difference (P > 0.05). (3) The Bakri balloons were placed via vagina in 38 cases, and successful hemostasis was achieved in 36 cases, with the successful rate of 95% (36/38). The balloons were placed via cesarean section incision in 71 cases, and succeeded in 66 cases, the successful rate was 93% (66/71). There was no statistically significant difference between the two approaches. The retaining time of Bakri balloon was (22.0 ± 3.0) hours in success group and (3.0 ± 1.0) hours in failure group, with statistically significant difference (P < 0.05). (4) There was no intrauterine infection occurred. Ultrasound scan after 6 weeks postpartum found no abnormal signs in pelvis. All patients were followed up for 2-6 months postpartum, no complications were found. CONCLUSION: Bakri balloon tamponade is an effective, safe, simple and quick approach in the treatment of PPH.

Caesarean scar pregnancy: a precursor of placenta percreta/accreta.

In the last decade, diagnosis of caesarean scar (CS) pregnancy and abnormal placental invasion has gone up significantly. It appears that the history of previous caesarean section is the predisposing factor common to both conditions. Until now, these are treated as a separate entity and therefore managed differently. Recent available evidence suggests that these are not a separate entity but rather a continuum of the same condition. If the caesarean scar pregnancy is managed expectantly in the 1st trimester, most likely it evolves into placenta accreta. This leads invariably to peripartum hysterectomy for postpartum haemorrhage (PPH) and severe maternal morbidity. Early diagnosis and intervention may give a favourable outcome.