Management Of Placenta Accreta Research Articles

Association Between Myomectomy and Placenta Accreta Spectrum

Study Objective To examine the relationship between prior myomectomy and placenta accreta spectrum (PAS). Design A retrospective chart review of all laparoscopic and abdominal myomectomies performed between 2014 - 2016. Obstetrical outcomes following surgery were collected through April 2019. Setting An academic hospital with a comprehensive fibroid treatment center and a multidisciplinary treatment team dedicated to the management of placenta accreta. Patients or Participants All patients who underwent a laparoscopic myomectomy (standard and robotic-assisted) or abdominal myomectomy between 2014 - 2016. Interventions Demographics, pelvic imaging, intraoperative findings, fibroid burden on final pathology, and future mode of delivery recommendations were collected for each procedure. Subsequent obstetrical outcomes including clinical pregnancy, antepartum imaging suspicious for PAS, mode of delivery, clinical diagnosis of PAS, and pathologic PAS were collected for all patients. Measurements and Main Results Of 315 patients who underwent myomectomy between 2014 - 2016, 43 patients subsequently became pregnant, resulting in 23 deliveries (7.3%). 16 of 20 patients underwent a cesarean delivery due to history of a prior myomectomy, 13 of which had a documented endometrial cavity entry at time of myomectomy. There were three cases of clinical PAS at time of delivery, all associated with a prior abdominal myomectomy. Two cases had PAS confirmed on final pathology. Two cases were associated with possible intrauterine synechiae identified during a uterine cavity evaluation following myomectomy, prior to conception. Only one case had antepartum imaging concerning for PAS. There were no cases of PAS amongst patients who had undergone a laparoscopic myomectomy. Conclusion PAS was associated with prior abdominal but not laparoscopic myomectomy. The subsequent development of intrauterine synechiae following abdominal myomectomy may be an identifiable finding during postoperative uterine cavity evaluation. This finding may help stratify the risk of PAS following myomectomy prior to conception, and better guide preoperative risk counseling prior to cesarean delivery.

Comparison of the efficacy of prophylactic balloon occlusion of the abdominal aorta at or below the level of the renal artery in women with placenta accreta undergoing cesarean section

Objective To compare the safety and efficacy of prophylactic balloon occlusion of the abdominal aorta (PBOA) performed at the level of the renal artery (PBOA-ARA) or below this level (PBOA-BRA) for the management of placenta accreta. Methods We conducted a retrospective investigation of 57 women scheduled for cesarean delivery who underwent PBOA at our hospital between October 2015 and July 2017. The balloon occlusion was performed at (PBOA-ARA group; n = 30) or below (PBOA-BRA group; n = 27) the renal artery origin. The perioperative data of the two groups were compared. Results Estimated blood loss was lower in the PBOA-ARA group than in the PBOA-BRA group (p > .05). There were no intergroup differences in intraoperative blood transfusion volume, hemoglobin reduction, urine output, and serum levels of creatinine and blood urea nitrogen. Postballoon release hemorrhage occurred in eight patients of the PBOA-BRA group, but in none of the PBOA-ARA group, indicating a significant difference (p = .007). Subgroup analysis of placenta types revealed that the estimated blood loss among women with placenta increta in the PBOA-ARA group was less than that in the PBOA-BRA group (p = .015), which was reflected by a significant difference in the reduction of hemoglobin levels (p = .042). Conclusions PBOA at the level of the renal artery entailed lesser blood loss than that performed below the renal artery origin, particularly in the case of placenta increta; this, in turn, reduces the risk of postpartum hemorrhage from ovarian arteries and subsequent blockade of the ovarian artery origin.

Retrospective analysis of 586 cases of placenta previa and accreta

In this study, we conducted a retrospective investigation of all cases of placenta previa and accreta that were treated at a tertiary-level hospital to assess the effectiveness of balloon catheterisation at different levels. We evaluated the surgical and neonatal outcomes of 586 cases of placenta previa and accreta that were treated at our facility. This is the largest study of its kind. Depending on the severity and position of accreta, patients underwent balloon catheter placement in the aorta (n = 252) or common iliac artery (n = 38) before delivery by caesarean section. Data were collected regarding the duration of the surgery, number of cases (percentage) of balloon occlusion, and annual rate of hysterectomy. The blood loss (2207.89 ± 2044.95 ml) and transfusion volume (7.42 ± 7.872 U) in the common iliac occlusion group was greater than those in the aortic occlusion group (1967.66 ± 1466.64 ml and 6.54 ± 5.67 U, respectively); however, this difference did not reach statistical significance (p > .05). With the increase in the number of procedures performed over the years of study, the surgeons’ skills improved significantly. The choice of balloon catheterisation must be made with careful consideration. Our results highlight the significance of suture skill and the experience level of surgeons.IMPACT STATEMENTWhat is already known on this subject: The optimal method for the management of placenta accreta remains debateable. Prophylactic balloon catheters placed within arteries to control intraoperative bleeding play an important role in the management of patients with placenta accreta.What the results of this study add: The common iliac artery occlusion group tended to have a greater amount of blood loss and a higher requirement of transfusion than the aortic occlusion group; however, this difference was not statistically significant. We also analysed the difference in the complications across different periods of the study period and observed a clear improvement in the operative procedures over time.What the implications are of these findings for clinical practice and/or further research: Our study revealed that the surgeons’ proficiency increases over time, leading to improved results and a lower rate of hysterectomy over the course of several years. We recommend that the choice for balloon catheter occlusion be made with caution and after careful consideration.

Feasibility of HIFU for Management of Placenta Accreta (HIFU-ACCRETA)

Feasibility of HIFU for Management of Placenta Accreta (HIFU-ACCRETA)

The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: a case-control study

Objective: While surgical management is the treatment of choice for abnormally invasive placenta, the role of supracervical hysterectomy in this setting is not well established. We aimed to compare supracervical versus total cesarean hysterectomy as a surgical option for abnormally invasive placenta.Methods: We carried out an 8-year retrospective case-control study. Six cases of a patient treated by total hysterectomy were matched and compared to 30 controls treated by supracervical hysterectomy. Matching of cases with controls was based on coexisting placenta previa, a number of previous cesarean sections, and age, with five controls per case. Cases and controls were comparable in placental invasion topography. We compared the operative approach in all histologically identified cases of abnormally invasive placenta.Results: Overall, 36 women with histologically proven abnormally invasive placenta were identified. Composite blood products morbidity was higher among total hysterectomy patients (p = .02). Freshly frozen plasma utilization was greater among total hysterectomy patients (p = .01). Median operative time (142 ± 48 versus 136 ± 58 minutes) and hospitalization time (8.9 ± 3.1 versus 7.3 ± 1.5 days) were comparable between those who underwent supracervical versus total hysterectomy (p > .05). No case of maternal or neonatal death was encountered.Conclusion: The favorable maternal and perinatal outcomes observed in our study, suggest that supracervical hysterectomy should be considered as the first-line approach in cases of abnormally invasive placenta managed operatively.

Detection of Asherman\u2019s syndrome after conservative management of placenta accreta: a case report

BackgroundWe present a case involving conservative treatment of placenta accreta, with a subsequent diagnosis of Asherman’s syndrome.Case presentationA 41-year-old Japanese woman (G2P0A2) delivered a healthy male infant via cesarean section due to preeclampsia. The placenta did not spontaneously separate and was manually removed. Adhesion was tight and placenta accreta was diagnosed. During the procedure, no uterine inversion or perforation, and no uterine cavity adhesion, were observed. Four months postoperatively, hysteroscopy was performed. Adhesion was detected at the fundus of her uterus where the placenta had adhered to the uterus. Asherman’s syndrome was diagnosed.ConclusionsAsherman’s syndrome might occur after conservative management of placenta accreta, which may be a direct cause of placenta accreta recurrence. When Asherman’s syndrome is diagnosed, the site of the placenta and adhesion should be monitored during subsequent pregnancies.

Evaluation of three-step procedure (Shehata's technique) as a conservative management for placenta accreta at a tertiary care hospital in Egypt

ObjectiveTo evaluate the benefits and risks of three-step technique as a conservative treatment for women with placenta accreta and desiring future fertility. Study designThis study is a retrospective study where the files of 91 cases of placenta accreta managed by three-step technique were reviewed. This study was conducted at Tanta University Hospitals in the period from June 1, 2015 to May 31, 2017. All demographic and operative data were extracted and recorded. ResultsThe mean age was 32.44±2.72 years; the mean operative time was 81.65±15.68min. The mean gestational age at operation was 35.67±1.19 weeks. The technique succeeded to preserve the uterus in 86 cases and failed in 5 cases. There was no cases required ICU admission with mean hospital stay of 3.065±1.04 days. The postoperative morbidities were mild and in the form of fever (n=9) and wound sepsis (n=4), pyometra (n=1) and secondary hemorrhage (n=1). ConclusionThe three-step procedure is effective as a uterine sparing technique in management of placenta accreta with success rate of 94.5%. The operative and postoperative complications were minimal and expected in such case.

Clinical pearls part 3: anaesthetic management of abnormally invasive placentation.

Abnormal placentation is a clinical condition seen increasingly in the pregnant population. It is associated with significant morbidity and mortality, which may be mitigated through robust multidisciplinary care for these patients. The role of maternal critical care for these patients has largely been ignored in the literature. Advances in pharmacological management of bleeding with recent publications of large multicentre trials in addition to new technologies in the management of massive obstetric haemorrhage (MOH) have revolutionized the management of abnormal placentation. These include the use of tranexamic acid, interventional radiology, cell saver technology, and point-of-care coagulation tests. The role of maternal critical care for the optimization of postoperative complications and physiological derangements has not been considered widely in the literature. This article summarizes the current evidence for interventions and suggests a protocol for the management of these high-risk patients. A robust protocol outlining the key elements of the management of placenta accreta, including optimizing postoperative care, should be in place to promote desired outcomes.

Conservative Management of Placenta Accreta of Seven Cases

Introduction: Placenta accreta is a potentially life threatening obstetrical condition. The incidence has increased. Diagnosis before delivery allows multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. Prenatal ultrasonography is used to support the diagnosis and guide clinical management leading probably to favorable outcomes. Actually a conservative option which includes leaving all or part of the placenta in situ when fertility preservation is desired is recommended. Methods: We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta in gynecology-obstetrics department of the university hospital Mohammed the VI of Marrakesh; Morocco; from January the first 2014 to January the second 2016. Results: We found seven cases. We described: The epidemiological characteristics, risk factors, management of placenta accreta, outcomes and prognosis. The incidence of placenta accreta was 1/3847 deliveries. The mean term of delivery was 35 weeks. We have adopted a successful conservative treatment in six cases (71.4%). The radical treatment was adopted in one patient initially admitted for severe post-partum hemorrhage; the prognosis was good in 85.7% cases. Conclusion: Conservative management of placenta accreta is a safe and efficient and is an interesting alternative for hysterectomy.

Uterine Rupture Secondary to Placenta Percreta on Previa: A Case Report of Successful Management by Caesarian Hysterectomy

Background: Placenta accreta is a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall. Its incidence is growing due to the rising rate of cesarean sections and advanced maternal age on delivery. It is becoming the foremost cause of obstetric hemorrhage leading to significant maternal and fetal morbidity and even mortality. Rarely placenta accreta may lead to spontaneous uterine rupture in the second or third trimester. Case report: A 28-year-old woman gravida 4, para 3, was admitted at the maternity ward of Mendefera regional referral hospital, at a gestational age of 27 weeks due to vaginal bleeding. She had history of 3 time’s caesarian section. At admission her vital sign was stable and her complete blood count was normal, ultrasound showed anterior placentation with partial placenta previa. She was given Dexamethasone 6 gm. IM twice daily for 2 days to enhance lung maturity. At 36 weeks of gestation, she experienced massive vaginal bleeding. A decision was made to perform emergency cesarean section. The possibility of morbidly adherent placenta was considered. Intra-operatively, the placenta was found with engorged blood vessels under the rectus fascia with ruptured uterus and there was adhesion of rectus sheath with part of the uterus. A transverse uterine incision was made at the upper border of the placental attachment to uterus to deliver the fetus. After successful delivery of the fetus, the placenta was found to be densely adhered to the lower uterine segment, penetrating through it and adhered to the posterior wall of the urinary bladder. It was decided to do caesarian hysterectomy with the placenta left in situ. During discharge both the mother and the baby were in good condition. Conclusion: Placenta accreta is a potentially life-threatening obstetric condition that requires a meticulous approach to management. If a multiparous woman with a previous caesarian section is found to have placenta previa, the possibility of placenta accreta should be considered in the diagnosis of the patient. Grayscale ultrasonography is sufficient for the diagnosis of placenta accreta. The recommended management of placenta accreta is planned caesarian hysterectomy.

Maternal outcomes after different surgical techniques in placenta accreta: a prospective study

Background Placenta accreta (PA) is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management nowadays owing to increased incidence of PA in parallel with the increased cesarean section rates. With the age of the patients with PA getting younger and fertility preservation being required, until now, there is no unique approach to management of PA. Objective The purpose of this study was to describe the efficacy and safety of different surgical procedure in conservative treatment of PA to evaluate their role in minimizing major surgical intervention, especially hysterectomy with its comorbidities. Patients and methods This prospective, surgical case-series study included 49 consecutive patients with PA who were prenatally diagnosed by ultrasound or MRI at the Department of Gynecology and Obstetrics of Shebin El-Kom Teaching Hospital (Menoufia, Egypt) from August 2012 to July 2017, and informed consent was obtained from all participants before surgery. We recorded demographic profile, obstetric characteristics of patients, operative parameters of patients, and surgical outcomes. Results In this 5-year period, among 12 250 deliveries, only 49 patients met the diagnostic criteria of placenta accrete (4/1000). In our study group, the patients’ mean age at delivery was 30.45 (5.5) years, and their mean BMI was 28.5 (2.5). Overall, 33 patients were scheduled for cesarean section and 16 patients were emergency cesarean cases owing to active bleeding or labor. In 12 (24.49%) patients in this study, the attempts of delivery by cesarean plus different surgical techniques failed because of immediate heavy bleeding originating from cervix that necessitated emergent hysterectomy as a life-threating condition. The rate of successful uterine preservation was high (77.27%) in uterine artery ligation and internal iliac artery ligation, 70% in uterine artery ligation and ovarian artery ligation, and 70% in Shehata's simple procedure, but low in modified B-lynch suture (40%) and in one-step procedure (50%). Maternal mortality rate was 2.04%, including one maternal death. Conclusion Our surgical approaches are effective and successful in minimizing major surgical interventions especially hysterectomy with its comorbidities in PA management. Nevertheless, the best policy remains a matter of debate.

Cornual Placenta Accreta Managed with Mini Modifified B-Lynch Suture Technique

Placenta accreta represents abnormal, firmly adherent placental implantation with invasion into the uterine wall. The consequence of partial or complete absence of decidua basalis and defective formation of the Nitabuch (fibrinoid) layer are considered in the pathogenesis. A 35-yearold woman attended our emergency clinic, having been diagnosed with preterm premature rupture of the membranes at 23 weeks' gestation. She was delivered by cesarean section at 26 weeks' gestation. During caesarean section, it was determined that the placenta was located in the right cornual region of the uterus and adhered there with the appearance of placenta accreta. The patient was treated with mini-modified B-Lynch suture.

Outcome of Stepwise Uterine Sparing Approach as a Conservative Surgical Management of Placenta Accreta

Outcome of Stepwise Uterine Sparing Approach as a Conservative Surgical Management of Placenta Accreta

Comparison of results of Bakri balloon tamponade and caesarean hysterectomy in management of placenta accreta and increta: a retrospective study

The aim of this study was to compare the postoperative results of the patients who were treated with Bakri balloon tamponade or hysterectomy for placenta accreta and increta. Patients who were diagnosed with placenta accreta or increta preoperatively and intraoperatively and treated with Bakri balloon tamponade (Group 1) or caesarean hysterectomy (Group 2) were compared in regards to the postoperative results. Among the 36 patients diagnosed with placenta accreta or increta, 19 patients were treated with Bakri balloon tamponade while 17 cases were treated with hysterectomy. Intraoperative blood loss amount was 1794 ± 725 ml in G1, which was lower than that in G2 (2694 ± 893 ml). Blood transfusion amount was 2.7 ± 2.6 units in G1, lower than that in G2 (5.7 ± 2.4 units), too. Operation time was 64.5 ± 29 min and 140 ± 51 min in G1 and G2, respectively, showing significant differences between two groups. The success rate of Bakri balloon was determined as 84.21%. In conclusion, cases with placenta accreta/increta, with predicted placental detachment who are willing to preserve fertility, application of uterine balloon tamponade devices before the hysterectomy is encouraging with its advantages compared with the hysterectomy. Impact statement What is already known on this subject: Invasive placental anomalies are the most common indication of postpartum hysterectomy. Recently, uterine balloon tamponade was also included in the treatment modalities of postpartum haemorrhage.This study aimed to compare the postoperative results of UBT or hysterectomy for patients with placenta accreta and increta. What the results of this study add: In this study, the total amount of blood loss was higher in the caesarean hysterectomy group when compared with the Bakri balloon tamponade group. The mean transfusion requirement, mean operation time and hospitalisation period was significantly longer in the caesarean hysterectomy group. The success rate of the Bakri balloon was determined as 84.21%. Two patients who were treated with balloon application had a successful pregnancy and delivery later. Maternal mortality was reported in neither balloon nor hysterectomy groups. What the implications are of these findings for clinical practice and/or further research: In conclusion, patients diagnosed with placenta accreta/increta with ultrasound should be taken into the operation in elective conditions, if possible, on lithotomy position. In cases with predicted placental detachment that are willing to preserve fertility, application of uterine balloon tamponade devices before the hysterectomy has advantages compared with the hysterectomy.

On opportunity for emergency cesarean hysterectomy and pregnancy outcomes of patients with placenta accreta.

Effective diagnosis and clinical management of placenta accreta (PA) in China are not clear. The purpose of the study was to analyze the risk factors and diagnosis of PA, maternal and neonatal outcomes in patients with PA. It was a retrospective study of cases with PA, confirmed by histologically and/or clinically suspected during 3 years in 2 tertiary referral hospitals. The incidence rate of patients with PA, who had history of artificial abortion, cesarean section (CS), and placenta previa (PP) was 94%, 70%, and 72%, respectively. In 29 patients of scheduled CS group, 12 cases were performed with cesarean hysterectomy. Mean estimated blood loss (EBL) was 1.5 L, and 17 babies were admitted to neonatal intensive care unit (NICU). In the 18 cases of emergency CS group, 6 cases were performed cesarean hysterectomy. Mean EBL was 2.4 L, and 16 babies were admitted to NICU. The difference of mean EBL, cases of fetal admitted to intensive care unit in 2 groups was significant difference (P < .05).Women with history of uterine curettage, CS or PP are more likely to have PA. PA should be diagnosed early and accurately via ultrasound and magnetic resonance imaging. Maternal and neonatal outcomes in the scheduled CS are better than in emergency CS. Emergency peripartum hysterectomy is a feasible method under the circumstances of heave, fast bleeding, and the failure of conservative surgery.

Management of placenta accreta in an Australian tertiary referral centre: a ten-year experience

To report a ten-year experience in management of a highly morbid obstetrical condition in placenta accreta (PA) at a tertiary referral centre, uniquely equipped with an integrated Interventional Radiology theatre, with a primary aim to guide best practice. Retrospective analysis of all histologically proven PA cases at a tertiary centre in Australia between January 2004 and December 2013. Medical records were reviewed for obstetrics history, operative details, post-operative management and neonatal outcome. Sixteen cases of PA were identified during the tinie period; 75% had identifiable risk factors for PA and 87.5% of patients were diagnosed antenatally. Mean gestational age at time of delivery was 34 ±3.4 weeks. Ten cases were performed electively, while the remaining underwent emergency caesarean section. One patient was managed conservatively with placenta left insitu; time to complete resolution of placenta was 71 days. Among patients who underwent hysterectomy (15/16), the proportion of total (n=8) vs. subtotal (n=7) hysterectomy was similar. Average operating time was 123 ± 45.9 minutes. Compared to emergency cases, patients who underwent elective surgery had significantly lower blood loss (2.2 vs. 3.1 L, p < 0.05). Common iliac artery balloons were deployed in eight cases, with a non-statistically significant reduction in intraoperative blood loss (2 vs. 3.2 L, p < 0.05). Fifty percent of patients required ICU admission. Neonatal survival at six months was 93.75% (15/16). The present report demonstrates the importance of timely diagnosis and comprehensive preparation in the surgical management of patients with placenta accreta. The availability of relevant services in the peri-operative phase, including: obstetricians, interventional radiology facility and personnel, intensive care, and neonatology teams, are crucial in achieving optimal outcome for the patient and neonate. In line with reports in the literature, the authors advocate a team-based multidisciplinary approach in a tertiary-level centre for management of this high-risk condition.

Anesthetic and Obstetric Management of Placenta Accreta: Clinical Experience and Available Evidence

Abnormally implanted, invasive, or adherent placenta has become one of the most serious problems in obstetrics, comprising a leading cause of maternal hemorrhage, the most common cause of peripartum hysterectomy and an increasingly important contributor to cesarean delivery morbidity. Currently, up to 3 in 1000 pregnancies in the USA are complicated by placenta accreta, increta, or percreta, and the incidence is increasing in parallel with the rising cesarean delivery rate. Yet, despite the high morbidity and mortality associated with placenta accreta, consensus guidelines are lacking regarding the management of women with this condition.

Comparison of Two Protocols for Management of Placenta Accreta at a Tertiary Care Center in Pakistan

ABSTRACT Objectives To evaluate the morbidity of placenta accreta when managed by two different protocols. Materials and methods All women with placenta accreta coming to Abbasi Shaheed Hospital were included and divided in two groups. Group I included all women with accreta who were managed by lower segment transverse incision in the year 2013. Group II included all women whose accreta was dealt with classical incision in the year 2014. Morbidity from placenta accreta in all these cases was assessed. Results A total of 4220 deliveries took place during study. Placenta accrete was diagnosed in 24 cases (incidence = 0.0056%). Mean age of patients in group II was 28.58 ± 3.28 years and in group I was 29.75 ± 2.18 years. Blood products were received by 9(75%) patients in group I, and by 1(8.33%) in group II (p = 0.002). Intensive care unit admissions in group I were 75% and 25% in group II (p = 0.014). Renal sequelae occurred in 7 women in group I (58.3%) whereas none were observed in group II (p = 0.002). The mean duration of hospital stay was 9.83 ± 2.95 days in group I and 2.75 ± 1.215 days in group II. Conclusion Prevention of massive hemorrhage is the key factor in reducing maternal morbidity in placenta accreta cases. Clinical significance Dealing with accreta via midline incision in low resource settings leads to reduced morbidity. How to cite this article Izhar R, Husain S, Tahir S, Husain S. Comparison of Two Protocols for Management of Placenta Accreta at a Tertiary Care Center in Pakistan. J South Asian Feder Obst Gynae 2017;9(1):18-24.

Uterine artery embolization for management of placenta accreta, a single-center experience and literature review

“Morbidly adherent placenta” is a term that describes the continuum of placenta accreta, increta, and percreta. Placenta accreta is the least invasive form, whereas placenta percreta represents a complete penetration of the trophoblast through the uterus that reaches the serosal surface and potentially invades the bladder, rectal wall, and pelvic vessels. Leaving the placenta in situ in the setting of abnormally invasive placenta is now widely practiced. We herein present three cases of abnormal placental implantation diagnosed by antenatal ultrasound and magnetic resonance imaging, in which uterine artery embolization was performed to induce placental infarction and eventually rapid regression but most importantly to minimize peripartum and postpartum bleeding. As we do this, we sought to review the risks of placenta accreta, increta, and percreta and evaluate the role of endovascular therapy to improve maternal outcomes when abnormal placental implantation occurs.

Uterine Artery Embolization for Management of Placenta Accreta, a Single-center Experience and Literature Review

Abstract“Morbidly adherent placenta” is a term that describes the continuum of placenta accreta, increta, and percreta. Placenta accreta is the least invasive form, whereas placenta percreta represents a complete penetration of the trophoblast through the uterus that reaches the serosal surface and potentially invades the bladder, rectal wall, and pelvic vessels. Leaving the placenta in situ in the setting of abnormally invasive placenta is now widely practiced. We herein present three cases of abnormal placental implantation diagnosed by antenatal ultrasound and magnetic resonance imaging, in which uterine artery embolization was performed to induce placental infarction and eventually rapid regression but most importantly to minimize peripartum and postpartum bleeding. As we do this, we sought to review the risks of placenta accreta, increta, and percreta and evaluate the role of endovascular therapy to improve maternal outcomes when abnormal placental implantation occurs.