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The evolution of multidisciplinary team-based care for women with placenta accreta spectrum (PAS) disorder has delivered step-wise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care, and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy in order to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe PAS disorder.

Objective To determine whether circulating fetal levels of the vasodilator atrial natriuretic peptide (ANP) are reduced in pregnancies complicated by intrauterine growth retardation (IUGR). Design Prospective observational study. Setting Subjects 25 normal singleton pregnancies delivered at term by spontaneous vertex delivery (n = 16) or by elective caesarean section (n= 9), and a series of 14 singleton pregnancies complicated by IUGR. Intervention Measurement of ANP by radio-immunoassay in maternal venous, umbilical artery, and umbilical vein plasma from a series of normal, and IUGR pregnancies. Main outcome measures Comparison of plasma ANP levels between the three groups; relation between fetal ANP, Po, and pH. Results Mode of delivery did not influence either maternal, umbilical artery or umbilical vein plasma A N P levels in normal term singleton pregnancies. Umbilical vein ANP levels were significantly higher in the I U G R group when compared with normal pregnancies at term (mean 66 95%, CI 36-122 vs mean 37, 95% C I 29-47 pgiml, P = 0.03) and were inversely related to umbilical artery p H (R2 = 65%;Conclusions These data suggest that umbilical vein ANP levels are elevated in pregnancies complicated by IUGR, and rise appropriately in response to the stress of acidosis. In the absence of any receptor or second messenger defect within fetoplacental vascular smooth muscle, these data suggest that ANP is not directly implicated in the vascular pathophysiology of IUGR.University teaching hospital and research laboratory.

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