Placenta accreta spectrum (PAS) is associated with substantial intraoperative hemorrhage. Abdominal aortic balloon occlusion (AABO) has been introduced to mitigate blood loss, though its benefit remains debated. This study, registered at ClinicalTrials.gov (NCT06721182), assessed maternal outcomes in women with PAS undergoing cesarean delivery managed either with abdominal aortic balloon occlusion or standard surgical care alone. The study (n = 65) and control (n = 75) groups were randomly assigned. Primary outcomes were estimated intraoperative blood loss and transfusion requirements. Secondary outcomes included operative time, hysterectomy, intensive care unit (ICU) admission, length of hospitalization, and complications. Management with AABO was associated with a reduction in estimated intraoperative blood loss (1433.08 ± 1064.97 mL for AABO vs. 2213.33 ± 1574.06 mL in control) and lower transfusion requirements (687.48 ± 979.23 mL for AABO vs. 1161.84 ± 1140.33 mL in control). The incidence of hysterectomy was lower among patients managed with AABO; while this difference was not statistically significant, it was regarded as clinically important. No significant differences were observed in ICU admission rates, duration of hospital stay, or operative time. Procedure-related complications were observed. AABO was associated with lower perioperative blood loss and transfusion requirements, without an increase in overall complications.