Objective. Massive postpartum hemorrhage (PPH) is one of the most serious complications during delivery. Hysterectomy is commonly performed when other conventional treatment attempts fail. Bakri balloon tamponade (BBT) is a novel conservative management option for PPH. Little is known of the effectiveness of this procedure. We report a large case series from a tertiary teaching hospital. Design. Retrospective case series (October 2008–June 2011). Setting. University teaching hospital. Population. Forty‐four women with massive PPH (blood loss >1000 mL) and six other women with expected high risk of PPH (blood loss <1000 mL) managed by BBT. Methods. Chart review. Main outcome measures. Achievement of definitive hemostasis by BBT among the study population. Results. Among the women treated with BBT, the cause of PPH was uterine atony (16%), cervical rupture (14%), vaginal rupture and/or paravaginal hematoma (22%), placenta previa (18%) and placental retention (30%). The overall success rate was 86%. Seven of the 50 patients needed additional procedures. Of the seven failures, supravaginal uterine amputation or hysterectomy was required in four cases and embolization of the uterine arteries in three cases. Conclusions. BBT is a simple, readily available, effective and safe procedure for the management of PPH in selective cases. BBT does not exclude the use of other procedures if necessary. Even if BBT failed, it may provide temporary tamponade and time to prepare for other interventions or transportation from local hospital to tertiary centre. We suggest that BBT should be included in the PPH protocol.

Introduction: Placenta accreta spectrum (PAS) is a condition often resulting in severe maternal morbidity. Scheduled delivery by an experienced team has been shown to improve maternal outcomes; however, the benefits must be weighed against the risk of iatrogenic prematurity. The aim of this study is to investigate the rates of emergency delivery seen for antenatally suspected PAS and compare the resulting outcomes in the 15 referral centers of the International Society for PAS (IS‐PAS).Material and methods: Fifteen centers provided cases between 2008 and 2019. The women included were divided into two groups according to whether they had a planned or an emergency cesarean delivery. Delivery was defined as “planned” when performed at a time and date to suit the team. All the remaining cases were classified as “emergency”. Maternal characteristics and neonatal outcomes were compared between the two groups according to gestation at delivery.Results: In all, 356 women were included. Of these, 239 (67%) underwent a planned delivery and 117 (33%) an emergency delivery. Vaginal bleeding was the indication for emergency delivery in 41 of the 117 women (41%). There were no significant differences in terms of blood loss, transfusion rates or major maternal morbidity between planned and emergency deliveries. However, the rate of maternal intensive therapy unit admission was increased with emergency delivery (45% vs 33%, P = .02). Antepartum hemorrhage was the only independent predictor of emergency delivery (aOR: 4.3, 95% confidence interval 2.4‐7.7). Emergency delivery due to vaginal bleeding was more frequent with false‐positive cases (antenatally suspected but not confirmed as PAS at delivery) and the milder grades of PAS (accreta/increta). The rate of infants experiencing any major neonatal morbidity was 25% at 34⁺¹ to 36⁺⁰ weeks and 19% at >36⁺⁰ weeks.Conclusions: Emergency delivery in centers of excellence did not increase blood loss, transfusion rates or maternal morbidity. The single greatest risk factor for emergency delivery was antenatal hemorrhage. When adequate expertise and resources are available, to defer delivery in women with no significant antenatal bleeding and no risk factors for pre‐term birth until >36⁺⁰ weeks can be considered to improve fetal outcomes. Further studies are needed to investigate this fully.

Introduction: Placenta accreta spectrum (PAS) carries a high burden of adverse maternal outcomes, especially significant blood loss, which can be life‐threatening. Different management strategies have been proposed but the association of clinical risk factors and surgical management options during cesarean delivery with high blood loss is not clear.Material and methods: In this international multicenter study, 338 women with PAS undergoing cesarean delivery were included. Fourteen European and one non‐European center (USA) provided cases treated retrospectively between 2008 and 2014 and prospectively from 2014 to 2019. Peripartum blood loss was estimated visually and/or by weighing and measuring of volume. Participants were grouped based on blood loss above or below the 75th percentile (>3500 ml) and the 90th percentile (>5500 ml).Results: Placenta percreta was found in 58% of cases. Median blood loss was 2000 ml (range: 150‐20 000 ml). Unplanned hysterectomy was associated with an increased risk of blood loss >3500 ml when compared with planned hysterectomy (adjusted OR [aOR] 3.7 [1.5‐9.4], p = 0.01). Focal resection was associated with blood loss comparable to that of planned hysterectomy (crude OR 0.7 [0.2–2.1], p = 0.49). Blood loss >3500 ml was less common in patients undergoing successful conservative management (placenta left in situ, aOR 0.1 [0.0–0.6], p = 0.02) but was more common in patients who required delayed hysterectomy (aOR 6.5 [1.7–24.4], p = 0.001). Arterial occlusion methods (uterine or iliac artery ligation, embolization or intravascular balloons), application of uterotonic medication or tranexamic acid showed no significant effect on blood loss >3500 ml. Patients delivered by surgeons without experience in PAS were more likely to experience blood loss >3500 ml (aOR 3.0 [1.4–6.4], p = 0.01).Conclusions: In pregnant women with PAS, the likelihood of blood loss >3500 ml was reduced in planned vs unplanned cesarean delivery, and when the surgery was performed by a specialist experienced in the management of PAS. This reinforces the necessity of delivery by an expert team. Conservative management was also associated with less blood loss, but only if successful. Therefore, careful patient selection is of great importance. Our study showed no consistent benefit of other adjunct measures such as arterial occlusion techniques, uterotonics or tranexamic acid.

Placenta accreta spectrum is a pregnancy complication associated with severe morbidity and maternal mortality especially when not suspected antenatally and appropriate management instigated. Women in resource‐limited settings are more likely to face adverse outcomes due to logistic, technical, and resource inadequacies. Accurate prenatal imaging is an important step in ensuring good outcomes because it allows adequate preparation and an appropriate management approach. This article provides a simple three‐step approach aimed at guiding clinicians and sonographers with minimal experience in placental accreta spectrum through risk stratification and basic prenatal screening for this condition both with and without Doppler ultrasound.

Introduction: Management options for women with placenta accreta spectrum (PAS) comprise termination of pregnancy before the viable gestational age, leaving the placenta in situ for subsequent reabsorption of the placenta or delayed hysterectomy, manual removal of placenta after vaginal delivery or during cesarean section, focal resection of the affected uterine wall, and peripartum hysterectomy. The aim of this observational study was to describe actual clinical management and outcomes in PAS in a large international cohort.Material and methods: Data from women in 15 referral centers of the International Society of PAS (IS‐PAS) were analyzed and correlated with the clinical classification of the IS‐PAS: From Grade 1 (no PAS) to Grade 6 (invasion into pelvic organs other than the bladder). PAS was usually diagnosed antenatally and the operators performing ultrasound rated the likelihood of PAS on a Likert scale of 1 to 10.Results: In total, 442 women were registered in the database. No maternal deaths occurred. Mean blood loss was 2600 mL (range 150‐20 000 mL). Placenta previa was present in 375 (84.8%) women and there was a history of a previous cesarean in 329 (74.4%) women. The PAS likelihood score was strongly correlated with the PAS grade (P < .001). The mode of delivery in the majority of women (n = 252, 57.0%) was cesarean hysterectomy, with a repeat laparotomy in 20 (7.9%) due to complications. In 48 women (10.8%), the placenta was intentionally left in situ, of those, 20 (41.7%) had a delayed hysterectomy. In 26 women (5.9%), focal resection was performed. Termination of pregnancy was performed in 9 (2.0%), of whom 5 had fetal abnormalities. The placenta could be removed in 90 women (20.4%) at cesarean, and in 17 (3.9%) after vaginal delivery indicating mild or no PAS. In 34 women (7.7%) with an antenatal diagnosis of PAS, the placenta spontaneously separated (false positives). We found lower blood loss (P < .002) in 2018‐2019 compared with 2009‐2017, suggesting a positive learning curve.Conclusions: In referral centers, the most common management for severe PAS was cesarean hysterectomy, followed by leaving the placenta in situ and focal resection. Prenatal diagnosis correlated with clinical PAS grade. No maternal deaths occurred.