الفهرس 
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Abstract
Placenta accreta is becoming a common complication of pregnancy. The incidence of placental invasion is increasing because of the increased rate of cesarean section. Prenatal identification of PA is essential to manage optimal delivery circumstances for these women. Hysterectomy has been the best management option in PA, but this represents a problem for patients who desire to preserve the uterus for future fertility thus, alternatives management options include leaving the placenta after CD with uterine devascularization, uterine artery embolization, uterine compression sutures, and/or under-running sutures of the placental bed. Different techniques have been developed to decrease intraoperative blood loss depend on reducing pelvic circulation, primarily of the internal iliac arteries for disruption of the arterial blood supply to the uterus and preserving the blood supply to other pelvic structures. This has been accomplished either by temporary balloon occlusion or by intraoperative ligation of the internal iliac arteries. Surgical IIAL is often used to attempt to control otherwise intractable obstetric hemorrhage. Occlusion or ligation of the internal iliac arteries does not halt blood flow to the uterus because there is a rich supply of collaterals. However, the technique reduces pulse pressure distal to the site of occlusion, thus minimizing blood loss during hysterectomy. Bilateral ligation of internal iliac arteries was reported to decrease the pulse pressure in the distal artery by as much as 85%, whereas blood flow is reduced by at most 50%, thereby simulating a venous rather than arterial circulation and promoting hemostasis. Although surgeons may be reluctant to perform bilateral hypogastric artery ligation for fear of injury to the pelvic viscera, there is no evidence that there is any significant impairment of function of the pelvic viscera. If the procedure is performed correctly, there is no morbidity, either short or long-term. Ligation of the internal iliac arteries has limited effectiveness (40%), as immediately after occlusion, a network of collateral circulations is established, involving the lumbar, ileolumbar, middle and lateral sacral, and middle and superior rectal arteries. Either ligation of the anterior division of internal iliac or uterine artery is often employed in a trial to control PPH prior to resorting to hysterectomy, although it may only serve to delay hysterectomy. A failure rate of 40-60% has been demonstrated for PPH and it is less likely to be successful in cases of bleeding PA, thus delaying definitive treatment. However, it may be performed prior to peripartum hysterectomy in an attempt to reduce operative blood loss. In this study, in an attempt to evaluate the efficacy of IIA suture ligation before bladder dissection during conservative management of cases of morbidly adherent placenta using (CIC)we enrolled 42 patients with placenta previa (major and minor); divided into two groups: •group A (with bilateral ligation of internal iliac artery) (n = 21) In this group, intraoperative bilateral internal iliac arteries ligation was performed before any attempt to remove the abnormally adherent placenta, which is the main source of severe bleeding that usually occurs in such a situation, a technique to reduce the pulse pressure distal to the level of ligation, thus minimizing blood loss during CD in placenta previa accerta. •group B (without ligation of internal iliac artery) (n = 21). In our study, the amount of blood loss in the IIAL group was more than the group without IIAL. There was a statistically significantly higher number of packed RBCs transfused units, total estimated blood loss (liters) in group A vs group B. In group A, there were 4 packed RBCs transfused units, blood loss was 3. 3 liters, (hemoglobin was 10. 6 ± 0. 7 preoperatively and 10. 6 ± 1. 2 postoperatively and hematocrit was 33. 5 ± 2. 3 preoperatively and 31. 3 ± 4. 4 postoperatively). But in group B, there were 2 packed RBCs transfused units, blood loss was 1. 76 liters, (hemoglobin was 11. 2 ± 0. 8 preoperatively and 11. 3 ± 1 postoperatively and hematocrit was 33. 3 ± 2. 5 preoperatively and 32. 9 ± 1. 2 postoperatively). In our study (where we used CIC suture as a conservative method to save the uterus during management of PAS), the decrease in the intraoperative blood loss noted among the group without IIAL (group B) in comparison to the group that had IIAL not only reconfirms the findings of the previous studies that IIAL does not reduce intraoperative blood loss among antenatally diagnosed cases of AIP, but it may be even associated with increased intraoperative blood loss when using CIC suture as a conservative method during management. This might be explained by two things. First: by the fact that (CIC) is an effective conservative management via exerting rapid haemostatic effect through rapid immediate direct pressure against the bleeding points/sinuses from the placental bed without the need for IIA ligation which exerts its haemostatic effect indirectly via decrease pulse pressure in arteries distal to the ligation, hence promoting haemostasis through plug formation which takes time occur. Second:The blood loss that occur during the time spent to performe the procedure of IIAL on both sides. In our study, the duration of the operative procedure (minutes) varied significantly between the two groups (237± 64 in the group with IIAL vs 169 ± 38 in the group without IIAL; P value 0. 001). In our study, the rate of hysterectomy was statistically higher among group with IIAL (GroupA) (6/21= 28. 6%) than among cases not have IIAL (group B) (2/21= 9. 5%). Regarding postoperative complications, in our study there was a statistically significant difference in the occurrence of postoperative complications between the two groups. In group A (group with IIAL), bladder injury occurred in 3 patients (14. 3%). On the other hand, in group B (without IIAL) bladder injury occurred only in one patient (4. 7%). None of the cases developed vascular or neurologic complications. Correlation between postoperative complications and clinical data in our study revealed no statistically significant association between occurrence of postoperative complications and clinical parameters. However, there was medium strength association between hysterectomy and gravidity; as number of gravidities rises, the proportion of hysterectomy increases. This might be explained by the fact that with rising the gravidity, the resort to conserve and save the uterus becomes less than that for women with few gravidity. This study showed that bilateral IIAL, as an intervention to decrease the blood loss during conservative management for AIP using cervico-isthmic compression suture (CIC), is not beneficial. In fact, it increased the operative duration time significantly when compared with the control group, with no significant impact on intraoperative or postoperative blood loss. Also, it is associated with a higher incidence of urologic complications. These findings make IIAL during conservative management of PAS using CIC is not routinely recommended as a prophylactic method to decrease intraoperative blood loss. However, owing to the marked heterogenicty of PAS cases (from mild to moderate to severe) in either group in our study and together with the small number of cases included in the study, we recommend the need for a further large well- matched studies to make a more firm conclusion and recommendation to our findings.