الفهرس 
Studying the role of ligation of the anterior division of the internal iliac artery in conservative management of patients diagnosed with partial or focal placenta accreta spectrum
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Abstract
Placenta accreta spectrum (PAS) is a medical condition caused by abnormal trophoblastic
invasion of the placental tissue into the uterine wall. Compared to a normal pregnancy, PAS is
associated with an increased risk of maternal morbidities and higher rates of maternal death that
result from the marked intraoperative hemorrhage occurring during its management. (Usta et
al.2005)
The worldwide increasing rate of caesarean deliveries is associated with a global rise in the
incidence of PAS. Early diagnosis is the key for the appropriate management planning of this
condition. Ultrasound is the gold standard diagnostic modality for PAS. Other radiological
diagnostic tools may be of aid such as magnetic resonance imaging (MRI). However, definitive
diagnosis can‘t be established without the intraoperative gross assessment of the placenta and its
postoperative histopathological evaluation. (Boroomand Fard M et al.2020)
Research significance
PAS is usually managed by caesarean hysterectomy (CH) however; many uterine preservation
techniques are recently tailored aiming at preserving the women‘s future fertility. Nevertheless,
uterine preserving techniques are associated with higher risk for maternal morbidities and blood
loss. In a hopeful attempt to lower the blood loss in uterine preserving surgery, we performed
ligation of the anterior division of the internal iliac artery being the main blood supply to the
pelvic organs. This was done as a result of the lack of complex resources as balloon occlusion of
the IIA by intervention radiology, which is quite the case in most middle and low income
countries.
Patients and methods
Aiming at studying the role of IIA ligation in lowering the estimated blood loss volume in
conservative management of a variant of PAS; focal accretas and partial thickness invasion, 44
patients were enrolled in our study. Those patients were randomly divided into 2 groups; a study
group –in which ligation of the anterior division of the internal iliac artery was done during their
operation and a control group in which we didn‘t ligate the same vessel.Results:
The mean estimated blood loss (EBL) after 24 hours in the study group is 1050.83 ± 401.57,
while in the control group it is 1196.30 ± 414.25 showing no significant difference between both
groups (p-value = 0.244). There was also no statistical significance regarding neither the
operative morbidities nor the need for blood transfusion between both groups. Coming to
operative time, there was no statistical significance between both groups. Nevertheless, its worth
mentioning that the mean operative time for the study group is 133.64 ± 47.16 mins. while it is
111.36 ± 29.65 mins. for the control group -20 mins. longer operative time than the control group
with a p-value of 0.069.
Conclusion:
Our study concluded that the ligation of the internal iliac artery isn‘t quite beneficial in lowering
the estimated blood loss during the uterine preservation management in cases of focal placental
adherence. Moreover, during this step, the operative time might be relatively longer and surgical
complications might occur. IIAL shouldn‘t be a routine step in uterine preservation surgery in
management of cases with morbidly adherent placenta and it should be preserved for cases with
marked blood loss. However, pelvic surgeons should be familiar with the anatomy of the IIA and
the technique for its proper ligation when needed.