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.

Placenta accreta spectrum (PAS) includes varying combinations of abnormal placental implantation that may be accompanied by deficiency of uterine wall integrity. 1 A classification system by the International Federation of Gynecology and Obstetrics (FIGO) describes PAS disorders depending on the degree of uterine and parametrial invasion. 2 The risk of developing PAS disorders increases

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