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Sir,

Cook et al.[1] are to be congratulated on their recent cohort study examining clinical outcomes in multiple repeat caesarean section. Given the national trends in caesarean section prevalence, the challenges in caring for this population of women will become increasingly relevant to the obstetric community. The evidence presented for an excess morbidity burden also carries with it important implications for healthcare resource provision.

We concur with the authors' assertion that specialist tertiary care represents the ideal environment for operative intervention; however, we feel that their recommendation for mandatory availability of cell salvage and interventional radiology for women with a high risk of placenta accreta because of multiple repeat caesarean section and placenta praevia is premature. Our systematic review of cell salvage in caesarean section published in BJOG in 2009 identified only one small, unreliable randomised trial on which to base recommendations for practice.[2] Equally, there is a lack of evidence from randomised studies to support the contention that interventional radiology is beneficial, and observational studies suggest that this may not be the case.[3]

The clinical and cost effectiveness of these techniques compared with standard care without them remains the subject of genuine clinical uncertainty. They are expensive technologies, with potential adverse effects that require careful consideration in a risk–benefit assessment. In view of the paucity of evidence recommending their widespread use, we should await evidence from appropriately powered randomised controlled trials before definitive recommendations are made.

A multicentre trial of cell salvage in caesarean section in women at risk of haemorrhage (SALVO, ISRCTN66118656, http://blizard.qmul.ac.uk/research-generation/681-salvo.html) has been funded by the National Institute for Health Research, Health Technology Assessment Programme to examine the clinical and cost effectiveness of this intervention. The study has recently received multicentre research ethics committee approval, and will shortly begin deployment into units across the UK. The trial aims to recruit over 3000 women and has broad eligibility criteria, including abnormalities of placentation. We would encourage clinicians to test their uncertainty and consider recruiting to this study, and to maintain equipoise about the usefulness of the intervention until such time as the outcome is known. Only by acquisition of a definitive answer can national policy become better informed.

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