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Authors' reply

Sir,

We appreciate the comments of Dr Marasinghe et al. about our article concerning a caesarean technique involving a transverse fundal incision in women with placenta praevia that covers much of the anterior uterine wall, when placenta accreta cannot be ruled out.[1] As suggested by Dr Marasinghe, placenta accreta was confirmed postoperatively in 19 women by histopathological evidence of placental invasion into the myometrium, clinical assessment of abnormal adherence of the placenta, and/or evidence of gross placental invasion during surgery. Because it is difficult to completely rule out placenta accreta preoperatively, we performed a transverse fundal incision that could have been avoided in the 15 women who did not have placenta accreta. Dr Marasinghe et al. recommend that magnetic resonance imaging and three-dimensional power Doppler should be performed for the antenatal diagnosis or exclusion of placenta accreta[2, 3]; we completely agree. However, as these latest techniques are not available everywhere, we should consider increasing the accuracy of the antenatal diagnosis of placenta accreta using ordinary methods, while simultaneously preparing for possible complications encountered as a result of this condition.

The major concern with our procedure is the unknown risk of uterine rupture during subsequent pregnancies, as suggested by Dr Marasinghe. He proposed a high transverse incision in the upper uterine segment immediately above the placental margin, rather than a fundal incision. We should emphasise that our method should be used only as a last resort, i.e. when other operative procedures are considered too risky in women who desire a future pregnancy.[1] We often perform the technique described by Dr Marasinghe in women with placenta praevia accreta, and understand and agree that a high transverse incision in the upper uterine segment allows a shorter and lower transverse skin incision and precise placement of sutures with direct visualisation of the bleeding point from the detached placental plane. We disagree, however, that the placement of sutures in the lower segment through a fundal incision is more difficult than with the approach through a high transverse incision. Using the fundal incision technique, the non-dissected myometrium of the uterine body can strongly contract after childbirth, facilitating clear visualisation of any bleeding points in the lower segment/cervix. Moreover, a large transverse uterine incision allows the precise placement of haemostatic sutures, even in the lowest segment of the uterus.[1] The muscular layer at the uterine fundus is not as thick as we had previously thought: the thickness of the uterine myometrium is gradually reduced towards the uterine fundus.[4] Therefore, our technique involves minimal bleeding from the surgical wound in the uterine fundus, and any bleeding can easily be controlled. We encourage Dr Marasinghe and other obstetricians to try the transverse uterine fundal incision for placenta praevia accreta when other operative procedures might be difficult.

image

Figure 1. The thickness of the uterine myometrium gradually reduces towards the uterine fundus. (Figure modified from Standring[4]).

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Although further studies are needed, our operative technique may reduce the complications caused by caesarean delivery in women with placenta praevia accreta. We would like to undertake further collaborative research regarding the safety of our technique for subsequent pregnancies.

References

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  2. References
  • 1
    Kotsuji F, Nishijima K, Kurokawa T, Yoshida Y, Sekiya T, Banzai M, et al. Transverse uterine fundal incision for placenta praevia with accreta, involving the entire anterior uterine wall: a case series. BJOG 2013;120:11449.
  • 2
    Masselli G, Brunelli R, Casciani E, Polettini E, Piccioni MG, Anceschi M, et al. Magnetic resonance imaging in the evaluation of placental adhesive disorders: correlation with color Doppler ultrasound. Eur Radiol 2008;18:12929.
  • 3
    Shih JC, Palacios Jaraquemada JM, Su YN, Shyu MK, Lin CH, Lin SY, et al. Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol 2009;33:193203.
  • 4
    Standring S, Ellis H, Healy JC, Johnson D, Williams A, Implantation, placentation, pregnancy and parturition. In: Standring S, Ellis H, Healy JC, Johnson D, Williams A, editors. Gray's Anatomy: the Anatomical Basis of Clinical Practice, 39th edn. London: Elsevier Churchill Livingstone; 2005. 1345 pp.