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Sir,

We read with interest the paper by Kotsuji et al.[1] who are proposing a transverse uterine fundal incision for the delivery of pregnancies complicated by placenta praevia with accreta. We agree with the authors that this technique is likely to be associated with a higher rate of uterine rupture before and during labour in subsequent pregnancies, probably similar to that observed after classical caesarean section.

The management of placenta accreta is complex, and often requires a combination of surgical, radiological and medical techniques, and within this context an accurate antenatal diagnosis is pivotal for an effective and safe treatment plan.[2] We were therefore concerned to read that the diagnosis of placenta accreta was not achieved before delivery in 15/34 (44%) of the cases presented in this series. Placenta accreta was first diagnosed with greyscale ultrasound in the 1980's, and with the development of high-resolution colour Doppler imaging, the sensitivity of ultrasound reached 90% at the end of the 1990's.[2] The negative predictive value of ultrasound has been recently reported to be as high as 98%.[3] Posterior placenta praevia accreta can be more difficult to diagnose antenatally, and may require transvaginal ultrasound and magnetic resonance imaging (MRI).[2] Considering that all the cases recruited in their study presented as anterior placenta praevia it is difficult to understand why, between 2006 and 2010, the authors could not obtain an accurate prenatal diagnosis of placenta accreta in at least 90% of their cases. Furthermore, the authors provide no information on the grade of the placenta praevia and the degree of placenta accreta (in depth and extension), which are important factors for deciding on the type of therapeutic procedures to be used and for discussing intraoperative risks with the patient.

The authors are proposing to use their new technique to facilitate the safe manual removal of an abnormally adherent anterior placenta praevia. In their methodology, the authors state that they attempted to manually remove the placenta under direct observation. In the results section, however, they state that in all 15 women with strong evidence of placenta accreta at surgery, no attempt was made to manually remove the placenta, and that in all of these cases the surgeons immediately performed a hysterectomy. This suggests that their ‘novel’ procedure was mainly applied to women who did not have placenta accreta, and therefore did not actually require this complex and potentially harmful surgery.

One of the major benefits of antenatal diagnosis of placenta accreta is to avoid trying to detach the placenta during delivery, which inevitably leads to major bleeding and emergency hysterectomy.[2] It is therefore not surprising that 16 out the 19 cases of placenta praevia with accreta reported in this series required a hysterectomy. As the transverse uterine fundal incision they described is not very different from the high midline vertical incision described previously by the same group of authors,[4] and by others, the overall methodology proposed here by Kotsuji et al. [1] is associated with a higher morbidity, and does not allow for the conservative management of the uterus.

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