Authors' reply: Transverse uterine fundal incision in placenta praevia with possible placenta accreta

Authors


Authors' reply

Sir,

We are grateful for the opportunity to respond to the letter submitted by Drs Jauniaux and Jurkovic.[1]

Jauniaux and Jurkovic have emphasised the importance of the antenatal diagnosis of placenta accreta; we agree with this. However, because of the difficulty in completely ruling out the existence of placenta accreta preoperatively, we used a transverse fundal incision that should have been avoided in the 15 women without placenta accreta.[2] The negative predictive value (NPV) of ultrasonography in diagnosing placenta accreta was recently reported to be as high as 98% and the positive predictive value (PPV) was 68%.[3] In contrast, in our case series, in our attempt to increase the NPV to 100%, the PPV for the antenatal diagnosis of placenta accreta may have been compromised. Hence, in our study, the PPV and NPV for the antenatal diagnosis of placenta accreta were 56 and 100%, respectively. Of course, we agree that a PPV of 56% is not ideal. Indeed, we should increase the accuracy of the antenatal diagnosis of placenta accreta, while simultaneously preparing for the possible difficulties associated with the condition.

Jauniaux and Jurkovic claimed that our operation is a complex and harmful surgery. They also emphasised that a transverse uterine fundal incision was mainly applied to women who did not have placenta accreta, and that the overall methodology proposed by us is associated with a higher morbidity and does not allow for the conservative management of the uterus. We have to say that they probably do not completely understand the proposed procedure. Our simple operative procedure mainly comprises a transverse fundal incision that avoids transecting the placenta.[2] The most beneficial aspect of our operation is that it reduces the copious bleeding that occurs after transecting the placenta in women with placenta praevia accreta. Fortunately, the study by Esakoff et al.,[3] referred to by Jauniaux and Jurkovic, elucidates the value of the transverse uterine fundal incision. In this study, the median ‘estimated blood loss’ was 3000 ml (range 1350–11,000 ml) in the placenta praevia accreta group, and 1000 ml (range 700–3000 ml) in the placenta praevia group.[3] On the other hand, in our case series, the median ‘fluid loss’ was 1769 g (230–4220 g) in the accreta group compared with 1053 g (499–3250 g) in the placenta praevia group. We directly measured the total fluid loss by adding the bleeding and amniotic fluid volume, which was calculated differently from the method used by Esakoff et al. Although the operative procedures performed by Esakoff et al. were not clearly described, our transverse fundal incision may reduce the blood loss associated with caesarean deliveries in women with placenta praevia or placenta praevia accreta. We recommend that Drs Jauniaux and Jurkovic carefully watch our supplemental video, which demonstrates the transverse uterine fundal incision technique. In the case illustrated, a £2-coin-sized placental lesion was observed even though the greater part of the placenta was removed. Postoperatively, this woman was diagnosed with a focal placenta increta. After carefully watching the supplemental video, would Jauniaux suggest that our procedure be applied to women who do not have placenta accreta, and that it does not allow for conservative management of the uterus? Although our operation does not aim to preserve fertility, it does indeed allow fertility preservation.

In our case series, 15 women underwent immediate hysterectomy without any attempt to remove the placenta immediately after the transverse uterine fundal incision. In addition, we attempted to remove the placenta in the remaining 19 women in whom placenta accreta could not be ruled out, but we suspected shallow and/or focal involvements of the uterine myometrium. Jauniaux emphasised that 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.[4] Although we completely agree with the doctor, our operative strategies do not contradict their assertion. The transverse uterine fundal incision enables the surgeon to attempt placenta removal and allows simultaneous avoidance of major bleeding.

I still remember the occasion at a medical conference when I first reported the transverse uterine fundal incision. The Japanese physicians in the audience voiced many negative opinions. However, our technique now holds a firm place as an alternative for extensive anterior placenta praevia accreta in Japan. We encourage Drs Jauniaux and Jurkovic to try the transverse uterine fundal incision for placenta praevia accreta, as an alternative when other operative procedures might be complicated. The incidence of placenta praevia accreta—a major cause of maternal mortality—has increased because of the rising rate of caesarean delivery. We believe that the caesarean technique for placenta praevia and placenta accreta should evolve in the near future to relieve anxiety in pregnant women resulting from the fear of this disease.[2, 5] Although additional studies are needed for further validation, our operative technique may reduce complications caused by caesarean delivery in women with placenta praevia accreta.

As suggested by Jauniaux and Jurkovic, we did not present all the data regarding our study because of the limitations inherent in the article type. We understand that many researchers are keenly interested in our ‘novel’ caesarean technique with transverse fundal incision. We have obtained recent information confirming that a few women in our study group subsequently conceived and gave birth to living infants. We will present further details of our study in the near future.

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