Optimal management strategies for placenta accreta
Authors' Reply



Thank you for allowing us the opportunity to respond the recent letter by Drs Carcopino, d’Ercole and Bretelle.1 The authors express concern regarding our analysis of the potential impact of ureteral stents on maternal morbidity in cases of placenta accreta. Specifically, your letter suggests that we compared outcome between all cases of accreta (suspected and unsuspected combined) based on the presence or absence of preoperatively placed ureteral stents. This is not the case. Because of the bias that would be introduced by comparing the outcomes of women with antenatally suspected placenta accreta to those of women with unsuspected accreta, we only compared the potential impact of operative interventions (including preoperative ureteral stents) in the group of 52 women with antenatally suspected placenta accreta (see Table 4). We used a composite morbidity measure to assess outcome because of a relatively small sample size and the uncommon major morbidities assessed. We acknowledge that this is less robust than evaluating each complication separately. Nonetheless, it was the only reasonable approach given the relative rarity of placenta accreta in a single institution. We entirely agree with the authors that our study design does not permit us to conclude that ureteral stents are useful in cases of placenta accreta. In fact, we explicitly state this in the paper. Nonetheless, in our anecdotal experience they have been useful. In cases of suspected accreta, it is the practice of most of our colleagues to use preoperative ureteral stenting. The greatest blood loss in these cases occurs during dissection of the bladder from the lower uterine segment and ureteral stents allow for more rapid, continuous localisation of the ureters which may reduce operative time and blood loss while also reducing the likelihood of ureteral injury. Until appropriate randomised controlled clinical trials are conducted, such anecdotal case series are the best information available to practicing clinicians.

The authors suggest that we drew conclusions regarding the utility of conservative management from only two cases in our cohort who were managed without hysterectomy. In fact, we avoided any specific comment on the utility of conservative management specifically because our dataset and study design was insufficient to assess this strategy. Conversely, there is considerable publication bias in papers reporting successful expectant management. Our statement in the manuscript and our response now are the same. We advise caution and extensive counseling of women who feel strongly about attempting uterine preservation based on significant maternal morbidity that can result.

We agree that our cohort was subject to bias and we acknowledged this limitation in our manuscript. The only way to determine the best way to care for women with placenta accreta is through properly designed clinical trials. Until such data are available, case series such as ours can provide some guidance to clinicians regarding others experience with this morbid and increasingly common condition. It is our hope that obstetricians will continue to publish their institutional experiences so that the available evidence base for decision making can continue to grow.