We read with interest the review by Eller et al.1 of the management of placenta accreta published in April 2009. Although previously the standard method has involved hysterectomy, we agree with the authors that in order to prevent uncontrollable haemorrhage it is important not to try and remove the placenta. However, there are some further comments that we feel we should make.2
We consider that the design of this study does not allow the authors to draw the conclusions they state. The decrease of maternal morbidity associated with preoperative ureteric stent placement is not necessarily linked in a causal fashion. While scheduled caesarean section was associated with significant lower mean blood loss, there was no significant reduction in the overall morbidity. Many confounding factors could have biased the results to produce such an association with reduced blood loss. Stent placement was only attempted in women who were suspected of having placenta accreta. In this group, authors reported a significant lower rate of attempted placental removal (P < 0.001, Fisher’s exact test). We suspect that this has led to an overestimation of the benefit of preoperative ureteric stent placement on maternal morbidity, because unanticipated discovery of placenta accreta is associated with higher levels morbidity than when it is diagnosed preoperatively. In common with other authors, we do not believe that ureteric stents should systematically be placed before caesarean section in case of suspected placenta accreta. Analysis of our own practice supports this view.3 We consider that the appropriate conclusion of this cohort analysis is that antenatal suspicion of placenta accreta results in a significant reduction in attempts to remove the placenta and thus reduces early maternal morbidity. Eller et al.1 suggest hysterectomy as the first line treatment; however, conservative management of placenta accreta has been recently described in selected cases. The management of placenta accreta is still a major clinical challenge as future fertility continues to be an important desire in a significant number of patients. We do not think that the authors should have drawn conclusions from a single case. Currently, increasing numbers of reports are appearing describing the efficacy and consequences of conservative management of placenta accreta.3,4 All of those involved in the care of women with placenta accreta should be aware of this possibility.