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Diagnosing placenta accreta

Published:October 14, 2014DOI:https://doi.org/10.1016/j.ajog.2014.10.017
      To the Editors:
      While we wish to underscore a statement made in the editorial by Dr Nageotte,
      • Nageotte M.P.
      Always be vigilant for placenta accreta.
      we wish to also add a relevant comment to the article by Bowman et al
      • Bowman Z.S.
      • Eller A.G.
      • Kennedy A.M.
      • et al.
      Accuracy of ultrasound for the prediction of placenta accreta.
      discussed in this same issue. In our own institution, we have seen a significant rise in the incidence of placenta accreta (doubling in the past dozen years), emphasizing the obvious contribution of the recently rising rate of cesarean. The concern that this should raise for the average practicing obstetrician is considerable, with regard to the results of this commonly unanticipated occurrence.
      Dr Bowman et al
      • Bowman Z.S.
      • Eller A.G.
      • Kennedy A.M.
      • et al.
      Accuracy of ultrasound for the prediction of placenta accreta.
      questioned the value of its antepartum sonographic detection, yet the absence of consistent use of advanced currently available features of ultrasound (eg, color Doppler, 3-dimensional imaging) may be the reason for this described lack of diagnostic benefit, which nonetheless has been documented elsewhere.
      • Berkley E.M.
      • Abuhamad A.Z.
      Prenatal diagnosis of placenta accreta: is sonography all we need?.
      We respectfully challenge the conclusion made in this manuscript, since it does not correspond with our own experience.

      References

        • Nageotte M.P.
        Always be vigilant for placenta accreta.
        Am J Obstet Gynecol. 2014; 211: 87-88
        • Bowman Z.S.
        • Eller A.G.
        • Kennedy A.M.
        • et al.
        Accuracy of ultrasound for the prediction of placenta accreta.
        Am J Obstet Gynecol. 2014; 211: 177.e1-177.e7
        • Berkley E.M.
        • Abuhamad A.Z.
        Prenatal diagnosis of placenta accreta: is sonography all we need?.
        J Ultrasound Med. 2013; 32: 1345-1350

      Linked Article

      • Accuracy of ultrasound for the prediction of placenta accreta
        American Journal of Obstetrics & GynecologyVol. 211Issue 2
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          Ultrasound has been reported to be greater than 90% sensitive for the diagnosis of accreta. Prior studies may be subject to bias because of single expert observers, suspicion for accreta, and knowledge of risk factors. We aimed to assess the accuracy of ultrasound for the prediction of accreta.
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      • Always be vigilant for placenta accreta
        American Journal of Obstetrics & GynecologyVol. 211Issue 2
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          Perhaps there is no greater obstetrical surgical challenge than that of managing a delivery complicated by placenta accreta. Placenta accreta results from a defect of the decidua basalis, which allows invasive placental implantation into varying depths of the myometrium, thus preventing normal separation of the placenta from the uterine wall at the time of delivery.
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      • Reply
        American Journal of Obstetrics & GynecologyVol. 212Issue 2
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          We thank Drs Levine and Fernandez for their interest in our recent article regarding accuracy of ultrasound for the diagnosis of placenta accreta. We agree that ultrasound is reasonably useful for the diagnosis of accreta and that it may be improved with newer technology. However, our purpose was to illustrate that the modality is imperfect and that there might be room for improvement. Additionally, we discussed that the pretest probability for accreta is strongly driven by clinical history, and that posttest probabilities after ultrasound examination may not significantly alter clinical decision making in certain high-risk patients (eg, those with placenta previa and >2 prior cesarean deliveries).
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