Accepted: 13 March 2023
DOI: 10.1111/1471-0528.17496
LETTER TO THE EDITOR
How to differentiate intraoperatively between placenta accreta
spectrum and uterine dehiscence?
Dear Dr. Papageorghiou,
We read with interest the article by Professor Hussein
et al.,1 which sheds light on the high frequency of uterine
dehiscence (UD) cases that are misinterpreted as placenta
accreta spectrum (PAS) and managed with radical and
potentially morbid interventions, such as hysterectomy.
Professor Hussein invites an expert in PAS sonographic
diagnosis to review the prenatal images of women taken to
surgery on suspicion of PAS. Likewise, he invites an expert
in PAS surgery to review the intraoperative images of these
women. In both cases, the opinion of the experts was equiv-
ocal, wrongly classifying as PAS several patients who really
had a UD.
This article adds to a growing body of work by the
same group2 that highlights the difficulty of distinguish-
ing between these two conditions, even in the hands of
seasoned practitioners. This begs the question of how
challenging it must be for clinicians without access to
such specialised resources. Even more importantly: is it
necessary to establish this differential diagnosis in the
operating room?
In light of this, we offer the following comments:
1. Rather than relying on a definitive prenatal diagno-
sis of PAS, why not treat all ‘PAS suggestive cases’
as a general problem? When treating a patient, more
important than providing a name (which, for PAS,
requires histological analysis, trying to separate the
placenta or an evaluation of the surgical specimen),
a protocolised approach is required, which allows in-
dividualising management according to the in-­surgery
findings (Figure 1). This should be undertaken without
exposing the patient to the risks and consequences of
overly aggressive treatment or insufficient interventions
to solve the problem at hand. After surgery, what was
learned should be complemented with the histological
analysis of any tissue obtained.
2. Hussein et al. highlight the importance of reconsider-
ing the treatment of PAS when there is doubt. We have
performed many hysterectomies in patients with UD in
the past, which does not mean that these patients did not
have morbidity risk. Patients with prenatal findings sug-
gestive of PAS who ultimately did not have that diagnosis
have high associated morbidity. We agree with the au-
thors when pointing out that UD with placenta previa
is not an easy condition to treat. Improper management
BJOG. 2023;00:1–3. wileyonlinelibrary.com/journal/bjo
can cause massive bleeding and additional complica-
tions, which can be at least as severe as in some patients
with PAS. The possible combinations between UD and
different histological degrees of PAS are multiple3 and
their surgical relevance is less than the topography of the
abnormality, which is linked to the risk of bleeding and
surgical difficulty.4
3. One-­step conservative surgery is a useful intervention in
most PAS cases and in patients with UD4 (Figure 1). In
other words, it is an applicable strategy for most patients
with abnormality of the anterior aspect of the uterus,
suggestive of PAS, even before establishing the definitive
diagnosis.
In summary, we believe that the authors' article makes a
valuable contribution to the ongoing discussion around the
diagnosis and management of PAS and UD. By highlighting
the complexities of these conditions and the challenges of
accurate diagnosis, the authors have opened up important
avenues for further research and discussion.
DATA AVA I L A BI L I T Y S TAT E M E N T
The data that support this letter are openly available in:
BJOG. 2023;130(1): 42–­50. doi: 10.1111/1471-­0528.17286. Am
J Obstet Gynecol. 2022;226(6): 837.e1–­837.e13. doi: 10.1016/j.
ajog.2021.12.030. J Matern Fetal Neonatal Med. 2022. doi:
10.1080/14767058.2022.2154572. Am J Obstet Gynecol
MFM. 2022;5(2): 100802. 10.1016/j.ajogmf.2022.100802.
Álbaro Jose Nieto-­Calvache1
José M. Palacios-­Jaraquemada2,3,4
Nicolás Basanta3,4
Rozi Aditya Aryananda5,6
1
Placenta Accreta Spectrum Clinic, Fundación Valle
del Lili, Cali, Colombia
2
Department of Obstetrics and Gynaecology, CEMIC
University Hospital, Buenos Aires, Argentina
3
1st Anatomy Chair, School of Medicine, University of
Buenos Aires, Buenos Aires, Argentina
4
Fernández Hospital and 1st Anatomy Chair, School
of Medicine, University of Buenos Aires, Buenos Aires,
Argentina
5
Obstetrics & Gynaecology Department, Dr. Soetomo
Academic General Hospital, Surabaya, Indonesia
6
Universitas Airlangga, Surabaya, Indonesia
© 2023 John Wiley & Sons Ltd. | 1
2 |    LETTER TO THE EDITOR

F I G U R E 1 Intraoperative staging allows evaluation of the location (affected uterine wall and the relationship between the injury and the
vesicouterine peritoneal fold) and nature (presence or absence of vesicouterine fibrosis) of placenta accreta spectrum (PAS). Using the PAS topographic
classification3 and confirming that the bladder can be separated from the uterus and that there is enough healthy myometrial tissue to reconstruct the
uterus (more than 2 cm of myometrium over the cervix and more than 50% of the uterine circumference), one-­step conservative surgery (OSCS) can be
applied to patients with an abnormality of the anterior aspect of the uterus suggestive of PAS (regardless of whether it is definitely uterine dehiscence
or PAS). In the lower part of the image, two patients with suspected PAS, are shown. On the left, (A) a patient with type 1 PAS in whom the anterior
face of the uterus is exposed by ligating the neoformed vesicouterine pedicles (B) and an en-­bloc resection of the abnormal area with the placenta (C) is
performed to finally reconstruct the uterus (D). On the right, a patient in whom an abnormality suggestive of PAS is observed in the uterine segment
(A) but the retrovesical dissection rules out the existence of vesicouterine pedicles (B). En-­bloc resection of the abnormal area is performed, without
attempting to detach the placenta (C) and the uterus is reconstructed (D). Analysis of the surgical specimen obtained, and histology rule out PAS,
confirming uterine dehiscence in this second case. Abbreviation: MSTH, modified sub-­total hysterectomy.
LETTER TO THE EDITOR    | 3

intraoperative findings on surgical outcomes in patients at high risk

Correspondence
Álbaro Jose Nieto-­Calvache, Placenta Accreta
Spectrum Clinic, Fundación Valle del Lili, Carrera 98
# 18 -­49. Cali, Colombia.
Email: albaro.nieto@fvl.org.co
ORC I D
Álbaro Jose Nieto-­Calvache https://orcid.
org/0000-0001-5639-9127
José M. Palacios-­Jaraquemada https://orcid.
org/0000-0002-5240-5320
Nicolás Basanta https://orcid.org/0000-0002-0435-6704
Rozi Aditya Aryananda https://orcid.
org/0000-0001-6674-7682
R EFER ENCES
1. Hussein AM, Fox K, Bhide A, Elbarmelgy RA, Elbarmelgy RM,
Thabet MM, et al. The impact of preoperative ultrasound and
of placenta accreta spectrum. BJOG. 2023;130(1):42–­50. https://doi.
org/10.1111/1471-­0528.17286
2. Jauniaux E, Hecht JL, Elbarmelgy RA, Elbarmelgy RM, Thabet
MM, Hussein AM. Searching for placenta percreta: a prospective
cohort and systematic review of case reports. Am J Obstet Gynecol.
2022;226(6):837.e1–­837.e13. https://doi.org/10.1016/j.ajog.2021.12.030
3. Palacios-­Jaraquemada JM, Basanta N, Nieto-­Calvache AJ, Aryananda
RA. Comprehensive surgical staging for placenta accreta spec-
trum. J Matern Fetal Neonatal Med. 2022;35:10660–­ 6. https://doi.
org/10.1080/14767​058.2022.2154572
4. Nieto-­Calvache AJ, Palacios-­Jaraquemada JM, Aryananda R, Basanta
N, Aguilera R, Benavides JP, et al. How to perform the one-­step con-
servative surgery for placenta accreta spectrum move by move. Am
J Obstet Gynecol MFM. 2023;5(2):100802. https://doi.org/10.1016/j.
ajogmf.2022.100802
S U PP ORT I N G I N F OR M AT ION
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.