Interpretation (in light of other evidence):
There has been recent evidence of PASD being a disorder of defective decidua and uterine dehiscence rather than destructive trophoblastic invasion (9). When there is a high index of suspicion for PASD, there is often pre-operative uncertainty around the true extent of the problem due to lack of sensitivity of screening tools including obstetric ultrasound and pelvic MRI, for both detection and determination of extent of uterine wall involvement. In our experience, in patients with previous Caesarean section with PASD, a low lying placenta in the current pregnancy is invariably found to be occupying the isthmocele, rather than to be adherent to it, consistent with PASD being a disorder of defective decidua and uterine dehiscence rather than a disease of trophoblastic invasion. The integrity of the myometrium in the area of placental attachment in the anterior wall, rather than the placentation itself, impedes safe access to avascular dissection planes. Thus our starting approach from the posterior uterine wall for removal of placenta is aimed at improving the speed and safety of the procedure. Our results supported this approach. Future research, in the form of a larger prospective study, is required to further assess its morbidity, performance relative to other conservative surgeries and the subsequent reproductive and gynaecological outcomes.