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.