Response to Letter

In Reply: We thank our colleagues form Portugal and the United Kingdom for responding to our article in the September 2024 issue and for sharing their remarks.1 With our systematic review and meta-analysis, we aimed to assess whether prophylactic placement of balloon catheters or sheaths before planned cesarean delivery in women with placenta accreta spectrum disorder (PAS) is associated with reduced perioperative blood loss compared with no prophylactic radiologic intervention. Our findings suggest that prophylactic placement of balloon catheters or sheaths before planned cesarean delivery in women with PAS disorder may, in some cases, substantially reduce perioperative blood loss. The first remark the authors make is that it is important to acknowledge that prophylactic placement of balloon catheters in women with suspected PAS may lead to their placement in women without PAS. We discussed this point in our Discussion. Because the decision to use a prophylactic radiologic intervention is always made antepartum, there is indeed a risk of overtreatment. However, considering that PAS is a high-risk condition, it is a balancing act between this, the risk of severe maternal outcomes, and the risk of complications. The second remark addresses the results of uterine artery embolization. Our review presents only five studies on prophylactic embolization of the uterine artery, all of which were assessed as having severe or critical risk of bias. These were subsequently excluded in a sensitivity analysis. This high risk of bias, combined with the wide confidence intervals due to the small sample size, limits the interpretation of the findings on uterine artery embolization. Thirdly, the authors mention that prophylactic intervention lengthens the procedure time. This is indeed an important note in the case of an emergency setting. We did not address emergency settings in our study; our focus was on the setting of planned cesarean delivery. Finally, the authors note the important fact that there is no one size fits all and that the severity of PAS, as well as the experience and skills of the surgical team, should be part of the consideration. Our review of the currently available literature on prophylactic radiologic interventions adds just one piece to the puzzle of defining the optimal intrapartum management strategies in women with PAS.