Comment on “Surgical Morbidity following Planned Hysterectomy versus Conservative Management for Placenta Accreta Spectrum: A Systematic Review and Meta-analysis”

Surgical Morbidity following Planned Hysterectomy versus Conservative Management for Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

We read with great interest the systematic review and meta-analysis titled “Surgical morbidity following planned hysterectomy versus conservative management for placenta accreta spectrum: a systematic review and meta-analysis” by Futterman et al.[1] The study addresses a pivotal clinical issue, shedding light on the comparative surgical morbidity associated with conservative management versus planned hysterectomy. The authors' comprehensive approach and detailed analysis are commendable; however, we would like to offer a few constructive suggestions that could enhance the robustness of their findings and provide further clarity for clinicians managing placenta accreta spectrum (PAS).

First, the inclusion of studies with varying levels of methodological rigor highlights the importance of performing a sensitivity analysis based on study quality. The ROBINS-I assessment revealed a range of biases across the included studies, which could impact the pooled results.[2] By stratifying the meta-analysis according to study quality, the authors could assess whether lower-quality studies disproportionately influenced the outcomes. Such an analysis would strengthen the validity of the conclusions and provide a clearer understanding of the reliability of the findings, particularly in high-quality studies.

Second, the application of the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to evaluate the certainty of evidence would have added significant value. GRADE is a widely accepted framework that helps clinicians understand the strength and applicability of evidence for specific outcomes.[3] [4] In this study, important outcomes such as intensive care unit admission, disseminated intravascular coagulation/coagulopathy, bladder injury, and blood transfusion requirements could benefit from GRADE evaluation to clarify the level of confidence in these findings. Incorporating such an analysis would provide readers with a better understanding of how confidently the results can be applied in clinical practice.

Lastly, while the focus on surgical morbidity is crucial, the inclusion of patient-centered outcomes could further enrich the analysis. Metrics such as long-term fertility preservation, psychological impact, and quality of life are particularly relevant in PAS cases where conservative management aims to preserve reproductive potential. Additionally, highlighting context-specific challenges, such as access to interventional radiology or the availability of experienced multidisciplinary teams, could provide practical insights for clinicians working in diverse health care settings. These considerations would make the study more directly applicable to real-world clinical scenarios.

This meta-analysis represents a valuable contribution to understanding the management of PAS and underscores the benefits of conservative management in reducing surgical morbidity. However, integrating sensitivity analyses, GRADE assessment, and patient-centered outcomes in future studies could further enhance the applicability and strength of these findings. We appreciate the authors' significant efforts and hope that these suggestions will serve to refine future systematic reviews and meta-analyses in this critical area of obstetrics.

Author's Contribution

L.T. provided comments on methodological aspects written the edited the draft.

Publication History

Received: 10 January 2025

Accepted: 23 January 2025

Accepted Manuscript online:
23 January 2025

Article published online:
18 March 2025

• References

• 1 Futterman ID, Gomes C, Sher O. et al. Surgical morbidity following planned hysterectomy versus conservative management for placenta accreta spectrum: a systematic review and meta-analysis. Am J Perinatol 2024; (e-pub ahead of print). doi:
• 2 Peters JA, Farhadloo M. The effects of non-pharmaceutical interventions on COVID-19 cases, hospitalizations, and mortality: a systematic literature review and meta-analysis. AJPM Focus 2023; 2 (04) 100125
• 3 Dewidar O, Lotfi T, Langendam MW. et al; eCOVID-19 recommendations map collaborators. Good or best practice statements: proposal for the operationalisation and implementation of GRADE guidance. BMJ Evid Based Med 2023; 28 (03) 189-196
• 4 Pandey P, Shabil M, Bushi G. Comment on “Sodium fluorescein and 5-aminolevulinic acid fluorescence-guided biopsy in brain lesions: a systematic review and meta-analysis”. J Neurooncol 2024; 170 (03) 677-678