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REFERENCES
1. Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol 2011;204:322.e1-6.

Letters to the Editors

2. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112:14-20. 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.06.096

Arteriovenous malformation following conservative treatment of placenta percreta with uterine artery embolization but no adjunctive therapy
TO THE EDITORS: We read with interest the case series reported by Barber et al,1 which highlights the risk of arteriovenous malformation (AVM) after conservative treatment of placenta percreta with uterine artery embolization (UAE) and adjunctive therapy. As these 3 reported cases occurred after adjunctive therapy (etoposide), the authors proposed the hypothesis that adjunctive therapy may have less of an effect on newly formed vessels and their progression to form AVMs. They also state that they report, to their knowledge, the rst case of AVM following conservative treatment of placenta percreta.1 We would like to note that we have, in fact, previously published a case of AVM that occurred after a conservative treatment of placenta percreta without bladder invasion.2 Additional treatment included UAE but no antineoplastic agent (methotrexate or etoposide). Similar to the 3 cases reported by Barber et al,1 our AVM required a hysterectomy.2 This case was observed in a large national multicenter study including 167 cases of placenta accreta treated conservatively, where 18 cases were placenta percreta. Among these latter cases, additional uterine devascularization procedures were performed in 13 cases (8 UAEs and 5 vessel ligations).2 Although no denitive conclusion can be drawn from these limited data, and the pathophysiology of AVM following conservative treatment remains unknown, one can simply observe that the 2 common points of these 4 cases are: (1) the character percreta of the placental invasion; and (2) the additional treatment by UAE. Nevertheless, this does not exclude a possible role played by an antineoplastic agent in the pathophysiology of AVM. These 4 cases underline the need to continue to report maternal outcome following conservative treatment of placenta accreta/ percreta, particularly because optimal treatment protocol of conservative treatment remains unknown.1,2 As regards the optimal treatment for placenta percreta with adjacent pelvic structures, we could not agree more with the authors when they recommend performing conservative treatment.1,2 Concerning the optimal treatment for placenta accreta/ increta, we agree with the authors that conservative treatment is associated with severe maternal morbidity.2 Nevertheless, this is also true regarding cesarean-hysterectomy for placenta accreta.3 Therefore, until a randomized controlled trial is performed, we believe that conservative treatment is an option in cases of placenta accreta/increta for patients who are properly counseled and motivated, in particular, for women who want the option of future pregnancy4 and agree to close follow-up monitoring.2 f
Loc Sentilhes, MD, PhD Philippe Descamps, MD, PhD Department of Obstetrics and Gynecology Angers University Hospital 4, rue Larrey 49000 Angers, France loicsentilhes@hotmail.com Franois Gofnet, MD, PhD Maternit Port-Royal Hospital, Cochin APHP University Ren Descartes Paris, France
The authors report no conict of interest.

REFERENCES
1. Barber J, Tressler TB, Willis GS, et al. Arteriovenous malformation identication after conservative management of placenta percreta with uterine artery embolization and adjunctive therapy. Am J Obstet Gynecol 2011;5:e4-8. 2. Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment for placenta accreta. Obstet Gynecol 2010; 115:526-34. 3. Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol 2011;117:331-7. 4. Sentilhes L, Kayem G, Ambroselli C, et al. Fertility and pregnancy outcomes following conservative treatment for placenta accreta. Hum Reprod 2010;25:2803-10. 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.06.097

REPLY
We appreciate Dr Sentilhes and colleagues comments and interest in our work.1 The recognition of their reported case of an arteriovenous malformation (AVM) after conservative therapy has been noted.2 As stated in our article, a PubMed search failed to identify any other cases. While we did reference the work of Dr Sentilhes et al,2 it was unclear, based on that publication, if that patient had received adjunctive therapy in addition to a uterine devascularization procedure, uterine artery embolization, or vessel ligation, and therefore, we chose not to include it in our series. We agree with the commonality of the cases, including placenta percreta with uterine artery embolization, and cannot comment on the pathophysiology of AVM
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