Ascribing to the trend of rising cesarean delivery rates in the last decades, placenta accreta has become the most important cause of peripartum hysterectomy. Traditionally, cesarean hysterectomy is performedwhen placenta accreta is diagnosed, but this approach leads to the undesirable loss of fertility [1]. Manual removal of placenta (MROP) is one form of uterine salvage technique [1,2] and many obstetricians still perform MROP with the belief that it could salvage the uterus and, should the attempt be unsuccessful, a prompt hysterectomy could prevent and/or control serious hemorrhage. To date, only one comparative study has been conducted and it found that MROP would lead to increased risk of hysterectomy, hemorrhage, and blood transfusion [3]. However, it is not clear whether the increase in bleeding complications was due to MROP, the increased hysterectomy rates, or both. To evaluate the risks directly associated with MROP a retrospective case-control study was conducted to compare the clinical outcome of cesarean hysterectomies following placental removal (MROP study group) with those in which the placenta was kept in situ (PLI control group). To maintain clinical relevance the study covered only those cases that were antenatally diagnosed by ultrasound when there was a choice in the options for management. The study evaluated 59 (82%) of a total of 72 cases of peripartum hysterectomies performed at the Mater Mothers Hospital in Brisbane, Queensland, Australia from January 1995 to December 2005. There were 22 cases (37%) of ultrasounddiagnosed placenta accreta, 18 cases of accreta not detected antenatally, and 19 cases of non-accreta. Of the ultrasounddiagnosed accreta, 8 cases were in the MROP group, 13 in the PLI group, and 1 case was excluded because the placenta handling was inadequately described. Twenty of these cases were later confirmed to have placenta accreta on histology, but 2 cases in the MROP group were not because they had extensive tissue disruption to the placental bed from oversewing and curettage. Fisher exact test (for categorical variables) and Wilcoxon–Mann–Whitney test (for continuous variables) were used in the statistical analysis. A P valueb0.05 was considered statistically significant. There were no differences between the 2 groups in maternal age, gravidity, parity, gestation at delivery, and previous cesarean delivery. However, body mass index was greater in the MROP compared with the PLI group (34.2 kg/m2 vs 24.7 kg/m2, P=0.019). Surgical characteristics in both groups were comparable (Table 1). However, women in the MROP group required an extra 7.7 units of blood (P=0.038) and 6.1 units of platelet transfusions (P=0.006). They also had greater estimated blood loss and fresh frozen plasma transfusion, despite comparable preoperative and postoperative hemoglobin levels. The 2 groups did not differ significantly in the other perioperative outcome measures, maternal/perinatal mortality rates, and accreta subtypes. The study demonstrated that hysterectomy following MROP was associated with greater blood loss and transfusion than hysterectomy performed with the placenta left in situ. The fact that the cases studied were all antenatally diagnosed provides a strong argument against MROP for those with known accreta.Moreover, because 45% of placenta accreta cases were not detected by ultrasound, it is important to consider avoiding MROP if there were intraoperative signs of accreta. There area few shortfalls of this retrospective study: (1) small sample size despite covering over a decade; (2) incomplete data collection due to lost charts and unclear documentation; (3) possibility of selection bias; and (4) using estimated blood loss as