ICAN Accreta Awareness Month – Diagnosis, Treatment, and a Cautionary Story

By The Well-Rounded Mama, September 29, 2013

Placenta Accreta, Part Four: Diagnosis, Treatment and a Cautionary Story

Read the full article here.

Summary:

Placenta Accreta is a rare but very serious complication that is associated with prior uterine instrumentation procedures. Although it can occur after a number of different procedures, it is most strongly associated with prior cesarean.  It is most common with rising numbers of prior cesareans but can occur even in women with only one prior cesarean.

Accretas come in three different levels of severity, but make no mistake, all are potentially life-threatening. Although minor degrees of accreta can often be resolved without major repercussions, the potential for serious complications is always there and must be taken seriously. And the potential complications with the most severe forms are sobering indeed.

Of course, it’s only fair to point out that even though the risk for abnormal placentation rises with each cesarean, most women with prior cesareans do not experience placenta previa or accreta. And most cesareans go well, even higher-order cesareans.  So if you have had cesareans before, don’t panic. Chances are you’ll be okay.

However, from a public health point of view, the take-home message is that risks start rising rapidly as the total number of cesareans increase.

Complications like previa and accreta are more common after three to four or more cesareans. However, sometimes these complications happen when a woman has “only” had one or two prior cesareans. Just because you’ve only had one or two cesareans instead of four doesn’t mean you aren’t at risk. It all depends on how well your uterus was able to repair itself and exactly where an embryo implants.

And although the absolute risk for previa and accreta overall is low, it’s far higher than it is in women who have never had any cesareans.

Don’t forget, sometimes there are babies and women who die from placenta accreta/percreta, or have very near misses.

At the very least, it often results in severe hemorrhage, hysterectomy, loss of fertility, uterine rupture, and significant damage to the urological system or abdomen of the mother, not to mention prematurity in the baby.

This is why it is important to avoid the first cesarean whenever possible, to not automatically schedule repeat cesareans in most women, and to make sure that VBAC stays an option for as many women as possible.

Unfortunately, this is the exact opposite of what’s happening in many places right now. And that’s why the world will continue to see a strong rise in the number of women experiencing placenta accreta and all its complications.  As one recent study concluded:

If primary and secondary cesarean rates continue to rise as they have in recent years, by 2020 the cesarean delivery rate will be 56.2%, and there will be an additional 6236 placenta previas, 4504 placenta accretas, and 130 maternal deaths annually…If cesarean rates continue to increase, the annual incidence of placenta previa, placenta accreta, and maternal death will also rise substantially.

A Concluding Story

This topic is on my mind because an online friend of mine recently faced placenta accreta. She has given me permission to share her story.

She had an excellent OB and surgical team, her accreta didn’t look too severe, and she had her surgery at a very good hospital. But she knew that there were no guarantees, that sometimes an accreta that doesn’t look major turns out to be more serious. She was uneasy after reading the story of the mother in Utah who died recently due to placenta accreta and worried about leaving her other children behind.

In the end, I’m happy to report that she had an overall “good” outcome.  They were able to hold off the cesarean until almost term, so the baby was not very premature at all.  The mom didn’t need to have emergency surgery; they were able to hold off until a very extensive team of surgeons and specialists were standing by, ready to intervene if needed.

Sadly, though, her accreta was severe enough that they did have to do a hysterectomy. Now this mother has lost her uterus and any chance at future children.  She also suffered a lot of blood loss, including internal bleeding after the cesarean that left her with a lot of fatigue and very serious and long-lasting pain.

What’s so frustrating is that this might have been preventable. Mismanagement by care providers in pregnancies previous to this one led her down this path and that she is angry about.

She is a woman of size who followed the common birth trajectory of many heavier women ─ pressured into an induction because of her providers’ fears about postdates and big baby. Like so many in that situation, she ended with a c-section for “failure to progress” with a malpositioned baby. Like about twelve to thirty percent of big moms, she developed an infection and had a rough recovery.

She was promised that she could pursue a VBAC but was given the old bait-and-switch routine at the end of her second pregnancy.  Many care providers tell high-BMI women they can have a VBAC and then find some reason at the end why they shouldn’t have one after all. They pressured her into a repeat cesarean because they told her she was overdue (she wasn’t) and because they feared a big baby (baby was 7 lbs.).  So she ended up with a totally unnecessary 2nd c-section.

She planned a VBA2C in her third pregnancy. She did labor this time but ended up with another cesarean after manipulation by her caregivers. Her cesarean scar re-opened postpartum, she ended up back in the hospital, and the scar took 4 months to heal.  She experienced severe postpartum depression and PTSD.

She planned a VBA3C with her next pregnancy and was fortunate to have an understanding OB who was supportive. However, due to massive scar tissue in the area, she felt like she needed to have the repeat cesarean in the end. She just had a gut feeling it was the most prudent thing to do with so much scar tissue. Her OB was able to help clean up all the considerable adhesions inside when he did her fourth cesarean, and she was able to avoid the infections and difficulties that had accompanied her earlier cesareans. It was hard because it wasn’t the outcome she wanted, but she did feel it was the most prudent choice under her circumstances.

She spent a lot of time getting in shape for her next pregnancy, hoping to be able to go for a VBA4C, only to find out early in the pregnancy that she had both placenta previa and placenta accreta, an ominous finding for someone with multiple prior cesareans. Gone was the hope for a VBAC; now the focus was on making sure she and baby would survive.

In the end, she did lose her uterus and could have lost her baby and her life….all because her past caregivers pushed her down the path of over-intervention and into all those cesareans due to her weight.

THIS is why I fight so hard against a too-high cesarean rate, and in particular against the astronomically high cesarean rate in high-BMI women.

Remember, a high cesarean rate in high-BMI women doesn’t start in the operating room. It starts with the high rate of interventions in the women of size, especially the astronomically high induction rate.

A few researchers are beginning to catch on to this.  In one study, the authors point out:

We can conclude that a morbidly obese woman in spontaneous labour has a 70% chance of achieving a vaginal delivery but this falls to only 48% if labour is induced…Management of morbidly obese women with a singleton pregnancy should aim for vaginal delivery and await spontaneous onset of labour.

A high induction rate, a failure to be patient during labor, exaggerated fears about vaginal birth in women of size, and a low threshold for surgical intervention are the engines driving the high cesarean rate in obese women. And this, in turn, drives the higher rate of poor outcomes among women of size, including fetal distress, wound infections, and now placental complications.

If 50% (or more in some studies) of obese women are ending up with cesareans, then it is only logical that many will develop placenta previa and/or accreta as a result.

Very high cesarean rates and lack of access to VBAC disproportionately expose obese women to the risk of serious morbidity and even mortality with cesareans and abnormal placentation; this MUST stop.

Lives are depending on it.

ICAN accreta blood drop

#ICANsavelives


Reposted with permission from The Well-Rounded Mama.

References are on the original post here.

Part One, Part Two, Part Three, and Part Four of this series.