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ICAN Accreta Awareness Month – What is Placenta Accreta?
By The Well-Rounded Mama, August 26, 2013
Placenta Accreta, Part One: What Is Accreta?
Read the full article here.
Summary:
Placenta accreta comes in three levels of severity ─ accreta, increta, and percreta.
Thankfully, most accretas don’t involve an increta or a percreta. However, even without these severe forms, an accreta is still a very serious complication that has the potential to become life-threatening.
Fortunately, foreknowledge of an accreta, careful management protocols, and being in the right delivery setting can significantly lower the risk of mortality and morbidity. So if you have been told that you have an accreta, don’t panic. Chances are that you and your baby will be okay.
However, you need to know that a significant blood loss is likely, a transfusion may be needed, and a hysterectomy is a distinct possibility (depending on the severity of the accreta). In the most severe cases, nearby organs may be damaged as well. Management and delivery at a large regional hospital with OBs that are very experienced with dealing with accretas will optimize your chances for the best outcomes.
Sadly, the incidence of accretas has increased in parallel with the rising cesarean rate. This is because scarring and damage to the uterine lining during a cesarean predisposes to abnormal placentation. Indeed, the more cesareans a woman has, the higher her risk for placenta accreta.
Some risk factors for accretas cannot be controlled, but a high underlying cesarean rate is a risk factor that is preventable on a population-wide basis, and routine repeat cesareans is a risk factor that is highly preventable on an individual basis.
Placenta accreta is an extremely serious complication that is becoming all too common. A casual attitude towards cesareans, an over-utilization of them in low-risk mothers, and a lack of access to Vaginal Birth After Cesarean (VBAC) is part of the cause.
This is yet another reason why reducing the cesarean rate and keeping access to VBAC is so important.
ICAN Awareness Month – Placenta Accreta: Multiple C-Sections Can Kill Mother
Barbara George nearly hemorrhaged to death while doctors delivered her fifth child at Hackensack Medical Center in New Jersey — and that was in 2010, not 1910. The stay-at-home mother from South Orange was diagnosed with placenta accreta, a life-threatening condition where the placenta grows into the uterine wall and sometimes beyond. George, 38, had the most invasive form — percreta — and the placenta dangerously penetrated the entire uterine wall and had attached itself to her bladder.
Once a rare event that affected 1 in 30,000 pregnant women in the 1950s and 1960s, placenta accreta now affects 1 in 2,500 pregnancies, according to a 2007 report in the Journal of Obstetrics and Gynecology. In some hospitals, the number is as high as 1 in 522. And doctors say the main reason is the dramatic rise in the number of cesarean sections — about 38 percent of all pregnancies in New Jersey, the second highest in the nation.
“The rule of thumb is if you have one C-section and the placenta sits right on top of the scar, the risk of placenta accreta is 25 percent,” said Dr. Abdulla Al-Khan, director of the Division of Fetal Medicine and Surgery at Hackensack University Medical Center. “If you’ve had two previous C-sections the risk is close to 50 percent and three, it’s 75 percent and four, it’s invariably closer to 100 percent.” Al-Khan and his team performed seven hours of complex surgery on George, first delivering the baby in a sternum to pubic bone vertical incision, then cauterizing veins to detach the placenta from the bladder and finally a hysterectomy.
“I always thought it would never happen to me,” said George, who delivered at 34 weeks gestation. “Mother nature protects the uterus,” said Al-Kahn. “The Nitabach layer kind of prevents the placenta from invading the uterine wall.” But a cesarean, or any kind of surgery, including an abortion or a D& C, can destroy that layer allowing the placenta to invade the body cavity.
The risk of the mother dying in childbirth has been cut by 99 percent since the turn of the 20th century, from 850 deaths per 100,000 births in 1900 to 7.5 in 1982, according to the Centers for Disease Control and Prevention. But between 1998 and 1999, the maternal mortality rate rose by 13 percent and continued to creep upwards, according to the CDC. New Jersey saw 40 maternal deaths last year, according to Dr. Joseph Apuzzio, chair of the state’s morbidity and mortality review committee and an obstetrician at New Jersey Medical School in Newark.
Doctors are also seeing other complications in pregnancy that increase maternal risk: more diabetes and preeclampsia, a higher number of twins and multiples and advanced maternal age. “When we natural age, we have more medical conditions,” said Al-Kahn. “Pregnancy always exacerbates things.” Babies are also larger, compared with a century ago, even though the size of the female pelvis has not changed at all, he said. A rise in cases of placenta accreta due to multiple cesareans is also contributing to maternal death statistics.
“Now patients have a right to make shared decisions with their doctor,” he said. “It’s self-empowerment. If I can have a tummy tuck and rhinoplasty, why can’t I have a cesarean delivery?” Al-Kahn jump-started the high-risk program at Hackensack after one of his patients nearly died in 2004. The woman had had only one previous cesarean and the placenta in her second pregnancy had implanted right on top of her scar.
“She started bleeding at 35 weeks and we took her into the operating room to deliver the baby,” said Al-Kahn. “It got to the point that she went into shock and needed 33 units of blood. We intubated her and she was three days on a ventilator. She lost half of her bladder and it took 12 hours in the operating room to save her life. I said to myself, ‘God save this individual so she can live to be with her two kids and her husband,” said Al-Kahn. “I never wanted that to happen again.”
Since the program was started in 2005, Al-Kahn has seen more than 60 patients with the risky condition. Both mortality and the number of transfusions have dropped, he said. George, who had four other high-risk pregnancies because of preeclampsia and diabetes, was referred to Hackensack after her own doctor saw something ominous on an MRI.
“I could just see her trying to maintain a professional exterior and see she had more concerns than she wanted to let on,” said George. When she learned she had placenta accreta, she prepared for the worst and got her affairs in order. “It was very difficult,” said George. “I’m the type of person that tends to think it’s not going to happen to me. I didn’t want to deal with the what-ifs. But we had to have that conversation. It was so surreal.”
Her doctor sent her straight to Hackensack where George was given magnesium and steroids to encourage the baby’s lung development. In the middle of New Jersey blizzards on Dec. 27, Hannah was delivered by a long cesarean cut from the sternum to the pubic bone. There was never any danger to the baby, who was born in 45 minutes, but doctors were worried about George, cauterizing every blood vessel using hypothermic techniques so they could slowly peel away the placenta from the bladder.
“I feel so grateful,” she said of her now 3-month-old daughter. “Hannah is amazing and has really brought this family together in such a way, I can’t explain it.” But George said that her experience is a warning to other women who opt for cesarean sections when surgery is not medically necessary. “A cesarean should never be done to accommodate your schedule or because of your fears of pain,” she said. “It’s an unnecessary trauma to the body and it should not be treated as an alternative to natural childbirth.”
#ICANsavelives
Reposted with permission from ABCNews
ICAN Accreta Awareness Month – Welcome to October 2017!
- We will be sharing graphics about accreta everyday. Follow us on Facebook, Pinterest, Twitter, and Instagram and share in your circles.
- We will be sharing informative articles.
- We will be sharing birth stories and pictures of accreta moms.
- On October 15th, we will be remembering and honoring the moms and babies that we lost to accreta, a very real risk with this condition.
Previous Cesarean Increases Likelihood of Future Hysterectomy Complications
The International Cesarean Awareness Network is proud to have Henci Goer, medical author and international speaker, on our advisory committee. In addition to her books and numerous online writings, she is also the founder and director of Childbirth U, a website dedicated to educating pregnant women about their birth options. We have selected the following article to share with our readers.
Previous Cesarean Increases Likelihood of Future Hysterectomy Complications
If the list of cesarean harms weren’t long enough already, Consumer Reports points to another one: women who have hysterectomies are more likely to experience complications if they have previously had cesareans. Let’s take a look at the study.
Investigators identified a population of 7685 Danish women who had given birth and who subsequently had a hysterectomy for noncancerous reasons when they weren’t pregnant and were more than 45 days past giving birth. They then looked at the association between mode of birth and need for re-operation after the hysterectomy as well as other complications according to whether the women had no, one, or multiple prior cesareans.
After adjusting for factors that might influence both the need for cesarean and the likelihood of hysterectomy complications, they found that one prior cesarean increased the likelihood of needing re-operation by 30% and two or more increased need by 35% compared with women with no prior cesarean. With 4% of women with only vaginal births needing re-operation, this amounted to 2 more women with at least one prior cesarean per 100. Women with 2 or more prior cesareans were also 30% more likely to experience surgical complications (primarily bleeding or infection), which, at a baseline rate of 12% among women with no prior cesarean, amounted to 4 more women per 100. Finally, women with 2 or more prior cesareans were 93% more likely—nearly double the odds—to need a blood transfusion. With 2.5% of women with no prior cesarean needing transfusion, this amounted to 2.5 more women per 100. Both the study authors and the Consumer Reports commenters think the probable cause for the increased complication rates is that adhesions (internal scar tissue) formed consequent to cesarean surgery make further surgery more complex and more likely to result in injury.
In addition, women with prior cesareans were more likely to have an abdominal hysterectomy (42% no prior cesarean; 60% 1 prior cesarean; 68% multiple prior cesareans) as opposed to the less invasive vaginal or laparoscopic hysterectomy. Study authors observe that this is probably because of concern that adhesions could increase the potential for bladder injury or difficulty removing the uterus via these other routes. Minimally invasive surgery, they note, results in shorter recovery time, less pain, and a smaller incision.
Study authors also note that while the overall Danish cesarean rate is 21%, it was 32% in women having a future hysterectomy. This could be because women who have cesareans have health or gynecologic problems that increase their risk of needing a hysterectomy, but it could also be because cesarean surgery increases the likelihood of complications leading to the need for later hysterectomy (chronic pain, bleeding disorders, adenomyosis, and adhesions).
The Consumer Reports article adds that hysterectomies down the road aren’t the only drawback. Women with prior cesareans are also more likely to require a hysterectomy or experience serious complications in conjunction with subsequent births, whether they are planned VBACs or repeat cesareans.
The Take-Away: The excess in rates of re-operation and other complications with downstream hysterectomy may be small, but they add to the reasons why cesareans shouldn’t be undertaken lightly. Worrisome too, the study raises the possibility that cesarean surgery may increase the need for hysterectomy in the future.
Henci Goer, award-winning medical writer and internationally known speaker, is an acknowledged expert on evidence-based maternity care. Her first book, Obstetric Myths Versus Research Realities, was a valued resource for childbirth professionals. Its successor, Optimal Care in Childbirth: The Case for a Physiologic Approach, won the American College of Nurse-Midwives “Best Book of the Year” award. Goer has also written The Thinking Woman’s Guide to a Better Birth, which gives pregnant women access to the research evidence, as well as consumer education pamphlets and articles for trade, consumer, and academic periodicals; and she posts regularly on Lamaze International’s Science & Sensibility. Goer is founder and director of Childbirth U, a website offering narrated slide lectures to help pregnant women make informed decisions and obtain optimal care for themselves and their babies.
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