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| Illustration of placentas (and truncated umbilical cords), showing the difference between normal and abnormal placental implantation with differing degrees of accreta; look at the light red areas where the placenta touches the uterus to see the difference Image from Wikimedia Commons |
As a follow-up to the discussions we have had about too-high cesarean rates, we have been talking about abnormal placentation in future pregnancies after a cesarean, including:
- placental abruption (the placenta shearing off before the baby is ready to be born)
- placenta previa (a low-lying placenta that covers or nearly covers the cervix)
- placenta accreta (an abnormally attached placenta that has difficulty detaching after birth)
Placenta Accreta
As mentioned in Part One and Part Two of this series, placenta accreta is an abnormally attached placenta. For the sake of clarity, let's review the basics of how it happens.
In a normal pregnancy, the decidua (lining of the uterus) prevents the placenta from invading the uterine wall.
In placenta accreta, the decidua is thin or deficient in some areas, probably due to damage or scar tissue. This allows the placenta to attach itself directly into the maternal tissues.
How deeply the placenta attaches (or grows into the uterus) determines the severity of the accreta.
There are three levels of severity of accretas.
In Placenta Accreta, the placenta invades the deficient decidual layer and attaches to the wall of the uterus. About 75% of accretas are in this form.
In Placenta Increta, the placenta actually grows deeply into the muscle of the uterus (myometrium).
In the most severe form, Placenta Percreta, the placenta grows not only into the muscle of the uterus but through the outer layer (serosa) and often into adjacent structures nearby, usually the mother's bladder or bowels.
Thankfully, most accretas don't involve an increta or a percreta. Most of the time, an accreta is "just" attached to the wall of the uterus, but does not grow into or through it. Still, even this level of accreta can result in serious problems.
Fortunately, foreknowledge of an accreta, careful management protocols, and being in the right delivery setting can significantly lower the risk for mortality and morbidity.
Risks to the Mother
Most cases fall somewhere between these two possibilities.
The severity of placenta accreta depends on how many of the placental cotyledons (the tree-like chorionic villus branching structure seen inside the box on the diagram) have adhered to the uterine wall and how deeply they have embedded.
Some cases are a focal accreta (only one cotyledon is abnormally attached).
Some are partial accretas (just a few of the cotyledons are abnormally attached)
Still others are a total accreta (all of the cotyledons are abnormally attached).
No matter how many cotyledons are involved, accreta is a serious complication of pregnancy for many reasons. The main risks involve blood loss, short-term complications from blood loss (anemia, transfusion, coagulopathy), long-term complications from bleeding (Sheehan's Syndrome), hysterectomy, organ damage, and maternal mortality.
The baby is also at risk from prematurity, undergrowth, and stillbirth. Future pregnancies, if any, are also at increased risk for complications.
Because of the seriousness of these risks and the physical trials many women with accreta endure, they are also at risk emotionally for Post-Traumatic Stress Disorder (PTSD).
Blood Loss
The main risk from accretas of all types centers around blood loss.
Normal blood loss is around 500 mL in a vaginal birth and around 1000 mL in a cesarean section.
In contrast, the average blood loss in women with placenta accreta is 3,000–5,000 mL. This means that blood loss is a very serious issue in accretas, even relatively mild ones.
Why do women lose so much blood with accreta? The abnormal attachment means that the placenta cannot separate from the uterus after the baby is born. As a result, the mother's arteries cannot shut off their flow of blood to the placenta and the mother begins to bleed severely.
Because the placenta and uterus are highly vascular and because the blood flow to support a pregnancy is considerable, accretas (especially the more severe forms) have the potential for massive hemorrhages. One study noted:
Complications of Blood Loss
Even when the accreta is not that severe, the accompanying blood loss can result in postpartum anemia. This can affect milk supply, inhibit healing, and leave the mother tired and drained for many months afterwards.
Many women with accreta end up needing a blood transfusion ─ sometimes multiple ones. As ACOG notes in its guideline on managing accreta:
Sheehan's Syndrome
One under-diagnosed long-term complication of massive blood loss is Sheehan's Syndrome. Although most women with accreta do not experience this condition, women who do have it may suffer with it for years before it is recognized and treated.
Because of the unique demands of pregnancy, a woman's pituitary is particularly vulnerable to damage from blood loss during birth. In Sheehan's Syndrome, the hemorrhage during birth is so severe that the blood supply to the pituitary gland is compromised, resulting in partial tissue death.
Since the pituitary is a "master gland" controlling many other glands, a partially functioning pituitary can cause problems, especially long-term.
Low milk supply or inability to breastfeed is the only problem evident immediately; missing or infrequent periods may also occur but not be recognized as an issue for some time because the woman is postpartum.
Hypothyroidism often develops as time goes on, and significant fatigue, intolerance to cold, and dry skin is common. Some women may experience loss of body hair, premature aging, and low blood pressure. Periods may never re-start or may never occur regularly.
Sometimes an adrenal crisis will develop, often triggered by another health crisis to which the body cannot adequately respond. Diabetes, electrolyte imbalances, and congestive heart failure are possible late complications of the syndrome as well. In worst-case scenarios, coma and even death can occur.
Sheehan's Syndrome is under-diagnosed because most of its symptoms come on gradually and are similar to other problems (like anemia, fatigue, aging, etc.). It can go undetected for years and often only gets recognized when a different health issue throws the woman into an adrenal crisis.
Any woman who experienced a significant bleed during birth and difficulty breastfeeding postpartum should be tested for Sheehan's Syndrome as soon as possible, especially if her period did not restart in a timely manner despite not being able to breastfeed.
Any woman with a significant bleed should also alert her General Practitioner to her history of hemorrhage during childbirth so she can be evaluated for Sheehan's Syndrome periodically over the years. Remember, this condition may develop gradually over time, so it must be tested for periodically as you age.
To test for Sheehan's Syndrome, thyroid, cortisol, and adrenal hormone tests need to be performed. An MRI of the head may also be indicated.
The most common treatment for Sheehan's Syndrome involves hormone replacements until menopause, and thyroid and/or adrenal medications for life as needed. The earlier it is diagnosed and treated, the better the outcome.
Hysterectomy
Sadly, in many women, accreta-related bleeding during the birth can be so severe that a hysterectomy is needed to stop the bleeding, thus ending the woman's fertility forever.
In one study, 90% of women with accreta ended up having a hysterectomy.
However, this high rate probably reflects the fact that the most accepted method for delivering an accreta pregnancy is cesarean hysterectomy. This is done to proactively limit the potential for bleeding. Doctors open the uterus (away from the placenta), deliver the baby, leave the placenta in place, and just remove the uterus and placenta together without trying to detach the placenta at all.
Many hysterectomies in this situation also take out the cervix, especially when placenta previa is also present. Sometimes, women also lose their tubes and ovaries in the hysterectomy, though every attempt to preserve the ovaries is made in order to lessen the need for hormone therapy.
It used to be that cesarean hysterectomy was the only treatment that doctors would consider with an accreta. It's still considered the most optimal choice, but doctors will sometimes consider a less radical alternative if the mother still desires more children, is not experiencing severe bleeding episodes, or expresses a strong desire to keep her uterus.
This alternative treatment leaves the placenta in place, hoping the body will dissolve and reabsorb it over time. Very strong drugs may be used to aid in this process. This uterus-conserving approach is no guarantee of success; many result in delayed hysterectomies. However, sometimes it does work, and is an option that can be discussed for more minor cases of accreta in women who desire more children.
Incretas and percretas, on the other hand, will almost always necessitate a hysterectomy.
Damage to Surrounding Organs
Along with the usual surgical risks of infection, blood clots, anesthesia problems, etc., the woman with accreta is at increased risk for damage to the organs surrounding the uterus. This may be as a result of the accreta itself, as a complication of the surgery to remove it, or as a result of massive blood loss.
Because of the bladder's proximity to the uterus and low-lying placentas, a percreta most often invades the mother's bladder, often causing it significant damage. A urologist is usually involved in a percreta delivery in order to have an expert in this anatomy ready to repair the bladder and ureters. Some women with percretas are left with bladder fistulas (holes) or a very small bladder after repair. A few lose their bladders altogether.
Sometimes the intestines, uterine ligaments, or blood vessels are affected by a percreta. Thus, the medical team may also necessitate general surgeons to repair the abdominal organs, or interventional radiologists to place stents (to protect ureters) and balloons (to reduce the bleeding).
Most often, organ damage occurs secondary to hysterectomy or a complicated surgery. In one recent Australian study, for example, about half the women with accretas sustained surgical injuries and about 20% needed re-operation later. The bladder, ureters, and intestines are the most common sites of accidental surgical damage, which can have long-lasting implications for the mother. Infection is also a big risk if an intestine is nicked during surgery.
Finally, if D.I.C. occurs after major blood loss, organs can be damaged as a consequence of the coagulation issues and blood loss. Lung and kidney damage are the most common, but sometimes other organs are damaged as well.
Maternal Mortality
Although rare in modern medical settings, women can and have died from the massive blood loss of an accreta and accompanying complications.
One study found a maternal mortality rate of 7% from accretas. Studies from third world countries can have even higher maternal mortality rates.
Although precautionary planning and good management can lessen these rates, even ACOG admits, "Maternal death may occur despite optimal planning, transfusion management, and surgical care."
This is why accretas must be taken very seriously indeed.
Risks to the Baby
Accretas have risks for the baby too, although usually not as severe as for the mother.
Sometimes the baby does not grow properly; there is an increased risk for Small-for-Gestational-Age (SGA) babies with accreta. This is probably because the placental blood flow can be compromised with some accretas.
Accretas are also associated with a significant risk of prematurity due to bleeding issues. The more severe the accreta, the more likely the baby will be born early because of antepartum bleeding issues. This means these families often have to deal with all the issues of prematurity, including bleeding on the brain, necrotizing enterocolitis, vision or hearing issues, jaundice, unstable blood sugar, and difficulties with feeding.
Most significant accretas are delivered by planned cesarean around 34-36 weeks because of the fear of hemorrhage and the need to have a planned delivery so that a team of specialists can be on hand to intervene if needed. Often the doctors will administer a course of steroids a few days before the planned delivery (or if an early delivery seems likely because of bleeding episodes) in order to help mature the baby's lungs.
Babies born from pregnancies with accreta tend to have lower Apgar scores and more stays in the Neonatal Intensive Care Unit. Whether this is because of prematurity alone or whether placenta accreta adds an extra risk on top of the prematurity is unclear at this time.
Tragically, sometimes babies die because of accretas. Sometimes delivery occurs before fetal viability because of massive bleeding or uterine rupture. Sometimes a crisis occurs unexpectedly and a cesarean cannot be done quickly enough to save the baby. Sometimes the premature baby encounters complications like infection or breathing problems that just can't be overcome.
Thankfully, it should be noted that most of the time, babies of accreta pregnancies do survive. They are usually premature, with all the complications that prematurity can involve, but they usually do survive.
Future Pregnancies
As mentioned in Part One and Part Two of this series, placenta accreta is an abnormally attached placenta. For the sake of clarity, let's review the basics of how it happens.
In a normal pregnancy, the decidua (lining of the uterus) prevents the placenta from invading the uterine wall.
In placenta accreta, the decidua is thin or deficient in some areas, probably due to damage or scar tissue. This allows the placenta to attach itself directly into the maternal tissues.
How deeply the placenta attaches (or grows into the uterus) determines the severity of the accreta.
There are three levels of severity of accretas.
In the most severe form, Placenta Percreta, the placenta grows not only into the muscle of the uterus but through the outer layer (serosa) and often into adjacent structures nearby, usually the mother's bladder or bowels.
Thankfully, most accretas don't involve an increta or a percreta. Most of the time, an accreta is "just" attached to the wall of the uterus, but does not grow into or through it. Still, even this level of accreta can result in serious problems.
Fortunately, foreknowledge of an accreta, careful management protocols, and being in the right delivery setting can significantly lower the risk for mortality and morbidity.
Risks to the Mother
Important Note: While the risks of placenta accreta are considerable and women need to be informed about them, they must be kept in perspective. Many women with placenta accreta do reasonably well, as do their babies. If you have accreta, don't read the list of possible risks below and panic. Remember that these are only possibilities. They have to be taken seriously, but they are not predestined outcomes. A lot depends on how serious your accreta is and how well it is managed.The outcome of placenta accreta varies from case to case. Mild accretas, although risky, can often be resolved without serious morbidity. Severe percretas, on the other hand, are one of the most dangerous obstetric situations around.
Most cases fall somewhere between these two possibilities.
 |
| Placental Cotyledon - structure in box Image from Wikimedia Commons |
Some cases are a focal accreta (only one cotyledon is abnormally attached).
Some are partial accretas (just a few of the cotyledons are abnormally attached)
Still others are a total accreta (all of the cotyledons are abnormally attached).
No matter how many cotyledons are involved, accreta is a serious complication of pregnancy for many reasons. The main risks involve blood loss, short-term complications from blood loss (anemia, transfusion, coagulopathy), long-term complications from bleeding (Sheehan's Syndrome), hysterectomy, organ damage, and maternal mortality.
The baby is also at risk from prematurity, undergrowth, and stillbirth. Future pregnancies, if any, are also at increased risk for complications.
Because of the seriousness of these risks and the physical trials many women with accreta endure, they are also at risk emotionally for Post-Traumatic Stress Disorder (PTSD).
Blood Loss
The main risk from accretas of all types centers around blood loss.
Normal blood loss is around 500 mL in a vaginal birth and around 1000 mL in a cesarean section.
In contrast, the average blood loss in women with placenta accreta is 3,000–5,000 mL. This means that blood loss is a very serious issue in accretas, even relatively mild ones.
Why do women lose so much blood with accreta? The abnormal attachment means that the placenta cannot separate from the uterus after the baby is born. As a result, the mother's arteries cannot shut off their flow of blood to the placenta and the mother begins to bleed severely.
Because the placenta and uterus are highly vascular and because the blood flow to support a pregnancy is considerable, accretas (especially the more severe forms) have the potential for massive hemorrhages. One study noted:
Even with the best possible management, the blood loss associated with placenta accreta can resemble that of a major trauma.This level of blood loss can have significant effects on the mother, sometimes lasting long after the birth.
Complications of Blood Loss
Even when the accreta is not that severe, the accompanying blood loss can result in postpartum anemia. This can affect milk supply, inhibit healing, and leave the mother tired and drained for many months afterwards.
Many women with accreta end up needing a blood transfusion ─ sometimes multiple ones. As ACOG notes in its guideline on managing accreta:
As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells.In a worst-case scenario, a massive hemorrhage can lead to coagulopathy (blood clotting not working properly anymore). Disseminated Intravascular Coagulation (D.I.C.) may develop and can lead to shock, organ failure, and even death. As one source summarizes:
In DIC, the body's natural ability to regulate blood clotting does not function properly. This causes the blood's clotting cells (platelets) to clump together and clog small blood vessels throughout the body. This excessive clotting damages organs, destroys blood cells, and depletes the supply of platelets and other clotting factors so that the blood is no longer able to clot normally. This often causes widespread bleeding, both internally and externally.The potential for serious bleeding and D.I.C. is one of the reasons that it is so important to deliver accretas in a high-level hospital with protocols and supplies in place for dealing with massive hemorrhages.
Sheehan's Syndrome
One under-diagnosed long-term complication of massive blood loss is Sheehan's Syndrome. Although most women with accreta do not experience this condition, women who do have it may suffer with it for years before it is recognized and treated.
Since the pituitary is a "master gland" controlling many other glands, a partially functioning pituitary can cause problems, especially long-term.
Low milk supply or inability to breastfeed is the only problem evident immediately; missing or infrequent periods may also occur but not be recognized as an issue for some time because the woman is postpartum.
Hypothyroidism often develops as time goes on, and significant fatigue, intolerance to cold, and dry skin is common. Some women may experience loss of body hair, premature aging, and low blood pressure. Periods may never re-start or may never occur regularly.
Sometimes an adrenal crisis will develop, often triggered by another health crisis to which the body cannot adequately respond. Diabetes, electrolyte imbalances, and congestive heart failure are possible late complications of the syndrome as well. In worst-case scenarios, coma and even death can occur.
Sheehan's Syndrome is under-diagnosed because most of its symptoms come on gradually and are similar to other problems (like anemia, fatigue, aging, etc.). It can go undetected for years and often only gets recognized when a different health issue throws the woman into an adrenal crisis.
Any woman who experienced a significant bleed during birth and difficulty breastfeeding postpartum should be tested for Sheehan's Syndrome as soon as possible, especially if her period did not restart in a timely manner despite not being able to breastfeed.
Any woman with a significant bleed should also alert her General Practitioner to her history of hemorrhage during childbirth so she can be evaluated for Sheehan's Syndrome periodically over the years. Remember, this condition may develop gradually over time, so it must be tested for periodically as you age.
To test for Sheehan's Syndrome, thyroid, cortisol, and adrenal hormone tests need to be performed. An MRI of the head may also be indicated.
The most common treatment for Sheehan's Syndrome involves hormone replacements until menopause, and thyroid and/or adrenal medications for life as needed. The earlier it is diagnosed and treated, the better the outcome.
Hysterectomy
Sadly, in many women, accreta-related bleeding during the birth can be so severe that a hysterectomy is needed to stop the bleeding, thus ending the woman's fertility forever.
In one study, 90% of women with accreta ended up having a hysterectomy.
However, this high rate probably reflects the fact that the most accepted method for delivering an accreta pregnancy is cesarean hysterectomy. This is done to proactively limit the potential for bleeding. Doctors open the uterus (away from the placenta), deliver the baby, leave the placenta in place, and just remove the uterus and placenta together without trying to detach the placenta at all.
Many hysterectomies in this situation also take out the cervix, especially when placenta previa is also present. Sometimes, women also lose their tubes and ovaries in the hysterectomy, though every attempt to preserve the ovaries is made in order to lessen the need for hormone therapy.
It used to be that cesarean hysterectomy was the only treatment that doctors would consider with an accreta. It's still considered the most optimal choice, but doctors will sometimes consider a less radical alternative if the mother still desires more children, is not experiencing severe bleeding episodes, or expresses a strong desire to keep her uterus.
This alternative treatment leaves the placenta in place, hoping the body will dissolve and reabsorb it over time. Very strong drugs may be used to aid in this process. This uterus-conserving approach is no guarantee of success; many result in delayed hysterectomies. However, sometimes it does work, and is an option that can be discussed for more minor cases of accreta in women who desire more children.
Incretas and percretas, on the other hand, will almost always necessitate a hysterectomy.
Damage to Surrounding Organs
Along with the usual surgical risks of infection, blood clots, anesthesia problems, etc., the woman with accreta is at increased risk for damage to the organs surrounding the uterus. This may be as a result of the accreta itself, as a complication of the surgery to remove it, or as a result of massive blood loss.
Because of the bladder's proximity to the uterus and low-lying placentas, a percreta most often invades the mother's bladder, often causing it significant damage. A urologist is usually involved in a percreta delivery in order to have an expert in this anatomy ready to repair the bladder and ureters. Some women with percretas are left with bladder fistulas (holes) or a very small bladder after repair. A few lose their bladders altogether.
Sometimes the intestines, uterine ligaments, or blood vessels are affected by a percreta. Thus, the medical team may also necessitate general surgeons to repair the abdominal organs, or interventional radiologists to place stents (to protect ureters) and balloons (to reduce the bleeding).
Most often, organ damage occurs secondary to hysterectomy or a complicated surgery. In one recent Australian study, for example, about half the women with accretas sustained surgical injuries and about 20% needed re-operation later. The bladder, ureters, and intestines are the most common sites of accidental surgical damage, which can have long-lasting implications for the mother. Infection is also a big risk if an intestine is nicked during surgery.
Finally, if D.I.C. occurs after major blood loss, organs can be damaged as a consequence of the coagulation issues and blood loss. Lung and kidney damage are the most common, but sometimes other organs are damaged as well.
Maternal Mortality
Although rare in modern medical settings, women can and have died from the massive blood loss of an accreta and accompanying complications.
One study found a maternal mortality rate of 7% from accretas. Studies from third world countries can have even higher maternal mortality rates.
Although precautionary planning and good management can lessen these rates, even ACOG admits, "Maternal death may occur despite optimal planning, transfusion management, and surgical care."
This is why accretas must be taken very seriously indeed.
Risks to the Baby
Accretas have risks for the baby too, although usually not as severe as for the mother.
Sometimes the baby does not grow properly; there is an increased risk for Small-for-Gestational-Age (SGA) babies with accreta. This is probably because the placental blood flow can be compromised with some accretas.
Accretas are also associated with a significant risk of prematurity due to bleeding issues. The more severe the accreta, the more likely the baby will be born early because of antepartum bleeding issues. This means these families often have to deal with all the issues of prematurity, including bleeding on the brain, necrotizing enterocolitis, vision or hearing issues, jaundice, unstable blood sugar, and difficulties with feeding.
Most significant accretas are delivered by planned cesarean around 34-36 weeks because of the fear of hemorrhage and the need to have a planned delivery so that a team of specialists can be on hand to intervene if needed. Often the doctors will administer a course of steroids a few days before the planned delivery (or if an early delivery seems likely because of bleeding episodes) in order to help mature the baby's lungs.
Babies born from pregnancies with accreta tend to have lower Apgar scores and more stays in the Neonatal Intensive Care Unit. Whether this is because of prematurity alone or whether placenta accreta adds an extra risk on top of the prematurity is unclear at this time.
Tragically, sometimes babies die because of accretas. Sometimes delivery occurs before fetal viability because of massive bleeding or uterine rupture. Sometimes a crisis occurs unexpectedly and a cesarean cannot be done quickly enough to save the baby. Sometimes the premature baby encounters complications like infection or breathing problems that just can't be overcome.
Thankfully, it should be noted that most of the time, babies of accreta pregnancies do survive. They are usually premature, with all the complications that prematurity can involve, but they usually do survive.
Future Pregnancies
Pregnancy after accreta is possible, assuming the uterus was able to be saved. However, the mother still remains at elevated risk for complications in future pregnancies.
In one recent study, the records of 30 pregnancies that occurred after a pregnancy with accreta were examined. The mothers were at risk of recurrent accreta (13%), as well as a greater risk of uterine rupture (3.3%), the need for blood transfusions (16.4%), and hysterectomy (3.3%).
If pregnancy after accreta occurs, extra vigilance in testing and during birth is probably indicated.
Emotional Impact
The emotional upheaval that can accompany an accreta should not be underestimated. Having a life-threatening condition is frightening. Facing your own mortality is always difficult, but even more so when your children are still young and may be left motherless.
Dealing with the blood loss alone can be scary, even when the accreta is relatively minor. Severe cases of accreta can have hemorrhages that are truly frightening and deeply traumatic.
In addition, many women are put on months of bedrest before the birth or need to spend time in the Intensive Care Unit (I.C.U.) afterwards. There are experiences that emotionally impact even the most level-headed and emotionally stable people.
For those who experience hysterectomy, the emotional devastation of losing your uterus and all your future fertility forever can be substantial. Even those who did not want more children can be surprised at the emotional impact of losing their uterus.
Furthermore, most women with accreta must also deal with a premature baby and all the physical and emotional ups and downs that entails.
As a result, many women with accretas experience significant symptoms of PTSD. Many benefit from emotional support during and after the pregnancy.
Organizations like Sidelines can provide valuable support during an accreta pregnancy, and Solace for Mothers is a great organization to help process PTSD afterwards. If flashbacks, anxiety or intrusive thoughts are an issue for you, many women have found EMDR (Eye Movement Desensitization and Reprocessing) helpful.
If pregnancy after accreta occurs, extra vigilance in testing and during birth is probably indicated.
Emotional Impact
The emotional upheaval that can accompany an accreta should not be underestimated. Having a life-threatening condition is frightening. Facing your own mortality is always difficult, but even more so when your children are still young and may be left motherless.
Dealing with the blood loss alone can be scary, even when the accreta is relatively minor. Severe cases of accreta can have hemorrhages that are truly frightening and deeply traumatic.
In addition, many women are put on months of bedrest before the birth or need to spend time in the Intensive Care Unit (I.C.U.) afterwards. There are experiences that emotionally impact even the most level-headed and emotionally stable people.
For those who experience hysterectomy, the emotional devastation of losing your uterus and all your future fertility forever can be substantial. Even those who did not want more children can be surprised at the emotional impact of losing their uterus.
Furthermore, most women with accreta must also deal with a premature baby and all the physical and emotional ups and downs that entails.
As a result, many women with accretas experience significant symptoms of PTSD. Many benefit from emotional support during and after the pregnancy.
Organizations like Sidelines can provide valuable support during an accreta pregnancy, and Solace for Mothers is a great organization to help process PTSD afterwards. If flashbacks, anxiety or intrusive thoughts are an issue for you, many women have found EMDR (Eye Movement Desensitization and Reprocessing) helpful.
Summary
Accretas may be mild or severe, but all involve a very significant risk for complications.
Blood loss is the most common and serious risk of accretas. Secondary to the blood loss, other complications like D.I.C., long-lasting anemia, and Sheehan's Syndrome can occur.
Mothers can also experience damage to abdominal organs near the uterus, either from a percreta, surgical damage, or impairment secondary to blood loss.
Mothers can also experience damage to abdominal organs near the uterus, either from a percreta, surgical damage, or impairment secondary to blood loss.
Most women with significant accretas also lose their uterus, forever impacting their fertility. Emotionally, many experience significant post-traumatic stress issues as well.
Babies of accreta pregnancies are also affected. They are nearly always born premature, with all the complications this can entail. They may also be small for their age, and may spend significant amounts of time in the NICU.
Although rare in modern medical facilities in the First World, occasionally mothers and/or babies even lose their lives due to accreta, despite excellent planning and the best possible care.
Clearly, accreta is a complication which deserves to be taken very seriously indeed.
Since cesarean section is the biggest risk factor for accretas, the high cesarean rate in many parts of the world has significant implications. Lowering the rate of non-indicated cesareans and increasing access to VBAC may help prevent many cases of this MAJOR complication.
Research References
J Matern Fetal Neonatal Med. 2013 May 3. [Epub ahead of print] Placenta accreta and maternal morbidity in the Republic of Ireland, 2005-2010. Upson K, Silver RM, Greene R, Lutomski J, Holt VL. PMID: 23638753
J Perinat Med. 2013 Mar;41(2):141-9. doi: 10.1515/jpm-2012-0219. Placenta accreta and the risk of adverse maternal and neonatal outcomes. Balayla J, Bondarenko HD. PMID: 23241664
Accreta Information
- ACOG's Committee Opinion on Management of Placenta Accreta
- RCOG's Guideline on Management of Placenta Accreta
- Wikipedia entry on Placenta Accreta
- http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0052893
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3516467/pdf/ijwh-4-587.pdf
- http://www.obgmanagement.com/fileadmin/obg_archive/pdf/1408/1408OBGM_Article2.pdf
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2777065/
- http://obguide.org/articles/placenta-accreta
Information on Sheehan's Syndrome
Morbidity Associated with Placenta Accreta
J Matern Fetal Neonatal Med. 2013 May 3. [Epub ahead of print] Placenta accreta and maternal morbidity in the Republic of Ireland, 2005-2010. Upson K, Silver RM, Greene R, Lutomski J, Holt VL. PMID: 23638753
...RESULTS: Placenta accreta prevalence increased 34% from 2005 to 2010 (7.9/10,000 deliveries versus 10.6/10,000 deliveries). This condition was associated with a substantial increased risk of hemorrhage (aOR 16.6, 95% CI:13.4-20.5), hysterectomy (aOR 950.6, 95% CI:632.9-1427.9), procedures to reduce uterine blood flow (aOR 72.4, 95% CI:35.1-149.4), transfusion (aOR 41.8, 95% CI:33.4-52.2), anemia (aOR 15.1, 95% CI:10.8-21.0), abdominal organ injury (aOR 8.2, 95% CI:5.2-13.1), bladder surgery (aOR 38.5, 95% CI:21.8-68.1), mechanical ventilation (aOR 63.2, 95% CI:28.4-140.6), intensive care unit admission (aOR 41.3, 95% CI:30.0-56.9), and co-existing placenta previa (aOR 23.2, 95% CI:16.8-31.8) as well as increased risk of cesarean section, longer hospitalization and stillbirth. CONCLUSIONS: To our knowledge, this is the first study to use a comparison group of deliveries without placenta accreta and quantitatively illustrate with odds ratios the profound adverse health effects of this condition on the mother.Ultrasound Obstet Gynecol. 2011 Mar;37(3):324-7. doi: 10.1002/uog.8827. Epub 2011 Feb 8. Diagnosis and morbidity of placenta accreta. Esakoff TF, Sparks TN, Kaimal AJ, Kim LH, Feldstein VA, Goldstein RB, Cheng YW, Caughey AB. PMID: 20812377
...METHODS: This was a retrospective cohort study of all women with previa with/without accreta examined at the University of California, San Francisco (UCSF) between 2002 and 2008...RESULTS:...Compared with previa alone, accreta had an odds ratio (OR) of 89.6 (95% CI, 19.44-412.95) for estimated blood loss > 2 L, an OR of 29.6 (95% CI, 8.20-107.00) for transfusion and an OR of 8.52 (95% CI, 2.58-28.11) for length of hospital stay > 4 days....Curr Opin Anaesthesiol. 2011 Jun;24(3):274-81. doi: 10.1097/ACO.0b013e328345d8b7. Anesthetic management of patients with placenta accreta and resuscitation strategies for associated massive hemorrhage. Snegovskikh D, Clebone A, Norwitz E. PMID: 21494133
...RECENT FINDINGS: The incidence of placenta accreta is rising in parallel with the increased rate of cesarean delivery. If accreta is diagnosed or suspected preoperatively, anesthetic management can be optimized. Even with the best possible management, the blood loss associated with placenta accreta can resemble that of a major trauma. The use of Damage Control Resuscitation strategies to guide transfusion may improve morbidity and mortality. SUMMARY: Careful planning and close communication are essential between anesthesiology, obstetric, interventional radiology, gynecologic oncology, blood bank, and specialized surgical teams when taking care of a patient with placenta accreta.Aust N Z J Obstet Gynaecol. 2004 Jun;44(3):210-3. Is placenta accreta catching up with us? Armstrong CA, Harding S, Matthews T, Dickinson JE. PMID: 15191444
...METHODS: A retrospective review of all cases of placenta accreta and variants during the period of 1998-2002...RESULTS: ...Seventy-eight percent of cases had had at least one prior Caesarean birth, and 88% of cases were associated with placenta praevia. Pre-delivery ultrasonography was performed in all cases, providing diagnostic sensitivity of 63% and specificity of 43% with a predictive value of 76%. Hysterectomy was performed in 91% of cases with median intraoperative blood loss of 3000 mL. There were no maternal deaths in the current series. CONCLUSION: A strong association between placenta accreta, placenta praevia and prior Caesarean birth has been demonstrated...Hawaii Med J. 2002 Apr;61(4):66-9. Urologic complications of placenta percreta invading the urinary bladder: a case report and review of the literature. Washecka R, Behling A. PMID: 12050959
...METHODS: The first reported case of placenta percreta with urinary bladder invasion in Hawaii is presented. Medline search and literature review identified an additional 53 patients. A meta-analysis of all 54 cases was performed. RESULTS: Hematuria was present initially in 31% (17/54) patients. Of these, 9 of 17 required transfusion support. A preoperative diagnosis was established by ultrasound or MRI in 33% of patients. Cystoscopy was performed in 12 patients and did not make a preoperative diagnosis in any patient. 39 urologic complications included bladder laceration 26%, urinary fistula 13%, gross hematuria 9%, ureteral transection 6%, and small capacity bladder 4%. Partial cystectomy was performed in 44% (24/54). Three maternal deaths and 14 fetal deaths occurred. Only 1 patient subsequently had a delivery. CONCLUSION: Readily identifiable risk factors by history are important to suggest placenta percreta in pregnant patients with gross hematuria. Ultrasound and/or MRI can establish a preoperative diagnosis. Cystoscopy did not identify any patient preoperatively. Partial cystectomy is commonly required for extensive or deep bladder invasion.Am J Obstet Gynecol. 1996 Dec;175(6):1632-8. The management of placenta percreta: conservative and operative strategies. O'Brien JM, Barton JR, Donaldson ES. PMID: 8987952
...RESULTS: Fifty-five of the 109 cases (50%) reported by members of the Society of Perinatal Obstetricians were suspected ante partum. Complications associated with this disorder included uterine rupture (3 cases), transfusion of > 10 units (44 cases, 40%), ureteral ligation or fistula formation (5 cases each, 5%), infection (31 cases, 28%), perinatal death (10 cases, 9%), and maternal death (8 cases, 7%). Management options included surgical removal of the uterus and involved tissues (101 cases, 93%) and conservative treatment with the placenta left in situ after delivery (8 cases, 7%)....Acta Obstet Gynecol Scand. 2013 Apr;92(4):461-4. doi: 10.1111/aogs.12083. Abnormally invasive placenta: changing trends in diagnosis and management. Guleria K, Gupta B, Agarwal S, Suneja A, Vaid N, Jain S. PMID: 23517217 (study from India)
Trends in patient profile, clinical presentation, diagnosis, management options and outcome of abnormally invasive placenta (AIP) were retrospectively evaluated at a tertiary care centre from 2001 to 2010. AIP was diagnosed when confirmed by ultrasound or MRI, when complete manual removal of placenta was not possible or when histological confirmation was achieved in a hysterectomy specimen. The first and second halves of the time period were compared. The total number of cases was 56 and the incidence increased significantly in the second half. Main risk factors were placenta previa and previous cesarean section. Antenatal diagnosis by ultrasound was made in 72% in the second half, compared with 35% in the first half (p = 0.009). Maternal mortality was 29% in the first half and 21% in the second half. Hysterectomy was the mainstay in management; elective procedures being significantly higher in the second half.Acta Obstet Gynecol Scand. 2013 Apr;92(4):445-50. doi: 10.1111/aogs.12075. Epub 2013 Jan 24. Surgical management of placenta accreta: a 10-year experience. Grace Tan SE, Jobling TW, Wallace EM, McNeilage LJ, Manolitsas T, Hodges RJ. PMID: 23311505
...DESIGN: Retrospective case series. SETTING: Quaternary perinatal referral center in Melbourne, Australia...RESULTS: Between 1999 and 2009, 33 women were diagnosised with invasive placentation. A total of 27 were confirmed histologically after hysterectomy: 12 accreta, one increta, and 14 percreta. Median blood loss was 2 L. There was a 1.8-L reduction in mean blood loss with elective vs. emergency hysterectomy (p = 0.04). Nearly two-thirds of women required four or more units of packed red-blood-cells. Half of the women suffered from surgical complications, mostly from bladder injury. The risk of returning to theater for further surgery was 20%. Women with placenta percreta were more likely to require additional blood products (p = 0.03), sustain renal tract injury (p = 0.003) and require intensive care admission (p = 0.002). CONCLUSIONS: A primary surgical approach to management of placenta accreta is associated with significant maternal morbidity, even when managed in a dedicated quaternary perinatal referral center.Risks to the Baby
J Perinat Med. 2013 Mar;41(2):141-9. doi: 10.1515/jpm-2012-0219. Placenta accreta and the risk of adverse maternal and neonatal outcomes. Balayla J, Bondarenko HD. PMID: 23241664
...METHODS: We conducted a complete literature review using PubMed, MEDLINE, Cochrane Database Reviews, UptoDate, DocGuide, as well as Google scholar and textbook literature... RESULTS: We reviewed 34 studies conducted between 1977 and 2012. A total number of 508,617 deliveries were studied, with 865 cases of confirmed placenta accreta (average pooled incidence = 1/588)....The most significant maternal outcomes include the need for postpartum transfusion due to hemorrhage and peripartum hysterectomy. Maternal mortality remains rare but significantly higher than among matched, postpartum controls. Important neonatal outcomes include preterm birth, low birth weight, small for gestational age, and reduced 5-min Apgar scores. Whether the need for neonatal intensive care unit admission and steroid administration is iatrogenic and whether an increased risk of perinatal mortality is a clinically significant and independent outcome remain controversial. CONCLUSION: Although there is a significant shortage of studies on the subject, it appears that placenta accreta is associated with adverse maternal and neonatal outcomes, some of which may be life threatening. Prenatal diagnosis and adequate planning, particularly in high-risk populations, may be indicated for the reduction of these adverse outcomes.
Placenta Accreta and Subsequent Pregnancies
Am J Obstet Gynecol. 2013 Mar;208(3):219.e1-7. doi: 10.1016/j.ajog.2012.12.037. Epub 2013 Jan 8. Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births.
Eshkoli T, Weintraub AY, Sergienko R, Sheiner E. PMID: 23313722
Am J Obstet Gynecol. 2013 Mar;208(3):219.e1-7. doi: 10.1016/j.ajog.2012.12.037. Epub 2013 Jan 8. Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births.
Eshkoli T, Weintraub AY, Sergienko R, Sheiner E. PMID: 23313722
OBJECTIVE: We sought to evaluate risk factors and perinatal outcomes of pregnancies complicated with placenta accreta and to study perinatal outcomes in subsequent pregnancies....RESULTS: During the study period [1988-2011], there were 34,869 CD, of which 0.4% (n = 139) were complicated with placenta accreta...There were 30 subsequent pregnancies of women with placenta accreta. Recurrent accreta occurred in 4 patients (13.3%). Previous placenta accreta was significantly associated with uterine rupture (3.3% vs 0.3%, P < .01) peripartum hysterectomy (3.3% vs 0.2%, P < .001), and the need for blood transfusions (16.7% vs 4%, P < .001). Nevertheless, increased risk for adverse perinatal outcomes such as low Apgar scores at 1 and 5 minutes and perinatal mortality was not found in these patients....
My daughter Joy was born at 23 weeks last year. Due to modern medicine and prayers she is doing great today. I hemorrhaged at 17 weeks for the first of 4 times because of 100% placenta previa, which turned into placenta accreta (which I believe was caused by 3 prior c-sections). After she came home from 121 days in the NICU, I wrote a memoir called "From Hope To Joy" about my life-threatening pregnancy and my daughter's 4 months in the NICU (with my 3 young sons at home), which is now available on Amazon. It was quite a roller coaster that I am certain some of you have been on or are currently riding on. My goal of writing our memoir is to give a realistic look at what lies ahead to families with preemies in the NICU while showing them that hope can turn into Joy and that miracles can happen. Please see my website www.micropreemie.net and www.facebook.com/jenniferdegl
ReplyDeleteThank you.
Jennifer, thank you for sharing your experience. I looked at your Facebook page and website. Thank you for your honest and forthright sharing, and for giving hope (and yes, joy!) to mothers of preemies everywhere. I'm also glad you speak out about the importance of avoiding repeat cesareans whenever possible.
ReplyDeleteBlessings on your family. Thank you for your comments.
That's some scary experience. Isn't 24 weeks the cut-off for most abortions?
ReplyDeleteYour daughter is truly a miracle to have survived that. I looked at your facebook, and the picture at the top of her in the NICU, she looks a bit like an alien, all bony and skin stretched out. That's not to say that this is bad, just that I've never seen a baby born that soon.
Wow.
Thank you for posting this article on Placenta Accreta. I'm glad I'm reading this after my ordeal but good information for anyone who may be faced with this severe complication. I suffered from Placenta Accreta in my third pregnancy. My uterus ruptured hours before my planned c section throwing everyone into panic mode. I bled out 4l of blood and needed a hysterectomy. Throughout my pregnancy, my dr ensured me that transfusions were rare and I would be fine as long as we planned ahead for surgery. I'm glad he was so positive because it kept me calm for 31wks. My accreta was caused by my 2 prior c sections, placenta previa and my age all combined. Although c sections can be needed and life saving in certain situations, I also feel they are becoming too common and too frequent setting moms up for more risks if they want future pregnancies. Please read the story the hospital did on me and my son. http://www.centraljerseyhealthandlife.com/September-2013/Special-Delivery/
ReplyDeleteI have had 2 deliveries, both were undetected accretas. 1st delivery followed a D&C for a previous missed miscarriage. I delivered without intervention and without pain meds. The problem started after the baby was born, when my placenta stayed stuck. The attending provider did immediate manual removal in the delivery suite (again, no pain medication) and send me home 2 days later. 3 weeks later I was hemorrhaging at home and had to be taken to the OR to remove patches of retained placenta. Pathology was not done. 18 months later we discovered that my cervix had scarred shut and had to be dilated open. 3 years later I was pregnant again, and obviously scared. I was monitored by a perinatologist and had regular ultrasounds. 9 days after my 27 week check I felt reduced movement. Ultrasound confirmed my daughters heart had stopped. I was induced for vaginal delivery the next day. Once again, the placenta stayed stuck after delivery. Holding on for an hour until the attending got involved and bleeding had begun. This time I was rushed to the OR for a more humane manual removal. Placenta path confirmed a complete accreta. And the pathologist got her hands on the slides from my previous postpartum D&c which showed evidence of at least a focal accreta. Its been a harrowing experience to say the least.
ReplyDeleteMy question now, almost 3 years out, is this; is there a formal screening process or a gold standard screening tool for patients, to determine who is at increased risk for accreta due to previous D&C, misplaced IUD, previa, termination, or C-section. I work within my quality department and have asked to be involved in researching this subject further. aliabrown@yahoo.com.
Thank you,
Alia
Alia, I think you ask a great question. If there is a screening process like this, I'm unaware of it. Any providers out there know?
ReplyDeleteMy best guess is this. All of these things you listed are risk factors for accreta but there are sooo many variables that come into play I don't see how anyone can reliably predict who will and won't be affected. All that they can tell you is that you are at increased risk, but they can't really quantify that risk.
A lot has to do with where the egg implants. If it implants on or near an area with myometrial damage or scarring, there is probably a high chance of accreta. But chances are that even if you have myometrial damage or scarring in some areas, there are other areas in the uterus that are not affected. So if the egg implants in the undamaged areas, chances are you won't have an accreta. But how can you predict with any certainty where a fertilized egg will implant? That's pretty random. And as far as I know there is no way to encourage a fertilized egg to implant in one area or another. It just goes where it goes.
I would think a screening tool could tell you that you have X, Y, or Z as a risk factor for accreta, and the more risk factors you have, the more likely you might get an accreta. Yet thousands of women with powerful risk factors (like multiple cesareans etc.) never get accretas, and some women with very minor risk factors (only a prior D&C) get one. It's a mystery.
I'm sorry; I wish I had better answers for you. If anyone does, please chime in.