|Brandy and her 7th baby postpartum|
Notice the large central IV line in her neck and IV line in her arm for quick blood transfusion
As part of Cesarean Awareness Month, we are drawing attention to the high cesarean rate and the public health implications of too many cesareans.
One of the complications of multiple cesareans is that the placenta in a subsequent pregnancy can implant too low in the uterus (placenta previa) or grow into the uterine wall (placenta accreta).
This can cause life-threatening complications, including premature birth, impaired growth, or stillbirth for the baby, and severe hemorrhage, hysterectomy, and even death for the mother. Placental abruption (placenta detaching too early) is another potential risk after a prior cesarean.
We've written about placental complications after cesarean before. As a brief reminder, there are three levels of severity in accretas:
- Accreta (placenta is abnormally attached to uterus and can't detach easily after birth)
- Increta (placenta grows into the wall of the uterus and cannot detach after birth)
- Percreta (placenta grown through the wall of the uterus and into surrounding organs)
|Image Source: Reitman 2011, Anesthesiology|
[If you are looking for more technical information about placenta accreta, see Part One (what is accreta, how a placenta works), Part Two (risk factors, symptoms, and incidence of accreta), Part Three (risks to mother, baby, and future pregnancies), and Part Four (diagnosis and treatment) of my prior series on placenta accreta.]
This time, rather than writing about what accreta is and how to manage it, we present the first-hand story of one mother's experience with placenta accreta (increta in her case).
It's important to remember that placenta accreta is real and affects real women and babies. Do enough cesareans, and increasing numbers of women will face this devastating and life-threatening complication. I've known several women now who have been affected by this condition; all suffered severe hemorrhages and several lost their fertility and uteri forever. One lost her baby and very nearly her life too.
That's why it's so important to do cesareans only when medically indicated and to keep VBAC (Vaginal Birth After Cesarean) an option for those who want it.
Brandy has had 7 births and 2 miscarriages. 3 of her births were by cesarean.
Yes, high parity is a risk factor for placental complications, but multiple cesareans is a stronger risk factor. Combine the two and the risks multiply.
Her first birth was a c-section after mismanagement by her doctor. She was told she'd never deliver a baby over 8 lbs. and that her babies were "too big" for her to deliver vaginally. She developed a terrible infection and wasn't allowed to hold her baby for 3 days.
Her second birth was a VBAC at 32 weeks. The placenta detached prematurely and baby might have had some lack of oxygen issues. He passed away at 21 months from seizures.
She miscarried her next pregnancy. Her third birth was another VBAC. She had to fight hard for it when her labor stalled for a little while but in the end she had a VBAC.
Her fourth birth was a CBAC (Cesarean Birth After Cesarean). She had a big baby (10 lbs.) and her doctor scared her into a repeat cesarean because of a recent shoulder dystocia in the practice.
Her fifth birth was another CBAC. Her doctor was opposed to a VBA2C. After her water broke and labor did not start for several days, she had the repeat cesarean. The doctor said she had very little scarring and could have more children. The risks of multiple cesareans, including accreta, were never mentioned.
In her next pregnancy, Brandy weighed the potential risks of VBAC after multiple cesareans against the cumulative risks of multiple cesareans and chose VBAC. She stayed at home in order to have a supportive provider. Her sixth baby was a homebirth VBA3C. He was 11 lbs. 4 oz., three lbs. bigger than her first doctor said she could ever birth vaginally.
She had another miscarriage again, then became pregnant a few months later. She planned another VBAC. Unfortunately, this time the fertilized egg implanted low, near the cervix (placenta previa) and the placenta grew into the uterine wall and into the cervix itself (placenta increta).
In the end she lost her uterus and most of her cervix and suffered a severe hemorrhage but was very fortunate to escape with her baby and her life.
This is the story of Brandy's placenta accreta pregnancy and birth.
I was so excited when I found out I was pregnant. I was also very scared since I had just miscarried 8 months prior. At 7 weeks when I started spotting I just knew something was wrong. I had no idea what the real problem was and what I would end up facing.
I decided to go to the ER and get checked. It was a pleasant surprise to see a healthy little heart beat. I did notice on my discharge paper that it was noted that the placenta had attached to the lower uterine segment.
A week went by and I was still spotting. I called my OB and they decided to schedule a ultrasound to check on things. The ultrasound tech noted that I had a short cervical length. I was sent to a perinatologist to see if they wanted to place a stitch. I was very confused. I had already carried 6 other children. I did deliver one of my babies at 32 weeks, but I never had a incompetent cervix.
The perinatologist quickly pointed out that I had a complete posterior placenta previa. I was so upset; I knew that would mean another c-section. I had already had 3 c-sections; I did not want another. I had already begun dreaming of another beautiful HBA3C. I had it in my head how I was gonna make a music list and dance through labor. I was gonna walk around outside in the nice cool October weather. I was looking forward to feeling every contraction and being more relaxed this time since it would be my 2nd HBA3C. [kmom note: Home Birth After 3 Cesareans]
Time went on and I continued to get ultrasounds monthly. It was always the same thing...the placenta had not moved. I was still spotting everyday; it was there every time I wiped. At one ultrasound appointment my OB made a comment that she saw a lot of placental lakes. I started researching placental lakes and learned that they are seen a whole lot with accreta. I started to worry.
I finally got good news at my 20 week ultrasound. The perinatologist said it looked like the placenta had moved and it was only the tip of it covering my cervix. He did say that there was a blood clot covering the cervix now, but that my body should reabsorb it. I questioned him a little bit about the blood clot. He reminded me that I had been spotting and that is what it was from. I had noticed the spotting had been slowing down so it all made sense. It was good news! The placenta moved some and I had a healthy baby boy. No one had to tell me I was having a boy; he decided to show off for momma.
I left the doctor's office practically skipping. I went and bought a bunch of "It's a Boy" balloons and filled a bag with them to let my other kids tear open. We were all so happy and back to planning our home birth.
At the next ultrasound I was 24 weeks and I just knew they were gonna tell me the placenta had moved more. The look on the ultrasound tech's face said something was wrong. When she told me she wanted the doctor to see it I felt my stomach go into my throat.
Two minutes felt like a century as the doctor was looking at the ultrasound. He said, “What I believed was a blood clot last appointment actually looks like a accreta.” He then went on to say that unfortunately with your c-section history and what this looks like, it I am pretty sure we will have to take your womb.
He went on to show me how vascular one section of the uterus was. He continued to talk about unfortunately this is like the weather, there is nothing you can do about it. He continued to talk and all I heard was some mumble about any OB can do a hysterectomy and I should be able to deliver at my local hospital.
I was numb, how could this be. I waited at the check-out desk trying to breathe, trying not to cry. I got my card for my next appointment as the tears started to fall. I don’t know how I walked to my car. My phone rang and I could not get out hello.
After I had a little while to process things and talk to a few people I decided to go to get a second opinion in Baltimore. The blood clot theory made sense. My spotting stopped at 22 weeks. I figured that was a good sign. The specialist in Baltimore knew more about accreta and could give me better answers.
Once I got to my appointment in Baltimore, that look the first tech had, I saw it all over again. This look of fear, maybe even confusion, just like the tech before she went to go get the doctor. He showed me that the placenta was supposed to look black on the ultrasound and there was these weird gray areas. He told me that at the least we were dealing with increta, but that he believed it was percreta.
He went on to say all my care would be transferred there. That with this condition there would be massive blood loss and my local hospital could not handle delivering me. I tried to be strong but I burst into tears. We decided to do a MRI to try to get a better ideal if any of my other organs were involved.
Everything then just became a blur. I spent every Monday in Baltimore seeing doctors and having ultrasounds. The group of specialist were waiting on the MRI results to decide whether to deliver closer to 34 or 36 weeks.
Once the MRI results came back it looked like no other organs were involved but that the placenta was invading the uterine wall. I was so happy to get the news that none of my other organs were involved. That was the first time through all of this I got good news. It is funny looking back now how wonderful that news really was to me. Since I was doing good and had no bleeds they decided to schedule my c-section at 36 weeks. Some of the doctors were still hopeful that once they got in there the placenta would detach easily.
I had 6 weeks until delivery and I was trying to understand and accept things. I was terrified. I felt like a ticking time bomb. I could not sleep. My husband was working nights so I was alone with 4 little ones, eight and under. I was scared I would have a bleed in the middle of the night and the kids would be terrified. When I did sleep I would have nightmares of having a c- section and my incision opening up and I was standing there holding my insides.
I would hold my little ones and wonder if I would be able to see them grow up. I would think, "My 2 year-old will not remember me." I think all these thoughts but had no patience with my kids. Then I would think if I don’t make it all they will remember is me snapping at them.
One of the hardest things I had to deal with was knowing that the people that got me here by doing 3 unnecessary c-sections on me were the same people I now had to trust to get me out of this.
As the weeks went by I realized that I had no control over the outcome. I had to do the best I could and control what I could and give the rest to God. I had to believe that even if I did not make it through that God would take care of my kids and it would be OK.
Days before my delivery I had to go do pre-op blood work and meet with anesthesia. I was told with the blood loss they were expecting I may have a lot of swelling and fluid in my lungs. They may have to keep me asleep until Friday until the swelling went down. They wanted my family to be prepared. That broke my heart to think I may not see my baby on the day he was born. They said I would go home with a bladder bag if they had to do the hysterectomy. With the scar tissue from my c-section they were sure that they would rip my bladder when they removed my uterus.
Delivery day came saying good bye to my kids was one of the hardest things I ever had to do. They were so excited to meet their brother the next day. And I had no idea if I would ever meet my baby or see my other kids again.
I got to the hospital around midnight. They got me situated in my room and then let me sleep for a few hours. I would doze off for a few minutes then wake back up with a knot in my stomach and a lump in my throat. I didn't want to be there. I wanted to run far far away from that place.
At 6 a.m. they came in and started to get me prepped for surgery. We had decided that it was best for me to just be put under general. My surgeon was afraid he would lose time if I began to hemorrhage and they had to put me under then. They did not want the baby to be under general any longer then he had to.
All the prep was done in my room. Anesthesia came and placed a central line in my neck and a large IV in my wrist; both of those were for blood transfusion. They also placed a monitor in my wrist that would send labs and gives them second-by-second blood pressure reading. By this time I was numb, I had shut down. I just prayed and sang worship songs in my head and took myself away from there.
My surgeon came in and did a quick ultrasound to see where he was gonna cut. As funny as it sounds I was still hoping that he was gonna find that the placenta had moved.
Once it was time to go to the OR the two main surgeons wheeled me down. My husband got off on another floor to wait in the waiting room. I just wanted to scream, “NO!” I didn't want my husband to go. I wanted him there when I fell asleep. I just gave him a kiss and told him I will see you in little while. He said a quick prayer and slipped off the elevator.
We were outside the O.R. doors and had to wait. The blood bank had not brought down the blood that was to be on stand-by in the O.R. There were doctors everywhere. My neck hurt so bad from the central line. I could barely move. And there was so many people coming up introducing themselves. MY nurse kept saying, “Oh my goodness, everyone is here.” She said, "You have the best of the best!"
All of a sudden here comes two big coolers. I just hear everyone say, “OK, let's go.” My surgeon told me, "I have been resting for 2 days for your surgery."
I said, “Hey, you have to take good care of me. I have lots of little ones that need me.” He said, “Brandy, we know what you got and we are gonna take good care of you.”
Things got real busy in the O.R., they put the oxygen mask on me, and kept telling me to to take nice slow breaths. The mask made me feel like I could not breathe. I was getting frustrated that I was not asleep yet. I wanted it over. No matter what the outcome was gonna be I was ready to get there. Everyone was rubbing my arms telling me that they were there and they aren't gonna leave, that I was OK. I remember thinking I am never gonna fall asleep.
I heard, "Don’t talk, you still have the breathing tube in." I raised my arm and started to write in the air. The nurse got me a paper and pen. I wrote "b" and dozed off, I wrote "a" and dozed off. The nurse said, "Are you writing 'baby'?" and I shook my head yes! She told me that he was healthy, 7lbs 2.5 oz. He had no problems and went straight to the newborn nursery.
They took the breathing tube out and I said, "Is it Friday?" and the nurse said, "No, it is Thursday, 2 in the afternoon!" I was so so happy my baby was OK and I was still here. It was finally over! The worry, the fear, the unknown!
My surgeon came and held my hand and told me that they did have to do the hysterectomy, the main vein in the placenta had grew very deep into my cervix. They also had to take most of my cervix. I lost 7 ½ liters of blood. I was given 13 units of blood products.
[kmom note: 7.5 L is 7500 ml. Normal blood loss in a vaginal birth is 500 ml; 1000 in a cesarean. She had more than 7x the normal blood loss for a cesarean.]
[kmom note: 7.5 L is 7500 ml. Normal blood loss in a vaginal birth is 500 ml; 1000 in a cesarean. She had more than 7x the normal blood loss for a cesarean.]
I didn't care at that point. I was alive, my baby was healthy! We made it to the other side. PRAISE GOD we were OK!
I met my little man when he was 8 hours old. He is perfect. I would do it all again to have him. We have both done very well recovering physically. I didn't need a bladder bag after all. I delivered on a Thursday and we came home together on Sunday.
But emotionally it has not been so easy. I do sit here in disbelief sometimes wondering why me? Other days I get angry. I want to punch something and yell GIVE ME MY UTERUS BACK! I mourn the loss of my fertility, the loss of his birth and the first 8 hours of his life. The loss of my last pregnancy. The loss of some relationships that have been damaged through all this for one reason or another.
I share my story not to scare anyone. I know what it feels like to be scared into something. I would never want to do that to someone else. I just want women to be aware of all possible complications. I want women to be able to give true consent and be aware of all risks.
If sharing my story saves one women from having a different ending than me then it wasn't all for nothing. Accreta is not talked about, but it is real, very real!