Jordan H. Perlow, MD, is a maternal fetal medicine specialist and director of Maternal-Fetal Medicine at Banner – University Medical Center Phoenix. His office can be reached at (602) 839-2647.
Question: My wife has had a second cesarean section and I’m worried about all possible conditions that might develop in a future pregnancy. One I’ve heard about is placenta accreta -- what is it and what can be done to improve the outcome for someone diagnosed with the condition?
Answer: Placenta accreta is a serious, life-threatening condition that develops when the placenta grows too deeply into the uterine wall. During every pregnancy, the placenta grows inside the uterus, attached to the uterine wall, and supplies the baby with nutrition and oxygen through the umbilical cord.
Following delivery, the placenta normally separates easily from the uterus. But in patients with placenta accreta, it's extremely hard to remove and can result in massive bleeding; fatalaties have been reported.
This condition is increasing in frequency due to the increased cesarean section rate and likely now occurs in more than 1/1000 pregnancies. The chance of a placenta accreta is greatest when placenta previa (placenta covering the cervix; noted on ultrasound) is detected in a woman who has had a prior cesarean section, and the risk increases if a woman has had more than one cesarean section.
Ideally, the condition will be diagnosed during pregnancy by an ultrasound. In that case, the baby can be delivered by a planned cesarean section at a perinatal center, with a designated multidisciplinary team of surgeons and others who have experience in dealing with this life-threatening problem. This would be followed immediately with a hysterectomy, or the surgical removal of the uterus, which allows for a safer removal of the placenta. Removing the uterus would mean the mother would not be able to have any more babies.
The pregnancy is managed entirely differently than a normal pregnancy. Ideally, the patient is admitted to the hospital in the third trimester for hospitalized bed rest in anticipation of delivery by cesarean hysterectomy several weeks prior to term; this is done to minimize the chances of labor which can cause placental separation or uterine rupture, a potentially catastrophic situation.
During this hospitalization, the patient will meet countless members of the team that will attend to her during delivery. Again, ideally, delivery occurs in a designated surgical suite with a surgical team which may consist of a maternal-fetal medicine specialist, trauma surgeon, gynecological oncologist, urologist, interventional radiologist, anesthesiologist, and nursing specialists from several disciplines. A cell saver unit technologist, and laboratory and blood bank personnel are designated to respond to the needs of the patient at the direction of the team. A neonatologist is also present to attend to the baby who will generally be several weeks premature.
The goal is to get as far in the pregnancy as reasonable, to allow for the infant to have the best chance of healthy survival, but not to let the pregnancy go so far as to compromise the potential for maternal survival. Not uncommonly the patient may require intensive care postoperatively, and the postpartum stay is typically several days longer than for a regular delivery.