By Rosanne Moore and Anissa Orr
Growing trend toward C-section delivery contributes to rise in a serious complication
With the rise of Cesarean births and morbidly adherent placenta cases, Texas Children’s Pavilion for Women continues to attract a growing number of patients across the nation due to its successful treatment of this potentially fatal condition.
A mother is waiting to see her unborn baby appear in black and white on the screen beside the exam room bed. She’s anxious, and as she peers at the obstetrician, the look on the doctor’s face says it all. His concern is followed by, “You have placenta percreta.”
What does it mean, and what happens now? It’s a question more and more women find themselves facing as the rate of Cesarean births increases.
Morbidly adherent placenta is a rare but serious pregnancy complication in which the placenta and its blood vessels can attach to or grow deeply into the wall of the uterus, keeping the placenta from detaching after childbirth. In the case of placenta accreta, the placenta attaches to the innermost layers of uterine muscle. In cases of placenta increta, it deeply invades the muscle. With placenta percreta, the placenta penetrates the uterine wall entirely and can even invade nearby organs such as the bladder.
As the rate of Cesarean (C-section) deliveries increases, morbidly adherent placenta is becoming more common in pregnant women. Women who have had prior C-sections or other uterine surgeries are more at risk for these complications because the placenta can latch on to the surgical scar too firmly. Once rare — with only one in 4,027 pregnancies affected in the 1970s — morbidly adherent placenta now occurs in roughly one in 500 to 1,000 pregnancies. About 1 percent of women die from this condition due to massive hemorrhage.
CONVENIENCE VS. CAUTION
Texas Children’s Maternal-Fetal Medicine Specialist Karin Fox, MD, says the data raises serious questions about choosing a Cesarean delivery for convenience or preference rather than medical need. Leading organizations such as the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists are now advising physicians to take steps when possible to prevent the first Cesarean delivery.
“Cesarean delivery can be lifesaving for some women but must be medically indicated,” said Fox, a member of the multidisciplinary placenta accreta team at Texas Children’s Pavilion for Women. “Doctors should educate their patients on the benefits and risks of Cesarean delivery, including their risk factors for placenta accreta.”
The Pavilion for Women — world-renowned for its comprehensive, multidisciplinary care and focus on high-risk pregnancies — treated 27 cases of morbidly adherent placenta in the past 12 months, a majority of which are percreta cases. Patients across the U.S. are referred to Texas Children’s once they have been diagnosed with placenta accreta, increta or percreta, depending on the depth of uterine invasion.
A RACE AGAINST TIME
Khadajah Winchester, a mother of two, never expected her third pregnancy would end in a life-or-death struggle. She remembers September 6, 2013, vividly.
While in her Alexandria, La. home 240 miles away from Houston, Winchester recalls racing to the bathroom in the middle of the night.
“I was bleeding everywhere,” Winchester said. “I thought I’d had a miscarriage.”
Winchester’s husband rushed his 35-weeks-pregnant wife to the emergency room, where doctors gave her three pints of blood before she was whisked away by air ambulance to Texas Children’s Pavilion for Women. When she arrived at 2:30 a.m., Winchester didn’t fully comprehend the seriousness of her medical condition until she was wheeled into the crowded operating room.
“I looked in the room, and there were people everywhere,” Winchester said. “I asked, ‘What’s going on?’ and the nurse said, ‘Baby, you are about to have a baby.’ I just cried.”
She recalls Fox cutting through the confusion to console her and explain what was going to happen next. Comforted, she digested the information, prayed and mentally prepared herself for the surgery.
Winchester, who had two previous Cesarean deliveries, had developed placenta percreta, and her placenta had invaded part of her bladder. Doctors noticed increased vascularity — a cluster of blood vessels that are unusually enlarged and susceptible to rupture during delivery — between her bladder and uterus. To reduce bleeding, her physicians made an incision high on Winchester’s uterus to avoid touching her placenta. Despite minimal bleeding during the actual delivery of her 6-pound 7-ounce baby girl, Brooklyn, Winchester began bleeding profusely from the numerous vessels that had fed her invasive placenta.
She lost copious amounts of blood during surgery that required a massive 25-pint blood transfusion.
“I hardly had blood pumping through my veins, and if I had gone to a hospital in my hometown of Alexandria, I would have died,” Winchester said. “Hospitals in smaller communities don’t carry the large volume of blood or provide the comprehensive care that I needed to survive.”
Winchester credits her story of survival to the highly skilled, multidisciplinary team of physicians at the Pavilion for Women who meticulously prepared and planned for her emergency surgery.
“Our experience and success in treating even the most severe cases of morbidly adherent placenta continues to attract a growing number of patients from across the country,” said Texas Children’s Ob/Gyn-in-Chief Michael A. Belfort, MD, a world-renowned expert in morbidly adherent placenta and founder of the Morbidly Adherent Placenta Program at Baylor College of Medicine. “Our success is rooted in our ability to work as a team.”
Patients with morbidly adherent placenta receive care from a diverse group of specialists representing different areas of expertise, including maternal-fetal medicine, gynecologic oncology, anesthesiology, urology, neonatology, radiology, critical care medicine and blood bank services.
“Since it’s difficult to predict how severe the actual bleeding will be for each individual patient, our team works closely with the hospital’s blood bank to ensure an adequate supply of blood products is available for surgery, and to help manage transfusions,” Fox said.
“We rely on our anesthesiology team to administer blood and draw labs to ensure electrolytes remain stable in addition to keeping the patient comfortable. Urologists are mobilized to provide expertise when the placenta imbeds itself into the urinary system.”
The approach that gynecologic oncology surgeons use to remove uterine cancer inspired the team’s technique for treating placenta percreta, since the abnormal placenta acts like a cancer invading the outside of where it is supposed to be growing. “We take a wider approach when we perform a hysterectomy to reduce the potential for blood loss,” said Texas Children’s gynecologic oncologist and surgeon, Concepcion Diaz-Arrastia, MD. “We remove the uterus and cervix in a modified radical hysterectomy, along with a small amount of the tissue that attaches the uterus to the pelvis as if it were cancerous.”
Belfort and his extraordinary team have treated 82 patients with morbidly adherent placenta in the past three years at the Pavilion for Women.
EARLY DIAGNOSIS, BETTER OUTCOMES
Early diagnosis of morbidly adherent placenta prior to delivery is crucial to help ensure the best possible outcomes for mother and baby. Texas Children’s maternal-fetal medicine experts recommend that patients with risk factors for morbidly adherent placenta consult with specialists early — ideally by 24 to 28 weeks of pregnancy.
“An early referral gives us time to talk to patients before we admit them to the hospital, and we can review each step of their personalized treatment plan,” Fox said.
A typical treatment plan includes state-of-the-art imaging, including 2-D and 3-D ultrasound and, in some cases, magnetic resonance imaging (MRI) to confirm cases difficult to see without ultrasound. After diagnosis, women with morbidly adherent placenta can expect more frequent prenatal visits compared to routine pregnancies. They are then scheduled for a planned C-section delivery at 34 to 35 weeks to minimize potential blood loss.
These women are admitted to the hospital one week prior to their scheduled deliveries — earlier, if they have bleeding or contractions. Once admitted, patients meet the Pavilion for Women’s multidisciplinary team of specialists prior to surgery.
In general, Fox said the safest way to manage morbidly adherent placenta is to deliver the baby by a Cesarean section followed immediately by hysterectomy. In select cases in which the placenta is not low-lying and when a patient would prefer to retain her uterus, it may be possible to remove the part of the uterus where the placenta is attached and repair the remaining organ. This option is rare and must be determined on a case-by-case basis.
A YEAR LATER
Nearly a year and a half after her surgery, Winchester and her daughter, Brooklyn, are doing very well. Last summer, she, her husband and their children moved to Pearland — further from their hometown of Alexandria, but closer to Texas Children’s, where Brooklyn’s story began.
“I can’t thank Dr. Fox and the team enough for saving my life,” Winchester said. “The doctors and nurses treated me like I was family. I still keep in contact with Dr. Fox and send her photos of Brooklyn, so she can see how fast she’s growing.”
Currently, the Pavilion for Women’s Morbidly Adherent Placenta team is collaborating with other morbidly adherent placenta treatment centers to add to the growing body of research on this condition.
“There’s still a lot be learned about morbidly adherent placenta,” Fox said. “Our goal is the safety and compassionate care of our mothers and babies. It is absolutely a team approach.”
MOM MAKES A GAME PLAN FOR A SUCCESSFUL OUTCOME
As a mom of three boys under age 5, Lindsey Gillespie had the pregnancy routine down.
So, when the tireless emergency room nurse from Dallas became pregnant with baby number four, she opted to have the gender-revealing ultrasound to determine whether to buy pink or blue baby clothes. Instead, the results planted seeds of worry: Gillespie’s obstetrician diagnosed her with morbidly adherent placenta.
While all three of her kids were C-section babies — a major risk factor for placenta accreta — Gillespie didn’t know anything about this pregnancy complication. She was told she’d need a hysterectomy after delivery, which “just devastated” her, she said, even though she wasn’t planning on having any more children.
But without the right treatment and specialized care, she could bleed to death. Her doctor had never treated a patient with placenta accreta and knew of few doctors who did in the Dallas/Fort Worth area Gillespie called home.
Weeks of frantic phone calls and Google searches finally led Gillespie to Texas Children’s Pavilion for Women, where she met with Ob/Gyn-in-Chief Michael A. Belfort, MD. Despite verification of placenta percreta, Gillespie’s delivery went smoothly and she gave birth to a healthy son, Gabriel, at just the right time — 34 weeks.
“We named him Gabriel because we wanted an angel on our side,” she said.
Following delivery, the team of Drs. Michael Belfort, Concepcion Diaz-Arrastia, Karin Fox and Alireza Shamshirsaz separated and removed Gillespie’s uterus and abnormal placenta, which had attached itself to the bladder and surrounding tissues. Remarkably, Gillespie did not need a blood transfusion and sailed through recovery.
Today, she is living the active life of a working mother of four kids.
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