102 105 mc19 prego accreta

out

with it!

Imagine giving birth to a healthy baby and then being told your placenta is stuck. Tatyana Leonov reports on placenta accreta

y

ou have given birth to your baby and

the muscles and breaches the covering layer.

now you are in theatre surrounded

It can then attach to other organs such as the

by obstetricians, vascular surgeons,

bladder and sometimes onto the bowel or anterior

gynaecological oncologists, haematologists,

abdominal wall. It is estimated that this form

radiologists, neonatologists, anaesthetists and

occurs in five to seven percent of cases.

urologists. It’s a large team of specialists and you’re wondering what is going on (and why you

Who can get it?

need them all there). You’ve got placenta accreta.

No-one knows why it occurs and unless there has been a problem in previous pregnancies or

What is placenta accreta?

other risk factors are known there is usually no

Placenta accreta is a rare condition – there are

warning. Dr Carlin explains, ‘Any woman who

estimated to be in the region of one in 500 to

has had a previous Caesarean and a low placenta

2,500 cases in Australia each year – and is a severe

is at risk and therefore requires careful evaluation

obstetric complication that involves a deep

of the placental location.’

attachment of the placenta into the middle layer

For Rebecca Catton, 31, a past Caesarean may

‘In simple terms placenta accreta is an abnormally adherent placenta; it’s very stuck,’ explains Dr Carlin of the uterine wall. ‘In simple terms placenta

have contributed to her placenta percreta. Her

accreta is an abnormally adherent placenta; it

birth experience with her first child, Jessyka,

is very stuck,’ explains Dr Andrew Carlin, the

now eight, was not quite what she had hoped for.

acting director of the Maternal Fetal Medicine

‘I was 41 weeks and three days pregnant when

Unit at the John Hunter Hospital in Newcastle,

I went into hospital to have an induction. The

NSW. ‘Placentas usually separate from the

staff induced me four times over the Tuesday,

mothers within 30 minutes at most.’

Wednesday and Thursday, and I never dilated despite having contractions,’ she explains.

Types of placenta accreta

By the Friday a Caesarean was suggested.

‘I was totally over it and beyond tired by this

• Placenta accreta involves an invasion of the

stage so I agreed,’ she says.

myometrium (middle layer of uterine wall),

Rebecca went on to have two more children

which doesn’t penetrate the entire muscle. This

without complications, Lachlan, four, and three-

form occurs in 75 to 78 percent of cases.

year-old Isobella, but it was with her fourth

• Placenta increta is when the placenta extends

pregnancy that the problem arose. Rebecca was

further into the myometrium and happens in

diagnosed with placenta previa (an obstetric

about 17 percent of cases.

complication in which the placenta is attached

• Placenta percreta is the worst of the lot and

to the uterine wall or close to covering the

comes about when the placenta goes through

cervix) at around 13 weeks into her pregnancy,

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my child

PHOTOGRAPHY photolibrary

There are three main types:

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pregnancy & birth

pregnancy & birth

but it didn’t cause concern to her doctor till her

cord is cut and the uterus is stitched up. The

22-week scan when it was mentioned: ‘I went to

patient then usually has a radiological procedure

the doctor and asked about it a few times, but

to close the large vessels supplying the uterus

always got the same response – that it was rare

to minimise blood loss. This is most commonly

and probably not a problem.’

done in theatre, on the table if bleeding is heavy,

Rebecca had more ultrasounds (they’d lost

or it can be performed after the operation in the

a twin in the early stages of the pregnancy) and

interventional radiology suite (and is usually a

kept asking till finally her doctors said she did

single procedure).

not have to worry. ‘I was relieved and felt like I could enjoy being pregnant,’ she says.

Rebecca was advised to give birth to Lola early

‘The risks then are of bleeding and infection – sometimes several days or even weeks after the operation,’ explains Dr Carlin. After several

It had grown through my uterus and had attached to my bladder. My only choice was to lose my uterus because of her history and was required to go

months, if all goes well, the placenta progressively

under a general anaesthetic.

shrinks away.

‘I was wheeled into surgery where David, my

• A Caesarean followed by hysterectomy

husband, was not allowed in with me – we never

(otherwise known as Caesarean hysterectomy)

even got to say goodbye to each other. The doctors

is another option. ‘This is a big operation but

placed a mask over my face to put me to sleep.

it reduces the risks of delayed infection and

I can remember looking around the room and

bleeding,’ explains Dr Carlin. ‘This has been

wondering why there were 30 plus people there.

the gold standard for some time but causes

Then I was out,’ she explains.

infertility.’ For Rebecca this was the best choice

Rebecca woke up in pain and was told she had

because they could not stop the bleeding. ‘The

had a hysterectomy due to her placenta percreta.

placenta had grown through my uterus and had

‘I’d lost four litres of blood (the average human

attached to my bladder. The only choice was to

body holds between four and five litres) and had

lose my uterus to save my life.’

to have four units of blood, two units of plasma

• Another approach is the “extirpative method”,

and a few more units of fluid to keep me going,’

which is forced manual removal (by hand in

she says. It was only later that she was told that

the uterus) of the placenta after delivery. Dr

she had had a Caesarean hysterectomy.

Carlin explains this method is no longer used by sensible obstetricians as it’s considered too

What are the treatment options?

dangerous due to the risks of uncontrollable and life-threatening bleeding.

There are a number of treatment options and these vary depending on the condition of the

What about afterwards?

placenta accreta. These options include:

Luckily there are no immediate risks to the

• If the placenta accreta is known or suspected,

newborn with placenta accreta as the problems

the woman’s delivery is planned very carefully.

usually start after the baby has been delivered,

‘A multi-disciplinary team of obstetricians,

when the placenta is found to be adherent.

gynaecological oncologists, radiologists, vascular

Generally, if picked up early, both the mother

surgeons and sometimes anaesthetists, urologists,

and baby will be OK. This is due to the range of

haematologists and neonatologists are involved,’

technology and specialists we have available

explains Dr Carlin.

today in Australia.

• Another option is to have the baby delivered

‘We have managed several patients with

through the top of the uterus rather than the

placenta accreta at the John Hunter since I arrived

front, then to assess the placenta. If the placenta

in July 2008,’ says Dr Carlin, ‘and so far all cases

is stuck then it is usually left in. This is known

have been successful – mothers and babies alive

as conservative management and patients can

and well, and in most cases with the uterus

choose this option to preserve their fertility. The

still intact.’

•