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.’
•