It’s 10 a.m. on a Tuesday morning in a hospital conference room, and this not your average birthday planning committee. Here’s the invitation list for the multidisciplinary meeting to plan this Cesarean section:
- Maternal Fetal Medicine (that’s me), the high-risk obstetrics team
- Gynecologic oncology as the premier surgeons of the female pelvis, because we’re planning on performing a hysterectomy immediately after delivering the baby.
- Interventional radiology, because often we will do a small procedure to temporarily block blood flow to the uterus right before the surgery starts.
- Urology, because the bladder is right next to the uterus, and in this case, right next to the placenta, and may become damaged in the course of the surgery.
- Neonatal intensive care, because we are going to need to deliver this baby early in order to minimize the risks to the mother, and so the baby will be going to the NICU.
- Blood bank, because even with all of the above, we usually need to transfuse enormous amounts of blood products to keep the patient alive.
- Anesthesiology, because they’re in charge of keeping the mom and fetus alive during the surgery.
- Nursing, because they need to know everything we plan on doing, and they need to make sure we have the equipment and manpower to do it.
- Critical care, because these patients almost always need an intensive care unit bed after their surgery.
By the end of the list, it’s a pretty big birthday party. But this is not a normal pregnancy, and not a normal delivery. This patient has a placenta that has grown abnormally, called a placenta accreta. Unless we plan this surgery very carefully, this pregnancy could kill her.
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Placentas are, for the most part, simply amazing. They’re one of the first parts of the pregnancy to form—a whole organ that humans make simply for the purpose of nourishing a new human. The placenta lands in the uterus, and grows downward and outward. Complicated structural and immune changes of pregnancy allow the woman’s body to tolerate what, in other circumstances, we would probably perceive as a parasitic invasion.
That’s what happens most of the time, when everything is working properly. Sometimes, however, the placenta doesn’t get the signal to stop growing. It keeps spreading, down and out, through the lining of the uterus. That’s called a placenta accreta. Or the placenta can keep growing through to the muscle wall of the uterus. That’s called a placenta increta. And, horrifyingly, it can penetrate through the uterus, working its way to adjacent organs such as the bladder or bowel. That’s called a placenta percreta.
Most of the time, pregnancies with these problems don’t have symptoms. Long ago, the first sign would often be noted after delivery, when difficulty removing a placenta would be accompanied by enormous, life-threatening amounts of blood loss. These days, with modern imaging techniques, we can often make the diagnosis prenatally.
When the time for delivery arrives, the usual mode of surgery involves a preterm Cesarean section to deliver the baby, immediately followed by the removal of the uterus, with the placenta still attached. So the best-case scenarios end with a preterm baby, a woman who has no future fertility, and a patient who has undergone major surgery. The worst-case scenario involves massive, life-threatening hemorrhage and multiple surgical and postoperative complications. Our job is to give her the best outcome, but prepare for the worst.
There’s an obvious metaphor here, of course, about pregnancy and motherhood, and how they can devour a woman from the inside. But the setup for a placenta accreta often starts long ago, with a prior pregnancy. The other metaphor is that we carry some of the choices that we make forever, and some of them we never heal from entirely.