Placenta Accreta: Multiple C-Sections Can Kill Mother

Maternal deaths in childbirth are on the rise in the U.S. since 1999.

April 18, 2011, 10:43 AM

April 18, 2011— -- Barbara George nearly hemorrhaged to death while doctors delivered her fifth child at Hackensack Medical Center in New Jersey -- and that was in 2010, not 1910.

The stay-at-home mother from South Orange was diagnosed with placenta accreta, a life-threatening condition where the placenta grows into the uterine wall and sometimes beyond.

George, 38, had the most invasive form -- percreta -- and the placenta dangerously penetrated the entire uterine wall and had attached itself to her bladder.

Once a rare event that affected 1 in 30,000 pregnant women in the 1950s and 1960s, placenta accreta now affects 1 in 2,500 pregnancies, according to a 2007 report in the Journal of Obstetrics and Gynecology. In some hospitals, the number is as high as 1 in 522.

And doctors say the main reason is the dramatic rise in the number of Caesarian sections -- about 38 percent of all pregnancies in New Jersey, the second highest in the nation.

"The rule of thumb is if you have one C-section and the placenta sits right on top of the scar, the risk of placenta accreta is 25 percent," said Dr. Abdulla Al-Khan, director of the Division of Fetal Medicine and Surgery at Hackensack University Medical Center.

"If you've had two previous C-sections the risk is close to 50 percent and three, it's 75 percent and four, it's invariably closer to 100 percent."

Al-Khan and his team performed seven hours of complex surgery on George, first delivering the baby in a sternum to pubic bone vertical incision, then cauterizing veins to detach the placenta from the bladder and finally a hysterectomy.

"I always thought it would never happen to me," said George, who delivered at 34 weeks gestation."Mother nature protects the uterus," said Al-Kahn. "The Nitabach layer kind of prevents the placenta from invading the uterine wall."

But a Caesarian, or any kind of surgery, including an abortion or a D& C, can destroy that layer allowing the placenta to invade the body cavity.

The risk of the mother dying in childbirth has been cut by 99 percent since the turn of the 20th century, from 850 deaths per 100,000 births in 1900 to 7.5 in 1982, according to the Centers for Disease Control and Prevention.

But between 1998 and 1999, the maternal mortality rate rose by 13 percent and and continued to creep upwards, according to the CDC.

New Jersey saw 40 maternal deaths last year, according to Dr. Joseph Apuzzio, chair of the state's morbidity and mortality review committee and an obstetrician at New Jersey Medical School in Newark.

More Women Demand Caesarians

Doctors are also seeing other complications in pregnancy that increase maternal risk: more diabetes and preeclampsia, a higher number of twins and multiples and advanced maternal age.

"When we natural age, we have more medical conditions," said Al-Kahn. "Pregnancy always exacerbates things."

Babies are also larger, compared with a century ago, even though the size of the female pelvis has not changed at all, he said. A rise in cases of placenta accreta due to multiple Caesarians is also contributing to maternal death statistics.

"Now patients have a right to make shared decisions with their doctor," he said. "It's self-empowerment. If I can have a tummy tuck and rhinoplasty, why can't I have a Caesarian delivery?"

Al-Kahn jump-started the high-risk program at Hackensack after one of his patients nearly died in 2004. The woman had had only one previous Caesarian and the placenta in her second pregnancy had implanted right on top of her scar.

"She started bleeding at 35 weeks and we took her into the operating room to deliver the baby," said Al-Kahn. "It got to the point that she went into shock and needed 33 units of blood. We intubated her and she was three days on a ventilator. She lost half of her bladder and it took 12 hours in the operating room to save her life."

"I said to myself, 'God save this individual so she can live to be with her two kids and her husband,'" said Al-Kahn. "I never wanted that to happen again."

Since the program was started in 2005, Al-Kahn has seen more than 60 patients with the risky condition. Both mortality and the number of transfusions have dropped, he said.

George, who had four other high-risk pregnancies because of preeclampsia and diabetes, was referred to Hackensack after her own doctor saw something ominous on an MRI.

"I could just see her trying to maintain a professional exterior and see she had more concerns than she wanted to let on," said George. When she learned she had placenta accrete, she prepared for the worst and got her affairs in order.

"It was very difficult," said George. "I'm the type of person that tends to think it's not going to happen to me. I didn't want to deal with the what-ifs. But we had to have that conversation. It was so surreal."

Her doctor sent her straight to Hackensack where George was given magnesium and steroids to encourage the baby's lung development. In the middle of New Jersey blizzards on Dec. 27, Hannah was delivered by a long Caesarian cut from the sternum to public bone.

There was never any danger to the baby, who was born in 45 minutes, but doctors were worried about George, cauterizing every blood vessel using hypothermic techniques so they could slowly peel away the placenta from the bladder.

"I feel so grateful," she said of her now 3-month-old daughter. "Hannah is amazing and has really brought this family together in such a way, I can't explain it."

But George said that her experience is a warning to other women who opt for Caesarian sections when surgery is not medically necessary.

"A Caesarian should never be done to accommodate your schedule or because of your fears of pain," she said. "It's an unnecessary trauma to the body and it should not be treated as an alternative to natural childbirth."

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