Abdulla Al-Kahn, MD, Vice-Chair Department of Obstetrics and Gynecology, Director of Maternal-Fetal Medicine and Surgery, Founder and Director of Center for Abnormal Placentation, Hackensack University Medical Center, talks about the dangers of placenta accreta and how to treat it.
What is placenta accreta?
AL-KHAN: Placenta accreta is a condition where the placenta invades into the myometrium. The myometrium is the muscle of the uterine wall. Placentas are generally not supposed to invade into the uterine wall. The Lord created, biologically, a protective layer that prevents the placenta from invading into the uterine wall. So whenever there’s disruption of that protective layer, then there is a propensity for the placenta, especially the very early primitive placenta during the period of embryogenesis, to invade into the uterine wall leading to this abnormal condition known as abnormally invasive placentation.
About what stage of pregnancy does this development begin to happen?
AL-KHAN: Well, the condition happens very early in pregnancy. It is dependent upon where the placenta or the embryo implants within the uterine cavity. The normal site for implantation of the embryo within the uterus is towards the top of the uterus, otherwise known as the fundus of the uterus. Interestingly, what we have seen is when you scar the uterus for whatever reason, whatever surgical procedure that is done to the uterus, the placenta has a propensity of adhering to that scarred side. If you see early implantation of the embryo, as early as the first trimester, right over the mother’s prior c-section scar, then theoretically, she could be at risk for this very morbid condition.
Is this something that doctors can tell is developing through an ultrasound?
AL-KHAN: Absolutely. I think with modern technology of ultrasound medicine, we’re able to truly and readily diagnosis this condition early in the game. I think the sensitivity, obviously, of diagnosing this condition is variable. It really depends upon centers which are very familiar with this condition. But we were able to diagnose this condition as early as six to even 10 weeks of gestation.
If it’s caught early, is there anything that can be done?
AL-KHAN: Yes. Early diagnosis is imperative and the reason for that is because you can have a strategy and a plan of care with the patient. This is a subject that really touches a lot of sensitivity but clearly, one must go back to the disease process. As the placenta invades deeper and deeper into the uterine wall, this condition can invade throughout the entire depth of the muscle and into the adjacent pelvic organs. As the placenta invades deeper and deeper, there’s more recruitment of abnormal vascularity and blood vessels to the pelvis. The mother is not only at risk of losing her uterus, losing her bladder and perhaps reconstructive surgery to the bladder, but the major problem is hemorrhage because of tremendous amount of vascularity. This condition clearly poses an enormous amount of surgical risk and complications to the mother. Having said that, it’s important to go back and have an adequate dialogue with the mother in a sense of is she willing to take these risks or not? If you do have an early diagnosis and she tells you she’s not willing to undergo a major operation that is going to subject her to a hysterectomy and other comorbidities. People do talk about interruption of pregnancy and there’s a lot of politics involved in medicine, so we’re not going to touch that. Mothers who do go through interruptions, it’s a very difficult and sensitive decision that they have to make. Having said that, that’s one option they could be counseled if they’re not willing to take the risk.
Can women safely go through a pregnancy if they have this condition?
AL-KHAN: Yes, they can. Ideally, the safest place for these patients to be delivered is at a center which is well-acquainted and acclimated. It takes an incredible orchestra to create the best music. It’s a similar concept when we deal with patients with significant pathology, you need a well-orchestrated group of talented surgeons, anesthesiologists, nursing staff, nurse circulators… the list just goes on, to ensure the safety of the mother.
If you don’t know that this condition is happening, does it become an emergency situation during delivery?
AL-KHAN: It does, and I think it becomes a deadly condition. If I may digress… Approximately 18 plus years ago, we had a wonderful patient. She had one prior cesarean delivery and she had a placenta previa, meaning the placenta was sitting right on top of the cervix in proximity to her prior cesarean scar. We didn’t really think much back then. We knew about abnormally invasive placentation placenta accreta, but we didn’t have the modality or technology or advances in ultrasound medicine or even MRI, in terms of diagnosing the severity of the disease. In the OR, to deal with the worst-case scenario, prevention is obviously better than a cure. We kept her in the hospital because she had an episode of bleeding about 28 weeks pregnant, and then she had another episode of bleeding at 32 weeks. By 35 weeks, she had a significant bleed while she was at the hospital. We rushed her to the main operating room. We were in the OR for over 14 hours. We had over nine specialists, from vascular surgeons, multiple urologists, trauma surgeons, general surgeons… to a point that nobody could even appreciate or understand the anatomy of the pelvis. That’s how distorted it was. The patient bled and had a massive transfusion. I would assume over 40 units of blood, to a point that we had no alternative but to leave her abdomen open. We had to leave clamps in her abdomen and pack her belly. She was on a ventilator for about three days and had multiple surgeries. She survived. The Lord meant it that she needed to live and be with her children and her family. It was a blessed thing. I was in the hospital for three days and I didn’t sleep. I just wanted to make sure that the patient walked out of the hospital alive because that was my responsibility. It was my job. I said I never want to do this again. I never want to go through this again. I never want another individual with such a condition to go through such a horrific course again. And that’s exactly when the whole accreta program developed, in which I took an interest in establishing a multidisciplinary team. I focused on advances in ultrasound medicine, worked with my radiology colleagues in utilizing MRI. We started introducing different surgical modalities, different techniques, different style. These were surgeries that, instead of doing a simple c-section, which usually takes about 40 minutes or an hour, we were spending now about eight to 12 hours methodically dissecting everything or perhaps doing staged surgical intervention. We had an incredible outcome. The program grew and built recognition nationally and internationally. We ultimately started developing a template in which we went to other organizations and kind of told them exactly what to do to ensure safety of their patients. We’ve operated on over 300 patients at our center, all of them with extensive pathology because we’re a referral center and they all have the extent of the disease process. We have been fortunate our mortality rate is zero. The Lord has been watching over us. Our transfusion rate is the lowest when compared to any other organization across the globe. Our surgical ICU admission is less than one to 2%. And all of the mothers have walked out of this organization doing extremely well. This is something that I don’t thank myself, I thank the entire team who basically got involved to ensure the safety of these patients.
Can you give me a sense as to why this is happening and happening with more frequency?
AL-KHAN: The incidence of abnormally invasive placentation, or placenta accrete, used to be very low. If you look back 60 years ago, the incidence was roughly about 1 in 30,000. By the time we got into the 1960s or 70s, that incidence went up to about 1 in 15,000. By the 2000s, the incidence was approximating about 1 in 1,200. If you look today, the incidents overall of developing abnormally invasive placentation is roughly 1 out of every 500 c-sections. It has been an astronomical rise. The reason for this rise is primarily the number of c-sections that has been happening in the United States and across the globe. What’s interesting is I have been blessed to give numerous talks across the globe and Turkey is dealing with a huge crisis with this condition. Mothers are dying, unfortunately, because of uncontrollable hemorrhage while they deliver the babies. In South America and Egypt there has been a huge rise in this condition. Why? Because it correlates with the number of c-sections that’s occurring in different parts of the world. We have taken a huge initiative in the United States to drop the rate of c-sections or unnecessary c-sections. We’re also seeing more uterine manipulative procedures. More and more mothers are having DNC’s, where they scrape the uterus because of various reasons. If they have uterine septal resection or reconstructive surgery on the uterus because of a polyp or fibroid, or myomectomies where they have benign tumors within the uterus, they’re taken out. So, any surgical procedure that is done to the uterus will lead to a defect in that protective layer.
What should women keep in mind as they’re going through another pregnancy that could be a risk factor for having this condition?
AL-KHAN: C-section is the biggest risk factor along with advanced maternal age. People with myomectomies, multiple DNC’s, and even IVF pregnancy is a risk factor for abnormally invasive placentation. Placenta previa on its own, where the placentas sitting on top of the cervix, is a risk factor. Irrespective of a prior uterine scar is a risk factor for abnormally invasive placentation. These are just some out of many other risk factors.
Can you tell me a little bit about Elise’s case?
AL-KHAN: Every patient who I’ve operated on has a special place in my heart. But unfortunately, as I age, I can’t remember 300 plus patients. But Elise’s and many others of them have been instrumental. My grandmother always stated, never ask the doctor, always ask the patient. The doctor has not gone through the pain of a kidney stone, but the patient has. I always believe that when mothers are diagnosed with this condition, they have a tremendous degree of anxiety and fear, fear of death, fear of not being around with their children. And no mother should ever fear childbirth. We should do everything to comfort them and make sure they have excellent health care providers and organizations to ensure the best outcome for them and their unborn fetus. One of the things we have utilized is to comfort these patients in the modern age of the Internet. There’s a lot of scary stuff out there about abnormal, invasive placentation’s, so these patients are scared. We felt the best advocate for patients who come to us are mothers who have been through similar experiences. So, Elise has been one of those individuals who came to us with this condition. The recommendation for her was to terminate the pregnancy, which are very difficult and sensitive decisions they have to make. She decided to continue the pregnancy and seek care at a facility. We comforted her and let her know we would provide the best of care. We guided her throughout the whole course of the pregnancy. She had a tough, long surgery, but did extremely well. She has a beautiful baby. She actually has two kids, and the new one is baby James. God bless him.
Was it an emergency situation for Elise?
AL-KHAN: Well, Elise had episodes of bleeding where we kept her in the hospital and knew that at some point, we would have to proceed with an emergency delivery. Once she started having the episodes of bleeding, we did admit her to the hospital. Then, when she had her recurrent episode of bleeding, we felt it was time for definitive surgery.
Is there anything else you would like to add that we haven’t covered?
AL-KHAN: Obstetrics has become complicated. I want to give all patients reassurance that there are enormous amounts of resources out there and health care facilities that can handle mothers with all sorts of medical and surgical complications. My advice is if you have an issue during the course of your pregnancy, you should have a frank dialogue with your general obstetrician so that you could be referred to appropriate consultants and centers where they could handle any medical or surgical comorbidity that you might have during your pregnancy. Pregnant patients are very vulnerable, and we should provide them all sorts of resources to make them comfortable throughout their pregnancy, especially in the postpartum period. I feel that a lot of patients who go through these very traumatic pregnancies will have a component of post-traumatic stress disorder. Once you allow a continued dialogue with your patients after the surgery, it helps. There has to be that continuity of care. A good mentor of mine said, “There are no brave doctors, only brave patients, and they have no clue how brave they are.”
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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