October is a month that highlights and recognizes many pregnancy, birth and postpartum topics for increased awareness including perinatal loss, safe sleep, SIDS and many other important topics. Science & Sensibility will be covering a lot of these topics as the month progresses, but today I want to bring awareness to placenta accreta. October is recognized as ICAN Accreta Awareness Month by the International Cesarean Awareness Network. Placenta accreta occurs when the placenta is abnormally attached to the uterus and has trouble detaching after delivery. Placenta Increta occurs when the placenta grows into the muscle of the uterus. Placenta percreta is when the placenta grows through the uterus and often attaches or involves other structures nearby, like the bladder or bowel. All of three of these situations are serious medical complications of birth and need to be handled by skilled obstetricians with trained OR teams and an ICU. Previous cesareans, D&Cs, myomectomies, or other invasive procedures on the uterus increase the risk of placental attachment abnormalities.

I cannot overstate how serious placenta accreta (and increta/percreta) can be. Jen Kamel, of VBACFacts.com wrote an amazing post for Science & Sensibility on this very topic, "Too Bad We Just Can't Ban Accreta - The Downstream Consequences of VBAC Bans".

Consequences of placenta accreta

1. massive obstetric hemorrhage
2. disseminated intravascular coagulopathy
3. need for hysterectomy
4. surgical injury to the ureters, bladder, bowel, or neurovascular structures
5. adult respiratory distress syndrome
6. acute transfusion reaction
7. electrolyte imbalance
8. renal failure
9. Average blood loss at delivery in women with placenta accreta is 3,000-5,000 mL
10. 90% of patients with placenta accreta require blood transfusion
11. 40% require more than 10 units of packed red blood cells
12. Maternal mortality with placenta accreta can be as high as 7%

The American College of Obstetricians and Gynecologists states that 'the incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate. Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either anterior or posterior placenta previa overlying the uterine scar. The authors of one study found that in the presence of a placenta previa, the risk of placenta accreta was 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater repeat cesarean deliveries.'

The entire month of October, ICAN is featuring stories from people who have experienced these placental complications. On their blog, you can learn more about the condition, read personal stories from families affected by accreta, and how you can personally help. Everyone can help those with placenta accreta by donating blood to their local blood bank. 90% of those diagnosed will require a blood transfusion and we can all ensure that local blood banks always have a sufficient supply of blood by donating regularly.

As childbirth educators, doulas L&D nurses, doctors and midwives, we all can work to help families have safe and healthy births. This involves education around cesarean prevention in childbirth classes and evidenced-based practice during labors and births. Since 88% of families have a repeat cesarean when they birth again, preventing the primary cesarean is critical if we want to reduce the morbidity and mortality associated with placenta accreta.

Lamaze International board member Jill Arnold and her colleague Kristen Terlizzi are the co-founders of the new organization National Accreta Foundation. Their mission:

Eliminating preventable maternal mortality and severe maternal morbidity attributable to placenta accreta.

The foundation will achieve this goal through a reduction in the incidence of preventable placenta accreta cases by lowering the rate of NTSV cesarean births nationwide to 23.9% or lower, lowering the rate of low-risk repeat cesarean births to 88.3% or lower and increasing the number of hospitals staffed and equipped to provide the appropriate level of care required for patients with previous cesarean sections and diagnosed cases of placenta accreta.

The National Accreta Foundation website is a goldmine of data and information on these conditions. I encourage you to browse around there and share this valuable resource with your students and clients. The fact that accreta now occurs in one in 333 pregnancies means that this can no longer be ignored and must be addressed promptly.

I asked Jill and Kristen why they started the National Accreta Foundation.

Jill Arnold: Starting a non-profit wasn't on my radar until I read Kristen Terlizzi's story in the Wall Street Journal last year. We found out our advocacy paths overlapped in California-based quality improvement projects, so we met up at the CDC-ACOG Maternal Mortality meeting in May and hit the ground running. With increasing awareness of maternal mortality and severe maternal morbidity in the U.S., the time for everyone to lend a hand in reducing preventable harm is right.

Kristen Terlizzi: One of the biggest misconceptions of Placenta Accreta is that it is rare. This used to be true, but the increase in the overall cesarean rate in the U.S. has caused the incidence of accreta to rise in parallel. In the 1980s accreta occurred in 1 in 1,250 pregnancies, while Placenta Accreta now affects 1 in 333 pregnancies. Although accreta is most often associated with a history of multiple cesareans, any uterine surgery puts the mother at risk of developing accreta in a future pregnancy. I had only one prior cesarean when I developed a severe case of Placenta Percreta in my second pregnancy.

If your clients, students or patients are facing an accreta or previa diagnosis, please consider referring them to ICAN's Accreta Awareness , Education and Support Facebook Group. This confidential peer to peer online support group is for people dealing with this in their current pregnancy or who parents who have experienced this complication in a prior pregnancy. Another fantastic resource is Hope for Accreta. They have an extensive website and also a Facebook page for support. Should you be able to attend, Hope for Accreta is holding a conference October 27-29, 2017 in Cleveland, Ohio. More info and registration can be found here.

Placenta accreta is serious and usually results in significant and often tragic outcomes. The time for awareness and action is now. Join me helping to raise awareness of this devastating pregnancy and birth complication.

References

Hudon L, Belfort MA, Broome DR. Diagnosis and management of placenta percreta: a review. Obstet Gynecol Surv 1998;53:509-17. [PubMed]

Placenta accreta. Committee Opinion No. 529. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:207-11.

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