October is Accreta Awareness Month. Placenta accreta is a rapidly rising complication of childbirth. One in 272 pregnant people is at risk for this potentially life-threatening condition. It is the abnormal attachment of the placenta in the area of a prior uterine scar. Placenta accreta puts mothers at risk for bleeding during pregnancy, premature birth, severe hemorrhage, blood transfusion, cesarean hysterectomy, and death.

The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine state that “the increasing rate of placenta accreta over the past four decades is likely due to a change in risk factors, most notably the increased rate of cesarean delivery.” For many mothers and babies, a cesarean section improves health outcomes and for others, it is a life-saving procedure. However, the medical associations note that the rise in cesareans has not improved health outcomes for mothers or babies overall.

Placenta accreta spectrum includes placenta increta where the placenta attaches itself more firmly in the uterine wall and placenta percreta, where the placenta grows through the uterine wall and invades other pelvic organs including the bladder.

The number of cesarean births has been increasing since the mid-1990s. In 2018, the overall cesarean delivery rate was 32.0%, a figure that has not changed much in the last two decades.

The odds for placenta accreta increase with each additional cesarean. In the 1970s and 1980s, the risk for placenta accreta ranged from 1 in 2,510 to 1 in 4,017. Today it’s nearly 1 in 300.

Placenta accreta is usually diagnosed during the second and third trimester of pregnancy by means of ultrasound or magnetic resonance imaging (MRI). However, it is sometimes detected only at the start of a repeat cesarean section.

Placenta accreta is a high-risk condition that often requires a cesarean section to be performed by a highly experienced multidisciplinary critical care team and the resources of a Level III or Level IV care hospital.

As many as 90% of expectant mothers with placenta accreta require a blood transfusion and 40% require more than 10 units of packed red blood cells. Attempting to remove the placenta after the birth of the baby can cause life-threatening hemorrhage, so it is usually safer for mothers if the physician removes the uterus with the placenta in place (cesarean hysterectomy).

Other risk factors for placenta accreta include advanced maternal age, prior uterine surgery, cervical dilation and curettage (D & C), having given birth to several children, and placenta previa, where the placenta partially or totally covers the mother’s cervix.

With a placenta previa and one or more prior cesareans, a mothers’ risk for placenta accreta spectrum is greatly increased. Placenta previa is found in more than 80% of accretas.

The practice of performing routine repeat cesareans contribute to the increase in placenta accreta. The way to reduce the risk for placenta accreta is to avoid performing the very first surgical procedure (primary cesarean) and to support a mother’s informed choice to labor for a vaginal birth after cesarean (VBAC).

Many cesareans are performed for non-medical reasons. Factors such as a hospital’s culture, time convenience, fear of malpractice liability, and physician practice style play a role in the decision to perform a cesarean section. A low-risk, first-time mother is up to 15 times more likely to have a primary cesarean birth at one hospital than another.

Obstetric guidelines support mothers who want to plan a VBAC and 3 out of 4 will have a safe vaginal birth. Yet in 2018 only 13.3% of U.S. mothers with a previous cesarean gave birth vaginally.

Nearly half of expectant mothers surveyed in California 2017 reported that they would have wanted to labor for a VBAC but their providers did not support their choice and recommended a routine repeat cesarean instead.

A cesarean is major abdominal surgery. For mothers, the short- and long-term risks are many including a higher risk for death for routine repeat cesareans compared to VBAC. Babies born by cesarean are at risk for breathing difficulties, admission to a Neonatal Intensive Care Nursery (NICU), lower rates of breastfeeding, and developing childhood asthma.

In 2018 1 in 4 low-risk, first-time U.S. mothers gave birth by cesarean. These are the mothers least expected to experience complications during labor and birth. They carried one fetus, head-first, and went into labor on their own, at term. That same year nearly 9 out of 10 mothers had a routine repeat cesarean.

Until the common practice of performing routine repeat cesareans is reversed and more physicians and hospitals support VBAC, the number of cesarean births will continue to increasingly put mothers at risk for placenta accreta.

#1in272 #accretaawareness