What is Placenta Accreta Spectrum (abnormal placentation)?
The placenta is the organ that develops during pregnancy that provides nutrients and oxygen to your baby. It is normally attached only to the inside surface of the uterus. When the baby is born it separates and comes out (the “afterbirth”). Sometimes the placenta attaches too deeply into the muscle of the uterus, sometimes even growing through the uterus muscle to become attached to surrounding organs (like the bladder). If this happens, it means the placenta will not separate from your uterus normally after delivery of your baby. Very heavy bleeding (also known as a postpartum hemorrhage) may occur from attempts to remove the placenta when it is stuck to the uterus, which could be life threatening.
What is the difference between accreta, increta, and percreta?
Placenta accreta: When the placenta grows too deeply into the uterine wall muscle (the myometrium).
Placenta increta: When the placenta grows even deeper, partially through the muscle layer of the uterus.
Placenta percreta: When the placenta grows completely through the muscle layers of the uterus and the outer layer of the uterus. Sometimes, the placenta may attach to surrounding organs, such as the bladder.
What will happen during the delivery?
A cesarean delivery is usually recommended, with the team prepared to remove the uterus (hysterectomy) if necessary. Make sure to discuss your options with your obstetrician. Usually the ovaries are not removed.
The type of anesthesia you will receive to keep you and your baby safe and comfortable will vary depending on your hospital and the unique circumstances of your condition. Sometimes, it is possible to deliver the baby while awake under neuraxial anesthesia (spinal, epidural, or a combined spinal and epidural) and sometimes general anesthesia (where you are completely asleep) is needed. Talk with your anesthesia providers to discuss your options.
IV: an intravenous (IV) catheter placed in the hand or arm (also called a “peripheral IV”). These IV’s are usually placed in the preoperative area and additional IV’s may be placed before the surgeons begin.
Can I be awake during the delivery?
This will also depend on your hospital and your unique condition. At some institutions, you may stay awake through the delivery of your baby. Once your baby has been delivered, your anesthesia team can give you some sedation or you can go to sleep depending on the surgery and your preferences. At other institutions you will be under general anesthesia throughout your operation. It is important to discuss your preferences (some people want to be awake, others prefer sedation after the baby is delivered, and some want to be asleep for the whole surgery) and all the options with your anesthesia providers. If you are awake, your support person can be with you. If you have general anesthesia (completely asleep), your support person will stay with the baby until you are in your recovery room.
Will I feel pain during the surgery?
While spinal and epidural anesthesia blocks pain sensations during surgery (numbing medication injected into your lower back), you may feel pressure or discomfort at different times during your cesarean delivery. Your anesthesia provider will check to make sure you are numb several times before allowing the surgery to start. Your anesthesia provider will also monitor you during your entire cesarean delivery to make sure you stay comfortable. If your anesthesia team puts you under general anesthesia, you will not be awake and will not feel discomfort.
Possible monitors the anesthesia team might use:
Arterial line (also known as an a-line): a thin, flexible tube that we place into your artery (usually in the wrist). If you are awake, numbing medicine will be used to make the procedure more comfortable. Alternatively, it can be placed after you are asleep if the plan is for you to be under general anesthesia. With the a-line, your blood pressure can be monitored every time your heart beats. This will allow us to monitor you very closely during your surgery. We will also be able to take blood samples through your a-line, to avoid sticking you with a needle every time.
Central venous catheter (also known as a CVC or central line): a long, soft, thin, hollow tube that is placed into a large vein, in the neck, upper chest, or groin. A central venous catheter differs from a peripheral IV. This type of catheter has special benefits in that it can deliver fluids, medication or blood into a larger vein.
Epidural: a long thin tube placed in your lower back before your surgery. The epidural blocks pain receptors. At some institutions, the epidural is left in place after your surgery is completed to help with pain after your surgery.
Will I need a blood transfusion?
If you lose too much blood where it could be life threatening, then you would need a blood transfusion. Please let your providers know early if you would not accept a blood transfusion even in an emergency (often due to religious reasons). Your anesthesia team will monitor you closely throughout the surgery to determine if you will require a blood transfusion. Your anesthesia providers will watch your heart rate and blood pressure and take blood samples to monitor your red blood cell levels.
Where will I recover from surgery?
Where you recover will depend on the hospital. If your procedure is straightforward, your anesthesia team will take you to a room on Labor and Delivery or a Post Anesthesia Care Unit (PACU, also known as the recovery room) where you will recover for at least an hour. In the PACU, a nurse will continue to monitor you and your pain control. After recovery in the PACU, you will be taken to your room on the hospital floor. If the surgery was more complicated, there is a chance that you may go to the Intensive Care Unit (ICU) to monitor you more closely.
How will my pain be controlled after surgery?
You may be given long acting pain medication through the spinal or epidural that would last for 18-24 hours. If you have an epidural that is left in place after the surgery, then you may be able to receive pain medication through the catheter that will help treat your pain. You can also have IV and oral pain medications throughout your recovery.
Will the surgery affect my ability to breastfeed?
It depends on many things. It is usually possible to breastfeed (or pump breast milk) after a delivery, even if your baby was born premature.
Almost all medications given for anesthesia for cesarean deliveries will not affect your ability to breastfeed. Avoid breastfeeding if you feel sleepy from anesthesia or pain medicines. Sometimes pain medications called opioids are necessary; these medicines can be present in very small amounts in your breast milk. Monitor your baby after breastfeeding for any signs of extra sleepiness – you can ask your nurse, lactation support staff, or pediatrician for help while you are in the hospital.
Having a high-risk pregnancy, undergoing a complicated delivery, and experiencing significant bleeding with delivery can be extremely stressful, so some women with abnormal placentation experience difficulty breastfeeding.
Mental Health After the Delivery
Having a high-risk pregnancy, possibly having your uterus removed, or receiving a blood transfusion can be extremely stressful. A lot of women and their support people experience anxiety, post traumatic stress, and depression around the delivery. It is also common to find it difficult to talk about your experience. However, it is important that you speak with your OB provider about your experience and many people benefit from speaking with a mental health provider as well. You are not alone and your team will help support you throughout the process and your recovery.