- What is Placenta Accreta Spectrum?
What is placenta accreta spectrum?
“Placenta accreta spectrum” covers a range of clinical conditions where the placenta is imbedded too deeply into the lining of the womb. The placenta is a temporary organ that connects the unborn baby to the wall of the womb via the umbilical cord. It provides oxygen and nutrients to the baby and removes waste products. In a normal pregnancy, the placenta will separate from the lining of the womb after the baby has been delivered. In cases of placenta accreta spectrum, the placenta is strongly attached to the lining of the womb and does not separate after the baby is born. The condition is rare, however due to various factors such as an increasing caesarean section rate and fertility treatments, placenta accreta is becoming more common. At the National Maternity hospital, between 15 and 20 patients are diagnosed with placenta accreta spectrum every year currently.
What is the difference between placenta accreta, increta and percreta?
Placenta accreta spectrum consists of three conditions; placenta accreta, placenta increta and placenta percreta, depending on how deeply the placenta is attached to the lining of the womb. Normally, the placenta attaches to the endometrium, the innermost lining of the womb However, in placenta accreta spectrum the placenta has grown beyond the endometrium .
Placenta accreta - the placenta has grown beyond the endometrium and has attached strongly to the myometrium, the muscular layer of the womb.
Placenta increta, the placenta has grown beyond the endometrium and has grown into and deeply invaded the myometrium.
Placenta percreta -, the placenta can attach and grow so deeply into the lining of the womb that it grows right through the outermost layer of the womb, the uterine serosa and often impacts other organs, such as the bladder.
Quality of life and Sexual function after PAS
Outcomes from PAS Mutli-displinary team
Mental health and Placenta Accreta Spectrum
Comparing three-dimensional models of placenta accreta spectrum with surgical findings
- What causes placenta accreta spectrum to develop?
What causes placenta accreta spectrum to develop?
Placenta accreta spectrum usually affects patients with one or more known risk factors.
The most common risk factors are:
- Having had a previous caesarean section. Placenta accreta spectrum can develop even after only one caesarean section. The higher the number of previous caesarean sections, the greater the risk.
- Having a low-lying placenta, a condition known as placenta previa. However, most women who have placenta previa do not have placenta accreta.
- Patients who have a combination of previous caesarean section and have a low-lying placenta (placenta previa) are at greatest risk of developing placenta accreta spectrum.
- Having had previous removal of a fibroid, a surgical procedure known as a myomectomy.
- Previous surgery for a miscarriage such as a “D&C”, Dilation and curettage, or a surgical termination.
- Previous “stuck placenta” in a prior pregnancy requiring removal in an operating theatre, referred to as “Manual Removal of Placenta”.
- Infertility treatments such as in-vitro fertilization.
- Some patients may have no know risk factors, however this is very rare.
- How is placenta accreta spectrum diagnosed?
How is placenta accreta spectrum diagnosed?
Usually there may be no signs or symptoms of placenta accreta. Some women may present with bleeding.
Placenta accreta spectrum is diagnosed on ultrasound. Diagnosis during pregnancy is important as it this allows the appropriate management and treatment plan to be put in place. Usually a number of ultrasounds are performed throughout the pregnancy to look closely at the placenta as the pregnancy progresses. While it is possible to diagnose the condition at any stage during pregnancy, usually the first signs are not seen until the 20 – 22 week anatomy ultrasound. In many cases the ultrasound features may not become apparent until later in pregnancy between 28 and 34 weeks.
Sometimes an MRI is arranged. MRI uses a strong magnetic field and radio waves to create detailed images of the organs and tissues within the body. While ultrasound is the best test to look at the placenta itself, an MRI allows the team of doctors to identify if other organs close to the womb, such as the bladder are involved or if the placenta is attached to the back of the womb - which is a rare event. Your team of doctors will use both the ultrasound and MRI images together to determine how deeply the placenta is attached to the lining of the womb. Both ultrasound and MRI are safe during pregnancy and do not harm your baby.
- How is placenta Accreta Managed?
How is placenta Accreta Managed?
Following a diagnosis of placenta accreta a number of specialists become involved in your pregnancy care . These include
- midwives input.
- consultant obstetrician ,
- anaesthetist ,
- a specialist in advanced pelvic surgery (usually a gynaecology oncologist ) ,
- Radiologists ( xray doctors )
- ultrasonographers ,
A patient support group is also available and they may contact you.
Each month at a multidisciplinary meeting, members of the team meet to discuss your care and plan for the safe delivery of your baby. A planned delivery is the safest method for mother and baby. If there is any severe bleeding or imminent concerns about the health of the mother or baby an emergency delivery may need to be performed.
You will meet a number of these specialists during your care .
You may need to be monitored as an inpatient in hospital . This may happen if you have had any bleeding or pain during your pregnancy or if you live a long way from the hospital. Some patients may be suitable for outpatient management.
An elective caesarean section is usually performed to deliver the baby . In the majority of cases a hysterectomy is also performed. This generally occurs between 34-36 weeks gestation . As the baby is delivered early you will need to receive 2 steroid injections for your baby prior to your caesarean section . These help aid the babies lung development. Your baby may need to spend some time in the neonatal unit following delivery. A paediatric team are present at the delivery.
2 types of anaesthesia are used to perform the surgery
Spinal anaesthetic . A needle is inserted into the back and the medication given makes you numb from the breasts to the tips of your toes . You do not feel any pain but you will still have sensation to touch. This allows you to be awake for the delivery of your baby .
General anaesthetic . This is where medication is given via a drip and face mask to put you to sleep . A general anaesthetic can be given following the delivery of the baby to proceed with the hysterectomy or it may be given at the start of the procedure.
A large incision is usually made on your abdomen usually from your pubic bone to above the belly button. In a selected number of cases an incision across your can abdomen can be performed.
Following the delivery of the baby, if the placenta does not detach from the womb naturally, which is a consequence of placenta accreta a hysterectomy ( removal of your womb and fallopian tubes) is performed. The reason for this is to prevent heavy bleeding which can be caused if the placenta is disturbed. Occasionally a placenta may seperate unexpectedly and a planned hysterectomy may not be necessary. The ovaries are left behind so you do not go into menopause.
You may require a blood transfusion during or post surgery . A special machine called a cell salvage is used to collect your own blood during the surgery . This is then given back to you following the procedure . You may also require blood from the laboratory .
Some mothers may need to have their planned surgery performed at either St Vincents University Hospital or the Mater Misericordiae University Hospital if interventional radiology is required. Following surgery at these hospitals you may be transferred back to the National Maternity Hospital after a few hours. Some mothers may need to stay overnight for observation. This is usually in a high dependency ward. However even if delivery is planned in a general hospital if emergency delivery is required before the planned date this will likely be performed in the National Maternity Hospital.
In selected cases a specialist X-ray doctor may insert balloons Into the blood vessels that supply the womb during the surgery . This helps to reduce the blood loss.
- As the risk of bleeding is high during a hysterectomy, it may be necessary to place “balloons” in the blood vessels which bring blood to the womb to reduce the risk of bleeding heavily
- The balloons are usually inserted through a blood vessel in the groin
- The balloons are inflated during the surgery and help to reduce the amount of blood lost during surgery
- This is only performed in select cases and a decision to use interventional radiology is made on a case by case basis at the monthly MDT
- What are the risks associated with Placenta Accreta?
What are the risks associated with placenta accreta?
- Historical studies suggest a 7% risk of death, however early diagnosis and planned delivery with an experienced team reduces this risk.
- Current estimates suggest a 2% risk of death
- Most commonly associated with heavy bleeding
- Higher risk if placenta accreta spectrum is not diagnosed during the pregnancy
1 in 10 women will suffer a major complication requiring an additional procedure or a return to the operating theatre, these include
- Most women loose at least 1 litre of blood during surgery, in severe case 5-8L of blood are lost
- 4 in 10 women require blood transfusion
- A cell saver may be used to give back blood
- Chest infections, wound infection and infections from intravenous catheters or central lines can occur
- An abscess or collection can form in the pelvis can develop which may require drainage which is usually done under x-ray guidance
Damage to adjacent organs
- The most common complication of surgery for placenta accreta is a bladder injury. This is sometimes necessary to resect the placenta in severe cases. Once identified the bladder can be repaired with a suture and a catheter is left in for 10 days. An x-ray to check the bladder may be performed before the catheter is removed
- In some cases, where the placenta is invaded very deeply into the womb, the ureters (tubes which carry urine from the kidney to the bladder) are at risk of being injured. This is because the ureters lie very close the womb. To reduce the risk of injury, a small stent may be placed in the ureter to protect the ureters during the surgery. If a ureter is damage during surgery you may require additional procedures
- Damage to the bowel is extremely rare in placenta accreta
- Although ovaries are conserved in virtually all cases, if there is excessive bleeding it may be necessary to remove one or both ovaries. Removal of both ovaries will result in a premature menopause
Developing a blood clot in the leg or the lung
- The combination of heavy bleeding and pelvic surgery increases your risk of developing a blood clot
- Please inform staff is you have a family history of blood clots
- You will be asked to wear TED stockings and will likely need to have blood thinning injections after your delivery
Hysterectomy and loss of fertility
- In a small number of cases it may be possible to preserve you uterus, this is option is discussed at the monthly multidisciplinary meeting
- Early delivery will likely require admission to the neonatal unit
- You will be reviewed by a member of the neonatal team before your delivery for an in depth discussion regarding the risks associated with early delivery
- Postnatal Period
After surgery you will be monitored closely in a high dependancy ward. In most cases this is only for one night. Following this you are transferred back to post natal ward.
A urinary catheter is inserted during your surgery. This stays in place until you are able to walk safely to the bathroom. Usually the next day.
A number of drips and monitors may be still attached following your surgery. Once again these are all usually removed the next day.
Blood test are usually taken to check your iron levels and the function of your kidneys.
To prevent blood clots forming ( a risk factor following surgery ) you are required to wear stockings for the duration of your stay in hospital. A small blood thinning injection is also given every day. Some mothers may require this medication at home for a few weeks following delivery. We encourage you to mobilise as soon as it safe to do so. A member of the physiotherapy team will help and guide you on how to do this safely.
You will be given pain relief medication to help ease any post operative pain. This can be in the form a tablets or a drip.
Most women are allowed to eat and drink soon after surgery.
You will normally be in hospital for approximately 4-5 days. If there are any concerns or complications you may need to stay for an extra period of time.
- What happens to my baby?
What happens to my baby?
Following the delivery of your baby he or she will need to be admitted to the neonatal unit. This is usually because we are delivering the baby earlier than expected. They may need help to fed, breathe and to regulate their temperature. Once mobilising you can visit your baby in the unit.
If you have your surgery in either St Vincents Hospital or the Mater Misericordiae Hospital, a team of Paediatric doctors and neonatal nurses will be present for the delivery of your baby. This is known as the neonatal transport team. Following delivery they will accompany your baby back to the neonatal unit.
How long your baby stays in the baby unit usually depends on how early they are born.
Your baby may need to stay in the hospital after you are discharged.
- What do I need to know about going home?
What do I need to know about going home?
On average it takes up to 6 weeks to recover from surgery. For some women this may be longer.
You may be discharged home before your baby can be discharged from the neonatal unit.
It is important to have someone at home with you.
On discharge from hospital you will be given a prescription for pain relief and any other medication that you may require such as the blood thinning injections, antibiotics or iron supplementation.
It is important to take these medications as directed.
It is important to eat and drink as normal.
The physiotherapists may give you exercises to perform at home . Avoid heavy lifting and strenuous exercise for the 1st 6 weeks.
You are advised not to drive. The can be for up to 6 weeks post surgery. You will need to check with your insurance company.
The public health nurse will visit with you post surgery. You may also be asked to attend you gp to have your staples removed. This usually 7-10 days post surgery.
A 6 week follow up appointment will be given to you.
If you have any concerns or are feeling unwell post surgery it is important to contact the hospital. You may be asked present to your GP or to the emergency department.
Some women may experience mental health changes following the birth of your baby.
These can include:
Baby blues - common , normal usually day 3-5 after the delivery of your baby.
Post natal depression 10-15% of women within the first year of giving birth.
Post traumatic stress disorder - a disorder which may present with intrusive and persistant re-experiences of traumatic events.
Support services are available trough the hospital via the perinatal mental health health department. You can also access help via your GP.
- Patient Stories
Shauna Kelly, Placenta Accreta Spectrum Survivor
When I was diagnosed with placenta accreta spectrum I didn’t know what to expect. It can be an emotional and overwhelming time for mums as many are also considering the practical implications of being a long stay patient in hospital. This video captures the emotional journey that many mums find themselves on. We hope it helps you understand your journey.
I received a Placenta Accreta diagnosis at an early 7-week scan on my fourth pregnancy in 2017. We had three children, Jack was turning 7, Beth 4 and our precious baby Scout was stillborn full term in 2016. Our hearts had been broken. Although we had to consider termination for my safety, our hearts wouldn’t allow us to take this route.
We found out we were having a girl and we named her Darcie.
I suffered numerous bleeds and each time thought I was losing Darcie. I was admitted to the National Maternity Hospital at 21 weeks +5 after heart breaking goodbyes with my husband and children. A couple of days after admission a scan revealed that I had seriously low amniotic fluid in my placenta and it was feared a small tear had occurred, this remained low for many weeks and our baby’s development was of huge concern.
My long stay in hospital was full of terror and isolation. But I had an amazing group of women in my room with threatening conditions and we all supported each other. We kept our curtains open and the days usually passed quickly with lots of laughs thrown in! I was lucky to live locally so my friends and family visited me every day, and supported Stephen juggling all that was necessary with me away. I was distraught every time my children visited and had to leave again. And the guilt I felt was overwhelming.
At 27 weeks +6, I was transferred to St Vincent’s Hospital for my surgery. I remained awake for 2 ¾ hours for preparatory work; a spinal / epidural, arterial line placed in my wrist, Intervention Radiology inserted balloons into my veins to be inflated to minimise bleeding, Urologists inserted stents to prevent injury to my bladder. I then received a general anaesthetic and went to sleep. I was in theatre for over 8 hours and lost 6 litres of blood; some of which was filtered and transfused back into me with a cell saver machine, I also received a few litres of donated blood. I had a total hysterectomy.
Darcie was alive but we were warned that her first week would be crucial to her survival, threats included a bleed on her brain, immature lungs not functioning or infection. She grew every day and was eventually discharged from NICU 7.5 weeks later.
Darcie has recently turned 2 and is amazing and perfect. Professor Donal Brennan and his team saved both our lives and we will be forever grateful for the unbelievable standard of care we received. My experience in Unit 3 pre surgery was one of compassion, empathy and dignity. And the team in NICU looked after Darcie so well.
I am still processing all I have been through 2 years later and there have been tough times along with overwhelming feelings of gratitude and enjoyment of my children. Being part of the set-up of Placenta Accreta Ireland and an advocate for patients and survivors has allowed me to give back and has also proved to be very cathartic. Not all Accreta patients have positive outcomes but with continuing research and support to patients and survivors, we can make a difference.
Beverley Campion, PAS Survivor
I was diagnosed with placenta accreta on my third pregnancy at week 33 gestation during a detailed scan at NMH. I was 31 years old at this time. My symptoms of PA were silent. I had no bleeding.
Once it was determined I had PA - it was explained to my husband and I that I would require caesarean-hysterectomy and possibly 3.5cm of my bladder resected. An MRI was also scheduled for a later date to reaffirm the diagnosis.
I was admitted to NMH on week 34 where I was monitored extensively until the delivery of my baby at week 36. This was an extremely hard time for me as I prepared to leave my two sons and husband for my stay at hospital.
Éabha Faye was delivered at 1132am on the 18th June 2019. My surgery continued for a further two and a half hours thereafter to remove my uterus, cervix & fallopian tubes. Fortunately, I did not require a blood transfusion. The surgery for placenta accreta is quite extensive and I was required to stay in HDU for 24 hours with a spinal block for my pain relief. This is not a straightforward C-Section, this was major abdominal surgery that left me with a vertical scar of approx. 12cm. This scar now reminds me of the team that saved my life!
I was then moved to postnatal care - however Éabha Faye would stay in NICU for two days as she was born under full general anaesthetic. It wasn’t until two days after my surgery that I would meet my daughter. Two of the midwives brought Éabha Faye to my room so that I could meet her - as you can imagine there was no skin to skin contact given the impact of the surgery - this still weighs heavy on my heart. But we were both on what would be the very start of our road to recovery and I was determined to stay strong & focused so as to get discharged from hospital ASAP.
After almost one month at hospital I left for home - albeit walking very slowly through the corridors and hugging the caring staff I had met along the way - we were almost halfway there.
Elaine Ní Bhraonáin, PAS Survivor
I was diagnosed with placenta accreta at 25 weeks on my third pregnancy. As I had had placenta previa on my previous pregnancy, I was aware of the severity of accreta. I was relieved that it had been picked up on ultrasound but knew I would have to have an MRI to confirm the condition. Having the MRI was terrifying but I knew it would give me the best chance of survival as my the accreta team would know exactly what they were dealing with.
When admitted, my heart sank saying goodbye to my 3 and 4 year old little boys as it was coming up to Christmas and I knew they would only be able to visit once a week as they were in Wexford with my elderly parents. Missing out on trips to Santa and playschool nativity performances broke my heart. Honestly, I felt resentment some days towards the tiny baby inside me and felt it unfair that this baby was already dictating my life so much and wasn’t even born yet. The first few days of my hospital stay were definitely the toughest, but I soon got into the swing of things, learned how to pass each day, knew what my emotional triggers were and knew how to manage them. I reminded myself each morning when I woke that we are a step closer to delivery day and my baby is fatter today than yesterday which hopefully would mean less NICU time for him.
I was awake for the first hour of my surgery and saw and heard my little baby cry when born which was of course magical but I was so weak from being on bedrest that I would have preferred to have been asleep for the duration of the surgery.
Unfortunately I bled heavily during the hysterectomy and had to have a completed replacement of blood. I lost over 6 litres of blood and required 13 transfusions.
When I woke up in recovery, my family were all around me. They all looked scared but so so relieved, I knew then everything was ok. I later learned about the huge blood loss but all I cared about was that my baby was doing ok in the NICU.
When we finally got home, we could be a normal family again. Simple things like playing lego with my boys, reading to them and making their preferred school lunches were actually what I missed the most. I still feel guilty about the time I spent away from them but realise how lucky I am to have come though this disease.
It has taken me a full year to come to terms with this conditional, both physically and mentally but the team at Holles Street and Placenta Accreta Irleland have given me the support I need every step of the way.
I owe my life to Prof Donal Brennan, Dr Zara Fronseca Kelly and their team. Míle Buíochas ó chroí as ucht mé a shábháil.
Faye Treacy, PAS Survivor
This was my fourth pregnancy, my first two were delivered by c sections the third resulted in a first trimester miscarriage.
I had suffered 2 small bleeds in the first trimester of this pregnancy, but early scans had shown a heart-beat and a viable pregnancy. I had no further complications after that and my 22 week scan showed a healthy baby but a low lying placenta.
At 23 weeks I had a bleed which woke me up and I went straight into hospital where I was admitted straight away. Scans were done and this was when placenta accreta was mentioned to me. I was given steroid injections to bring on the baby’s lung development in case they needed to deliver the baby. I was put on bed rest and was monitored very closely. This was such an emotional and terrifying time for me. I was visited by neonatal doctors who explained what would happen should my baby need to be delivered in the coming days and what it’s chances of survival were. Along with all that would be done for the baby I was told that the condition was extremely dangerous for me. The surgery is major and would most probably result in a hysterectomy being done at the time of delivery in order to reduce risk of fatality. With all the medical examinations beginning done on me and my unborn baby I was also having to deal with leaving my girls who were 5 and 3 years old for the foreseeable future until the baby had been delivered. I had never left them before and so this was an extremely anxious time for us all.
Luckily things stabilised and the bleeding stopped and after 6 days I was allowed home. The relief was huge but I felt like a ticking time bomb as I had been told it could happen again at any time and when it did I was to come straight back in. 2 weeks later I began to bleed again. Once again, I was admitted into NMH. Although the bleeding stopped again I was told I wasn’t going to be allowed home until after delivery as it was too dangerous. I was in hospital for 5 weeks before Rian was born at 31 weeks. During this time I received the best care I could have hoped for. The staff were amazing and I was lucky to be invited as the first placenta accreta in-patient to the Placenta Accreta Ireland (PAI)support Group meeting. This for me was a big confidence booster...I met the survivors which gave me such hope and a bit of light at the end of a very long dark tunnel.
3 weeks into my stay another accreta patient was admitted into the same ward, we became close friends and great support for each other. After I had attended the PAI meeting one of the PA survivors came to talk to us and offered such reassurance. She was so open and honest with us...we asked her every question that came to mind, our fears and concerns - big and small, and she answered them honestly. Nothing was sugar coated, and the reality was frightening but speaking to someone who had gone through it and being able to ask advice was very beneficial...and it gave me hope.
The Consultants would call into see me to give me any updates and go through the procedure nearer the time and talked about the hysterectomy they’d have to do in order to save my life. We discussed anaesthetic, possibility of blood transfusions and the placenta latching on to my bladder. Day of surgery was terrifying and so incredibly emotional. The surgery by all accounts went very well. Once the placenta had been separated from my bladder they did the hysterectomy. When I came round from the anaesthetic and saw my husband and I was very emotional but I was alive!!
Rian was born weighing just 4lb, he responded well to intervention and was taken to the NICU where he went from strength to strength.
Since then, I’ve been attending the monthly PAI support meetings. Sometimes I have really had to push myself to go as it can be difficult to talk about and emotionally draining at times. But the support I’ve received during them, from professionals and survivors, has been immense. And it makes me feel that I’m not alone.
Nicola Dunphy, PAS survivor
I was diagnosed with placenta accreta at 30 weeks during my last pregnancy. I had a low lying placenta all through the pregnancy so it was suspected from around 20 weeks. An MRI scan in NMH confirmed this terrifying diagnosis.
I was admitted to the hospital at 31 weeks in early December 2018. Saying goodbye to my 4 young children at home and my husband was heart breaking, and emotions were heightened by the fact that it was the Christmas period. I was completely lost initially during my long hospital stay but I soon got into a new routine and made some good buddies on the busy ward which helped get through the long days and also kept my mind distracted from the terrifying road that lay ahead.
My baby was delivered on 3 January 2019 and 35 plus weeks and she spent a number of days in the wonderful care of the NICU staff. I was awake during my entire surgery. I had a lot of blood loss following my surgery and I needed a number of blood transfusions. I was stayed in HDU for 2 nights so didn’t see my baby girl until she was 3 days old.
On returning home, I felt very strange and very vulnerable. I was very weak and sore but slowly I began to regain my strength and my confidence and life began to settle back to normal. I am eternally grateful for our 5 beautiful children and to Prof. Donal Brennan and the amazing medical team in NMH who got me and my baby over the line. The establishment of placenta accreta Ireland has been monumental in helping me with my recovery.
Caroline Kevany, PAS Survivor
My third and last pregnancy was unlike the previous two, which were both standard pregnancies without a blip, which ended in C-section deliveries. I found out I was expecting in early January 2017 and was thrilled, this was hopefully going to be our third baby with a distant lingering for a fourth if we were lucky enough. Towards the end of that same month I had an early scan privately around the 7week mark, as I had done in my other pregnancies. At the scan the sonographer said there was no heartbeat, a collapsed yolk sac; and it was most likely a missed miscarriage, she referred me to the National Maternity Hospital (NMH). Their sonographer said the same thing, however I had to have two further scans there before they would confirm this fully. At around the 9 week mark I was going in to have a final scan followed by a D & C, when the sonographer told me there was a baby and a heartbeat, measuring in line with the dates, I could not believe it; but I was so happy and rushed to call my husband who was about to travel back from the UK to collect me after the procedure. The sonographer said there were subchorionic hematomas (small bleeds) and I think the reason they could not detect a baby until this late stage was because of the early stages of Placenta Accreta Spectrum (PAS), that I was blissfully ignorant of at this time.
Life was good and Cleo (6), Oscar (3) and my husband Robert and I were all excited with the thoughts of a new addition to our family. It was only at the 20week anomaly scan that things became stressful and worrying once again, we were given an antenatal diagnosis of either unilateral or bilateral talipes (clubfoot) by the sonographer who also mentioned that my placenta was low lying and she said they would continue to monitor this. We were then referred to the high-risk unit in the hospital for regular check-ups, and to be honest I had no idea about the connection between previous C-sections and a low-lying placenta (Placenta Praevia) and the risk of PAS. Robert and I were totally distracted by there being potentially something wrong with our baby, that our entire focus was on her. At this stage I had the Harmony test done for Trisomy 13, 18 and 21 because of the clubfoot diagnosis, we were relieved when this came back negative. Later in the pregnancy towards the end of June I began to develop Polyhydramnios (too much amniotic fluid), at this stage my mind was in overdrive and melt down mode, reading about the connections with clubfoot, Polyhydramnios and the potential for genetic issues with our baby, the anxiety levels were sky high. I had convinced myself that there was something very wrong, so much so that when I was told I needed to have an MRI in Vincent’s Hospital to confirm whether I had PAS or not, it was at the very bottom of my list of things to worry about. The MRI confirmed that I had PAS and I was then referred to one of the NMH’s specialist consultants Dr. Ruaidhrí McVey who was going to look after me, my baby and manage the delivery, which was scheduled for 35w 5d, our September baby was no longer going to be a Virgo, she was going to be a Leo :)
Thankfully I had no bleeds through the entire pregnancy and therefore I did not have any long stays in hospital like so many of the amazing PAS mum heroes. I was admitted two days before delivery and given steroid injections to mature baby’s lungs. On the morning of my surgery I had a strong sense of calm about me, I was so happy that this was nearly over, I needed my daughter here to see her and all my hopes were that she would be healthy. I don’t think I fully understood at this stage what the implications of the surgery were. I was put under general anaesthetic on 17.08.17, with a central line inserted in my neck for blood transfusions and Margot was delivered safely that morning and brought straight to NICU and put on a CPAP to assist her breathing. The surgery lasted about 6hours and was longer than originally anticipated as I had a lot of blood loss, totalling just under 9 litres. During the operation I had a total hysterectomy and my bladder was sectioned, and ureters cut as they had stuck to my womb, I had several units of blood products transfused. When I woke up in the theatre and saw the clock it was almost 4pm. I was then transferred to HDU for about 30hours where I received more transfusions, Robert and my parents were at my bedside and I was able to look at photos of Margot on Robert’s phone. I managed a trip to NICU to meet my daughter two days later in a wheelchair, she was perfect, and I think one of the toughest bits is that she was never in my room with me, I always feel guilty about that missed time with her. The physical recovery was difficult and the pain hard to deal with at times, I had ileus arising from my bowels being handled during the surgery which made eating and drinking impossible for about 5days after the operation. Another really difficult thing to deal with was the fact that Margot had to stay on in Holles Street as she had issues with feeding, and we had to return to collect her two weeks after her birthday. The care that I was given in the NMH before, during and after the surgery was outstanding, Dr. McVey and Dr. Robson had a multi-disciplinary team in place to deal with all of the complications that can arise from PAS and the complex lifesaving surgery required.
It’s almost three years now since Margie was born and I think the emotional, long term effects from a traumatic experience like this should not be underestimated; and this is where the Placenta Accreta Ireland Support Group at the hospital has really helped, being able to connect with other women who have been through a similar experience and can give advice and support one another is just so important. Everyone’s PAS journey is different, but they are all as important as one another and I think so many of us just want to share our story and feel understood. Being able to meet in the NMH also gives me a legitimate excuse to visit the maternity hospital that I have such happy memories of January 2011 (Cleo), May 2013 (Oscar) and August 2017 (Margot).
Is placenta previa part of placenta accreta spectrum?
No, placenta previa is not part of placenta accreta spectrum. In placenta previa, the placenta is low lying and covering the cervix. The placenta is normally attached to the lining of the womb and will separate naturally following delivery of the baby. The term “previa” refers only to the location of the placenta inside the womb and there is no invasion of the placenta into the womb.
Are all cases diagnosed during the pregnancy?
In the National Maternity Hospital, 92% of cases are diagnosed during the pregnancy. Approximately 1 in 10 patients will not be diagnosed during pregnancy and the diagnosis is only made either at the time of caesarean section or following a vaginal delivery, where the placenta does not separate from the lining of the womb.
What happens after a diagnosis of placenta accreta?
Where a diagnosis of placenta accreta spectrum has been made, delivery of the baby will be by caesarean section.
In most cases, the baby will be delivered a number of weeks before the due date. Usually the delivery is planned for between 34-36 weeks. In some cases, where a diagnosis of placenta accreta spectrum is made very early in the pregnancy, delivery before 30 weeks may be necessary. Approximately 80% of patients will have an elective delivery if a pre-term delivery is planned. In some circumstances, an emergency delivery is necessary. This occurs in approximately 20% of patients. The most common reason for an emergency delivery is if you start bleeding or going into labour before your scheduled delivery date.
A planned delivery is safer for mother and baby as it minimizes the risk of bleeding and needing an emergency caesarean section.
Hospital admission may be necessary for close observation and monitoring in some cases, especially in cases where there has been bleeding in the pregnancy.
Is bed rest required once a diagnosis of placenta accreta spectrum has been made?
There is currently no evidence to support that bed rest is necessary. Any limitation to normal activities will be discussed on an individual case basis with the team providing care. Sexual intercourse can cause bleeding from the placenta and is not recommended once a diagnosis of placenta accreta spectrum has been made.
During the caesarean section what type of anesthetic is given?
The options for pain relief include either a spinal anaesthetic or a full anaesthetic.
Spinal: an injection is given into the lower back and the patient is numb from the waist down. This means the patient is awake for the delivery of the baby.
General anaesthetic: during a full anaesthetic the patient is fully asleep for the delivery of the baby. In cases where the patient remains awake for the delivery of the baby, they will routinely be then given a full anaesthetic and put to sleep after the baby has been delivered and while the hysterectomy is completed.
Many patients prefer to go asleep at the beginning of the surgery. This may be necessary in some cases to provide adequate pain relief or where heavy bleeding occurs.
What else is involved in preparation for surgery?
Arterial line: before the surgery is started, an arterial line will be placed in the patient’s wrist, as well as a number of other drips in the arm.
Central line: A central line is a long, thin, flexible tube placed in the neck through which medicines, fluids, or blood products can be given as well as blood tests taken. A central line may stay in for number of days, if required, and avoids the need to repeatedly use new needles to give medication and take blood tests.
Urinary Catheter: A tube will be placed in the bladder before surgery is started. This usually stays in until the patient is able to walk comfortably, however where a balder injury has occurred the catheter may need to stay for a number of days.
Why is removal of the womb necessary in placenta accreta spectrum?
In placenta accreta spectrum, once the baby has been delivered, the placenta stays firmly attached to the womb and there is a high risk of bleeding if attempts are made to remove the placenta.
Therefore, often the safest option is to remove the womb (hysterectomy) with the placenta to minimise the risk of blood loss.
Approximately 80% of patients will require a hysterectomy
- At the time of delivery of the baby, the womb is removed in the same surgery
- This may require a large incision on the skin from above the belly button to just above the pubic bone
- The baby will be delivered through an incision away from the placenta and the placenta is left undisturbed. This minimizes the risk of bleeding
- The womb is removed along with the fallopian tubes and the ovaries are left inside
Are there any alternative treatment options to hysterectomy?
While most patients with a diagnosis of placenta accreta spectrum will require removal of the womb, in some select cases other treatment options are available
- 1) The placenta may have grown deeply into the lining of womb only in one small area. The rest of the placenta may not be stuck and is attached normally to the rest of the womb. In these cases, this small area of the womb can be removed along with the placenta and the womb left inside. This is only suitable in a small number of cases. In cases where this approach has been planned during the pregnancy, sometimes during surgery it does become necessary to remove the womb. This may be because the placenta is grown more deeply into the womb than expected from ultrasound or due to heavy bleeding.
- 2) If the placenta starts to separate by itself, a gentle attempt to remove the placenta can be made. However, this is often associated with heavy bleeding and will only be attempted if the placenta starts to separate naturally.
- 3) In a few cases, there may be very little blood loss and the placenta can be left inside the womb, where it may absorb over a few months. However, this is not always successful, and 6 in 10 patients will need a hysterectomy at a later date. There is also a risk of heavy bleeding or developing an infection.
Will the ovaries be removed at the time of surgery?
No, your ovaries will not be removed. If you require a hysterectomy, your fallopian tubes will be removed and your ovaries left inside
What happens after the surgery?
- Most women will need to be admitted to the high-dependency unit for close monitoring and observation for at least 24 hours. During this time, the patient will have a catheter in the bladder and may have a number of drips in the arms and neck.
- Where the surgery has been uncomplicated and the blood loss minimal, the patient may only need to spend 3-4 nights in hospital after the delivery.
- However, if there was a complication or heavy bleeding, intensive care admission may be necessary for closer monitoring.
Will the baby need admission to the special care unit?
- The baby will usually need admission to the special care unit for support with breathing and feeding. This means that mother and baby will be separated following delivery.
- Steroids will be given to the mother which help to mature the baby’s lungs before delivery.
- How long the baby spends in the special care unit will depend on how early the baby is born.
Is it possible to breast feed after a hysterectomy?
Yes it is possible to breastfeed after a hysterectomy. Breastfeeding can be challenging with a premature baby after major surgery and lactation support is available if requested.
What recommendations are there for recovery from surgery?
- Iron supplementation if iron level was low on leaving the hospital
- To minimise the risk of a blood clot, wear compression stockings for 6 weeks and take blood thinning injections as prescribed, usually for 10 days
- The wound will take around 3-6 weeks to heal
- Regular pain relief is recommended after surgery in order to minimise break through pain
- Physiotherapy for pelvic floor function
How long will it take until normal activities can be resumed?
Recovery time is different for every person. It may take at least 6 weeks for the wound to heal and post-surgery pain to resolve. However, for some women this may take longer. During the first 6 weeks driving is not recommended.
- A postnatal review will be arranged in the hospital 6 weeks after surgery for a check up
- Patients may have spent a long time in the hospital before their surgery, and may go home before their baby has been discharged from the special care unit, so this can be a very challenging time for patients and their families
- Some women may suffer from depression, anxiety and post traumatic stress disorder
- Where a hysterectomy has been performed, it will not be possible to have further pregnancies and this can create additional anxiety around loss of fertility
- Follow up and support services are available in the hospital and through the patient support group to address any ongoing concerns.
- Additional Support
Placenta Accreta Ireland – Advocacy, Support, Research and Education
Placenta Accreta Ireland is a patient advocacy and support group that was founded in March 2019 by Professor Donal Brennan and patient advocate Naomi Cooney. Our aim is to support mums and their families who have been impacted by this serious pregnancy complication and to improve understanding of the causes and consequences of Placenta Accreta with a particular emphasis on the quality of life of survivors.
As a group we meet monthly in the National Maternity Hospital. Our group includes patients, survivors, and patient advocates. Our meetings are open to mums and their partners who are currently impacted by PAS or have been in the past. If you would like to join us, please contact us at firstname.lastname@example.org.
Due to Covid19 our meetings are currently taking place virtually via Zoom. For more information, please contact us at the email address above or via our social media Instagram: paireland_ or twitter: @placentaaccret3.
Perinatal Mental Health
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