Two placentas?

[Lynski]

My little sister had "slight" placenta previa at 20 weeks. She just had a follow up at 34 weeks to see if it's moved up. The tech said there were 2 placentas. When my sister questioned her she said "well, it's really more of a placental lobe." Now she's been sent to a perinatologist after her OB muttered something about cord insertion and then something about covering the cervix (the placenta HAS moved up.) From the sounds of things, the OB is pretty set on a c-sec. I've never heard of this two placenta thing, or placental lobes. I'm just irked that her OB is so eager for a c-sec and my sister is willing to go along even though she's unhappy about it. Can anyone give me an idea what they might be talking about and where I can research it? I need to send her real, unbiased info or she'll just swallow whatever her OB tells her.

[Reha]

This is called a Succenturiate Lobe. As far as talk of something still covering the cervix, perhaps they are talking about vasa previa??? (when a vessels runs through the membranes and over the cervix).

[Charmie981]

Yes, it sounds like a case of vasa previa, which is a legit. reason for a c-section. In the case of the "extra" placental lobe, if the placenta and lobe are on opposite sides of the amniotic sac, that lobe will have blood supply running to it from the placenta. If those blood vessels traverse the sac over the cervix, a vaginal birth could be disastrous.

There is a type of sonogram they can do...I can't remember WHAT kind...that will show for sure where the blood is flowing in the placenta and answer whether there's a vasa previa or not.

Also, it's possible that the doctor would prefer to do a c-section even w/o a vasa previa, because even if the blood vessels aren't across the cervix, it's possible that the blood vessels could rupture when the membranes do, which would also be catastrophic. It is a much smaller chance of catastrophe, though, and I'm sure every midwife with a few hundred births could tell you a story of looking at a placenta after a birth and saying "OMG, what if..." In a case like that, I wouldn't fault a HCP for considering a c-section, though, because it is a higher risk situation. However, bullying a woman who knows what she's getting into as far as risk is NOT something I would condone!!

ETA: in either case, if your sis ends up with a c-section, she should know that this is a very unusual thing and is not likely to repeat and she has every reason to think that she could VBAC in her next pregnancy.

[sadiejane08]

Color Doppler is the u/s technique that can diagnose vasa previa.

Vasa previa is extremely dangerous; I've just been diagnosed with it myself. The fetal mortality rate is astoundingly high, 50-95%, when undiagnosed. The problem is that when the mother's water breaks, the unprotected blood vessels running through the amniotic sac will also rupture, and the baby will bleed out within minutes.

The recommended protocol is hospitalization in the third trimester (in case of PROM, so an emergency c-section can be performed; you have only minutes to get the baby out safely, so the time from home to the ER can mean you're already too late) and a scheduled c-section by 35 weeks. Steroids to help mature the baby's lungs can also be helpful, and an amniocentesis can help determine if the baby's lungs are mature enough for delivery.

It truly and totally sucks, and I've been alternately in tears and enraged since I found out on Friday, but the danger should not be underestimated, and your sister shouldn't let anyone tell her it's less of a big deal than it is. The real problem would be if your sister's OB WASN'T pushing for a c-section. There is no other safe way to deliver the baby. (Believe me, I HATE this piece of information, but it's true.) The good news is this tragedy can be prevented: the survival rate for babies when VP is diagnosed and the protocol is followed is 97%. It's a rare condition, and even rarer that a u/s tech even looks for it, so your sister can count herself lucky (as can I; our u/s tech is getting a present when this is all over for literally saving our baby's life).

There are several research papers available on the Internet as well as a very good informative site where your sister can start:

www.vasaprevia.com

Good luck to your sister!

[Mama2Xander]

Originally Posted by sadiejane08

The problem is that when the mother's water breaks, the unprotected blood vessels running through the amniotic sac will also rupture, and the baby will bleed out within minutes.

It would be more accurate to say that the unprotected blood vessels *can* also rupture. Often the membranes will break in a way that causes the tear to run parallel to the vessels, not through them. This is often seen in undiagnosed vasa previas. I have seen it personally once, and in researching it since then I have come across several other reports of the same thing happening. Now, I am not saying that you should not take appropriate precautions if you do have a diagnosed vasa previa, just that the vessels don't always rupture.

It is VITAL to avoid artificial rupture of the membranes, as the amnihook could be put right through a vessel - another good reason to avoid ARM in any labour!

[sadiejane08]

Originally Posted by Mama2Xander

It would be more accurate to say that the unprotected blood vessels *can* also rupture. Often the membranes will break in a way that causes the tear to run parallel to the vessels, not through them. This is often seen in undiagnosed vasa previas. I have seen it personally once, and in researching it since then I have come across several other reports of the same thing happening. Now, I am not saying that you should not take appropriate precautions if you do have a diagnosed vasa previa, just that the vessels don't always rupture.

In my research on the subject, it seems likely that the blood vessels will rupture. I think it's safe to say that women with undiagnosed vasa previa who escape vessel rupture (which is also likely when the baby begins to descend into the birth canal, if it doesn't happen when the amniotic sac ruptures) are incredibly lucky, in the sense of beating the odds.

The consequences when rupture does happen are so significant that I don't think any woman with VP should take the chance on a vaginal delivery. I certainly won't be, though I fear c-section terribly and I am so upset about losing my homebirth. Even when a baby lives after rupture, he or she has often lost so much blood that transfusions are necessary and a significant NICU stay, and possible permanent damage, occur.

This is a very current issue for me, as I'm having to decide how to manage my own vasa previa, and the conclusion I've come to over the past 60 hours is that scheduled c-section, even of a significantlly premature baby (33, 34 weeks, with steroid shots to help mature the lungs before delivery) appears to provide a better outcome than an emergency c-section after vessel rupture even at term--let alone a vaginal delivery.

But each woman has to weigh the statistics, research, and situation for herself.

[Mama2Xander]

Originally Posted by sadiejane08

In my research on the subject, it seems likely that the blood vessels will rupture. I think it's safe to say that women with undiagnosed vasa previa who escape vessel rupture (which is also likely when the baby begins to descend into the birth canal, if it doesn't happen when the amniotic sac ruptures) are incredibly lucky, in the sense of beating the odds.

The consequences when rupture does happen are so significant that I don't think any woman with VP should take the chance on a vaginal delivery. I certainly won't be, though I fear c-section terribly and I am so upset about losing my homebirth. Even when a baby lives after rupture, he or she has often lost so much blood that transfusions are necessary and a significant NICU stay, and possible permanent damage, occur.

This is a very current issue for me, as I'm having to decide how to manage my own vasa previa, and the conclusion I've come to over the past 60 hours is that scheduled c-section, even of a significantlly premature baby (33, 34 weeks, with steroid shots to help mature the lungs before delivery) appears to provide a better outcome than an emergency c-section after vessel rupture even at term--let alone a vaginal delivery.

But each woman has to weigh the statistics, research, and situation for herself.

Oh, I *totally* didn't mean that I thought you were wrong for following the medical recommendations! Sorry if I came across that way. I just wanted to point out that the vessels do not always rupture, that's all. I was referring to undiagnosed cases.

I don't know how many times it has happened that there have been no consequences from a vasa previa, like I said I have personally seen it once (working as a L&D nurse, there was an undiagnosed vasa previa that was only noted after birth of the baby & placenta - the vessels were in the membranes - but the membranes had torn parallel to the vessels and there was absolutely no bleeding from them - vaginal birth), and heard several similar reports since then. I remember someone (one of the older nurses, I think?) saying that that often happens as long as the membranes rupture on their own. I guess it would partly depend on the strength of the vessels and membranes? I don't know. This is all based on undiagnosed vasa previa, of course, I am not referring to diagnosed vasa previas, when a cesarean would be performed, as you say.

Anyway, I hope that clarifies it... Good luck SadieJane, s

[Charmie981]

It's also important to note that a vasa previa is different than a vellamentous insertion of the cord or another situation where the vessels traverse the amniotic sac, but don't cross in front of the cervix. In a case where the vessels cross the cervix, there is no way to deliver vaginally with a good outcome, because as mentioned before, baby's head will put pressure on the vessels and cause them to rupture.

In the other cases, there is the risk of a rupture across the vessels, but as the vessels aren't directly in the path of the baby's head, it's a lesser risk, although still a risk. I've been at two labors where there was a vessel crossing the sac. One we transferred for fetal distress (baby putting pressure on the vessels, though not a vasa previa) and one we didn't even know about until we inspected the placenta .

It is very fortunate when a woman knows about a vasa previa, though. In my experience it is far too often not diagnosed, despite the insane prevalence of ultrasound in pregnancy.

[Mama2Xander]

Originally Posted by Charmie981

It's also important to note that a vasa previa is different than a vellamentous insertion of the cord or another situation where the vessels traverse the amniotic sac, but don't cross in front of the cervix. In a case where the vessels cross the cervix, there is no way to deliver vaginally with a good outcome, because as mentioned before, baby's head will put pressure on the vessels and cause them to rupture.

Yes, that is a good point to make (and another area I should have been more clear in, geez, where is my head today???)

In the case I saw though, I am sure they said it was a vasa previa too... but now I am wondering how you could say that with absolute certainty after the fact? They were basing that "diagnosis" on the examination of the membranes & placenta afterwards... and said that the vessels had been right at the bottom of the sac, ie. at or near the cervix. Maybe they were just off to the side a little bit, out of the way enough that it didn't matter? They also said that if the doc had done an ARM he probably would have punctured the vessels. I am confused now!

[Charmie981]

Originally Posted by Mama2Xander

I am wondering how you could say that with absolute certainty after the fact? They were basing that "diagnosis" on the examination of the membranes & placenta afterwards... and said that the vessels had been right at the bottom of the sac, ie. at or near the cervix.

IMO, there's really no way to know that after the fact. I'd say the fact that the baby survived is evidence that it was probably NOT a vasa previa, though I guess there's a slim chance it could have been.

I've also always been under the impression that in a vasa previa caused by a vellamentous insertion, as the baby descends, the baby's head puts pressure on the vessels and EVEN WITHOUT RUPTURE, the baby can have what amounts to a cord accident and die, which is why the protocol is to do a premature c-section, thereby preventing baby from fully engaging against that blood vessel. I guess in that circumstance it would depend on what vessel(s) were compressed, though?

In any case, they are both scary situations, though the vasa previa is BY FAR the more dangerous of the two.