Placenta accreta/percreta question

[Storm Bride]

DH and I are talking about maybe having one more baby - my fourth. I've had three c-sections, and it's obvious that if I want to give birth, I'm going to have to do so at home. So, I'm starting to try to pinpoint the things I'm concerned about before we start ttc.

First and foremost - if I'm homebirthing with an underground midwife, is there any way she can know if I've developed placenta accreta or placenta percreta? The idea of these conditions scares me a lot. I know they're rare, but just the idea of it makes me feel ill. I understand that they can show up on an ultrasound, but if I don't have a legal careprovider, I wouldn't be getting ultrasounds. Is there any other way to determine if the placenta is placed badly?

[mysticmomma]

what about seeing an ob or midwife that your insurance covers as well? They can order labs, u/s, etc. if you wish.
Trisha

[mwherbs]

I think that it is still hard to dx a placenta accreta or placenta percreta with ultrasound- usually done in 2nd trimester not an early ultrasound but what you could figure out is where the placenta is located- if it is a frontal placenta over the old scar there is a bigger chance you would have one of these complications but it is still just a chance.

Am J Obstet Gynecol. 2005 May;192(5):1458-61.

Abnormal placentation: twenty-year analysis.

Wu S, Kocherginsky M, Hibbard JU.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,
University of Chicago, Ill, USA.

OBJECTIVE: This study was undertaken to determine whether the rate of abnormal
placentation is increasing in conjunction with the cesarean rate and to evaluate
incidence, risk factors, and outcomes. STUDY DESIGN: Cases from 1982-2002 were
identified by histopathologic or strong clinical criteria. Risk factors were
assessed in a matched case-control study, and analyzed using conditional
logistic regression models. RESULTS: There were 64,359 deliveries, with cesarean
rates increasing from 12.5% (1982) to 23.5% (2002). The overall incidence of
placenta accreta was 1 in 533. Significant risk factors for placenta accreta in
our final analysis included advancing maternal age (odds ratio [OR] 1.13, 95% CI
1.089-1.194, P < .0001), 2 or more cesarean deliveries (OR 8.6, 95% CI
3.536-21.078, P < .0001), and previa (OR 51.4, 95% CI: 10.646-248.390, P <
.0001). CONCLUSION: The rate of placenta accreta increased in conjunction with
cesarean deliveries; the most important risk factors were previous cesarean
delivery, previa, and advanced maternal age.
--------------------------------
the other thing to know about is "CONSERVATIVE MANAGEMENT" which means if you aren't bleeding, as in partial an not completely retained do nothing- they leave it alone and it will detach eventually because it no longer has a circulatory system attached to it.
Obstet Gynecol. 2005 May;105(5 Pt 2):1247-50.

Conservative management of placenta previa percreta in a Jehovah's Witness.

Weinstein A, Chandra P, Schiavello H, Fleischer A.

Department of Obstetrics and Gynecology, Wyckoff Heights Medical Center,
Brooklyn, New York, 11237, USA.

BACKGROUND: Hemorrhage is a serious threat with placenta accreta, often
requiring aggressive operative intervention by hysterectomy and resuscitative
measures with large-volume blood replacement to ensure survival. Refusal to
accept transfusion makes management especially difficult. CASE: We report a
Jehovah's Witness patient who had 9 previous cesarean deliveries and presented
with anemia and placenta previa percreta invading the bladder wall. Management
objectives were to enhance the patient's status, using erythropoietin and
autologous transfusion, and to minimize the chance of hemorrhage by prophylactic
uterine artery embolization. The placenta was left in situ after the delivery
with no untoward consequences. Methotrexate was held in readiness, but was not
required as adjuvant therapy. CONCLUSION: Effective care of such patients
requires close collaborative team effort and advanced planning to ensure a good
outcome.

[ldsapmom]

It was my understanding that diagnosing accreta, although not perfect, can be done via ultrasound, sometimes MRI, and through elevated alpha-fetoprotein in the second trimester (or at least risk factors for accreta). I agree with mystic -- could you be seen by a regular OB or midwife covered by your insurance to get the "traditional" options of prenatal care yet have a homebirth with a homebirth midwife?

My best friend had an accreta, but it was totally random -- she ended up having a cesarean (it was her first baby) and almost lost her uterus. Incidentally she has chosen to have two more babies via cesarean since then, but initially it had nothing to do with any other "risk" factors, and it has not occured in any of her subsequent pregnancies.

[hippiemom]

I used a lay midwife for my third child. When I needed some dignostics later that she could not do (mainly ultrasound) I got this easily through my family doctor. He delivers for normal births, and can order tests at the hospital, but is less intense than an OB; he was very helpful.
Would an ultrasound be useful just to see where the placenta places in relationship to the scar, if for no other reason than to put your mind at ease... I admire your choice to birth at home and I wish you a wonderful experience. :thumb

[mwherbs]

I meant to say also you could get some "shadow care" so you could get an ultrasound ordered.. because it may pick up a problem or clarify the issue better


Idsapmom-- I don't understand why your friend had a primary c-section for accreta-- unless it was also previa which is common to have the 2 together-- accreta as far as I know doesn't pose any "risk" for the birth of the baby has more to do with mom and hemorrhage- because the placental tissue has invaded deeply into maternal tissue- including through the uterus and into other things like the bladder(percreta)

[Storm Bride]

I've been thinking about "shadow care". I'm afraid that would add a lot of stress, but it does seem to be the only way I could get diagnostics such as ultrasound done. My other provider would have to be an OB - protocols here require a "high risk" mom to see an OB. I could see my FP, but I'd have to see the OB as well. Yuck.

Thanks for all the information! The conditions are even more rare than I'd realized, but I'm not thrilled that I fit under two of the risk factors!

I love this forum. I'll probably be back as more questions occur to me.

[ldsapmom]

mwherbs, it was for failure to progress, the accreta was not found until they went in. After baby was delivered, she started to hemorrhage. They sent her dh out, gave her a lot of blood, and her wonderful OB started scraping out her placenta, which he described as "hamburger." She was fortunate that she had a more old-school doctor, as when she switched providers to a younger doc, after looking at her history he said most would just take out her uterus. It was a scary emergency situation. They wonder if baby did not move down because he was held back by a short cord and a fused placenta, but they don't really know. Her water broke and labor started, then 36 hours later they did the cesarean.

[MamaTaraX]

Lisa, I'm just excitedto hear you talk about having another baby :) NO help about the placenta though :)

Namaste, Tara
mama to Doodle (7), Butterfly (2), and Rythm (due at home 1/06)

[Storm Bride]

If dh agrees to it, another baby is a definite. I've wanted four for 20 years, and I'm soooo close now. I won't bring a child into the world with a father who doesn't want it (I did that once, already - because his dad lied about it), but nothing else would stop me. I'd even have another section if I absolutely had to...but I don't think I do. My only worry at this point is age-related. I know the odds of having a Down's Syndrome baby start to climb in the late 30's and early 40's...