Scary pregnancy condition requires special surgical team, technology

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Katie Cochran remembers all the “what if’s” circling through her head during a harrowing 45-minute nighttime drive to the hospital. She was just 33 weeks into her third pregnancy and bleeding heavily. She kept feeling her stomach to make sure her baby was moving and kicking.
“It came out of absolutely nowhere,” she describes. “I was absolutely terrified. I didn’t know if my placenta had ruptured, because I had never experienced that type of bleeding. Never. It was awful.”
Cochran understood that a placenta rupture was a real possibility after being diagnosed with a rare condition called percreta where the placenta grows through the uterus and into other organs in the abdomen. “Mine actually went completely through my uterus and attached itself to my bladder,” she explains.
Cochran knew a special surgical team would be assembled at Community Regional Medical Center waiting to care for her. But she also knew the risk of death for her and her baby was very real.
“We had to think about that and take it seriously, that it was a possibility,” Cochran shares what went through her and her husband’s minds. They also have two young daughters, Megan, 5, and Natalie, 3. “We didn’t know what was happening, but we knew we had to hightail it to the hospital.”

Childbirth is risky in U.S. depending where you are

One in 14 women in the U.S. with placenta accreta or placenta percreta bled to death during childbirth in 2017, the last year national statistics are available. Overall pregnancy-related deaths have steadily risen in the U.S. since 1987 when the Centers for Disease Control and Prevention began tracking it. Now there are 17.3 deaths per 100,000 childbirths, a 240% increase over the last two decades. That’s about 700 women a year who die during childbirth or from complications afterwards.
In California — which has made a concerted effort to reduce the risks of childbirth and the conditions that increase the incidence of accreta or percreta — maternal mortality rates are much lower. And in the Fresno area, no mothers with this condition have died since Community Regional assembled a multi-specialty surgical team five years ago to handle such complex deliveries, says Pamela Emeney, medical director of University Obstetrics & Gynecology Center. She leads the effort and trains UCSF Fresno residents in these kinds of OB surgeries.
As the high-risk pregnancy and delivery center for a five-county area, Community Regional is the only place in the region with the expertise and technology for an accreta surgical team. Last year the team did 29 of these risky surgical deliveries and involved UCSF residents in all of them to ensure such expertise continues to grow.
“We’re very lucky here that we have everything we need so our mortality rate is very, very low,” says Dr. Emeney. “Prematurity is what you see most commonly for babies since they’re usually delivered by 34 or by 38 weeks. The goal is not to deliver during an emergency. We want to get everything prepped, to get the blood, get the team and do this in a controlled environment. If someone comes in bleeding in labor, we can mobilize that team quickly.”

Masked doctor stands in operating room with her surgical team

Community Regional’s high-risk pregnancy team was able to stabilize Cochran for another six days after her terrifying rush to the hospital. The team did a planned cesarean and hysterectomy on September 10. This condition almost always requires a hysterectomy to save the mother’s life.

C-sections increase the risk

As C-section rates have risen, so have the incidence of accreta and percreta. During the 1980s, only 1 out of every 1,250 births involved this risky condition. It has since quadrupled to 1 in 272 births.
“Back in the 1970s and 80s, after your second C-section you were told ‘We’re going to tie your tubes because of the risks.’ But over time that’s changed…now if women want more than two C-sections they can,” says Dr. Emeney. An accreta, she explains, “can happen with any sort of uterine abnormality, most commonly cesarean sections. But it can happen after surgeries, like if a woman has fibroids removed. Or maybe they miscarried and there was a scraping on the lining of the uterus.”
Cochran says she figures her two previous deliveries might have put her at risk for accreta. “I think my situation was partially my age, being a little older, having multiple kids and having two C-sections. All those things combined to put me at greater risk.”
If the placenta tries to attach to the very spot where there’s scarring inside the womb, it will try to grow around the scarring to get to a better blood supply for the baby. “The placenta can implant anywhere … It’s really a random event that happens. We’ve had women who have five, six, nine C-sections and this never happens. That’s a little bit a luck of the draw,” says Dr. Emeney. She tells women not to dwell on what they did or didn’t do.

Placentas sometimes grow too far — difficult to diagnose

Normally after birth the placenta peels off easily from where it’s been attached to the uterus for 9 months. An accreta is when the placenta grows abnormally into the uterus. “It can even grow through it and grow into your bowel and bladder,” explains Dr. Emeney. “It can grow like weeds or the root of a tree and grow abnormally.”
Dr. Emeney uses the analogy of an orange to explain the risk to patients. You always want one that peels easily. When it sticks while you’re peeling, it tears bits of orange and squirts juice.
“And if that placenta accreta is pulled you can bleed to death quite quickly … About a third of your blood supply goes to your uterus to grow that baby, so you’re talking about blood vessels that can be huge,” she continues.
During a typical vaginal birth, women lose about half a quart or one unit of blood, and lose about a quart of blood during a standard cesarean. A cesarean-hysterectomy for an accreta takes four to six units of blood. “But we’ve had as much as 34 units used and in one case many, many years ago, a patient received over 100 units and a week later she walked out of here and two weeks later that baby was carried out,” Dr. Emeney says.
Cochran says the first indication that she was at risk was slight bleeding. Her first sonogram showed her placenta might be over her cervix, requiring a normal C-section. But a second ultrasound with a high-risk pregnancy specialist diagnosed accreta. Finally, an MRI and follow-up ultrasounds showed her placenta might be growing beyond her uterus, a condition called percreta. She was referred to the Valley’s only accreta surgical team at Community Regional.

Expert team approach required for safe deliveries

The accreta surgical team involves several specialists in case the placenta has reached vital organs. Dr. Emeney ticks off the list: “We have general surgery, radiology, anesthesia, interventional radiologists, colorectal surgeons, trauma surgeons, a urologist, NICU [neonatal intensive care], lactation specialists and social work.”
Having multiple specialties working together is the key to safer outcomes in such complex surgeries; it makes the procedure quicker as each expert steps in to do their part.

Father and mother in NICU with newborn son

It was a multi-specialty team Cochran trusted: “I cannot say enough incredible things about the whole staff at CRMC. We were taken care of, we were encouraged. Everything was well planned out and everything that was explained to us was very easy to understand. We felt very confident in Dr. Emeney and the entire team that took care of us.”

Advances in science, technology improve outcomes

Michael Hough, a certified registered nurse anesthetist, is usually the first in the hybrid operating suite, to prep the accreta patients. “This kind of surgery is really a marriage between trauma and OB. This technology we have comes from Iraq and wartime trauma situations,” he says, referring to the Belmont Rapid Infuser used to warm and pump blood in quickly.
“It’s a huge hemorrhage risk that you have to set up and handle by inserting large invasive lines while mom is awake and you make her comfortable while you do it,” continues Hough. He uses a narcotic that makes his patient euphoric, desensitizes her to pain and breaks down in the body, wearing off 5 minutes after he turns it off.
Hough needs to put a big tube in her neck to pump in blood quickly, he needs other smaller IVs to control aesthesia drugs, and others to help measure the blood during surgery. He’s able to monitor blood volume, blood pressure, heart rate, clotting factors, blood oxygen and calcium levels during surgery to ensure the best recovery. “Science has improved so much and we have great technology,” Hough says. “These patients don’t go to the ICU on a ventilator afterwards.”
After Hough sets up, interventional radiologists come in next to insert balloons into the abdomen through catheters. They’ll be inflated to put pressure on places when bleeding happens.

Medical team and families prepare for the worst

Right before Hough puts his patients to sleep with a general anesthetic, mothers are handed a phone. “We let them talk to her loved ones, because it may be the last time they talk to her,” Hough says.
“The first (accreta) patient we did was expected to die. Her placenta grew through her uterus into her bladder and into her abdomen wall.” Hough says she had rejected a plan to deliver really early, opting to continue her risky pregnancy to give her baby a better chance at survival. “She was living for her baby. She had video taken with her and her kids. We did her surgery at 30 weeks. And it didn’t end up being as bad once we got in as we originally thought it was. That mom and baby did great.”
After mothers are put under, Dr. Emeney steps in. “Once you put mom asleep and take baby out, you have to do it fast. The longer the baby takes to come out the more that baby takes up the (anesthesia) drugs,” explains Hough. “Dr. Emeney’s really good and gets that baby out in a minute and half.”
A nurse stands ready to snap photos and video of the baby’s first breath and first cry, helping capture the happy memories that family members normally would if it were a routine delivery. Cochran says Dr. Emeney was the first person she saw in recovery, gleefully holding up a screen showing her a tiny, healthy baby boy, her son.

Blond mom and her three small children sit together on a couch

“He was 4 lbs., 9 oz. and he did great. He was in the NICU just 10 days,” Cochran says. During that time, she and her husband stayed across the street from the hospital at Terry’s House, Community’s hospitality home for loved ones of patients.
“Mark Jason — we call him MJ for short — is loved by his sisters more than anything in the world. He’s so sweet,” Cochran describes. “His eyes just light up when he looks at me. We have a very special bond.”

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