When a Cesarean Is the Only Option

Posted by Brigham and Women's Hospital February 16, 2016

Dr. Daniela Carusi, Director of Surgical Obstetrics

Dr. Daniela Carusi, Director of Surgical Obstetrics

For some women, vaginal birth is just not possible due to the risks to the mother and baby. The most common conditions during pregnancy that require cesarean delivery include placenta previa, placenta accreta, previous major surgery of the uterus, and high-order multiples (three or more babies). While the need for a cesarean initially may be disappointing to an expectant mother, planning for the delivery can make the experience more positive.

In today’s blog post, obstetrician Dr. Daniela Carusi, Director of Surgical Obstetrics at Brigham and Women’s Hospital (BWH), offers valuable information and helpful advice for women who are preparing for the birth of a baby by cesarean section (C-section).

Timing is key.

In cases with high risk of bleeding or uterine rupture with contractions, the cesarean is typically scheduled several weeks before the due date. This is to minimize the risk that the mother will go into labor before the scheduled cesarean.

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Placenta Accreta: Myths and Facts

Posted by Brigham and Women's Hospital December 3, 2015

Doppler study showing hypervascular accreta.

Doppler study showing placenta accreta.

Author: Daniela Carusi, MD, MSc, Director of Surgical Obstetrics at Brigham and Women’s Hospital and Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.

Many of my patients diagnosed with placenta accreta, a complication that develops during pregnancy, receive inconsistent information about the condition and its consequences. Today’s blog post addresses some of the common misunderstandings I encounter among women who have been diagnosed with placenta accreta. Though placenta accreta can cause complications during child birth, a physician who specializes in high-risk pregnancy can safely manage the condition.

What is Placenta Accreta?

Placenta accreta develops when the placenta, the organ that provides nutrients and other support to a developing fetus, attaches too deeply to the wall of a mother’s uterus.

Myth #1: Women with placenta accreta will hemorrhage during childbirth.

Fact #1: Women with accreta are certainly at high risk for bleeding and hemorrhage, which is why expert care is needed. However, accreta can occur in a wide range of circumstances and not every woman will hemorrhage. The likelihood of a hemorrhage depends on the individual conditions of your placenta. During pregnancy, bleeding and hemorrhage are more related to placenta previa (placenta covering the cervix) than to the accreta. An accreta that develops without previa would be less likely to bleed.

The risk of hemorrhage may also may be related to how the placenta is treated at the time of delivery. When delivering a baby from a uterus with an accreta, particular care is given to where the incision is made. Many women with accreta will have an up-and-down incision, to deliver the baby without disturbing the accreta. If the accreta is low in the uterus, which is usually the case, this incision allows a safe delivery above this area. Regardless of the hemorrhage risk, it’s important that experienced, high-risk obstetricians who understand your specific needs and risks manage your baby’s delivery.

Myth #2: Women diagnosed with placenta accreta must have a hysterectomy.

Fact #2: A hysterectomy is a highly effective treatment for minimizing hemorrhage, but is not always necessary. In general, large accretas are most safely managed with a hysterectomy. However, small or “focal” accretas can sometimes be removed without a hysterectomy. In other cases, patients and their doctors may agree that leaving some or all of the accreta in the uterus (rather than removing the uterus) is a reasonable option. These decisions are complicated and require extensive discussion with an experienced obstetrician.

Myth #3: A woman with placenta accreta can carry her baby to term.

Fact #3: The majority of women with placenta accreta need to deliver weeks before their due dates, even if there has been no bleeding. This is often the best option for a controlled delivery, where all risks can be managed safely. If a woman experiences heavy bleeding, an earlier delivery may be especially important. Delivery with placenta accreta requires a very complex surgery, often with a multidisciplinary team of surgeons, so it is best to deliver your baby as soon as it is safe, in terms of the baby’s health and the mother’s wellbeing. Typically, this occurs at week 34 of gestation (6 weeks before a mother’s due date) and no later than week 36-37 of gestation though this may vary among individual women.

Myth #4: Placenta accreta can be detected before delivery.

Fact #4: An ultrasound or MRI image can usually detect a placenta accreta, but not always. For example, an ultrasound or MRI may detect increased vascularity (or blood flow) that is beyond normal. That could be evidence of a possible accreta. A pregnant uterus, however, always has extra blood flow to some degree. This makes interpreting ultrasound and MRI images particularly challenging. Having images reviewed by a radiologist and obstetrician who are experienced in identifying placenta accreta cases is important, although even then there can be some uncertainty. Women at high risk for placenta accreta should deliver with a team of experienced doctors who are prepared to manage an accreta and possible hemorrhage, even if accreta was not detected on ultrasound or MRI.

Myth #5: A vaginal delivery is not possible with placenta accreta.

Fact #5: Many, if not most, women with placenta accreta also have placenta previa, have had a previous cesarean section, or both. A placenta previa always requires a cesarean section because the placenta is covering the cervix. Similarly, it is usually safest for women with placenta accreta who have had a previous cesarean section to deliver their baby via cesarean again. This is especially true if the placenta is attached to the scar from the previous cesarean. The safety of labor with a placenta invading a cesarean section scar has never been evaluated, and the risk of rupture and major hemorrhage may be higher in this situation. If you do not have a placenta previa, you may be able to deliver vaginally. However, this delivery may be complicated and is at a higher risk for hemorrhage. It is important to talk to an obstetrician with experience in this area before deciding on a vaginal versus cesarean delivery.

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