Tuesday, 9 October 2018

Women Are Dying From This: Taking Cesareans Seriously

When women have cesareans, they are rarely warned that a possible complication can be placental problems in future pregnancies.

Many women (and especially higher weight women) are pressured into cesareans in their first pregnancy. Many of these same women are counseled away from Vaginal Birth After Cesarean (VBAC) and into repeat cesareans in subsequent pregnancies.

Few of these women have been told that cesareans raise the risk for Placenta Accreta, a very serious complication, and that every cesarean increases the risk for it. I know *I* wasn't told this. This is a tremendous disservice to parents and to the importance of informed consent.

About Accreta

In Placenta Accreta, the fertilized egg implants near or on scar tissue in the uterus. This scar tissue is usually from a prior cesarean, but can also be from a D&C procedure, fibroid removals, a perforation from an IUD, or any uterine surgery or instrumentation. The placenta then grows into the uterine wall in this scar tissue. After the baby is born (often prematurely), the placenta can't separate properly and bleeding can become prolific. If the bleeding is not resolved, the mother can die.

There are degrees of Placenta Accreta. When the placenta grows into the uterine wall, that's Placenta Accreta. 

When the placenta invades the muscles of the uterus, that's known as Placenta Increta.

When the placenta grows through the uterine wall and into nearby organs like the bladder, that's called Placenta Percreta. All are extremely serious conditions, but percreta is the most serious of all.

The accreta rate has risen over the years as the cesarean rate has increased. Doctors are seeing more and more cases these days of what used to be a very rare complication. Some data indicate that the accreta rate has risen from about 1 in 4000 in the 1970s to about 1 in 533 now.

You can read more about this in my blog series on Placenta Accreta.
  • Part One - What Is Placenta Accreta?
  • Part Two - Life-Threatening Complication of Prior Cesarean 
  • Part Three - Risks to Mother and Baby
  • Part Four - Diagnosis, Treatment, and a Cautionary Story
The absolute numerical risk of accreta occurring in any one person is low, even with prior cesareans. Most women who have had cesareans will not experience an accreta. However, it is such a life-threatening condition that even a relatively small incidence carries a tremendous burden of complications, cost, and potential loss of life.

The more cesareans you have had, the greater the risk for accreta. In one very large study (Silver 2006), accreta was present in:
  • 0.24% of women undergoing their first cesarean (previously unscarred)
  • 0.31% of women undergoing their second cesarean (one prior cesarean)
  • 0.57% of women undergoing their third cesarean (two prior cesareans)
  • 2.13% of women undergoing their fourth cesarean (three prior cesareans)
  • 2.33% of women undergoing their fifth cesarean (four prior cesareans)
  • 6.74% of women undergoing their sixth or more cesarean (five or more prior cesareans)
This is why it is important to avoid automatic repeat cesareans and to keep VBAC a viable choice. Multiple repeat cesareans are the single most preventable factor for accretas. 

Accreta does sometimes occur after only one cesarean, like the woman in the video below, and that's why it's important to prevent a first cesarean whenever possible as well.

One Mother's Accreta Story

This mother had only had ONE prior cesarean, but still developed accreta with baby #2. Her first cesarean was a planned cesarean, urged by her OB. She was never warned that her cesarean meant accreta was a potential risk for the future.

THIS is why the high cesarean rate matters. On a case-by-case basis, a cesarean can be a good thing. But the public health implication of a high cesarean rate is that more women will develop life-threatening complications like placenta accreta, more babies will be born prematurely, and more women will die or experience permanent damage. Sometimes even after only one cesarean.

If we want to decrease maternal mortality rates and prevent complications from accreta, we MUST decrease cesarean rates. As the mother in the video below states:
A cesarean can be a life-saving intervention. The goal is not to eliminate cesareans. The goal is to make decisions regarding cesareans appropriately, and to recognize that even an uncomplicated cesarean and recovery can still put the mother at significant future risk....

She continues:
"There are too many cesareans now, 1 in 3 births, and researchers estimate that as many as 50% of those are unnecessary. 
And since a prior cesarean is a significant risk factor for developing a future accreta, that means that there are women developing accreta when it could have been prevented. So the easiest way to reduce the amount of accretas is to reduce cesarean levels... 
Women are dying from this, and mothers are dying from this. We need to take the risks of a cesarean seriously."

via The Well-Rounded Mama