Svenja Carlson knew plenty about high-risk pregnancies. The Colorado Springs elementary school music teacher’s first child, daughter Anja, had come to the world via emergency cesarean section five years earlier. Her second daughter, Raija, born in mid-2015, had also been a C-section – the placenta wouldn’t allow otherwise.
But the risks related to the 33-year-old’s third pregnancy dwarfed those of the others. In early October, she was diagnosed with placenta percreta, the most serious form of three life-threatening problems grouped under the umbrella of placenta accreta. It’s become much more common as C-sections – a big risk factor – have proliferated, increasing from about one in 4,000 pregnancies in the 1970s to one in about 530 pregnancies today.
What’s placenta percreta?
The various forms of placenta accreta happen when the life-giving placenta decides to cling to its own existence rather than be birthed with the baby for whom it provided oxygen and removed waste as surrogate in-womb lungs and kidneys. It hangs on in one of three ways. Placenta accreta occurs when the placenta binds itself to the uterus wall. Placenta increta involves invasion into the uterus’s muscles. Placenta percreta is when the placenta becomes a sort of malignancy, growing through the uterus wall and, often, into neighboring organs such as the kidney and bowels.
The birth of Carlson’s third daughter would involve a C-section followed immediately by a complex surgery made even more difficult by the deluge of blood that flows through the placenta – about 20 percent of a pregnant mother’s blood every minute at term.
It takes a team
Carlson’s doctor in Colorado Springs recognized a case beyond the ken of a lone obstetrician and gynecologist (OB-GYN’s). She knew whom to call. UCHealth University of Colorado Hospital hosts one of the few formal placenta accreta programs in the United States.
The UCH Placenta Accreta Response Team is led by University of Colorado School of Medicine OB-GYN Julie Scott, MD, a UCH’s Maternal Fetal Medicine specialist, and Saketh Guntupalli, MD, a CU gynecologic oncologist practicing at UCH. It was born of tragedy.
The day before Guntupalli joined the CU faculty in August 2012, a placenta accreta patient had died. There were extenuating circumstances: as a Jehovah’s Witness, she declined a blood transfusion despite such surgeries involving 2 liters to 5 liters of blood loss, on average, and often much more. Even the lesser of these is life-threatening; an average adult has around 5 liters of blood, period.
“It was a very traumatic experience for everyone involved,” Guntupalli said. “But we started to think about how we should manage these very complicated surgeries.”
The surgical skills of Guntupalli and fellow gynecologic oncologists would be a pillar of the program. Their practices routinely involve repairing what Scott described as “serious disease distortion of the pelvis” similar to what placenta percreta brings. But the team would also include experts in neonatology, urology, vascular surgery, colorectal surgery, general surgery, interventional radiology (to insert arterial balloons to slow blood loss), anesthesiology (to allow the mother to be awake for delivery and then anesthetize her for the complex surgery to follow), intensive-care medicine, and transfusion medicine, among others. Only major academic medical centers can bring such resources to bear.
Before the Placenta Accreta Response Team formed, placenta accreta surgeries happened ad-hoc at UCH, which is the case at most hospitals capable of handling them at all. Now the same doctors, nurses and support staff would come together as a group to plan and see each case through, then debrief afterwards to understand what went well and where they might improve. In addition to Guntupalli, Bradley Corr, MD, a gynecologic oncologist who trained under Guntupalli as a fellow, joined the CU faculty – and the team – in September 2016.
Loss and gain
Carlson was diagnosed with placenta percreta last Oct. 3. The UCH team was up-front about the nature of the surgery and the kinds of complications that can happen afterwards. The multidisciplinary team told her she could bear no more children after the surgery, which also involves a hysterectomy. Carlson and her husband Ryker weren’t necessarily planning on a fourth child, she said, but when it becomes a concrete impossibility, “it’s really a substantial blow,” she said.
She was admitted to UCH in late November when her blood pressure kept spiking and sagging. Nine days later, on Nov. 30, Corr performed Carlson’s surgery. She was awake for the birth of daughter Lilija and then under anesthesia for the next four-and-a-half hours. The placenta had pushed through the uterus and invaded a quarter-sized patch of the bladder’s outer wall. As Corr and a big OR team worked, she lost half her total blood volume. That was far from the worst the team had seen: a new mother lost 13 liters of blood in a surgery Guntupalli recently led.
“These are very hard cases,” Guntupalli said. “That one literally took two years off my life.”
But he adds that placenta accreta cases are rewarding, too, particularly when he visits patients afterwards and sees mothers holding their babies. Corr agreed, adding that the medical and surgical challenges of such cases also help advance medical care for future patients. The formal debriefings after each surgery help the team to build improvements into future cases, he said.
The program is growing, with increasing numbers of referrals coming in from across Colorado and surrounding states. As of mid-January, the team had done 48 cases in all.
“Every mom has walked out of the hospital, and we have had every baby survive and do well,” Guntupalli said.
Along the way, Guntupalli has trained Corr and three other gynecological oncology fellows in handling placenta accreta surgeries, including one still at UCH. The two others are practicing in Ohio and Oregon, where they can use the skills they developed under Guntupalli’s guidance to help placenta accreta patients far from Colorado.
Seven weeks after Lilija’s birth, Carlson was out and about, sharing her story as Raija, by then 18 months old, complained bitterly about her backseat video having run its course. She still wasn’t wearing pants with an actual belt, given some lingering tenderness, but was able to pick up and carry Raija or Lilija around on-demand (and there were lots of demands). She was planning on returning to work in mid-February.
She called UCH “an excellent, excellent hospital” where she knew she was in good hands.
“It was definitely a good experience, considering how traumatic it was,” she said.