It is a rare but serious pregnancy complication — one that could have easily taken the lives of three northern Colorado women.
“I was close to not making it,” said Christine Heim, who three years ago delivered a healthy baby girl but then started hemorrhaging. “It’s really opened my eyes to the significance of donating blood.”
Heim joined Kate McMeekin and Tonya Trostel to host a blood drive at UCHealth Medical Center of the Rockies in Loveland on June 22, 2018. They’ll host another on Sept. 20, 2019. They are connected as survivors, and they met via an international Facebook support group: Hope for Accreta.
“Accreta is rare enough that many don’t know or have never heard the term, but those who have will never forget it,” McMeekin said. “We hope to bring about awareness as well as give back for all that was done to keep us here with our families. The amazing teams that were with each of us during our delivery and the days to follow are truly heroes.”
In pregnancy, the placenta is an organ that develops inside the uterus and provides oxygen and nutrition to the baby, while also removing wastes. It connects to the baby through the umbilical cord, and after the delivery of a baby, a woman’s uterus contracts to deliver the placenta. A retained placenta can cause serious bleeding and infection.
Placenta accrete is the general term used to describe placenta accreta, increta and percreta — terms that more specifically indicate how much the placenta has penetrated surrounding areas.
Placenta accreta is a complication that occurs when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall, therefore preventing it from being delivered.
McMeekin refers to the day she survived accreta as her “survivor anniversary.” She will soon celebrate her second anniversary, and Heim just celebrated her third. The day of the blood drive will be Trostel’s one-year anniversary.
Heim, at only 12 weeks into her pregnancy in 2013, found out her baby had stopped growing and died five weeks before. Because her body had not naturally miscarried in that timeframe, she opted to use medication to shed the tissue rather than undergoing a dilation and curettage (D&C), when the cervix is dilated and a special instrument is used to scrape the uterine lining. However, a few weeks later, despite the medication, Heim started bleeding and rushed to the emergency room, where she had a D&C.
In April 2014, Heim got pregnant again. Because of the earlier miscarriage, doctors monitored her more often. At eight weeks, she noticed she was bleeding, but doctors told her it was a subchorionic hemorrhage — a common and generally benign condition — and would subside on its own. It did, and she had no issues for the remainder of her pregnancy, she said.
Pre-existing damage increases risk for accreta
Typically, when the placenta implants itself and causes accreta, it attaches to pre-existing damage within the uterus, such as scar tissue from a C-section. But any time there is uterine manipulation, such as a D&C, a woman’s risk for accreta increases, according to Dr. Saketh Guntupalli, an OB-GYN with UCHealth University of Colorado Hospital in Aurora.
On Jan. 5, 2015 — 41 weeks and three days into her pregnancy — Heim was induced, and she delivered her healthy girl in the early hours of Jan. 6 at UCHealth Poudre Valley Hospital in Fort Collins. But when it came time to deliver the placenta, Heim started experiencing extreme pain.
“The pain was worse than when I delivered the baby,” she said.
Heim was experiencing accreta. And because of the placenta’s attachment, the uterus became inverted as it tried to deliver the tissue, and Heim started hemorrhaging.
“I didn’t know what was going on, but a lot of doctors and nurses rushed into the room and took my daughter,” she said. “They ran me to the operating room, and then I woke up about five hours later in the intensive care unit.”
After repositioning her uterus, doctors performed a D&C and used a balloon, which is inflated inside the uterine cavity, to help stop the bleeding. She did not have to have a hysterectomy but did require eight units of blood.
For a woman who’s had one prior C-section and also has placenta previa, her chance of developing accreta is 3 percent. That increases to 11 percent if she’s had two C-sections, 40 percent after a third C-section, 61 percent after a fourth C-section, and 67 percent for more than five C-sections, according to uptodate.com
Without placenta previa, the risk for accreta drops to 0.03 percent after the first C-section, 0.2 percent after the second, 0.1 percent after the third, and 0.8 percent after the fourth or fifth.
Placenta previa also increases risk for accreta
Although it is difficult to diagnosis placenta accreta during pregnancy, placenta previa is usually identified early. Placenta previa occurs when the placental tissue extends over the cervix, and it too can cause complications at delivery. Its presence also increases the chances that a woman will have accreta, according to Dr. Alison Cowan, an OB-GYN with UCHealth Women’s Care Clinic in Loveland and Greeley.
However, about 90 percent of placenta previas found during routine ultrasound exams resolve before delivery, so Cowan stressed the fact that counseling a woman on her risk of accreta varies widely and is dependent on the specific circumstances of that pregnancy.
At 12 weeks gestation, McMeekin was diagnosed with placenta previa. She had a C-section with her first child, at 29 weeks gestation. These two preconditions greatly increased her risk of accreta.
When the previa she experienced did not resolve by 28 weeks, an MRI confirmed accreta at 32 weeks and doctors began planning for an early delivery — 35 weeks via C-section — followed by a hysterectomy.
McMeekin, who, as a nurse at UCHealth Medical Center of the Rockies, understood the potential for a bad outcome, struggled with learning the fate of her second delivery.
“Most nights leading up to the scheduled surgery I couldn’t sleep,” she said. “I have a 9-year-old son, and this is my first child with my husband. The thought of leaving them — those thoughts lingered.”
The option: hysterectomy
A cesarean hysterectomy is the only treatment path for accreta, according to Guntupalli. Although mortality rates are low, especially when accreta is diagnosed early, it is a very serious diagnosis, he said.
Guntupalli heads PART — Placenta Accreta Response Team — at UCH. It’s a team of highly trained gynecologic oncology physicians, maternal-fetal medicine practitioners, neonatologists and obstetric anesthesiologists who work together with other subspecialists from urology, interventional radiology and vascular surgery, as well as a support team of nurses and technicians in the blood bank, in an effort to reduce mortality and morbidity associated with this pregnancy complication.
“The mortality rate is low — even in the worst situations we can save a woman’s life,” Guntupalli said. “But accreta is certainly the most high-risk thing that can happen to a woman in pregnancy, and morbidity is upward of 5 to 10 percent because of blood loss, transfusion issues, the high risk of infections, lung injury … It’s a very serious diagnosis and a rare disease process that needs specific expertise to make sure the mom can have a good quality of life afterward.”
Trostel and her husband were celebrating five years of marriage and two healthy daughters when she became pregnant with her third child.
Just a few days short of 40 weeks into her healthy pregnancy, she went into labor and arrived at UCHealth Medical Center of the Rockies. Trostel had had a C-section with her first child, but had a successful vaginal birth after cesarean, or VBAC, with her second, and her third also would be a VBAC.
After an all-natural, no-drugs delivery, her baby girl was placed on her chest for some bonding time while her body was left to finish delivering the placenta. But after an hour had passed with doctors working to deliver the placenta —and more pain than Trostel had ever experienced with childbirth — she was told that they’d need to perform a D&C. She remembers nothing else until she woke up in the ICU seven hours later in a panic and unable to speak because of the tubes down her throat.
She wrote down her question on paper for her husband: Did I have a hysterectomy?
“He said, ‘yes,’ and I just started bawling,” Trostel said.
During the D&C, Trostel had started hemorrhaging.
“They tried several ways to stop the bleeding and nothing was working,” she said. “In order to save my life, they had to get the uterus out.”
Trostel required 11 units of blood. The average human body contains about 11 units of blood.
A random connection; lasting support
When Trostel started hemorrhaging, a “mass transfusion” page came through the department McMeekin works in at MCR, and she saw her coworkers hustling to the call.
“I remember the anesthesiologist dropping everything and running to the labor and delivery unit. I had heard there was a new mom bleeding and my heart sunk,” she said. “Accreta takes the lives of new moms all too frequently. Prior to my own delivery, I lost many nights of sleep because I was up worrying, crying, afraid that my husband and my boys would lose me. So, when I heard a mom was bleeding, I immediately sat down in my chair and prayed for her. I knew in my heart it was accreta.”
A few months later, McMeekin connected with Trostel on the Facebook support page and later met the mother she had prayed for. As with Heim, McMeekin was grateful to be able to discuss her accreta experience with a fellow survivor.
A Colorado-specific Accreta group called “Colorado Accreta Survivors” has been created on Facebook, according to Kate McMeekin. And survivors from all over Colorado joined these three mothers in support during the blood drive. As a group, they hope to have a blood drive in each of the hospital where a member has delivered, continue to bring about awareness, and be there to support other women as they go through the process. Another blood drive is scheduled Sept. 20, 2019.
“Support is very important as this is a very major surgery and women can feel a sense of loss after,” Guntupalli said. “Many times right after, the mom is happy to be alive and there for her new baby, but as time passes, the realization that she will no longer be able to have more children sets in.”
Trostel describes this feeling.
“Those first few months were horrible … mentally, emotionally and physically hard. I don’t know how to explain it to people who haven’t experienced it,” she said.
For Heim, it was about a year after her daughter’s birth that the realization hit her.
“It was then that it hit me how serious it all was,” she said. “Then I met Kate, and we bonded over it. When we realized there were three of us here in northern Colorado, we wanted to do something for other mothers. We wanted to give back the blood that we all had needed.”
Having an adequate supply of blood on hand in the case of an accreta delivery is vital for the health of the mother, said Dr. Saketh Guntupalli, an OB-Gyn with UCHealth University of Colorado Hospital in Aurora.
The UCHealth Garth Englund Blood Donation Center supplies blood not only for accreta patients but for all patients at UCHealth’s Poudre Valley Hospital, Medical Center of the Rockies and Estes Park Medical Center.
But in the summer, demand for blood increases while donations decrease because people are busy with vacation and travel. That makes the need to donate in the summertime even more important. Find a local drive near you this summer, host your own drive, or drop into one of the center’s locations in Fort Collins or Loveland to give the gift of life.