The Scary Box - Placenta Accreta/Increta/Percreta - [TW] Pregnancy Complications

By: Aunt Doula (01/24/2023)

Placenta Accreta/Increta/Percreta are the same issue but at differing levels of severity. All indicate an amount of placental infiltration into the uterus beyond the lining that connects the placenta to the blood supply of the pregnant person. This is a diagnosis that is often made after a baby is delivered and there is a prolonged and delayed time period of the placenta delivery or excessive blood loss when attempts are made to help the placenta deliver. With better ultrasonography machines, placental infiltration is being caught sooner prior to delivery in about 40% of cases.

In a normal pregnancy, the placenta implants itself into the endometrium, the innermost lining of the uterus that builds up every month in anticipation for a pregnancy, and if there is no pregnancy, sheds as a period. When a pregnancy does occur, the lining remains and supports the embryo implanting and sustaining it and facilitating a place for the placenta to grow and connect to the pregnant person's blood supply, supporting the pregnancy. This connection is firm so that the daily bumps and jostles of life do not cause any disruption to the placentas connection to the uterus. *Note: The placenta is capable of "moving" (as in cases of placenta previa) but this is very slow and carefully orchestrated by the organ and takes time. If the placenta is rapidly dislodged from the uterine lining, it is called a placenta abruption and is an emergency. This can be cause by weak vessels connecting the placenta, trauma to the belly or insufficient connections between the placenta and the uterus. *

In almost all cases of accreta, increta and percreta, the "safest" delivery path recommended is a C-section, not a vaginal delivery. You may qualify for a vaginal delivery with an experienced and supportive care team, however this may be difficult to obtain. It also depends upon the percentage of the placenta that has infiltrated and multiple other factors your doctor must consider before the decision for vaginal delivery can be made. Most doctors and many organizations recommend early proactive C-sections at 35-36 weeks gestation as the best course of action. A c-section allows for a quick and safe delivery of the baby followed as quickly by direct visualization of the placenta, uterus, and infiltration depth. In addition it gives immediate assessment of the need for hysterectomy and is considered the most protective of both the pregnant person and baby's lives. Uterus preserving treatment does exist under very special criteria and evaluation and are referred to as conservative management and expectant management. Their use goes beyond the scope of this post however they are mentioned for educational purposes to empower you to learn more and ask questions to your doctor if you are diagnosed during pregnancy. To understand more about each type of infiltration, read below.

Placenta Accreta is a level of infiltration of the placenta beyond the endometrium where it should have remained, into the uterine wall. This is the least invasive form of infiltration, however when vaginal delivery of the placenta is attempted, it may not deliver entirely, leaving pieces behind in the uterus which can cause significant complications such as infection or hemorrhage. If the baby is born via C-section, the surgeons will be removing the placenta after the baby and will be able to attend to and assess the accreta before closing your C-section incision. if you gave birth vaginally and the doctors encounter difficulty with the delivery of the placenta, they may try manual extraction of the placenta, surgical removal through curettage via the vagina, or the may need to make an incision in your abdomen much like a c-section and access the uterus directly to remove the placenta and stop any bleeding or perform a hysterectomy.

Placenta Increta is when the placenta invades past the endometrium lining, through the uterine wall, then still deeper into the muscle layer of the uterus. When a placenta is at this stage of infiltration, as mentioned above, many doctors will recommend a C-section delivery for the baby by 35-36 weeks to ensure the safety of the pregnant person and their baby as well as most effectively tend to the placental infiltration. In the case of increta, it is almost always recommended to undergo a hysterectomy. This is an important discussion to have with your doctor and surgeon to understand the damage that increta has caused and why future fertility is both unsafe and highly unlikely to succeed due to the amount of uterus that is necessary to remove in order to fully excise the placenta, or the dangers of uterine preserving management if possible.

Placenta Percreta is the most severe form of infiltration that results in the placenta invading through the 3 layers mentioned above, extending to the exterior of the uterus, and in some cases attaching tland infiltrating to the bladder or other abdominal structures. Placenta percreta is exceptionally rare but unfortunately nearly 100% result in a C-section birth at 35-36 weeks and requires a hysterectomy to remove all placental tissue with additional exploratory surgery to ensure careful removal of any infiltration to nearby organs and structures. Through this complete removal management, the risks are significantly reduced for adverse outcomes.

Cases of placental infiltration have been on the rise in the last number of decades, and the reasons are not entirely clear. While there are risk factors that impact chances of being affected such as prior C-section scars, prior curettage, damage to the uterus via other surgery, and IVF technologies, infiltration can still happen spontaneously without known cause and go undetected until birth. Learning about placental infiltration is placed in the scary box because it almost always results in hysterectomy, and that is both scary and not often on the tops of people's minds when they are going to have a baby.

Knowledge is power, and just after giving birth is not the time to be learning about placental infiltration and processing that you may be having a hysterectomy. During pregnancy is when you prepare for many things, delivery being one and in preparing for delivery is having a frank and open conversation with your partner (if applicable) about these situations so they aren't on the back foot learning on the fly either. The rules of the scary box still apply to whomever you share it with involved in your delivery, but it is important that they understand the most basic aspects of each topic so they can support you in your decisions should a complication arise. Sharing a quick run down is better than no run down, so if they aren't able to read through the entire sub, pick a time to go over these topics and just make sure they've heard the terms, understand in broad strokes what each is, and tell them what you're thinking - they may surprise you!

If you have any questions, please don't hesitate to reach out.