Preparing for the Worst Case Scenario

It is often estimated that patients only absorb a small amount of the spoken transaction with their health care providers. When I met with the perinatologist to discuss my placenta, I felt that I was not an exception. Although I am fluent in his language, I was a bit overwhelmed at that moment and I left the office with the feeling that I didn't have the full picture on our situation. Acknowledging that I have a lot of unfair advantages, I would wait until I had access to read my own report. This perinatology office is generally pretty slow to return normal reports. The turn-around time is about 1-2 weeks and I've come to accept that the longer it takes them to send a report, the more likely it is to be normal. The day after my scan, I received an email message confirming that my report was received and scanned into my electronic health record.

I had Co-worker print a copy for me. The details of my placenta read: anterior, total previa, grade 1, with placental lake. A placenta lake (also called lacunae) is a black sonolucent space within the placeta and can give the placenta a Swiss cheese like appearance. It indicates that there is a loss of placental homogeneity. The final comments noted; There is a COMPLETE ANTERIOR PLACENTA PREVIA. There are lacunae noted within the placenta, but without turbulent flow. A retroplacental clear space is visualised. Placental lacunae with placenta previa is associated with an increased risk of placenta accreta, but there is no definite evidence of placenta accreta on today's ultrasound. As I reviewed the report, my gut instinct told me that my previa was probably not going to resolve and the possibility of an accreta was more of a threat than I had previously anticipated. I showed the report to a colleague ,"Ugh" she reacted while making a face. Then she realised it was mine. "Oh, I'm so sorry!" she quickly recovered. No need. I wanted an honest response. She agreed it is a bit of an ominous prognosis.

I had my first visit with my Lead Physician where I was her patient and she was my Obstetrician. She had called to the perinatologist to discuss my case. Firstly, they both observed the irony and noted that Ob/Gyn providers just seem to be at a higher risk for weird and unusual complications. He really identified two separate concerns, the location of the placenta and the potential for an accreta. Even if my placenta moves, I could still have an accreta. He admitted that he has seen cases where previously noted lacunae or lakes resolve, but it didn't seem to be too often. The take home message was clear; I should prepare for the possibility and consequences of a placenta accreta. Something I more or less had already been doing.

As I've described the situation with a few non-medical people, I've been asked, "So what does that mean? You'll have to have a C/section?" The little voice inside my head wants to laugh a little and respond with oh, if only it were just a routine Caesarean delivery... The management for a placenta accreta is to perform a Caesarean hysterectomy. As the placenta is completely adherent to the uterine muscular wall, it can not be easily removed without risking massive hemorrhaging, so it is best just to remove the entire uterus. It is a very intricate and risky surgical procedure. My birth plan would look like this:

• A course of bethmethasone steroids 48 hours before scheduled delivery at 34 weeks gestation
• Pre-operative discussion of the potential intraoperative complications, including hemorrhage, need for transfusion, injury to bladder or bowel. Some of which may be life-threatening.
• Delivery in the Main Operating Room where fluroscopy is available.
• Two large bore IV catheters in place
• 3-way Foley Catheter and ureteral stents to help assess the integrity of the urinary tract as needed
• A sheath in the femoral artery to allow for interventional radiology to perform uterine artery embolisation to control bleeding during surgery
• Type specific blood products and clotting factors available at the time of delivery
• Experienced anesthesiologists and nursing staff. 
• A Gyn-Oncologist is often called to assist, not because of any cancerous potential, but for their excellent surgical skills
• Neonatology attendance
• An ICU bed should be available for postoperative care
• A scheduled delivery is optimal in order to coordinate all necessary personnel and equipment, and it is associated with less intraoperative blood loss. However, many patients will have a bleeding episode or go into preterm labour, necessitating an emergency delivery. 

I'm choosing not to focus on some of the life threatening consequences until I actually have to cross that bridge if I come to it. Rather, I'm preparing myself for the possibility of losing my uterus. In a way, it's even slightly ironic as I only wanted to have one child. All my reasons for only wanting one child are still intact. It just would be frustrating not to have that option any more. Medically, I know it's a straight forward decision. I reviewed the literature; in cases where a placenta accreta has been disturbed and is hemorrhaging, conservative measures are rarely effective and endanger the patient by delaying a hysterectomy. During the delay, massive hemorrhage can lead to a downward spiral of hypoperfusion of all organ systems, hypothermia, disseminated intravascular coagulopathy and metabolic acidosis... I already know that my uterus is useless. Even when uterine conservation can be preserved, reproductive outcomes are poor. Many patients have residual intrauterine synechiae leading to Asherman's Syndrome and they are at a very high risk of a repeat placenta accreta in the even of a subsequent pregnancy. I can't imagine that Dr Somebody that I Used to Know would even recommend transferring any embryos into a surviving uterus. Quite honestly, I would question him ethically if he did. It took us six embryos just to get a good one to stick and that was before we knew my uterus is shit. Perhaps I have found ultimate silver lining to our infertility journey. As we have three remaining embryos, we at least theoretically have the opportunity to try for a second child with a surrogate, even if we don't have the financial resources.

I've been clinging to a few positive aspects that I have in my favour. My placenta is anterior, and anterior previas are more likely to move and less likely to bleed. Cervical shortening is associated with an increased risk for bleeding and mine is a solid 43 mm. So far, my haemoglobin and haemotocrit are in a normal range and I plan to follow closely and proactively correct against anaemia. I have been allowed to exercise with modifications. I stopped running, but have continued swimming and going to Cross-Fit (although I'm not lifting).  Although the threat of pre-eclampsia is still present, my blood pressure has been within normal range. I feel great and I look great, even if the situation with my placenta is not great.

In such a strange way, I feel so fortunate to have this information now. A placenta accreta is most dangerous when it is undiagnosed. I have a lot of time to process the possibility losing my uterus. I've had two patients who needed an emergency postpartum hysterectomy and I can't imagine receiving that news just after giving birth. I was planning to resume using a Mir.ena IUD, not only for contraception so that we wouldn't have the post infertility surprise baby, but for menstrual suppression. After coordinating so many appointments and treatments around my cycle, I don't want to see AF for a long time. I was also considering Nex.planon so that I wouldn't even ovulate and be aware of luteal phase symptoms. As my pregnancy was dated based on my embryo transfer, I can't actually remember the day of my last menstrual period, which may actually be my last menstrual period.

My follow up scan was moved up one week, so I'll know a little sooner if this scenario will become my reality. At this point in time, if we have a take home mom and take home baby, we'll score it as a win. Anything else will be a bonus.