When the placenta is a dire threat

It was a typical night in the maternity theatre —  when we start counting the wee hours of the morning. The chatty camaraderie starts to wear off as each is engaged in an individual fight against the effects of their sleep-wake cycle, praying for the night to hasten and come to an end.

The peace was shattered by the labour ward nurse calling for attention. She handed the incoming patient over to our theatre nurse and anaesthesiologist at the theatre barrier with a wicked quip that we needed to gather our energies for the last lap of the night.

Valerie* was wheeled into the operating room and transferred to the operating table. She complained of cold and was quickly added a second blanket while we introduced ourselves and went about the business of preparing for the surgery.

Valerie had delivered her first two babies by caesarian section, due to the babies presenting in breech (buttocks first instead of head). She was looking forward to closing her obstetric career with this third delivery and had even consented to permanent sterilisation. She was scheduled for surgery three days down the week but the baby had other ideas and had chosen to come early, waking Valerie up with mild labour pains.

So here we were, with a planned surgery suddenly turned emergency. Valerie’s innocent curiosity was refreshing, the boost we all needed to finish the night on a high tempo. We had no idea just how high tempo this was going to be!

Within minutes, we were set to go. Valerie was comfortably under spinal anaesthesia, all prepped up for the incision. We removed the old scar easily entered the abdomen. And that was the last time we used the term ‘easy’. There was lots of scarring inside her abdomen as a result of the previous surgeries. This was expected.

What was not expected was to find the placenta right in our face, having clawed its way through the entire uterine wall and grown through from the inside, out, to the surface. The bladder was not spared either. The rogue placenta had also gotten stuck onto a portion of the bladder wall.

This is when you recite the Hail Mary even when you are not Catholic. Sleep was long forgotten and adrenaline was pumping like crazy. Valerie was promptly put under general anaesthesia as the phones started ringing incessantly,mobilising everyone for help; the blood transfusion unit was alerted to prepare multiple units of blood products; the senior anaesthesiologist, the urology team and the senior obstetricians were on their way and the paediatrician was alerted to come and attend to the baby.

With utmost care, we attempted to extract the baby with as little interference to the placenta as possible. The little one safely made it and was handed over to the mother. Now it was time to face the dragon. The cavalry had arrived and we were as ready as we would ever be. The cantankerous placenta had begun to bleed and in an effort to stem the tide, we had clamped some of the big blood vessels supplying the uterus.

The team went through a harrowing dawn. The placenta had to be separated from the bladder by the urologists, which ended up involving cutting out some of the bladder itself. Then came the removal of the uterus. She bled gallons throughout the surgery, causing the anaesthetic and lab teams to sweat for hours. Five hours later, the team was satisfied that the bleeding was finally fully arrested. She had been transfused seven units of red blood cells and multiple units of fresh frozen plasma, a component that helps with blood clotting.

Placenta Accreta Syndrome (PAS) is a condition where the placenta develops abnormally. In a normal setting, the placenta forms and lies against the inner lining of the uterus, the endometrium; separated by a special plate called the decidual plate. In PAS, the endometrium is not properly formed, or may be too thin. This results in failure of formation of the decidual plate. This allows the placenta to expand into the endometrium and beyond, into the uterine muscles, the serosa (the outermost covering of the uterus) and may breach the uterus and extend to other pelvic organs like the bladder and the gut.

At delivery of the baby, the placenta normally separates from the uterus along the decidual plate and comes out of the uterus, allowing the empty uterus to contract tightly and reduce the bleeding of uterine vessels, hence protecting he mother from postpartum haemorrhage. However, in placenta accreta, the absence of a decidual plate means there is no clear plane and the separation of the placenta tears into huge blood vessels that will bleed a river. Shearing off the other pelvic organs leaves exposed blood vessels that are difficult to tie up.

PAS comes with a myriad of complications, including severe bleeding, shock, losing the uterus in an effort to keep the mother alive, complications of massive blood transfusion, need for intensive care unit (ICU) care, injury to other organs, and death. PAS is every obstetrician’s nightmare. Where possible, it is a pregnancy complication that need to be identified as early as possible through a good quality antenatal ultrasound scan. This allows for the team to plan for the eventual delivery or refer patients where resources are insufficient to handle this level of complications. This is the best chance a patient has at surviving. 

Valerie showed up with no prior knowledge of the risk she was carrying around. I was extremely grateful that she had come to us, not a less resourced facility; otherwise she would not have made it. There was a collective sigh of relief when she was wheeled from the operating room to the intensive care unit. She had lived to see another sunrise. My biggest bargain with God was that her three children needed a mother; they had done nothing to deserve growing up orphaned.

Dr Bosire is an obstetrician/ gynaecologist