“Placenta Accreta Part 1: Explanation, Risk Factors, and Diagnosis” – With Dr. Brett Einerson

Dr. Brett Einerson, assistant professor of OB/GYN and maternal-fetal medicine at the University of Utah, joins Dr. Fox to discuss placenta accreta. In this episode, they cover why Dr. Einerson chose to study and specialize in placenta accreta, what defines the condition, and common symptoms and risks.

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Dr. Nathan: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Dr. Brett Einerson, how are you doing? Welcome to the podcast.

Dr. Brett: It is great to be here.

Dr. Nathan: This is so exciting. And I appreciate you coming on, in general and also taking time out of your summer vacation to talk to me and to talk to our listeners about a really important topic. How’s it going over there in your vacation in Minnesota?

Dr. Brett: It is a little bit humid, more humid than I’m used to in Utah. But the sun is shining, and it’s another nice day in paradise.

Dr. Nathan: Our listeners might not know this, but I do. You’re a physician. You’re also an MPH, master’s in public health. And you are an assistant professor of OB-GYN and maternal-fetal medicine at the University of Utah. Amazing. So, I’m curious, how did you end up in Utah?

Dr. Brett: It was a long and sort of meandering route to Utah. I grew up in Minnesota. I went away to North Carolina for medical school. That’s where I got my MPH, at the University of North Carolina. And then I ended up in Chicago for residency and I wanted to try something totally different for fellowship. Fully expected to spend a couple of years out here and frolic in the mountains and then go back to the Midwest or some other part of the country. And I really got sucked into the people and the climate and everything else.

Dr. Nathan: Yeah. I mean, they’re amazing people at Utah. It’s one of these things that people would never realize, like why Utah, and I think part of it is just because everything is centralized. So, all of the high-risk patients go to basically one place and all of the transports come to one place. And so you have an amazing volume there, and acuity, and so you have to have really good people there. And so your department has built a really, really great team.

Dr. Brett: I agree with you. I work with some of the most inspiring and awesome, and frankly, normal people [inaudible 00:02:12].

Dr. Nathan: There’s so few of us who are normal. Yeah. Tell me about your time in Chicago. Because that’s my hometown, so say nice things. You’re at Northwestern?

Dr. Brett: That’s right. I went to Northwestern for residency. I love Chicago. It was totally different than I expected it to be. I fell in love with the city, rode the L train every day to the hospital at 5:00 in the morning to get to residency on time. I lived eight blocks south of Wrigley Field, became a wannabe Cubs fan, just had a fabulous…you know, ate the best food of my life and I had a just awesome four years there.

Dr. Nathan: That’s amazing. I’m curious, how’d you get interested in placenta accreta? Because, you know, clinically, research-wise, this is something that you’re involved in, you do.

Dr. Brett: That’s right. I run the placenta accreta program at University of Utah. And I got into it a little bit by just random circumstance. It wasn’t something that was on my radar necessarily as something I knew I wanted to focus on when I left residency. So, I did general OB-GYN residency and then I wanted to specialize as a high-risk pregnancy doctor like you are and sort of didn’t have accreta on my radar as something that was going to be a key feature of what I do. But when I came to the University of Utah, it just became apparent to me that this is a really difficult problem to deal with, a really scary thing for patients to face. It’s something that we are seeing increasing numbers of. In addition, I just didn’t see all that much helpful information in guidelines or in the research to tell us how to take care of these patients best. And so I got inspired to both take care of these patients and to help to do research in this area.

Dr. Nathan: Did you think you were going to be doing more on the fetal side when you were doing your fellowship at maternal-fetal medicine? Because a lot of people, you know, when they go into the fellowship, some of them are thinking, “Well, I’m going to really focus on the fetus, like diagnosis and ultrasound and procedures and others, you know, maternal health and maternal morbidity and complicated medical conditions.” And so you said you found yourself in accreta, which is more of the latter. Was that a surprise to you for that reason, or just you always were interested in maternal health, but not specifically, this area?

Dr. Brett: I think the second one that you had said. To me, I was always a little bit more interested in taking…you know, I wanted to be a well-rounded maternal-fetal medicine doctor, to be able to do ultrasound, and take care of families who have complex fetal diagnosis. I never had aspirations to sort of be within the fetal world. There was always the maternal component that really drew me and despite how difficult and frustrating it can be, I loved taking care of critically ill pregnant patients. I loved being somebody who sort of straddled the worlds of pregnancy care and medicine and critical care. And so the surprise for me was falling into the actual specific diagnosis of accreta, which honestly, I hadn’t seen that much of during residency. But when you come to Utah, where people have a lot more babies, and people have a lot less access to VBAC there just was an enriched group of…tons of people dealing with this issue that I haven’t seen nearly as much of in Northwestern.

Dr. Nathan: And the reason that there’s a lot of women there having a lot of babies is because of the high Mormon population?

Dr. Brett: Not just Mormon, I think Utah is one of the only states in the country that still sort of actively replacing the population with more people than are passing away. It’s just big families are a part of the culture, whether that’s Mormon or other cultural issues, people have big families.

Dr. Nathan: In our little circle in New York City, we have a similar practice, because we have a lot of women who have a lot of babies, we’re doing women’s, you know, fourth, fifth, sixth, seventh, eighth cesarean. And as we’ll talk about, that’s one of the ways you start taking care of people who have accretas as well, the volume goes up. And as you see, with more cesareans, there’s going to be more of this complication. It’s interesting that you talk about critical care and medicine because these are really involved, but accretas, you know, and our listeners will learn if they don’t know already, is very much a surgical field. Also, it’s, you know, really hands-on operations. Was that something that surprised you that you were doing a lot of these or were you always…like, in residency, were you really interested in oncology and doing those complicated gynecologic surgeries as well?

Dr. Brett: Yeah. In residency, I was one of those people who loved everything, and saw myself doing all of it, but also recognized pretty early on that I wanted to be the expert of something that was difficult to master. And so it’s hard at residency because I wanted specialization so I could be the expert, but specializations oftentimes means giving up a skill set that you learn in your more general training. Now, I really lamented the potential loss of some surgical procedures and skills in going in-depth maternal-fetal medicine. It was a hard decision for me because I did love surgery, I gravitated toward surgical procedures. But ultimately, what drew me into MFM was pregnancy and pregnant people and their families. And I love that time in a person’s life when they’re going through that sort of, you know, really, life-defining event. Pregnancy for me is endlessly fulfilling to help take care of patients and difficult. And so I knew I would always have challenging cases, challenging patients, and happy and sad situations going into MFM. But I did worry that I was going to lose out on some of the surgical skills that I had developed. And so accreta came along later in fellowship, and I was like, “Gosh, this is actually kind of a way where I can continue to flex that muscle I have been training in residency in terms of surgery, but stay within the MFM realm.”

Dr. Nathan: It’s interesting, and around the country, people who take care of women with accretas, some of them are OB-GYNs, some of them are maternal-fetal medicine specialists, some of them are GYN oncologists, some of them are general surgeons, and it is a very complex surgical technique that needs to be used, and so people can come at it from different angles. And it’s great that you got to continue to do that. So, good work. Good work, Brett.

Dr. Brett: Thank you.

Dr. Nathan: Let’s delve into placenta accreta itself because we’ve been talking about it for a few minutes. And some of our listeners might not even know what we’re talking about. How do you explain to people just, in general, what is a placenta accreta?

Dr. Brett: I tell people that the placenta is normally an organ that detaches easily, comes off after the delivery of the baby. So, it comes off of the surface of the uterus without any difficulty, or usually without any difficulty. And placenta accreta is what happens when the placenta finds its way into an area of the uterus that, usually that’s been scarred, either by cesarean or another procedure. And when it sets up in that area, early on, in gestation, it really digs into the muscle. And that’s not a normal place for a placenta to be or live throughout pregnancy. So, at the time of delivery, what happens is that the placenta doesn’t come off easily. And as a result, it either has to be sort of physically removed or surgically removed in a way that causes a lot of bleeding. And so that’s the way I describe it to patients is that it’s a placenta that just does not detach in the normal way. Additionally, I tell people as they start to learn more about it is that it’s a problem that really transforms the normal blood vessels into something much, much scarier. So, the blood vessel…blood needs to flow through the uterus to the placenta, normally for placenta, but in placenta accreta, it is really set up abnormally so that the blood goes sort of directly into the placenta. And when you remove that placenta, you can have really rapid and life-threatening bleeding.

Dr. Nathan: You know, when we talk to people about, let’s say, risk of an accreta, right, before they’re pregnant, and they’re like, “Well, what’s the big deal if the placenta gets stuck?” You know, it’s sort of harder to take out and, you know, “You have that all the time.” You know, it’s just…you know, you get something out, it’s not so easy to do. So, why do we care so much? You said there’s a risk of bleeding when the placenta comes out, but I think just to sort of quantify that, we’re not talking about bleeding, like a nosebleed, we’re talking about hemorrhage, right? This is like people can, you know, totally lose their entire blood volume quickly because these blood vessels are so huge. So, that’s one of the big things, that there’s a major risk for hemorrhage. What else are people at risk for if they have an accreta, and it’s not treated properly?

Dr. Brett: So, if we don’t know about the diagnosis of accreta, it can be a really life-threatening situation. To manage this rapid bleeding [inaudible 00:11:11] state, I mean, the way that the gynecologic oncologists who trained…one of them who trained me called it the potential for audible bleeding, you can just have, you know, bleeding that is so rapid that it just fills up the entire body within a matter of moments. So, that’s a risk as we’ve stated. The other problem is that it is very, very difficult to take care of this problem without removing the uterus. And while some alternatives to hysterectomy, which is the removal of the uterus, have been proposed, internationally, it’s still kind of a difficult to perform procedure and something that has risks unto itself. So, most women in the United States who have this diagnosis will end up with a hysterectomy at the time of their delivery, which, of course, means that their potential for fertility in the future is lost as well. With massive blood loss, some decent proportion, number of women will end up in the intensive care unit afterwards because when you lose a lot of blood, we have to give a lot of blood to keep you alive. And as a result, your body needs some time to transition so we can’t do that very safely in the normal post-operative or the postpartum unit. You know, oftentimes it will have to be in an intensive care unit. The last big thing that I think about is that because the placenta grows into the spaces in the uterus and pelvis that it’s not supposed to be, there is oftentimes damage to other organs in the pelvis. The most common one is the bladder. So, oftentimes the bladder has to, either be cut into or is already involved with placenta in a way that means that the bladder has to be partially resected and, you know, partially cut into and then repaired to safely get the uterus out. Like you said before, I mean, this is a surgically complicated situation, a life-threatening situation, and something that, you know, a lot of people haven’t even heard about until they come into the office to get the diagnosis.

Dr. Nathan: Yeah. And a lot of people also ask, okay, is there any risk to the baby with having this abnormally attached placenta? Like, does it affect the baby’s development or growth? Or does it put them at risk for delivering early, for example?

Dr. Brett: Yeah. The main risk is early delivery. So, what I tell patients is that the difference between a well-planned surgery where we’re all ready to go, and an emergency surgery in the middle of the night is like night and day, in terms of surgical difficulty, and in terms of the complexity of the surgery, and how dangerous it will be, and in terms of the stress that it puts on patients. The problem with accreta is that it sort of sits in an area that makes the uterus mad, for lack of a better word, and oftentimes patients will go into labor or break their bag of water earlier than they would have otherwise because of placenta accreta. So, as a result, it’s a long-winded way of saying this, but I deliver all patients preterm at 34 to 36 weeks, if not earlier, depending on the circumstances, to avoid that middle-of-the-night life-threatening emergency. So, premature is the big one. With regard to, like, how does the baby do throughout pregnancy? Actually, surprisingly well. I mean, we have some research that’s been done to look at whether or not the growth of the baby is affected, and we think it’s probably not. And so thankfully, the placenta still functions normally and provides the baby with everything that it needs while it’s growing. But the main threat to babies is the complications that come along with prematurity, so difficulties with breathing, difficulties with feeding, and growing.

Dr. Nathan: Right. And as you said, you’re in a tough spot, because on the one hand, you are going to deliver early to avoid, you know, that middle-of-the-night disaster where, you know, someone comes in at 36 and a half weeks, and they’re hemorrhaging before they get to the hospital, I mean, it could be the difference between life and death, literally. And then…

Dr. Brett: Absolutely.

Dr. Nathan: So, you’re like, okay, so we can’t have that, like, we just have to avoid that because it’s not an option that anyone wants to have. And so, how early do you deliver? Because we don’t know when someone’s going to go into labor on their own, or when the water is going to break. You know, if we had a crystal ball, we would do it the day before, right? Which is okay, you know, take that day and subtract one and let’s do the operation that day. But since we don’t know, you have to sort of do it early enough that it doesn’t happen, but not so early, that the baby is so premature, that he or she is going to have very severe complications. And so we do it around the same time, I think most people in the U.S. do it in that, like you said, the 34 to 36 weeks and potentially earlier if more things are going on. But that’s a significant risk, potentially. And also you can have that plan and it doesn’t work. Someone would go into labor, you know, a day before, you had it scheduled and the same problem could happen. Do you ever admit people to the hospital beforehand for X amount of time, leading up to the delivery?

Dr. Brett: The answer’s yes. What I tell people is that to stay out of the hospital, it kind of has to be the perfect storm of everything’s going right, like, your pregnancy has been uncomplicated, you’re not having any labor contractions, you don’t break your bag of water early, you don’t show any signs of preterm labor, you don’t have a lot of preterm births in your past. So, if all of those things are true, and things are going along great, then we try not to admit people until the day of their delivery or the day before. But I have a very, very low threshold to admit somebody at the hospital for anything that even resembles labor, or, you know, any amount of bleeding at all, and most people are going to be in the hospital for the remainder of their pregnancy, at least once they get up to the second and third trimester. So, we admit a lot of patients in the hospital, because, in part, you know, working in Utah means that at least half of my patients live more than three hours from the hospital. I cannot have somebody living four hours away, start bleeding at home at 33 weeks. I just can’t have that. So, it’s too dangerous for them and too hard on the systems to fly them here on an airplane and everything else to save their life. So, if patients are coming from a long ways away, I have them move to Salt Lake City and stay in some of the housing that we have set up for them. If they’re having any symptoms at all of labor, or they think they’ve broken their bag, or they have some spotting, have them in the hospital for much longer than I normally have a patient for the same complaints.

Dr. Nathan: Yeah. And this isn’t something that you want to just go to your local hospital or your local emergency room because, you know, they may be able to give you a blood transfusion and they may be able to draw some blood, but they may have no idea how to treat this, how to do this, you know, the operation and you’re stuck. And they know this, they don’t want you to show up there, right? It’s not good for anybody.

Dr. Brett: Exactly.

Dr. Nathan: You have to really go to a place that knows what they’re doing, and has a team set up. And that’s part…and we’ll talk about this part of planning when someone has it, but it’s one of these things that you figure, if you have a heart attack, you’re going to the closest hospital because every emergency room on earth knows what to do when someone’s having a heart attack or having a stroke or having…you know, falling and breaking a limb or something like that. But this is…you can’t just show up in any hospital with this condition, especially if you’re bleeding, it will not be good.

Dr. Brett: Exactly right. Most hospitals here in the country don’t have enough blood to keep people alive. There’s this problem if they start bleeding. And like you say, the expertise and the experience really matter. This problem is still uncommon enough, I used to say rare, but I really shouldn’t say rare, it’s uncommon enough that not every doc has seen a case, even every OB-GYN. And even if they have, they have a healthy fear of it, know what their hospital can or can’t handle. And the reality is that most hospitals do not have enough blood in their blood bank to safely keep people alive if they start bleeding heavily. So, you’re totally right. Experience matters. The blood bank matters. The number of cases that doctors take care of every year really will be able to make a difference in how patients do once they start moving towards the delivery of this problem.

Dr. Nathan: Right. Well, now that we scared all of our listeners into them thinking, “Oh my god, what if I have a placenta accreta, it’s not going to be good,” what are the risk factors? Like, how would someone know that they’re even at risk for this? Now, I will say that anyone who’s pregnant could have this. It could happen in someone’s first pregnancy, I’ve seen that, where it’s totally unexpected, nothing is suspected to happen to delivery, but that is exceedingly unusual, right? That’s really, really, really…that is rare, but what is a sort of a setup for this? Who should think I’m at risk for this, and I need to be sure this isn’t going on?

Dr. Brett: If your listeners listen to one moment in this podcast, I want to say that what you’ve just said, and what I’m about to say is probably the thing that I want them to take home more than anything, if you’ve had C-sections, one or more C-sections, and your placenta is low in your uterus, you are in an extraordinary risk for having this problem. And it doesn’t mean you’re bound to have it. If you’ve got a low placenta, which we call either a low lying placenta or a placenta previa, and a prior C-section, but you’re just at significantly higher risk for this problem. And so if you have had C-section before, and have a placenta that is set up low, I think you’ve got to have an expert who knows something about this problem. Take a look at your history, take a look at your ultrasound and figure out whether or not you’re at risk.

Dr. Nathan: Yeah. And I think one of the reasons it’s so confusing for patients is the terminology, there’s overlap, people hear placenta previa, people hear placenta accreta. They’re both like weird terms that both have the term placenta, and they’re very different, right? Previa just means it’s low down, covering the cervix, it’s like the location of the placenta is really what it indicates. And accreta means whether it’s stuck to the uterus or not, which can happen anywhere in the uterus. And so they spend the first half of the conversation trying to figure out what’s the difference between them. And then the second half is when we tell them, they’re linked. If you have a previa, it happens to increase your risk of an accreta, and then it starts getting really confusing, but yes, for whatever reason, and there are histologic reasons, but it is absolutely true when the placenta implants low down in the uterus, that is not where the uterus wanted it to implant, and it’s much more likely to be an accreta. And then if there’s a scar there from before because we make these cesarean scars low on the uterus, it just compounds that risk entirely. And I know you know these stats, it’s really crazy. Like, if you don’t have a placenta previa, the chance of having an accreta is 1% or less for pretty much everybody unless you’re the person who has had five, six, seve, eight C-sections, something really high number, right? If you’ve had one C-section, two C-sections and your placenta is in a good spot, you’re at very, very low risk. But if you have a placenta previa, where it’s in the wrong…you know, not the wrong, but a very low down location, it could be 2% to 3% risk of accreta. On your first pregnancy, it’s 10% if you’ve had a cesarean before, and it’s 40%, or 50%, if you had 2. So, the woman who comes to me with two prior cesareans and a diagnosable placenta previa, it is like, all right, we have to assume this placenta is stuck unless, you know, we can…you know, every single picture shows it’s not. And even then we’re worried when we do this, you know, the operation that it could be happening. It’s always on our minds. And that’s really important because I don’t think everyone out there knows that they’re at risk.

Dr. Brett: That’s exactly right. I give talks to sonographers and people who read ultrasound in the community, I mean, the thing that I [inaudible 00:23:12]…invariably, somebody will ask, what’s the most important thing I need to look for on an ultrasound when a patient comes in to figure out if they’ve got accreta? And I think they’re expecting me to say, well, you know, if you turn on the Doppler flow, it sort of looks like this, or if the placenta has this characteristic, sort of lakey-looking appearance, and that’s the thing that’s most reliable, no. It’s, does this person have placenta previa? Is the placenta low? And if it is, that’s a whole different risk category than anything else. So, on one of my slides in the slide deck that I have is, don’t forget previa is a sign of accreta.

Dr. Nathan: There are other operations people can have on the uterus that will increase the risk, and it’s not just cesarean, it could be a scar from a fibroid removed or something called Asherman’s with their scar tissue, or, you know, D&Cs for miscarriages or for abortions, and they’re all there but again, the risk is always higher with the previa. And why is there no great diagnosis for this? Meaning, unfortunately, when people come to me, I can tell them, you have a very high chance of this, you have a low chance of this, you have a medium chance of this, but why is it very rare that you could say you absolutely do have this, or you absolutely don’t have this?

Dr. Brett: Unfortunately, we’re just at a place where we don’t have the tools to tell somebody definitely yes or definitely no like they do in some other areas of medicine. So, we try to use ultrasound to determine if people are at risk. If they’ve got a previa, is this an accreta or is it not. But the reality in our practice, I’m sure you know as well as I do, is that sometimes it doesn’t look all that bad. And if you’re thinking to yourself, yeah, this placenta will probably come off and then you get to the day of their surgery, and that’s not the case at all. You get inside, and it looks totally different than what you’re expecting. And vice versa, sometimes you look at a placenta on an ultrasound, and it sort of gives you that little bit of hesitancy, like I don’t really like how this is looking, and then actually, by the time delivery comes around, it’s not looking too bad at all. So, what I would say is that a lot of the signs that you think show that you might have accreta are just normal signs on ultrasound. Unfortunately, we can’t be super reassured one way or the other…you know, you’re reassured that you don’t have it just based on an ultrasound, or totally you’re worried at your first ultrasound. So, oftentimes, what we need to do is take a look at how the placenta acts over the course of pregnancy. And then ultimately, we can get other tests. So there are people who are developing blood tests to try to make a better diagnosis and these people have tried to see if MRI can be helpful, which is a more advanced test that you can get to look at the placenta. But ultimately, it comes down to how does the placenta look on the inside and how does it act after delivery? One of the things that just really frustrates me for patients is the uncertainty of all of this. You go to the expert expecting to get yes, no, and what you hear is, I think you’re at risk, we’re gonna have to wait and see until the time of delivery.

Dr. Nathan: Yeah. It’s definitely unsatisfying. One of the ways I explain it to people, and most of the time when explaining it, I’m explaining it to the residents or the students, because they’re not freaked out, you know, in this conversation, you know, because with patients, it’s a whole different world because they’re worried, so what I’ll say, you know, I’ll put my hands together, like claps together, and I’ll say to them, how would you tell if there’s superglue between my hands holding them together versus not? And there’s no way to know, right? Because the attachment of the placenta to the uterus that’s abnormal could be microscopic. You wouldn’t see it by ultrasound until you try to…if I try to peel my hands apart and there’s superglue, well, when the skin starts falling off, you’ll know it’s superglued. And it’s the same thing with the placenta. And that’s sometimes how it is. So, when they present a patient says, “Okay, this is, you know, Mrs. Whatever, and she has four prior cesareans, she has a placenta previa, but it looked normal on ultrasound,” and I’ll be like, “I don’t really care.” Like, that’s great. It’s normal. I’m like, that’s nice to know, better it looks normal than it looks abnormal, but we’re still going to be prepared because just statistically, there’s like a 70% chance it’s going to be an accreta. And so if the ultrasound is normal, maybe it lowers it, whatever, to 20%, I don’t know, something, but it’s not going to lower to 0%. And if you’re not prepared, you don’t want to just be surprised in the middle of the operation when you try to take the placenta out, and then she starts bleeding. And so like you said, knowing it’s a previa, and knowing someone’s history is way more important than all the fancy knobs and colors and stuff we can do on an ultrasound. And most of that’s just experience. It’s not imaging skills, it’s really just having people who are aware of this and know it’s a risk and, you know, have the humility to know that ultrasounds are limited.

Dr. Brett: Humility is a great word for this because I think that when you take care of 10 patients with accreta, at least a couple of them are going to surprise you, in terms of the actual problem is worse than you thought when you looked at the ultrasound or the actual problem is not as bad as what the ultrasound looks like. And so if you’re talking to a doctor who feels very confident of the diagnosis or the outcomes, honestly, I think that that’s actually cause for some concern. With accreta, the honest opinion from people like me is that we’re not going to know for sure exactly how bad this is going to be until the day of your delivery. And that’s just the truth of the state of our care for patients right now. We haven’t yet figured out how to make a sure diagnosis, we haven’t yet figured out how to, for sure, roll this out. And while that is frustrating, it is just the truth.

Dr. Nathan: What did you find when you looked at MRIs? Because people think MRI is the big thing, it’s gonna solve everything, we can see better than ultrasound, we’re gonna make this diagnosis, rule it out, rule it in. What did you find in your research?

Dr. Brett: So, we found that MRI is a technology that can be misleading. The baseline assumption, both for doctors and for patients and other healthcare team members is that if you get the more expensive test that gives you the fancier looking images, that it’s going to be better. And that’s just not the case with MRI. MRI can be just as misleading if not more than ultrasound. So, what we found is that oftentimes when I get an MRI, sort of as a tiebreaker, you know, one of my colleagues thinks this ultrasound looks like accreta, another one says, “I’m not sure that that’s accreta, it’s probably going to be normal,” if I get the MRI as sort of a tiebreaker, oftentimes, it won’t tell me the right answer. And the way that we figured that out was just to look at what the ultrasound diagnosis was, and then the MRI diagnosis, and then we compare it to what actually happened when the patient had a delivery. And the MRI was not more accurate in telling us the truth of what was going on inside of the body than ultrasound and in fact, some of the time gave a falsely reassuring answer, which really is concerning to me. So, if the MRI says, “Don’t worry about this,” and then the patient goes back to rural Idaho to deliver, and it was wrong, that’s a problem, right? I’ve just sent her back to a hospital that can’t really take care of her. So, I think that MRI is imperfect, just like every other test that we have, but it’s a fancier and more expensive test, with fewer doctors who actually have the expertise to read it. So, my preference is to start with ultrasound and rely heavily on it. Now, there are probably some situations in which MRI can be helpful. There are certain locations in the uterus where the placenta can be difficult to see with ultrasound. In that case, maybe MRI is helpful. But I love your analogy with the superglue between your hands because whether you’re doing an ultrasound or an MRI, neither test knows if the superglue is there. And I think there’s this idea, especially…I mean, maybe I’m speaking to doctors and some of the patients, but I’ll say this, but MRI doesn’t have a better way of distinguishing between those microscopic changes than ultrasound, despite the fact that it costs more and takes more expertise to read and all the rest.

Dr. Nathan: Yeah. And also typically when you’re having an ultrasound…well, not typically, frequently, it’s going to be by the person who’s going to be taking care of you or someone who has the same career, at least, as the person taking care of you because a lot of them around the country are done by OB-GYNs, maternal-fetal medicine doctors, whereas MRIs are done by radiologists. And it’s not a knock on radiologists, they just, they don’t do gynecologic surgery. They don’t, right? It’s not their specialty. And so there is some, you know, level of that and interpretation. And if I recall, one of the interesting things in your study was that if you had an ultrasound diagnosis, and the MRI changed it, it said no, it’s not A, it’s B, it was just as likely to change it from a wrong to a right diagnosis as a right to a wrong diagnosis, right?

Dr. Brett: Exactly.

Dr. Nathan: It was just as likely to mislead you as to lead you in the right direction. It was like 50/50, wasn’t it?

Dr. Brett: Yes. And most concerning to me is that it was frequently the misdiagnosis, was a downgrading, meaning, ultrasound, you’re a little bit worried, the MRI says no big deal, this person can deliver wherever you want them to and that was wrong.

Dr. Nathan: Hey, everyone. I hope you enjoyed part one of my discussion with Brett Einerson on placenta accreta, explanation, risk factors, and diagnosis. In part two, we’re going to be discussing management and delivery. So, stay tuned for that podcast next week. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcasts, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address please feel free to email us at hw@healthfulwoman.com. Have a great day.

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