“Placenta Accreta, Part 2: Management and Delivery” – With Dr. Brett Einerson

Dr. Fox: 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. Today you’re going to hear part two of my discussion with Brett Einerson on placenta accreta management and delivery. In part one, Brett and I discussed what exactly is placenta accreta, who is at risk for one, and how we diagnose placenta accreta, or at least highly suspect it in someone. Part two of the podcast, which is what you are about to hear, starts with me asking Brett about what he does when he suspects someone does have a placenta accreta. How does he manage that pregnancy? So that’s what’s coming up next. Thanks a lot. So let’s say someone is either…there’s a high suspicion for a placenta accreta or enough suspicion just based on her history, you know, having the previa, having multiple cesareans regardless of ultrasound, what do we do during pregnancy to counsel them, to manage the pregnancy, to plan for delivery? What’s sort of your, I don’t wanna say protocol, but sort of like how you typically would start, let’s say, with this pregnancy?

Dr. Einerson: Yeah. So if we’re pretty sure of the diagnosis, then we start making plans for the surgical day, the delivery day right away. For patients, what that means is we modify a little bit sort of their approach to activity not. I know bed rest is a bad word in your world, and it is mine too, so I don’t do that.

Dr. Fox: For me, I could use a lot more of it, but for my patients, I agree.

Dr. Einerson: So bedrest is not part of the treatment, but pelvic rest, meaning no intercourse, is part of our recommendation. And, you know, it’s not really based on any actual research other than just a worry that with the placenta being low as it is for most patients with accreta and sitting right on top of the cervix, it’s possible that intercourse could cause bleeding. And if it causes bleeding, it’s not just run-of-the-mill spotting. It could be a lot heavier than that. So I recommend pelvic rest for patients who have placenta accreta. I see them at least every month and do an ultrasound about every month to follow the location of placenta, not necessarily to keep hemming and hawing about whether or not accreta is there, but to really figure out where on the uterus the placenta is located because that helps me to determine if they’ve got it and what the surgical approach is gonna be like.

We oftentimes, once we get up closer to the date of surgery, I will have patients, like I mentioned before, move closer to the hospital. So I tell patients that I feel best if they’re within 30 minutes of the hospital, 45 the most. So if they’re living far way, around 30 to 32 weeks is when they move to Salt Lake City or nearby. If they’re gonna have a planned preterm delivery, which almost all of them are, then we’ll consider steroids to help the baby’s organs mature to get it ready for the outside world. We want to make sure that their iron stores and their red blood cell counts are as close to normal as is possible because we want them to have sort of a full tank of blood in case they do have heavy bleeding.

And so we’ll do testing for iron levels and hemoglobin and give them additional iron if needed. And then we aim for that 34, 35, sometimes up to 36-week mark, depending on how things are going. What I tell people is, you know, you have any concerns, you’ve got to call in. And I kind of treat these patients a little bit more, I don’t wanna say preciously, but a little bit more intentionally than other patients. I give them a specific number to call so they don’t just go through the hospital line. If they’ve got questions, they get a direct line to one of the accreta experts.

Dr. Fox: That’s a real interesting idea. I like that. It’s different in New York City, obviously, for a whole host of reasons. We don’t have a lot of people living three, four hours away. Most of our patients are within that zone or close enough, you know, within an hour or something like that. But one of the things I always talk to patients about is, even if you live close, you always need a jump plan, right? Meaning, you know, if they had a prior C-section, they usually have children, right? So if you have a kid and you’re deciding we’re gonna go to the zoo today, me and my 3-year-old, great. What are you gonna do if you start bleeding? Like, what’s your plan, right? And it doesn’t mean you can’t go to the zoo, but say, “All right. I know that, you know, my partner’s at work and, you know, he or she can meet me at the hospital or my mother-in-law’s here and is on the way there. I could take my kid dropped off.” And, you know, you just need to have that because you can’t start thinking about what do I do with my 3-year-old while you’re bleeding heavy. It’s not a good time to figure that out.

And so I talk too about that all the time, like don’t be the only person at home at 2:00 in the morning with a 2-year-old because what if you bleed tonight? Who’s coming to take care of your 2-year-old while you go to the hospital? Have that worked out in advance? And I usually tell everyone with the placenta previa the same thing because they have risk of hemorrhage as well. You know, they don’t have to have an accreta to need a jump plan. But it’s one of these things that people don’t often think about. They think about packing their bag to make sure that, you know, they have the right charger for their iPhone when they go to the hospital, but this is more like a higher level, get there safe.

Dr. Einerson: Totally true. That’s a great point. And just as an example to illustrate how critical that is, I had a patient who moved down from Idaho and was living just 15 minutes from the hospital. And when she called me, I was on call that night, and when she called me, she had just started bleeding, and by the time she got to the emergency room and I met her there about 15 minutes later, she was totally covered in blood. And, again, I hope I’m not giving your listeners PTSD with gory horror stories, but I’m just reinforcing the point that it can’t be a, “Oh, yeah, we’ll start driving from an hour and a half away once we start bleeding,” that’s not an option. And we’re not… You know, if you’re gonna go ice fishing on the reservoir, I can’t be out there alone with no contingency plan to get back to the hospital ASAP if you start bleeding.

Dr. Fox: Right. We haven’t had a lot of ice fishing concerns in my part of town. Although I guess we could ask about that, you know, how much ice fishing do people do on the Central Park Reservoir in the winter, but that’s cool. One of the other things that we do frequently is we’ll check, you know, because if those patients, again, are, let’s say, you know, an hour away, hour, 15, and it’s hard to, you know, get space in Manhattan to, let’s say, you know, just move in for a month or something. We’ll sometimes do, you know, cervical lengths, and if it’s nice and long, you know, their chance of laboring is lower, and, you know, we’ll use that potentially to gauge who should come, you know, move in sooner, who shouldn’t. And, like you said, their history is an important part of it. And then who do you have them meet with or who do you meet with? Like, how do you assemble your team for the day? Because there’s a team that needs to be assembled. You don’t just show up like, “Hey, it’s me and my patient. Let’s operate.” You have, like, a whole, you know, group of people.

Dr. Einerson: Yeah. What I tell patients from the very beginning on our first consultation is that there is nothing special about me as the doctor that’s taking care of them other than I have a really effective way of coordinating a humongous team of super-smart people to keep you alive. The people that they meet in our system beforehand is a couple of people. One and critically is an OB anesthesiologist. So this is an anesthesiologist with specialized training to take care of women who’ve got really bad obstetric problems, including placenta accreta. So I will arrange for a preoperative consultation with them so that they can talk about what the experience is gonna be like from an anesthetic standpoint. For us, it’s not the same as a normal C-section. We do try to keep patients awake for the C-section part so that they can see and hear their baby. But then they go to sleep for the hysterectomy portion if we’re gonna do a hysterectomy. And so meeting with an anesthesiologist to go over their health problems and to talk through sort of the, this is gonna happen, then this is gonna happen is really helpful for patients. I also have the…

Dr. Fox: It’s also helpful for the anesthesiologists. They love knowing these patients in advance rather than just showing up and meeting them. Because they have questions they may wanna ask that we don’t know, we don’t remember. You know, they’re gonna look in their airway. You know, they’re going to, like… There are things that they wanna know before an hour before the surgery. So in our experience, the anesthesiologists appreciate it just as much as the patients do. It’s not a burden on them. They want to meet you before the surgery, for sure.

Dr. Einerson: Some of these cases will be the most difficult cases those anesthesiologists will take care of all year. And so, absolutely, they appreciate getting to know these patients beforehand. The other team that I have them meet with is actually our group of counselors and social workers. So this is a problem. If you haven’t already gotten PTSD from listening, you would definitely be at risk if you have this problem. This is a really harrowing and scary situation at the end. And, thankfully, almost all the time we end up on the other end with a healthy mom and a healthy baby. But that doesn’t mean that this is no big deal. This is a life-threatening, scary thing patients and families go through. So I have the meet with our clinical social worker and our mental health team so that they have a relationship with them beforehand so that when things get difficult afterwards, if they get difficult, then they’ve already been hooked into that system. If there are specific needs, like if I really think that it’s gonna be a complicated bladder case, like the bladder’s involved, then I will have them meet a bladder doctor, a urologist beforehand. And if there’s any other specific concerns about their surgical history or medical history, then I’ll have them meet with specialists for those organ systems as well.

Dr. Fox: Yeah. I mean, it’s very similar in our end. And, you know, we have them meet with, you know, whoever, and it’s certainly the anesthesiologist and others, and we always explain to the patients, like, this is a team like, like you said, it’s not one person. The nurses have to be on board with what’s going on, the surgical tech, the blood bank, right? You know, we talk to the blood bank in advance. You know, all these things have to be coordinated, and it’s absolutely true, first of all, just common sense, but also it’s been shown in multiple studies that two people with the same diagnosis of placenta accreta, one of whom is in a environment where things are planned, prepped, prepared, ready to go versus someone who’s just sort of like winging it, it’s night and day what the differences are. I mean, it’s literally the difference between life and death potentially. It’s crazy.

Dr. Einerson: That’s right. We try to get as many doctors and providers thinking about these patients as possible in advance of their surgery so that if something happens urgently and they come in the middle of the night, it’s not people thinking about their specific case for the first time. And the way that we do that at Utah is to have an interdisciplinary conference every month to talk about all of the upcoming and all of the past, recently past cases. What this does is helps make sure that I as the person who saw them for the consult, I’m on the same page with the anesthesiologist, with the other surgeons who are gonna help me out, sometimes with a radiologist who may be doing procedures on them, with a trauma surgeon in case they go to the ICU and with, you know, a laundry list of other team members who also want to be involved in the care of these patients.

And so it’s a big conference of 4 or 5 different specialties and 15 to 20 people that get together every month and really mentally prepare for when this patient’s case happens, whether it happens on the day of their intended delivery or in the weeks preceding it because they have a reason to deliver early. For us, it’s been a great way to all get on the same page. Some places do it like, you know, with a common email or with, you know, a phone call between a couple of the people who are gonna be taking care of those, but it’s hard to understate how important that interdisciplinary communication is. And like you said before, every study that’s ever looked at it has shown that interdisciplinary care that’s coordinated across specialties is superior in terms of safety than just, you know, the docs, the OB sees the patient or the MFM sees the patients and just sort of takes care of them by themselves.

Dr. Fox: It’s not the same thing as, let’s say, you know, building a house, right? So if I’m a general contractor, and I’m building a house from scratch for somebody, okay, so I’m coordinating. I got my person who does the framing, and I got my person who does the plumbing, and my electrician, and my roofer, and my painter. They don’t need to speak to each other. I can just tell, you know, the framer, “Here’s the plans. Frame these 12 rooms.” And then tell the plumber, “Here’s what we’re doing. Here’s where the toilet’s gonna be. Here’s where the sink is gonna be, you know, put the pipes in.” And, honestly, if the plumber and the framer never speak to each other, never meet each other, it probably doesn’t matter. I mean, maybe it’s nice if they know each other in case there’s, like, something that comes up, but it doesn’t make a big difference.

But for this, it’s not like that, right? Because there are so many decisions that have to be made that are dependent one on another and they’re intertwined, and you can’t just have the anesthesiologists working in, you know, her or his silo and the blood bank in their area and, like you said, the trauma surgeon, they’re like… Everyone needs to know and discuss this here. What are we doing? You know, what kind of incision are we making? What do we expect the time of surgery? Are we planning the hysterectomy? Are we gonna do a wait-and-see approach? Are we putting in balloons? Are we not? And, like, all these things of, when are we admitting? Are we giving steroids? You know, all this stuff. And then there’s also the social component, you know, who is their support system? Who’s their family? You know, what’s gonna happen? And everyone needs to be on the same page or it just doesn’t work well. And that is critical. And that’s also part of the reason why places that do this more frequently are used to this and the people know each other already, and they have a relationship, and they’ve had cases together, and they have experience together. And they have that working sort of, like you said, muscle memory of doing these cases, and, you know, that’s important.

Dr. Einerson: Because this is my area that I’m most interested in, I have close relationships with random people in anesthesia and surgery and radiology than I do with even some of my other OB-GYNs in my department. Not because I don’t like my OB-GYNs in my department, but because I am critically dependent and my patients are critically dependent on me having a good relationship with multiple specialties.

Dr. Fox: Right. You need their cell phones, you need…like, you need to be able to call them and, you know, text them and know exactly and they know who you are and they know that you know what you’re doing. And, I mean, we’re saying it over and over because it’s so critical. It changes everything with the management here. We don’t have to get into the nitty-gritty of, like, the surgical details because, you know, frankly, it’s not gonna be relevant to our listeners, exactly what happens. But, A, are there people who have a placenta accreta for whom you will potentially not do a hysterectomy and, B, how do you make that decision with them? Like, who potentially could have an accreta and still walk out of the hospital with their uterus?

Dr. Einerson: It’s a question that I think we still need more information about, but in my current practice, the people who probably have the best chance are those who have what we suspect to be accreta but is not a previa. So that’s an area of stuck placenta somewhere that’s not low down. Because what can sometimes happen is that you get inside and you have somebody who had a scar from a prior myomectomy, which is a fibroid removal, or D&C, or maybe they’ve just had in vitro fertilization, and then they have a area of placental adherence. And what can oftentimes be done is just to have that part of the uterus sort of, like, taken out with the placenta and then sewn back over. So there are… And this isn’t super common, honestly. It’s not something I recommend a ton, in part, because most of the accretas that I see, most of the patients who I see with accreta don’t fit that profile. Most of them have previa. But for the 10% or so who don’t, there is a chance that if they want to keep their uterus, they can by just sort of taking out that specific area of the uterus.

Dr. Fox: You mean, like, you sort of, like, cut out the placenta and the muscle of the uterus, take it all out together and then sew back the uterus that’s remaining? Like, take out a… It’s called a wedge resection or sort of a clinical term to take out a chunk of the uterus, so to speak, and just sew the rest back together.

Dr. Einerson: That’s right. Like, if it’s confined to a very small area on the middle of the upper part of the uterus, there’s a chance that when the placenta doesn’t come out, we can isolate that small area that’s affected, take out the underlying muscle with it and sew the uterus back together. And that’s probably…for a lot of patients, that is a lower risk procedure than having the whole uterus taken out. But for most patients who have accreta, specifically if it’s a previa, that’s not a good option because what placenta accreta does, honestly, is kind of destroys the lower part of the uterus. So even if you could sort of remove the placenta without totally removing the uterus, it would cause, first of all, a ton of bleeding, and second of all, there won’t be a lot of normal uterus to put back together. There are other parts of the world and other investigators who are looking at the possibility of leaving placentas in place.

Dr. Fox: Yeah. Let’s talk about that because people…that’s big on the Google, the Google is big on this one. Yeah. This is a definitely a Google one. It’s real, people do it. You know, good doctors do it, but it is complicated. So explain what exactly happens in that situation.

Dr. Einerson: Yeah. So for the patients who opt for this treatment, it’s generally conservative management, which is sort of a weird name for it, but leaving the…

Dr. Fox: Yeah. I don’t know, I don’t think that’s so conservative.

Dr. Einerson: Leaving the placenta in place and letting it slowly absorb away [crosstalk 00:18:23].

Dr. Fox: So you do a cesarean, right? You make an incision in the uterus, break the water bag, baby comes out, clamp the cord, cut the cord, baby goes to the pediatricians, the parents, you know, like a typical cesarean. And then instead of trying to remove the placenta, you do what? Or instead of removing the uterus also, you do what?

Dr. Einerson: You cut the cord very short, tie it off, and leave the placenta in place and then watch for a little while and make sure that initially there’s not a lot of bleeding and then sew the uterus up, watch for a while to make sure that there’s no bleeding, and then sew the abdomen back up. Yeah.

Dr. Fox: For the patient, it’s essentially having a cesarean, right? It’s just like a cesarean, again, if it works, except when it’s done, instead of the uterus being empty, there’s a placenta left inside that is still stuck. And what is the thought that it’s just gonna sort of shrivel up and go away or that it’s gonna fall out later? Or what is the hope, I would say?

Dr. Einerson: The hope is that it will shrink inside of the body and not detach like a placenta is sort of designed to do. So one of the problems with it is if it’s only partially attached, the rest of the placenta will actually usually try to detach. And so that could be a problem because then part of the placenta is trying to deliver while the part that is stuck won’t let it. Some of my colleagues in other countries who are commonly performing this procedure will say it’s actually the most severe cases, the most stuck-on placentas might be the best candidates for having conservative management or leaving the placenta in place because you can’t really detach the whole thing stuck on. But the idea is that slowly over the course of months, yes, I did say months, the placenta will slowly go away. And in some parts of the world, this has been described as a reasonable treatment that has decent outcomes, meaning you don’t have a lot of blood loss at the time of C-section because it’s just a C-section and not a complicated surgery. And then for about 75% to 80% of patients who keep their placenta inside, eventually the placenta just sort of goes away or it could be safely removed months later when it’s much, much smaller.

Dr. Fox: Right. And what about the other 25%?

Dr. Einerson: And the other 25% have a major complication. So don’t get me wrong. The current treatment is a difficult and risky procedure, you know, cesarean and hysterectomy. You’re doing a hysterectomy at the time of their delivery, is also a complicated surgery, but the major risks of leaving the placenta inside include an overwhelming infection from the placenta that’s not really supposed to be in the body that’s getting infected or commonly sort of partial detachment of the placenta and tons of bleeding as a result. And so in patients who we perform this for, we give them, like, the strictest instructions on how to return. We send them home with a letter that explains exactly what’s going on in their body so that if they ever have any symptoms of infection or bleeding and they encounter any healthcare provider, that they know exactly who to call, which is us, and they know that it’s an immediate emergency. It’s not a normal retained products of conception. It’s not normal postpartum bleeding. It’s an emergency if this patient starts to bleed. It’s an emergency if this person has signs of an infection. The other idea is that you don’t lose your uterus immediately. For about 15% to 20% of patients, they ultimately will lose their uterus during conservative treatment. But the risks that come along with that benefit are considerable and unfortunately are pretty unpredictable to have patients who… Most patients will have a reason to sort of stop conservative treatment within the first couple of hours or first couple of days, which is why we keep them in the hospital for longer, but some patients will go weeks with no complications and all of a sudden have an infection or a bleeding complications that can be very, very life-threatening and scary.

Dr. Fox: Do you offer this to patients?

Dr. Einerson: I have offered it to patients who come in seeking this as the treatment that they have already gotten consultations on before and select and for patients who have very, very similar disease. So these are patients where you look at the ultrasound and everybody is nervous. We talk about this as being a possible treatment that’s not standard of care in the United States, that is an option that they could consider along with us. But it’s not something that I consider to be the first-line treatment yet. And I’m not sure that it’s ever going to be. If somebody comes right down to it and says, “What do you think is the best treatment?” Almost, you know, the vast majority of patients who have accreta, the best treatment for them if they’ve got it is to have a hysterectomy at the time of their…

Dr. Fox: What would you say in your center, what percentage of women end up attempting what we call the conservative approach to leave the placenta inside? I’m just curious.

Dr. Einerson: Like 5% or less.

Dr. Fox: Yeah. So it’s really uncommon. And I think that’s an important lesson, you know, or message, I would say, for people listening that, you know, it’s Google-able, it’s out there, there are people doing this, and for some people, it’s gonna work, and you’re gonna hear a story that it was…you know, it saved the uterus, so to speak. And that’s absolutely true, but there’s also a lot of, you know, disasters, and it’s just not the common approach in the U.S. It’s not currently the way it’s gonna happen. So most centers are not so comfortable doing this, and the ones that do it are always a little bit uneasy about it, you know?

Dr. Einerson: Yeah. You can hear that uneasiness in my voice. We have done in patients who are insistent upon an attempt at it, but we watch them like hawks and worry a lot more about them, for sure. And almost all of them have come from two, or three, or four, or five other places that were like, “Nope. We don’t do that.”

Dr. Fox: Two more questions I wanna ask you before we wrap up. First question is, let’s say someone thinks she might be at risk for this, right? Either she has a bunch of cesareans in the past or she was told she has a previa or just, you know, she’s seeing doctors and they keep sort of looking at the placenta and they’re not sure, they’re this. And, you know, and she doesn’t feel that confident. What could she do? What are the options for someone in that situation?

Dr. Einerson: This is a really hard place for a patient to be in because it’s almost impossible for a patient to know what the expertise and experience level of their physician is. And it’s not common for patients to sort of have the wherewithal to say, “You know, I’m worried that my doctor might not know exactly what’s going on with this.” So I think patients who are at risk, meaning they’ve had a previa or they have had multiple prior cesareans, should think about asking questions of the person who’s doing their ultrasound, meaning, you know, the people who are reading the ultrasound or their OB-GYN, simple questions like, “I’ve heard about this problem, and I’ve got some risk factors. Do you think I need to see a specialist?” or, “How confident are you that I have, or might have, or don’t have this?” I think those are decent places to start, and patients, I think, feel sometimes like they can’t ask those questions because it sounds like you’re questioning your doctor, but my experience, most doctors don’t mind receiving questions like that, and if they didn’t have it on their radar before, then they’ll at least know that you’re worried about it and you know about it too. And so I think that’s a good place to start, that you just, you know, when you’re having your ultrasound, you say, “You know, I’ve heard that I have these risk factors. Do you think I’ve got placenta accreta?” And that, I think, opens up at least a line of communication where your doctor or your healthcare provider knows that you are aware of this and that they should be aware of it and that it’s something that they’ll need to keep a close eye on.

Dr. Fox: Yeah. I agree. And I think that, as you said, people are usually very hesitant. You know, because people are in general polite and sort of, you know, they like to, you know, defer to the experts, so to speak, and people are…they don’t wanna question the doctors much. I know everyone thinks that patients come in and saying, “You’re wrong. I saw this on Google, and you’re wrong. My sister told me this.” But most people are not like that. Most of them are like, you know, “The doctor knows. I can’t… You know, like, I’m not gonna start questioning.” But one of the ways people can gauge is, you know, if you ask a thoughtful question to your…whether it’s a doctor, you know, whoever’s taking care of you, let’s assume it’s an OB-GYN, and you say like, “Hey, I’ve had two cesareans. The placenta’s kind of low. What are the chances I have an accreta? Like, what do you think?” And just listen to the answer. And if it sounds really thoughtful, like, you know, okay, here’s why I think it is, here’s what I think it isn’t, and here’s what we’ve done in the past, here’s how we do this, here’s how we manage, here’s what happens in my hospital, and they really talk about it intelligently, and honestly, and openly, you’re probably in a good situation. Whereas if they blow you off, or you can’t understand what they’re saying, or it’s pretty clear they don’t know what you’re talking about, it might be time for a second opinion. And I think the simplest place to go for a second opinion or an opinion even if it’s just a first opinion, I would say in the U.S. it’s probably any maternal-fetal medicine specialist, like any, right? Will know enough about this even if they’re not the person who does it, you know…because not all MFMs do these complicated surgeries or run accreta centers, but they know enough to know, you know, how to triage these and say, “This is good. This is bad. You need to do this. You need to do that.” It’s probably the simplest, I would guess, if someone’s trying to figure out how they can see somebody in the U.S. Would you agree?

Dr. Einerson: Yeah. I think that’s right. About half my referrals come from other MFMs. Not every MFM is going to take care of these cases surgically, but I think that most MFMs now in 2021 are going to be cognizant of both the risk factors and the general appearance and location of the placenta that should raise their red flags. And so MFM is a great place to start because most of us should be aware of this problem.

Dr. Fox: Yeah. I mean, it’s part of our training.

Dr. Einerson: Yeah. Exactly. And not everybody who’s getting prenatal care needs to have an MFM do their ultrasound. But if you’ve got the risk factors, it seems like a really reasonable thing to ask for.

Dr. Fox: Let’s say your doctor or someone’s doctor says, “I do suspect you have an accreta, or I’m confident you have an accreta” or whatever it is, how would someone know that they’re gonna be in a place that’s gonna provide excellent care for them? This is really hard, obviously. There’s no good answer to this, and U.S. healthcare is a…you know, it’s got its issues, and we’re not gonna go into all of that, but just practical level, someone’s out there listening says, “My doctor thinks I have an accreta. Am I in the right place? Should I be in Utah? Like, I mean, how do they figure that out?”

Dr. Einerson: It’s a really difficult thing for patients to know. It’s even more difficult to know sort of what your experience level of your doctor is in terms of placenta accreta. But I think there are a couple of hints that I have for patients that may be helpful. So, one, you have to know that you’re not alone and that there are a huge number of women now online and elsewhere who’ve had this problem who can be helpful to you in knowing where some of the busier and better places are to get care. So one resource that I trust that patients can access is the National Accreta Foundation. This is an online group of advocates and survivors of accreta who really have the collective experience to know where they’ve had great experiences and where they’ve found out is not a great place to have your accreta surgery.

And so I think while it’s always a lot difficult to know how much you can trust online forums, and Facebook groups, and everything like that, I actually do trust the National Accreta Foundation to give solid advice on helping patients figure out where to go. There’s a couple of questions that can actually be really helpful. If you’re coming to your next doctor’s appointment, you know you’re at risk for this, they sort of think that you have it, I think there are some reasonable questions to ask that can point you down the right path. The first would be, “Do you think I need to be seen in a specialty center, or do you typically refer patients to a specialty center for this problem?” And sometimes doctors will say, “No. I don’t. You know, I usually take care of these patients, and it goes all right.” Or, “Yeah. I’ve got to refer patients with this problem.” And then you got your answer.

The other question that I ask if your doctor is talking to you about surgery is just to ask them what their experience has been, like how many cases have they taken care of in their career within the last couple of years. And I think there’s no magic number for competence or safety, but I do think that it is generally true in accreta care like in cancer care or any other highly specialized, somewhat uncommon problem that the more you see a problem…the more health system takes care of a problem, I should say, the more prepared they’re gonna be to take care of you in the worst-case scenario. And I just wanna harken back a little bit to previous parts of our conversation by saying that the best centers with the best outcomes are places that take care of multiple people every year that have pathways of multidisciplinary care set up and that tend on the side of being overprepared for cases. And so I think if you’re with your doctor and you’re wondering whether or not they should be the person to take care of you, I think asking about the number of cases they’ve seen, how they prepare for these surgeries, what specific approaches they’re gonna take, I think the overall conversation will lead you to either a place of confidence that they have done this a lot, they know what they’re doing, and they have a team set up or they don’t. And if they don’t, getting a second opinion at a busier place is…and those places you can find on the National Accreta Foundation or online for the Accreta Centers of Excellence are great places to start for a second opinion.

Dr. Fox: That’s really helpful. That’s great advice. And it’s an important message for people listening to know that this is…it is more common now than it used to be because of more cesareans are being done, you know, than used to be. But it’s still not that common. Most people who’ve had prior cesareans are never gonna have this. You know, they’re not gonna have that, you know, confluence of prior cesareans plus previa equal accreta and all this stuff. And so it’s something to be cognizant of, but it’s not something that I think people need to sort of, like, sit up at night worrying about, “I’ve had two C-sections. If I get pregnant again, you know, is it gonna be horrible?” Because that’s not typically the case. And, number two, even for someone who has an accreta, in the situations where it is suspected or diagnosed or highly suspected and you’re in a good center, the overwhelming likelihood is you will have a very detailed and potentially stressful pregnancy and intricate plan for delivery, and you will deliver and walk out of the hospital holding a healthy baby. And that’s the most likely thing that’s gonna happen if you’re getting good care. And I just think that that’s an important message, that it’s not something that we do to freak people out, but more so just explain, “This is complex. You got to know you have it, you need people to know what they’re doing, but if you are and they are, you should be okay.” Almost always.

Dr. Einerson: Absolutely. There’s a ton of uncertainty, and we can provide very little absolute answers in this situation, but if you’re at a place that sees patients like this all the time, you’re in good hands.

Dr. Fox: Brett, thank you so much for coming on the podcast. Thanks for taking so much time out of your vacation to do that. I really appreciate it. But it’s important to me, it’s important to our listeners to hear about this critical condition and important and sometimes confusing for patients, this condition, from someone who is an expert and someone who explains things well. You’re certainly one of those people, and I’m just really thankful that you agreed to do this.

Dr. Einerson: Thank you. I had a great time.

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, 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. The information discussed in “Healthful Woman” is intended for educational uses only and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.