A Team Approach to Managing a High-Risk Pregnancy

Quick Case Study

A 39-year-old woman consulted Duke Women’s Health Associates when she became pregnant with her second child. Her first pregnancy had required labor induction and cesarean delivery because the pregnancy had lasted well beyond her estimated date of delivery.

Results of routine ultrasonography performed at 18 weeks revealed placenta previa. She was referred to the Duke Maternal-Fetal Medicine (MFM) team, who specializes in high-risk pregnancies, to continue her care.

Question: What potentially dangerous condition was the patient at a high risk for, and how did the MFM team aid her in having a safe delivery?

Answer: The patient’s history and ultrasonographic findings were highly suggestive of placenta accreta. MFM assembled a multidisciplinary team to monitor the patient’s blood pressure and to decrease her risk of morbidity, blood loss, and pain during delivery and hysterectomy.

Chad Grotegut, MD, explains that MFM has a set management approach to treating women with ultrasonographic findings suggestive of placenta accreta, such as coexisting placenta previa, particularly for those with a history of cesarean delivery. Key to this approach is involvement of multiple disciplines at Duke, all of whom meet with the patient prior to delivery.

“We have assembled a highly skilled, multidisciplinary team to manage women with placenta accreta, as there is a high risk of catastrophic maternal hemorrhage and high rates of maternal mortality associated with the condition,” Grotegut says. “Our team includes MFM, obstetric anesthesia, interventional/vascular radiology, gynecologic oncology, neonatology, labor and delivery, and perioperative nursing.”

To ensure the full team would be present for the delivery, every step was planned and carefully scheduled. The patient required an early delivery to minimize her risk of going into labor or experiencing a large bleeding episode that would require an emergent delivery, so the MFM team scheduled her for cesarean delivery at 35 weeks.

On the day of delivery, an obstetric anesthesiologist inserted an arterial line to monitor her blood pressure and 2 epidural catheters to control her pain. Grotegut explains that the second epidural is placed above the standard epidural because a high incision is required on the abdomen to allow for a safe delivery.

A vascular radiologist then placed a large intravenous line into her right femoral artery so embolization to the uterine arteries could be performed to decrease blood loss if hysterectomy was required.

To deliver the neonate, a perinatologist made a vertical incision in the patient’s abdomen, followed by an incision high up on her uterus to avoid disturbing the placenta. After the delivery, the placenta failed to separate from the wall of the uterus, confirming that the patient had placenta accreta. Thus, hysterectomy was necessary.

The MFM team quickly closed the uterus, and, to decrease blood flow during the hysterectomy, the vascular radiologist performed uterine artery embolization. With the assistance of the gynecologic oncology team, the MFM team then performed hysterectomy.

Grotegut reports that both the mother and her infant had a smooth recovery and are doing well.

“This case illustrates Duke Labor & Delivery’s ability to handle very complex cases,” Grotegut remarks. “Placenta accreta is a very challenging obstetric condition and is becoming increasingly common as the cesarean delivery rate in this country has increased over the last 10 to 20 years. At Duke, we strive to take care of women across the Southeast who have pregnancy complications like placenta accreta.”

Placenta Accreta:
Recognizing the Signs

Health care professionals performing ultrasonography on pregnant women should have a high index of suspicion for placenta accreta, especially in women with placenta previa and a history of cesarean delivery. Classic findings on ultrasonography include:

  • Loss of border between placenta and uterine wall
  • Presence of lacunae or vascular spaces within body of placenta
  • Increased vascularity under placenta
  • Thin myometrial thickness under placenta

Early referral to centers such as Duke with a multidisciplinary team and expertise in placenta accreta may improve patient outcomes.