URBANA — Brittany Krisman was 24 weeks pregnant with her third child when she found out something at a routine ultrasound that would likely frighten any expectant mom.
“A nurse practitioner told me, ‘The good news is your baby is perfectly healthy,’” Krisman recalled. “‘But you have something going on.’”
Before the nurse could explain, Krisman, of St. Joseph, said she noticed the word “accreta” on her paperwork and began to cry.
“I said, ‘Oh my gosh, do I have accreta?’” she asked the nurse.
Because she’s a neonatal nurse at Carle Foundation Hospital, Krisman was well familiar with what that condition means.
Placenta accreta is a potentially life-threatening pregnancy complication in which the placenta grows too deeply into the wall of the uterus.
It isn’t the most prevalent pregnancy complication that can lead to maternal deaths in the U.S., but it’s been on a notable rise in the past few decades — as have pregnancy-related deaths themselves.
Since the 1980s, the number of accreta pregnancies has quadrupled, from one in 1,250 births to one in 272 as of 2016, according to the National Accreta Foundation. One of the major factors in the increase has been the steady rise in cesarean section births in the U.S.
Having a previous C-section birth, or births — as Krisman did out of medical necessity with her previous two pregnancies — significantly raises the risk for placenta accreta and the massive hemorrhaging that can come with it.
Krisman considers herself one of the fortunate ones, because this condition was caught for her in time for precautions to be taken.
For her, that meant spending the rest of her pregnancy in Carle hospital on bed rest and having her condition monitored closely.
Her son, Crew, now age 2, was born six weeks early — a healthy, nearly 6-pound baby, through another C-section birth, which is standard for accreta deliveries, she said.
That close monitoring ahead of the birth — plus having enough blood of the right type on hand for expectant mothers with accreta — are important for safe deliveries, according to Carle’s Jamie Mullin.
“You can have a lot of blood loss,” she said. “That’s where the danger part comes in for the moms.”
Higher death rate
It’s important to note that most women have safe and uncomplicated pregnancies, according to Dr. Daniel Mandel, a Carle maternal fetal medicine specialist.
Still, there are 700 pregnancy-related deaths a year in this country, with three out of five of those deaths considered to be preventable.
And while the number of pregnancy-related deaths in the U.S. is small compared to the number of live births, those deaths have increased in recent decades — from 7.2 deaths per 100,000 live births in 1987 to 17.2 deaths per live 100,000 in 2015, the most recent year for which national data is available.
Counted among those deaths are not only those that occur during pregnancy and delivery but deaths that occur up to a year after delivery when they result from pregnancy-aggravated conditions or complications.
In comparison with other developed countries, the U.S. falls at the bottom of the heap in terms of maternal safety.
A Commonwealth Fund study released in December set America’s maternal death rate a bit lower at 14 deaths per 100,000 — but even at that lower rate, the U.S. still had the highest rate of pregnancy-related deaths among 11 high-earning nations.
The maternal death rate in Sweden, for example, was 4 per 100,000 births.
Among the contributing factors in the U.S., researchers found, were lack of prenatal care and higher rates of obesity, heart disease and diabetes.
Not only that, the U.S. had among the highest rates of C-section births among the 11 countries, plus higher percentages of out-of-pocket costs and problems affording medical bills.
Women are more likely to die in the context of pregnancy when they’re socially/economically disadvantaged, older, heavier or haven’t had prenatal care, Mandel said. Race is also a factor, with black women much more likely to die from their pregnancies than women of other races.
Mandel called the rise in placenta accreta deaths in the U.S. “pretty dramatic.”
“A couple of decades ago, we were talking one or two in thousands,” he said.
In Illinois, 72 percent of pregnancy-related deaths were considered preventable, according to a state Department of Public Health report last fall.
From 2014-16, pregnancy-related deaths were three times higher among black women than non-Hispanic white women and much higher for moms over age 40 than those who were younger, according to the state report. Findings also include more than twice as many pregnancy-related deaths for women on Medicaid than those on private insurance and the number of pregnancy-related deaths among obese women at more than double those among women at normal weights.
“We’re definitely seeing maternal mortality and morbidity increasing in the U.S., not decreasing,” said Dr. Robert Abrams, Southern Illinois University’s chief of maternal-fetal medicine and a member of the state’s maternal mortality review committee.
In terms of elevated risks during pregnancy, what doctors are seeing more of these days are women with hypertension and preeclampsia, a pregnancy complication characterized by high blood pressure, Abrams said.
Hypertension raises the risk for heart disease and stroke — two conditions which account for about one-fourth of pregnancy-related deaths, according to the American College of Obstetrics and Gynecology.
For the safest pregnancies and deliveries, he and Mandel advise women to begin pregnancy in their best possible health and to get consistent prenatal care. And for some women planning a pregnancy, pre-pregnancy counseling is also in order.
Abrams said he can’t stress enough how important that consultation is for women who are, for example, obese and those who already have such chronic diseases as diabetes and hypertension to make sure their diseases are being well-managed and that pregnancy will be safe for them.
In some cases, he said, he’ll advise diet, exercise and appropriate medications for women before they conceive.
“The other thing I tell them is pregnancy, in and of itself, is kind of like a cardiovascular stress test,” he said. “Your body has never been this stressed.”
It’s not all on the women, though.
The state panel on which Abrams serves has also called for some changes at the state level, among them extending eligibility for Medicaid coverage from two months after the delivery to a year after and creating or expanding home visiting programs to target high-risk mothers during pregnancy and after the birth.
Medical providers can also do a better job assessing pregnancy-related risks for women, he said.
The most important prenatal visit is the first one, and doctors should carve out enough time to take a full medical history, assess the risks and, for those women at higher risk, refer them to a maternal fetal medicine specialist, Abrams said.
Annual gynecology exams are another opportunity to head off pregnancy complications. At those exams, providers can talk to women about their risks if they become pregnant and advise how to optimize their health, he said.
Abrams said Illinois has made some strides in improving maternal safety — for example, through an initiative in which hospitals have been working together to reduce hypertenstion-related maternal deaths.
And, he said, thankfully, efforts to recognize and treat more women at risk for hemorrhage have paid off in fewer of those deaths.
Hospitals such as St. John’s in Springfield and Carle also have established systems in place to connect women in rural areas with high-risk or potentially high-risk pregnancies to maternal fetal medicine specialists.
Since Krisman’s case, Mandel said Carle has also launched a placenta accreta spectrum project that includes educating the moms about the risks and having plans and a multidisciplinary team in place for care and a safe delivery.
“We sat down and said: Hey, this is something that is really important and we’re seeing a lot more of these,” he said.