For Wilson resident Ashley Long, it was a wonderful surprise: seeing not one but two heartbeats during a routine prenatal ultrasound.
“They told us about the twins at our nine-week appointment in October. We were super shocked, excited and scared,” Long says.
That early ultrasound was at Arbor ObGyn in Raleigh; for her more in-depth, 20-week anatomy scan, Long went to UNC Maternal-Fetal Medicine at REX. Unfortunately, that appointment was less exciting and more frightening.
Long’s doctor, Elizabeth Coviello, DO, and William Goodnight, MD, who interpreted her ultrasounds, became concerned that Long had placenta previa. That’s when the placenta, the organ that develops to provide nutrients to the baby, partly or completely covers the cervix, the opening to the birth canal.
The physicians also suspected Long was dealing with a more severe and unusual condition: placenta accreta, in which the placenta attaches too deeply into the uterine wall. Both conditions can cause severe bleeding and preterm birth; they typically require a C-section birth and sometimes removal of the uterus at the time of delivery.
Placenta Accreta and Placenta Previa
Normally, the placenta easily detaches from the wall of the uterus after delivery, but with placenta accreta it cannot.
“In a placenta accreta, the tissue doesn’t just connect to the uterus; it grows in and through the wall of the uterus. So there is no good way for the placenta to come off. If you remove the placenta, large blood vessels can open and rupture, causing the mother to bleed a dangerous amount,” Dr. Goodnight says.
But research published in 2016 found that the rate of placenta accreta in the United States was 1 in 272 for women who had a birth-related hospital discharge diagnosis. That was a higher rate than had been seen before, according to the American College of Obstetricians and Gynecologists.
“The condition has increased over the last several decades because the greatest risk factor for placenta previa and placenta accreta is a prior cesarean. As we continue to have more cesarean deliveries, the risk of placenta accreta goes up,” Dr. Goodnight says.
Long had a prior cesarean delivery while giving birth to her daughter Brynley, now age 3. For this pregnancy, Long had already decided to have another cesarean delivery, but her diagnosis made it more necessary—and possibly more complicated.
“From January to when we delivered, it was an up-and-down roller coaster. I thought I could have a rupture or bleeding at any moment. It was a really scary time for me and the babies,” Long says.
A Team Approach to a Complex Case
Surgical planning began quickly for this complex case. Placenta accreta requires an experienced, multidisciplinary team of experts working together to keep mom and baby healthy.
Dr. Coviello organized and directed the team of experts in maternal-fetal medicine, obstetric anesthesia, urology, gynecologic oncology and transfusion medicine who joined with blood bank personnel and intensive care unit providers.
A few days before Long’s planned surgical delivery on April 29, the group reviewed the plan for delivering Long’s babies safely. The date was chosen to get Long to 34 weeks; women with placenta accreta typically have C-sections between weeks 34 and 36 of pregnancy (a pregnancy is typically 40 weeks).
But on April 25, Long started to feel strong cramping in her stomach.
“The Saturday before my planned delivery, I ended up having one big contraction and I started to bleed. I was rushed to the hospital at Rocky Mount, and then I was transported to UNC,” Long says.
Because of the coronavirus disease (COVID-19) pandemic, UNC Health’s no-visitor policy was in place at the time. To monitor Long’s high-risk pregnancy, she was transferred to the antepartum (before birth) floor. Her husband, Bry, could not be with her during that time.
“It was hard on both of us. I was on the antepartum floor alone for three days. I just kept staying positive knowing I was so close to seeing my babies,” Long says.
But the pandemic did not slow down Long’s team of doctors and nurses, who monitored her closely in the hospital.
“Delivery before 34 weeks would have been indicated for fetal distress, maternal hemorrhage or preterm labor. She was too high risk to be at home, but we didn’t want to deliver before 34 weeks if not truly indicated,” Dr. Coviello says.
Long’s husband was able to reunite with her on April 28, and the next day, as planned, the operation began. Through a cesarean delivery, the UNC medical team’s plan was to remove the placenta and perform a hysterectomy to remove the uterus. Placenta accreta is almost always treated with a hysterectomy to avoid life-threatening bleeding.
“So all at the same time, we had to make an incision in the uterus, not disturb the placenta, deliver the babies, leave the placenta in place, and then expeditiously perform a hysterectomy—taking out the placenta and the uterus—while avoiding excessive bleeding,” Dr. Goodnight says.
The process took about three hours, but at the end, Long had her twins: a boy named Wallace who weighed 4 pounds, 14 ounces, and a girl named Brooklyn who weighed 5 pounds, 8.9 ounces.
“They came out two minutes apart. We heard their little cries, and my husband and I were so thrilled,” Long says.
Both babies were transported to the neonatal intensive care unit for observation, and Long moved to the postpartum floor within 12 hours after her surgery. She avoided needing treatment in the intensive care unit.
“Ashley did an amazing job. Her pain was very well controlled with oral medications, and she did not require any more blood product transfusions, which was remarkable,” Dr. Coviello says.
The Longs are doing well as a family of five, and Long is still feeling a major sense of relief that everything ended so well.
“I’m so grateful, and I can’t say enough good things about the nurses and doctors,” she says. “They took really good care of us during a really scary time.”
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