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Placenta problems in VBAMC/ after multiple repeat cesareans

I thought that I would take the data from the Silver (2006) that I’ve previously discussed and share it in a different way that would be helpful to women with multiple prior cesareans.  (You might find it worthwhile to read this article specifically, where you can view the data below in graphs, as well as other articles on placental abnormalities first.)  Remember that accreta is when the placenta abnormality deeply attaches into the uterus requiring surgical removal.  There is a 7% maternal mortality rate with accreta as well as a high rate of hemorrhage and hysterectomy.   One of the factors that determines your risk of accreta or previa is your number of prior cesareans.

Whether a mom has a repeat cesarean or a VBA1C, her risk of accreta (including increta and percreta) and previa in that pregnancy are:

risk of accreta: 0.31% (1 in 323)
risk of previa: 1.3% (1 in 77)
risk of accreta if previa is present: 11% (1 in 9)

Whether a mom plans a third cesarean or a VBA2C, her risk of accreta and previa in that pregnancy are:

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta if previa is present: 40% (1 in 2.5)

If a mom plans a fourth cesarean or a VBA3C, the risk during that pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta if previa is present: 61% (1 in 1.6)

The jump in risk from two prior cesareans to three prior cesareans is pretty huge…

If mom plans a fifth cesarean or a VBA4C, the risk during that pregnancy increases to:

risk of accreta: 2.33% (1 in 43)
risk of previa: 2.3% (1 in 43)
risk of accreta if previa is present: 67% (1 in 1.5)

If mom plans a sixth cesarean or a VBA5c, the risk during that pregnancy increases to:

risk of accreta: 6.74% (1 in 15)
risk of previa: 3.4% (1 in 29)
risk of accreta if previa is present: 67% (1 in 1.5)

Here are some stats to consider:

Silver (2006) found the following rates of accreta (including increta and percreta), during the first, second, third, fourth, fifth, and sixth cesareans: 0.24%, 0.31%, 0.57%, 2.13%, 2.33%, 6.74%.  (View a graph of this data.)

In other words, your risk of placenta accreta increases from first to sixth cesarean delivery:
1 in 417,
1 in 323,
1 in 175,
1 in 47,
1 in 43,
1 in 15.

Read more about accreta.

The studies that have been conducted (that I’m aware of) on uterine rupture in VBAMC are kind of small (including hundreds, not thousands of women).  So I don’t think we have an accurate idea of VBA3C rupture risk.  This site is a great resource.

Update:  When I posted a link to this article on Facebook, a mom left this comment:

Thank you for posting. My friend had 2 previous c-sections, and with her 3rd pregnancy had the bad luck of having both placenta accreta and placenta previa (both risks of repeat c-section). Her pregnancy was awful..lots of bleeding, hospitalizations, steriods and other drugs to help hold onto the pregnancy and bedrest at 20 weeks. They couldn’t do cerclage because of the placenta previa). In the end she had a healthy baby, but a 5 hour c-section surgery where she lost a lot of blood and needed a blood transfusion of 6 units of blood. She had to have a hysterectomy and also they removed part of her bladder because her placenta had embedded so far it was attached to her bladder! She was pissed that her doctor never warned her of the risks of repeat c-sections. She is 39 years old.

[and]

yes, you can share my comment. again, my friend ultimately is ok bec she was planning on having her tubes tied after this 3rd unplanned pregnancy — but she was upset initially bec her OB never shared with her any of these risks of repeat c-section…and she said “had I known, I would have really pushed for a vbac with #2″

These are the complication rates that Silver 2006 found in 30,000
women during multiple cesareans.The rates quoted were what he found during the third CS but, I think
the accreta and previa rates illustrate the risks that are present
during a third pregnancy after two prior CS.In other words, whether a mom has a third CS or a VBA2C, her risk of
accreta and previa in that third pregnancy are:

risk of accreta: 0.57% (1 in 175)
risk of previa: 1.14% (1 in 88)
risk of accreta *if* previa is present: 40% (1 in 2.5)

If she has a third CS and becomes pregnant again, the risk during that
fourth pregnancy increases to:

risk of accreta: 2.13% (1 in 47)
risk of previa: 2.27% (1 in 44)
risk of accreta *if* previa is present: 61% (1 in 1.6)

Compare that to the risks in a first pregnancy:

risk of accreta: 0.24% (1 in 417)
risk of previa: 6.4% (1 in 16) [yes, that figure is correct, previa was the reason for many of these women's primary CS]
risk of accreta *if* previa is present: 3% (1 in 33)

That means the risk of accreta increases 887% from the first pregnancy – a huge jump.

So, if it was me, getting that ultrasound and knowing I didn’t have these complications would give me huge peace of mind.

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10 comments to Placenta problems in VBAMC/ after multiple repeat cesareans

  • Dina

    I am a Mom that has had ten cesareans…. Have not had one medical complication due to the multiple cesareans, short term or long term over 25 years. I became a midwifery student and it was the first time I had heard of accrecia… I wondered why my OB was always so happy to announce that my place at was “high and at the back!”…. With these statistics….. I guess I have been “LUCKY!”. I’m not a fan of medical interventions!!!! I’m a product of being uninformed and lied to- my cesareans were ALL unnecessary!!!! But having this accrecia information- it is THE ONE thing, medical testing, that I would have if considering VBAC…. Make sure you “know” WHERE the placenta is. I would have an ultrasound to confirm. There are RISKS associated with repeat cesareans AND VBACS… It is really up to the woman to know her options. We as women cannot rely on medical people to “tell us the truth”. It is our personal responsibility to decide for ourselves. XOXO

  • I’m 24 weeks pregnant now and I’ve been diognosed with plasenta preevier ,acreater there not sure if it has attached it self to my bladder to this is my 4th baby now and will be my 4th csection.
    I’m pretty scared about when they deliver baby thoe .

    • Jen Kamel

      Kelly,

      The good news is, you know about the accreta/previa before labor. This gives your OB time to make the necessary special arrangements that will result in a better outcome then if it was diagnosed in labor. As scary as it is, you really do have a leg up because you know so early in your pregnancy.

      Best of luck and keep me posted!

      Warmly,

      Jen

  • Dina, I’m so sorry you were lied to! I was as well. My dr told me that VBACs were incredibly dangerous and that it was safe to have 9 cesareans. She told me that the risks do not increase and then downplayed the initial risks. She didn’t tell me about placenta problems, either. Since then I’ve had a hard time finding an OB willing to do repeat cesareans on me (nor do they want to do VBACs) and are shocked I was “allowed” to get pregnant with my fifth, sixth and seventh pregnancies. Like you, if I had known I would have insisted on that first VBAC. She was frank breech but only 5 lbs/34 weeks and I was nearing transition. I’m now a doula and training to be a midwife and hope to help women educate themselves as well!

    • Jen Kamel

      Sarah,

      I am so sorry. That is the secret truth about post-cesarean births. VBAC is a very important option especially for moms planning large families. It is unfortunate that family size is often not considered when moms are faced with their first post cesarean birth. As you know, once a mom has two cesareans, the number of providers willing to attend her VBACs greatly diminish if not totally disappear. It is my goal to share the information I have on this site so that women may understand the ramifications of post-cesarean birth options and how their future birth options are massively impacted by their current mode of delivery.

      Warmly,

      Jen

  • DEE

    i have had 3 cecerians the last one was due only to the fact that i could not find a doctor to deliver me regularly. i am confused on what to do with my current pregnancy, i realy want a large family and even though my dr tells me i can have at least 15 surgerys, i am a bit sceptical. it is very dificult that there is no solid suport to turn to to ask question of an objective perfresional, thank you dee

    • Jen Kamel

      Dee,

      A good place to start on info is here.

      I’ve also posted your question on Facebook to get additional feedback.

      Best,

      Jen

    • Jen Kamel

      Dee,

      The risks of cesareans increase at a statistically significant rate as the number of prior cesareans increase.

      There are women who have VBACs after three cesareans (VBA3C), but it can be hard to find a care provider depending where in the world you are.

      The evidence on the risks of VBA3C is limited, but you can review what we know here.

      I’ve also posted your comment on Facebook so you can get more feedback.

      Best,

      Jen

  • Silvia

    I hate all my previous obs for not telling me the risks of accreta when electing my rcb, but they would always tell me the risks of vbamc :’(