19wks to 23wks

At 19wks I learned that I had complete placenta previa (cpp) as well as placenta accreta, if not percreta. Accreta is a general term to define accreta (the placenta attaches to the uterine wall), increta (the placenta attaches through to the outer layer of the uterine muscle) and percreta (the placenta grows outside of the uterus, usually attaching itself to the bladder, pelvic wall, bowels, etc). The placenta will have a 'swiss cheese' or 'lakey' appearance. Delivery for these types of conditions is at 34 weeks. Although some OB's have pushed it back to 35-36wks. It has been shown the longer a woman with accreta is pg passed 34 the increased chances of bleeding occurs (I have a graph per Baylor College of Medicine that I need to dig up and upload).
An excerpt from ACOG:

ABSTRACT: Placenta accreta is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate. Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either an anterior or posterior placenta previa overlying the uterine scar. Diagnosis of placenta accreta before delivery allows multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. Grayscale ultrasonography is sensitive enough and specific enough for the diagnosis of placenta accreta; magnetic resonance imaging may be helpful in ambiguous cases. Although recognized obstetric risk factors allow the identification of most cases during the antepartum period, the diagnosis is occasionally discovered at the time of delivery. In general, the recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ because attempts at removal of the placenta are associated with significant hemorrhagic morbidity. However, surgical management of placenta accreta may be individualized. Although a planned delivery is the goal, a contingency plan for an emergency delivery should be developed for each patient, which may include following an institutional protocol for maternal hemorrhage management.

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Placenta accreta is a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall (1). When the chorionic villi invade only the myometrium, the term placenta increta is appropriate; whereas placenta percreta describes invasion through the myometrium and serosa, and occasionally into adjacent organs, such as the bladder. Clinically, placenta accreta becomes problematic during delivery when the placenta does not completely separate from the uterus and is followed by massive obstetric hemorrhage, leading to disseminated intravascular coagulopathy; the need for hysterectomy; surgical injury to the ureters, bladder, bowel, or neurovascular structures; adult respiratory distress syndrome; acute transfusion reaction; electrolyte imbalance; and renal failure. The average blood loss at delivery in women with placenta accreta is 3,000–5,000 mL (2). As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells. Maternal mortality with placenta accreta has been reported to be as high as 7% (3). Maternal death may occur despite optimal planning, transfusion management, and surgical care. From a cohort of 39,244 women who underwent cesarean delivery, researchers identified 186 that had a cesarean hysterectomy performed (4). The most common indication was placenta accreta (38%).

Incidence

The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate. Researchers have reported the incidence of placenta accreta as 1 in 533 pregnancies for the period of 1982–2002 (5). This contrasts sharply with previous reports, which ranged from 1 in 4,027 pregnancies in the 1970s, increasing to 1 in 2,510 pregnancies in the 1980s (6, 7).

Repeat Cesarean Delivery and Other Risk Factors

Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either anterior or posterior placenta previa overlying the uterine scar. The authors of one study found that in the presence of a placenta previa, the risk of placenta accreta was 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater repeat cesarean deliveries, respectively (8). Placenta previa without previous uterine surgery is associated with a 1–5% risk of placenta accreta. Besides advanced maternal age and multiparity, reported risk factors include any condition resulting in myometrial tissue damage followed by a secondary collagen repair, such as previous myomectomy, endometrial defects due to vigorous curettage resulting in Asherman syndrome (9), submucous leiomyomas, thermal ablation (10), and uterine artery embolization (11).

From there, at 20wks I went to the perinatologist. She concluded that I don't have cpp, although there is a piece of the placenta hanging over my cervix. My placenta is just not normal looking, period. Dx's from her, placenta accreta with a low lying placenta. She also suspected a partial placental abruption as well. I go back at 26wks to check things out. From there we'll get transferred to another OB/Peri/Hospital. Where? Well that's the million dollar question...literally. My husband and I are completely comfortable with traveling out of state to a more competent hospital. One that sees cases like this 40-60 times a year. From PA to VA, when I tell L&D nurses, OB's and the peri this number they were shocked. No hospital around here sees that many. From experiences from other women, this surgery could cost upwards towards a million. Then you factor in NICU costs and well we are looking at 1.3 million dollars. I have 100% maternity coverage...in VA. That means if we were to travel out of state we have to pay 20% of 1.3 million dollars....Sure I could stay in VA and deliver and probably make it out alive but am I willing to bet my life on it...? I'm thinking not. My Peri actually wants me to deliver right here, in a tiny little city (I call it a town, people around here call it a city) that is a level 2 trauma unit, if that. Their blood bank probably isn't capable of handling a hemorrhage as catastrophic as this surgery is known for. I feel she just wants to put her hands on me, use me to boost her, 1, accreta case just to say she has experience. Let's face it, these Dr.'s are privy to the fact that there WILL be more accreta cases popping up all over. Just read the stats above. With all the repeat sections, it's only going to get worse.