Psychological impact of abnormally invasive placenta: an underestimated and hidden morbidity

Introduction

Abnormally invasive placenta (AIP) is a pathological entity characterized by the abnormal insertion of the placenta into the implantation site with an incidence that ranges from 1:93000 to 1:111 pregnancies [1]. Among different types of abnormal placentation, classified according to the degree of placental villi invasion into the myometrium, placenta accreta represents a major complication of pregnancy and is associated with an increased risk of maternal morbidity and mortality [2], [3], [4]. The increasing rate of cesarean delivery over the past 50 years has greatly contributed to the increase in the occurrence of this complication [5]. In fact, although several risk factors have been reported for this condition (such as submucous myoma, advanced maternal age and hypertension), a previous cesarean delivery exponentially increases the risk of placenta accreta, reaching incidence rates among women with two or more prior cesarean deliveries of 39–60% [6]. The exact pathogenesis, however, still remains unknown, despite several hypotheses that have been proposed, including a maldevelopment of decidua, excessive trophoblastic invasion or a combination of both [7]. In order to minimize the complications associated with placenta accreta, an accurate preoperative diagnosis performed, classically, with ultrasound and, where needed, magnetic resonance imaging is crucial to planning a proper delivery and offering the best care to the pregnant [8], [9], [10], [11], [12]. The management of placenta accreta includes different treatments, ranging from the extirpative method (a forcible manual removal of the placenta), the conservative approach (which consists of leaving the placenta in situ during cesarean delivery), and the cesarean hysterectomy [12], [13], [14], [15], [16]. Although the latter represents the traditional, and usually the best approach in terms of efficacy and safety in the treatment of post-partum haemorrhages, hysterectomy is a tough and difficult choice for patients, and the subsequent emotional process is often associated with depression, severe and prolonged feelings of sadness/hopelessness, diminished interest in activities and in sexual intercourse [17]. Similarly, severe adverse psychological outcomes, including post-traumatic stress disorders (PTSD), have been reported as a result of traumatic birth events and, although women with antenatally diagnosed AIP are prepared for the possibility of a potential traumatic delivery, the risk of post-traumatic stress disorders is equally high [18, 19].

The aim of our study was to survey pregnant women to evaluate the psychological impact and the anxiety associated with a diagnosis of AIP during pregnancy.

Materials and methods

Results

Discussion

Abnormally invasive placenta, although is a rare obstetric complication is weighted by severe adverse psychological outcomes. According to pathologic diagnosis, AIP encompasses placenta accreta, characterized by villi adhering to the myometrium; placenta increta, characterized by villi invading the myometrium; placenta percreta, characterized by villi invading through the uterine serosa [22]. The main risk factors for AIP are advanced maternal age, obesity and previous cesarean section [23]. Emergency postpartum hysterectomy is usually considered the last resort for the management of postpartum hemorrhage, however, as reported by Michelet et al. 64% of women who underwent an unplanned hysterectomy successively suffered from PTSD [24]. Even in patients in whom the uterus was preserved, the perceptions and the memories related to the postpartum hemorrhage provoked persistent fear of dying, sexual problems, intense anxiety, depression and repercussion on marriage [14]. It has been reported that the psychological impact of hemorrhagic complications was associated neither with volume of bleeding nor with hysterectomy but with the variable of emergency/elective procedure [25]. However, despite patients with antenatally AIP diagnosis could expect a difficult delivery or postpartum complications which could require a hysterectomy; the risk of developing PTSD or other psychological symptoms is still increased [26]. Pregnant women may experience elevated levels of anxiety associated with potential adverse obstetrical outcomes, such as preterm birth or congenital birth defects [27]. So far, there is no published data on the psychological impact and anxiety of women who had a diagnosis of AIP. As reported by Welz et al., the condition is perceived as life-threatening and has a lasting impact on the overall health of patients involved, regardless of the type of treatment [28]. The aim of this cross-sectional survey study was to evaluate this psychological impact in pregnant women with placenta accreta. Considering the lack of available validated questionnaires regarding the anxiety related to AIP, we proposed three original questions which aimed to evaluate, on a VAS scale, the impact of an antenatally AIP diagnosis on women involved. Consistent with data reported in the literature, our study showed that diagnosis of placenta accreta had a severe phycological impact on pregnant women. More than half of the women reported, indeed, high anxiety levels regarding morbidity and mortality, and future sexual activities, assessed as VAS for anxiety scored ≥50. In particular, if the percentage of patients with VAS ≥50 was 47.9% for the first question, which regarded the counselling about AIP, this percentage increased to 75% and then 83.3% when domains as perioperative complications or long-term consequences were analyzed. This is particularly important as, more than AIP diagnosis itself, the fear of death and long-term consequences on social and sexual activities could impact the psychological health of women involved. A prompt and proper counselling could therefore reduce this “hidden” morbidity [29].

The study has several limitations. The number of included women was small, and the single-centre study design limited the generalizability of the findings. However, the rarity of this condition has made nearly unavoidable a small sample size. In addition, some women included in the study delivered at the time of COVID-19 pandemic. If there were any negative putative effects of COVID-19 on maternal anxiety it was possible that the effects of a diagnosis of placenta accreta could have also affected the findings [30]. Finally, the long term between deliveries and answers to the survey could also have influenced the results.

Conclusions

AIP represent a psychologically impacting condition. Among pregnant women with placenta accreta, more than half of the participants reported high anxiety levels regarding the maternal risk of AIP. Although proper preoperative counselling could limit this morbidity, the psychological effects of AIP diagnosis and treatment represent an underestimated and hidden morbidity. It is, therefore, crucial to identify those patients with a higher risk of postpartum detrimental effects. Further studies and larger sample size are required in order to evaluate the short- and long-term effects of AIP on the mental health of women involved. Our preliminary findings could enlighten the necessity of formulating proper and timely psychological interventions to improve mental health and psychological resilience in women with AIP.