Delivering exceptional care for pregnant women: MCHRI Faculty Scholar leads multi-disciplinary program in placental disorders

May 10, 2021

By Roxanna Van Norman

Coordinating care during labor and delivery is complex, and women with placental attachment complications face an extremely high risk for challenges. Typically, the placenta should detach away from the uterus as the child is born. For those who have placenta accreta, the placenta grows too deeply into the uterine wall and does not fully separate from the uterus during birth.

“It is a potentially life-threatening situation,” says Deirdre Lyell, MD, Professor of Obstetrics and Gynecology at Stanford School of Medicine. Women with placenta accreta may experience heavy and dangerous levels of blood loss during delivery, explains Dr. Lyell, who specializes in maternal-fetal medicine for high-risk obstetrics.

In 2010, Dr. Lyell founded the Program in Placental Disorders at Lucile Packard Children’s Hospital Stanford (LPCH) to better support women experiencing placental attachment complications. In the past, pregnant women were often referred to the ultrasound unit at LPCH and diagnosed with placenta accreta – sometimes late in the pregnancy. Receiving the patient at the hospital and the diagnosis so close to delivery was challenging for Dr. Lyell and her clinical team, and unsafe for the patient. 

Dr. Lyell wanted to take a more structured and deliberate approach – one that would implement a robust standard of operations, convene a team of physicians and hospital specialists, and facilitate referrals of patients with placenta accreta early in their pregnancies through the Fetal and Pregnancy Health Program at LPCH. She proposed a plan to grow a multi-disciplinary patient care program for women with placenta disorders and lead a research team to investigate why placenta accreta occurs in pregnancy.

In 2011, Stanford Maternal and Child Health Research Institute (MCHRI) named Dr. Lyell the Arline and Pete Harman Faculty Scholar (2011-2014), which came with total funding of $300,000 to support her project. With support from MCHRI, she focused on building the Program in Placental Disorders, drawing on the expertise of medical and surgical specialists from across the hospital and medical school to improve the treatment and care of pregnant women with placenta accreta.

“[I wanted to] build a program where we knew when these women were coming into our referral center, we had set protocols for how we would evaluate them by ultrasound, what we would do once we evaluated them, and how our division would handle them,” says Dr. Lyell, who serves as the medical director for the program. “We wanted a program that could serve our referral community in a systematic way.”

Planning ahead for delivery

While placenta accreta is rare among pregnancy cases, it has risen in the past decades. Recent trends in placenta accreta cases show this affects about 1 in 272 pregnancies and is likely linked to the increase in the number of cesarean rates in the last 30 to 40 years. 

Pregnant women are at the highest risk of developing placenta accreta if they previously had a cesarean delivery and their placenta is located low in the uterus, covering the cervix (also known as placenta previa). This condition can cause heavy and dangerous hemorrhaging during pregnancy and delivery.

Anticipating when and how much bleeding might occur during delivery is critical to planning a safe outcome, says Alex Butwick, MD, Professor of Anesthesiology, Perioperative and Pain Medicine. Together with the Division of Gynecologic Oncology and other members of the program’s multi-disciplinary team, Drs. Lyell and Butwick implemented a system‐wide approach for the planning and delivery of women with placenta accreta. 

“What Deirdre has done [with the Program in Placental Disorders] is a very good job of making sure referrals start early so we have the time and the wherewithal to plan ahead,” says Dr. Butwick, whose clinical and research focus is on preventing and managing obstetric hemorrhage – the leading cause of maternal morbidity and mortality. “It's so important that we all prepare in advance for hemorrhaging and that we have contingency plans in place when the day of delivery comes."

Preparation for the delivery ensures they have enough time to formulate a plan to track the pregnant women’s progress over time. Much of the delivery experience centers on providing safe and optimal approaches to mitigate bleeding during childbirth and ensuring the best medical and surgical outcomes for the mother and the baby. Often the surgical team will decide, based upon their evaluation of the uterus and the placenta, whether to move forward with a planned hysterectomy or not, an operation to remove the uterus.

Thanks to the efforts of the program, clinicians now more accurately diagnose placenta accreta and have reduced the number of blood transfusions for women who experience placental complications. 

Building, expanding research collaborations

During one of her research talks on placenta accreta, Dr. Lyell was approached by Julie Baker, PhD, Professor of Genetics, who was fascinated by the placenta growth invasion into the uterine wall. Could there be genetic or molecular signaling that would cause the abnormal placenta attachment?

To address this question, Drs. Lyell and Baker teamed with several collaborators at Stanford to build a repository of blood and tissue specimens from pregnant patients. The goal was to gain insights into the differences across pregnancies, and in particular, high-risk pregnancies. The researchers hoped to understand why these complex placental attachments happen and improve prenatal diagnosis of placenta accreta.

“We’ve been trying to identify biomarkers that can predict, perhaps by a blood test, who has placenta accreta,” says Dr. Lyell. The team, led by Dr. Baker and Elisa Zhang, PhD, a postdoctoral research fellow in the Division of Hematology, has identified specific genes that are upregulated in the placenta and fetal membranes in patients with placenta accreta. Findings from this study is currently en route for publication.

That's what this Harman Faculty Scholar grant allowed [us to do] in establishing a program to identify the right people interested in placental disorders, not only from the perspective of clinical care but also the perspective of research.

The research team has partnered with several centers nationwide and now has a sizeable tissue bank and database, enabling a multi-center approach for addressing the problem of placenta accreta. Dr. Lyell and her team are currently collaborating with the Stanford Metabolic Health Center, a funded partner of MCHRI, and the University of Utah to identify metabolic profiles that might differentiate women with placenta previa and acc reta from those with placenta previa alone, as their surgical risks are quite different.

Dr. Lyell’s work to build the tissue bank and database has grown locally and globally, helping researchers to facilitate and forge collaborations to find solutions to placenta accreta. She and her team continue to expand their research in many directions, including broadening their studies in proteomics, partnering with the California state database to expand their biobank, and collaborating with Dr. Baker’s lab to further their genentics research in placenta accreta.

At an annual meeting of the Society for Maternal-Fetal Medicine, Dr. Lyell had the opportunity to speak with other physicians, scientists, and researchers about placenta accreta. These discussions led to a collaborative effort in forming the Pan-American Society for Placenta Accreta Spectrum (PAS2), a non-profit organization dedicated to improving the lives of women with placenta accreta through collaborative research and education.

"That's what this Harman Faculty Scholar grant allowed [us to do] in establishing a program to identify the right people interested in placental disorders, not only from the perspective of clinical care but also the perspective of research,” says Dr. Lyell. “There are so many bright minds at Stanford, and throughout the U.S., with complementary expertise that accelerates innovation when we work together."

She credits her team members who have been instrumental to the Program in Placental Disorders’ growth: obstetricians, maternal-fetal medicine specialists, gynecologic oncologists, anesthesiologists, transfusion medicine specialists, critical care specialists, pathologists, trauma surgeons, intervention radiologists, epidemiologists, and scientific researchers from across hospital and Stanford School of Medicine. 

"The more you do something complicated together, the better you become at it," Dr. Lyell says. 

Dr. Lyell currently serves as the co-chair for the review panel on the MCHRI Clinician Educators (CE) Grants program, which provides funding for CEs to conduct innovative research projects. MCHRI expresses appreciation to Dr. Lyell for her service to supporting the grants progam and commitment to advancing maternal and child health research.

Roxanna Van Norman is the marketing manager for the Stanford Maternal and Child Health Research Institute.