Mallory Hoeve watched her baby’s tiny heart beat on the ultrasound screen.
And fell in love.
She couldn’t wait to welcome a third child to her family.
A week later, Mallory sat in an office at the Fetal Care Center at Spectrum Health Helen DeVos Children’s Hospital, struggling to comprehend the dangers that lay ahead.
Her pregnancy implanted in a scar from a previous cesarean section, explained Marcos Cordoba Munoz, MD, a Spectrum Health maternal fetal medicine specialist.
The rare complication puts both mother and baby at risk.
“At the first appointment, I knew there was a chance I could rupture at any point,” Mallory said. “I could lose my uterus and would not be able to have more children.”
Mallory and her husband, Joshua, discussed the risks and chose to continue with the pregnancy.
“It was both the hardest and easiest decision we have ever made,” she said. “I had seen the heartbeat and knew that was my baby on the screen. I couldn’t have made any other choice. But I also felt like we were on a train barreling down the track and I could only hold on.
“It was by far the most terrifying thing we have ever done.”
Indeed, many frightening moments lay ahead. Mallory never expected to have a hysterectomy at 33. Or to receive chemotherapy to shrink her placenta.
But as she cuddles Viola, a chubby-cheeked baby girl with a burst of fine blond hair, she speaks with gratitude for the team of specialists who guided them both through the complications of a cesarean scar pregnancy.
“It wasn’t exactly what we anticipated, but I survived, and we have a healthy baby girl,” Mallory said. “In the end we got where we needed to go.”
An ectopic pregnancy
The Hoeves, who live in Zeeland, Michigan, always planned to have a big family.
Their first two children, Gideon, 4, and Georgia, 3, were born by cesarean section.
Because it took a bit longer to become pregnant the third time, Mallory underwent an ultrasound at just four weeks. That’s when she learned the baby had not implanted, as it should, at the top of the uterus. Rather it had settled into the V-shaped cesarean scar.
“It is considered an ectopic pregnancy because it is not implanted in the right place,” Dr. Cordoba said.
It really was God given. There is no other way to explain how her story went.
Because of the risks involved, mothers often choose to stop the pregnancy, Dr. Cordoba said.
A placenta typically attaches superficially to the muscle of the uterus. But when it implants in a cesarean scar—where the muscle is thinner—it can easily overgrow into the muscle and attach deeply into it. It can even grow beyond the uterus and attach to other organs.
That can cause serious problems at delivery.
The life-sustaining power of the placenta is fueled by a steady supply of blood from mom—over a half-liter of blood flows into the placenta every minute by the end of pregnancy.
If the deeply embedded placenta does not detach after birth, a mother can have an episode of severe hemorrhage—and even bleed to death.
“If you are not prepared or anticipate it ahead of time, you can encounter these complications,” Dr. Cordoba said.
There also was a danger the placenta could rupture during the pregnancy, which could lead to life-threatening blood loss.
Ready for anything
The possibility of a sudden emergency hung like a shadow over the Hoeves in the coming months. They mobilized to prepare for anything.
Mallory left her job in finance a month earlier than anticipated.
She told little Gideon and Georgia that mommy couldn’t lift them. She couldn’t be alone with her children. She always had a family member nearby who could drive her to the hospital.
“My family is phenomenal,” she said. “I don’t know how we would have made it without their support.”
The plan called for a delivery by cesarean section at 34 weeks, possibly followed by a hysterectomy.
When her delivery date arrived, a relieved Mallory checked into Spectrum Health Butterworth Hospital. She soon learned her situation had become more precarious.
“Within about 20 minutes, we had a swarm of doctors in our room,” she said. “The MRI came back bad, very bad.”
The scan showed the placenta had grown through the uterus and attached to the large bowel and abdominal wall.
The multidisciplinary team assembled to see Mallory and her daughter through the delivery. They included maternal fetal medicine physicians and gynecology oncologists who would perform the hysterectomy, as well as colorectal surgeons, general surgeons and neonatal intensive care unit doctors and nurses ready to care for her baby.
Viola arrived weighing 6 pounds and quickly was put on a ventilator and taken to the NICU in the Gerber Foundation Neonatal Center at Helen DeVos Children’s Hospital. She fared well and soon breathed room air—without any support.
Although the team planned to remove Mallory’s uterus after delivery, the doctors worried about the placenta’s attachment to the bowel. It could increase the risk of bleeding, of a later bowel resection and the need for a colostomy.
Instead, they decided to take a new approach, one that had not been used before at Spectrum Health, said Leigh Seamon, DO, a gynecologic oncology surgeon.
They closed the uterus and left the placenta in place for six weeks before the hysterectomy.
Immediately after delivery, Mallory went to the interventional radiology unit, where a physician placed coils and beads in the artery that leads to the placenta. This blocked the blood supply and reduced the risk of bleeding.
Mallory also began a five-day series of chemotherapy treatments to shrink the placenta.
By mid-November, both Mallory and Viola had returned home.
“We tried to be a normal family for a little bit,” Mallory said.
But two days before her scheduled hysterectomy, she began to hemorrhage while wrapping Christmas gifts.
“My uterus was trying to birth the placenta,” she said.
She spent two days in the intensive care unit before undergoing the hysterectomy.
Because of the interventional radiology treatments and chemotherapy, Dr. Seamon was able to avoid an open surgery. She performed the hysterectomy with a minimally invasive procedure, which minimized blood loss and recovery time.
“It was a great success,” she said.
A mellow baby
In mid-February, Mallory came back for a doctor’s appointment and met up with Dr. Cordoba.
Viola took the spotlight. At 3½ months old, she charmed with smiles and bright eyes.
“She is very calm and mellow,” Mallory said. “She is super happy. She loves to cuddle.”
Viola especially loves to be a part of the family. When everyone eats dinner, she sits in a high chair and watches.
“She was worth every single thing we did,” Mallory said. “Even knowing what we had to do, I wouldn’t change it.”
The experience took an emotional toll, she acknowledged.
“I had some trauma afterward,” she said. “It’s a lot to deal with. But we are doing really well now. I’m back to normal. I can be the mom I wanted to be.”
She has connected online with other mothers dealing with cesarean scar pregnancy. Many tell her they didn’t know they had an option to continue the pregnancy.
“We have a happy ending, and we know how blessed we are,” she said.
For Mallory and others with a cesarean scar pregnancy, it is crucial to have access to a health system that can provide a high level of specialized care and to manage potential complications, Dr. Cordoba said.
“I am glad we have such a multidisciplinary team that is able to offer this type of intervention to these patients,” he said. “It’s actually a blessing to know we have this team available for them.”
Dr. Seamon keeps Viola’s birth announcement next to photos of her own children, as a reminder of the miracle of her birth.
“It really was God given,” she said. “There is no other way to explain how her story went.”
Viola is now sitting up, rolling everywhere and showing a spunky side to her personality. When she smiles, she reveals two bottom teeth.
“She has been perfectly healthy,” Mallory said. “We still marvel at how lucky we are to be able to raise her.”