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BackTable / OBGYN / Podcast / Transcript #4
Podcast Transcript: IR/OB Collaboration in Treating Postpartum Hemorrhage
with Dr. Roxane Rampersad and Dr. Anthony Shanks
On this episode, BackTable VI host Dr. Christopher Beck shares the mic with two Maternal Fetal Medicine (MFM) specialists, Drs. Roxane Rampersad at Washington University and Tony Shanks at Indiana University, to discuss cross-specialty management of postpartum hemorrhage (PPH) between OBGYN and interventional radiology (IR). You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Defining Postpartum Hemorrhage
(2) Acute vs Late Postpartum Hemorrhage
(3) Working Through the Differential for Postpartum Hemorrhage
(4) Management Options for an Atonic Uterus
(5) Utilizing the Bakri Balloon
(6) Triaging Patients to Interventional Radiology or the Operating Room
(7) The Importance of Massive Transfusion Protocols
(8) Placenta Accreta Spectrum: The Utility of Ultrasound and MRI
(9) Placenta Accreta Spectrum Management
(10) Offsetting Postpartum Hemorrhage: The Future State of Technology
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[Dr. Christopher Beck]
We have two guests on today. Dr. Roxane Rampersad. Am I pronouncing it correctly, Roxane?
[Dr. Roxane Rampersad]
That's correct, yes.
[Dr. Christopher Beck]
Okay, and Dr. Tony Shanks, so both OBGYNs, and I'll let them give some introductions and we'll talk about the topic today, obstetrical hemorrhage. I know it's a part of some interventional radiology practice, some people not, but it's a good topic. We're going to get some of the OBGYN perspective and dig into this a little bit more. Roxane, can we start with you?
[Dr. Roxane Rampersad]
Sure. Roxane Rampersad, maternal-fetal medicine at Washington University School of Medicine. My area of interest is patient safety and quality. This is a great talk for me. It's a really significant talk for me. I make a lot of protocols that deal with hemorrhage and look at metrics for hemorrhage and trying to figure out how we can decrease our risk for hemorrhage.
[Dr. Christopher Beck]
Excellent. Tony, how about you? What's your practice look like?
[Dr. Anthony Shanks]
Yes, so I'm a maternal-fetal medicine also, actually trained under Dr. Rampersad. I'm a little bit younger. Then we stayed on as faculty together. [laughs] Yes, very close. Then I moved back to Indiana, so I'm practicing maternal-fetal medicine. I have a big role in education. I'm the vice chair of education for OBGYN here at Indiana University. I think by nature of our specialty, we deal with a lot of complicated pregnancies. Of course, postpartum hemorrhage is a big thing that you have to be ready for.
(1) Defining Postpartum Hemorrhage
[Dr. Christopher Beck]
Okay, excellent. Maybe just talking about some ground rules, some definitions. Can we talk about what is postpartum hemorrhage? Roxane, why don't we start with you? Then I'll let you guys kind of guide the conversation after we get some floor information established.
[Dr. Roxane Rampersad]
Recently, ACOG has changed that definition to include blood loss greater than 1,000 ccs. I think that's the number that we're paying attention to. For vaginal delivery though, even though greater than 500 may not change your hemodynamic state, it's still an important number to look at for vaginal delivery. Greater than 500 and less than 1,000 is still an important number to pay attention to if someone has reached that state of blood loss after vaginal delivery.
[Dr. Anthony Shanks]
One thing I want to point out for people that are listening that don't know, ACOG is the American College of Obstetricians and Gynecologists and they set our ground rules for what we do in practice. I feel like many of us get a chance to serve on those committees to interpret the evidence and make these protocols, but we really take them as guidance on what we do. When we trained like when we talk about blood loss, if you remember--
[Dr. Christopher Beck]
When did you guys train? How far back are we talking?
[Dr. Roxane Rampersad]
Oh, Tony. Do you have to keep bringing that up?
[Dr. Roxane Rampersad]
We are not dinosaurs.
[Dr. Anthony Shanks]
We are not dinosaurs. That is true. Why I bring it up is, if you remember an interventional radiologist back when you were doing your clerkships through labor and delivery, the nature of deliveries, there is going to be blood loss at that time. When we do them, we used to qualitatively measure blood. I actually googled these pictures because I remember looking at a lap sponge and then having to make a guess on how much blood there is. Now, there's been this movement where we have to do quantitative blood loss. Dr. Rampersad, you want to tell us what quantitative blood loss is?
[Dr. Roxane Rampersad]
Gosh, quantitative blood loss, I think, is the bane of our practice at our university. You're right.
[Dr. Anthony Shanks]
Why is that?
[Dr. Roxane Rampersad]
Because it was really easy to estimate blood loss. I think we looked at the bag, we looked at the laps, and we looked at the blood all around, and we're like, "You know what? That's 500 ccs. We all learned what our 500 and what our 400 look like. Quantitative blood loss is a little bit more labor-intensive. Our nurses now have to gather everything that has blood on it and they have to weigh it.
They have to know what it weighs prior to the delivery and what it weighs with blood. We also have to take into account amniotic fluid, which is also lost at the time of delivery. It's not an easy thing to do, but it's something that we've switched over because qualitative blood loss is probably not as accurate as quantitative blood loss. I know that's controversial too.
There's a lot of people that battle that back and forth. I think even ACOG has changed a little bit on that where I don't think they're pushing, I think, quantitative blood loss. I think a lot of other societies and a lot of what are called perinatal quality collaboratives in each state that follow maternal mortality and follow metrics like these quality improvement metrics still use and are still pushing quantitative blood loss.
[Dr. Anthony Shanks]
It's like 1 gram is equivalent to 1 milliliter. With the new definitions of it being like 1,000 milliliters, whether it's a vaginal delivery or C-section. Now, it's really up to the nurses to help us out. Because when you're in a C-section, certainly, you're focused on the field and you're going to rely on your nurses to measure that. What Roxane was mentioning I find interesting is that there are so many things that we do where we're trying to be objective.
I do think going forward, I definitely feel like even though it's uncomfortable learning this new thing, I feel like it makes sense. We'll get better at measuring things and I think that we'll be able to respond to changes better. You're going to hear us use the term "protocol" a lot. I've shared this analogy with Roxane in the past, but I feel like labor and delivery, sometimes it's a lot like baseball. It's a sporting metaphor here is that there's a lot of times when you're just going to be sitting around.
You'll be waiting for the ball to be hit to you. When you have in your head like if you're in center field and you know if that ball is hit to you, what base you're going to throw to, same with protocols. I know exactly where I'm going to go with what's next. You have to think about that each time because even though we have some predictors that we'll get into, when it happens, you have to be ready in that moment and know where you're throwing.
[Dr. Roxane Rampersad]
This is why I like you, Tony, and why we're friends because you have an analogy for everything, everything in medicine. I love that because you break it down and I love that.
[Dr. Christopher Beck]
Do they all revolve around sports analogies?
[Dr. Roxane Rampersad]
Okay, go ahead.
[Dr. Anthony Shanks]
I check myself because I would say maybe a decade ago, they were very sports-heavy, and then people said, "Not everyone catches those, so I will bring in some pop culture things."
(2) Acute vs Late Postpartum Hemorrhage
[Dr. Christopher Beck]
All right, excellent. All right, so we know some quantitative numbers for postpartum hemorrhage. Do you guys make any distinction between early-late postpartum hemorrhage? Can you talk about maybe some of the timing issues regarding hemorrhage? Of course, you're counting laps and you're trying to have an idea of how much blood loss, but then there's also the clinical picture of what's the patient doing on the table or on the field.
[Dr. Roxane Rampersad]
Sure, so acute and late are how we differentiate the blood loss. Acute is within that first 24 hours and late is beyond that 24 hours and really up to 12 weeks is how we differentiate blood loss.
[Dr. Anthony Shanks]
Yes, I think in terms of the definitions, this early and late, that first 24 hours versus after, they may clue you in on what's happening for the non-OBGYNs that are listening to this. We always talk about the four T's, about the causes of postpartum hemorrhage. Now, we know it's going to be 1,000 ccs. Irregardless of delivery, we're going to quantitatively define it.
Those four T's stand for tone, trauma, tissue, and then thrombin is the last one. That's the order. When we say "tone," we think about uterine atony. You've got a uterus that's been working. All of a sudden, it doesn't want to. It doesn't want to clamp down. That's a big cause of that and the most common one. Trauma. If you had a vaginal delivery that needed an operative delivery, maybe you did forceps. You may have a laceration that needs to be addressed. That's the second most common.
The pathways that you do to fix that are going to be different. The third one is tissue. Did you leave something behind? Is this like a placenta accreta or maybe you had an accessory lobe that's still in there? Then the last one, the thrombin is just defects in the coagulation pathways. I think whether it's early or late, thinking about those four T's will help triage in your head what you're going to do at that time.
[Dr. Christopher Beck]
You were saying that sometimes the timing drives you in a certain differential, so how does the timing play into whether you think it's either atonic uterus versus trauma?
[Dr. Anthony Shanks]
Well, I think, actually, the clinical scenario that you're doing, I think I'm much more hyper-alert for possible lacerations if it's an operative delivery. If you're doing a vaginal delivery that's complicated for a large baby, you'll be ready for that. When you're in a C-section, you're right there, hands on the uterus. You know right away whether there's issues with tone. The first thing is you work through there. Whether it happens in the first 24 hours or the next 24 hours, I'm still thinking in that same pathway and what I'm going to do.
(3) Working Through the Differential for Postpartum Hemorrhage
[Dr. Christopher Beck]
Okay, got you. All right, so we can do it a couple of different ways. You can set the scene for a standard patient and how you work through this differential or work through your algorithm, or you can just talk about it either way. Roxane, do you want me to start with you?
[Dr. Roxane Rampersad]
Sure, so I think postpartum hemorrhage is always on every obstetrician's mind after the birth of a child. One of the things that happen is that we start oxytocin after the delivery of that baby. That's to help the uterus contract to allow us to decrease the blood loss.
[Dr. Christopher Beck]
That's regardless, that's all deliveries?
[Dr. Roxane Rampersad]
Really every delivery in the United States who has an IV hooked up. Most patients are on oxytocin already, but oxytocin is usually in the room and it's ready for that birth. After that birth, it's initiated. We initiate it before the delivery of the placenta. We have that going. It's at a really high rate and that is all to have that uterus contract down. At the same time while we're trying to deliver that uterus-- I'm sorry, that placenta-
[Dr. Christopher Beck]
Sure.
[Dr. Roxane Rampersad]
-we're watching, right? We're watching the blood loss. It can pick up. If it starts to pick up and it starts to increase and we're concerned about it, then I think that mobilizes a lot of people in the room that maybe we're starting to have a hemorrhage. We expedite delivery of the placenta. If that bleeding is ongoing, we start to feel that uterus. If it's atonic, meaning it feels soft, it doesn't feel contractile, then we know likely this is an atonic uterus.
Atony is the most common reason why patients have postpartum hemorrhage. At the same time, while you're massaging, trying to firm that uterus up and you're increasing your oxytocin, you're looking around. You're making sure you're not having any lacerations. You're going into your mind, "Am I hitting any of those T's like Tony mentioned? Do I have any lacerations? Do I think I could have retained tissue?"
Often, if that bleeding is ongoing, we're bringing in the ultrasound. We're checking to make sure we don't see any evidence of retained products. We're looking also at the blood. Is it clotting? If we start to see clots, we don't think that patient is in DIC. We don't think the coagulation cascade is affected. What we're feeling and what we're seeing helps to guide that management.
[Dr. Christopher Beck]
Okay. Tony, do you have anything to add on to that as far as how your algorithm is a little bit different or how you're working through that process in your head and what's happening in parallel as you're evaluating your patient and as you're making changes to the situation?
[Dr. Anthony Shanks]
We trained similarly, so we have similar algorithms and how we're going to handle that. I think the preparedness is a big key. They have these checklists now that many people will incorporate into their bundle where you can risk-stratify a patient before the delivery. When I explain things to medical students, you think of a uterus as a balloon that needs to come back together.
If someone's in a prolonged labor, maybe they have an infection that's going to keep it from coming down. They have multiple gestations where it's been over-expanded. I'm going to go in knowing I really am going to be concerned about that tone, "Is this uterus going to come down?" The other two things, which I'm sure we'll touch on in terms of the treatment, we prophylactically give oxytocin.
If we have issues with tone, we do have some other medications that we can use like Methergine or Hemabate. It's always good before you get into that delivery to know like, "Does my patient have any contraindications to these medications?" If she's got high blood pressure, I know I'm not going to give Methergine. She's an asthmatic. I'm not going to give Hemabate to those patients. I think going in anticipating if you're going to have problems, it's a big thing.
The other thing I'll say is the reproductive-age patients are typically very healthy. Certainly, in our line of work, we take care of moms that are complicated, that have medical problems. The majority of which, this is their healthiest time. If you have somebody that is manifesting tachycardia or hypotension, be concerned because that's certainly abnormal at that time.
(4) Management Options for an Atonic Uterus
[Dr. Christopher Beck]
Got you, okay. Once you know you have postpartum hemorrhage, you're working through your differential. I think it's easiest to talk about an atomic uterus. By far and away, the most common. We talked about starting oxytocin. We talked about the other medications that you have potentially at your disposal. Can you talk about what other options that you have, or at least let's talk about first, the conservative side like what you're doing for conservative management, and then what you're thinking of in terms of getting this patient ready for escalated level of, I don't know, care or treatment. Do you know what I mean by this?
[Dr. Anthony Shanks]
I'd love to hear your opinions on this, Roxane. We're blowing past the atonic uterus. We've gone through our medication algorithms. What are you guys doing next?
[Dr. Roxane Rampersad]
In my mind, the things I'm thinking about is what stage of hemorrhage I am and what the medications I'm going to need, and potentially what other, I think, actions I need to get done. If we start with the medications like you mentioned, Tony, and I'm not getting any response and I have ongoing bleeding, then I'm going down in my head, "What else am I supposed to do?"
The next thing for me to do in addition to the medications that we use to make the uterus more contractile that I'm thinking about TXA, the addition of TXA to help. Then if TXA is not helping, I'm thinking about tamponade, so introducing balloon tamponade, the uterus. Tamponade, the sites that are bleeding inside the uterus. For us, that's a Bakri balloon.
[Dr. Christopher Beck]
Roxane, I'm sorry to interrupt, but I don't know what TXA is. I suspect a couple of other people don't.
[Dr. Roxane Rampersad]
Yes, so that's tranexamic acid.
[Dr. Christopher Beck]
Okay, got you.
[Dr. Roxane Rampersad]
We use it not only in the OB world but also in the GYN world. When a hysterectomy is with ongoing bleeding, we can use TXA. GYN is not my world anymore. Tony, remind me. I think people also use TXA for heavy menstrual bleeding, don't they?
[Dr. Anthony Shanks]
Yes. In terms of how it actually works, it prevents that fibrinogen getting broken down by plasminogen. It works on that coagulation pathway. Technically, you can make these people hypercoagulable with that. There is a lot of studies that come out with TXA. I think people use it for the postpartum hemorrhage after three hours if you're still having ongoing bleeding.
I have come across in preparing for this talk. They have had some studies where they've done it prophylactically as part of bundles for people that they're anticipating being at risk and that they may show some potential benefits. I suspect that we'll continue to see more studies with TXA. I wanted to hear, Roxane, about the Bakri balloon because I mentioned to her. We're doing something called Jada at our institution. Tell us what the Bakri is, Roxane.
(5) Utilizing the Bakri Balloon
[Dr. Roxane Rampersad]
Bakri is essentially a balloon. Think about it as a big Foley catheter, but larger, and we can instill 300 to 500 ccs in that Bakri balloon. We introduce it into the uterus and then we instill fluids to inflate that balloon. It sits there for somewhere between 12 and 24 hours tamponading those sites, trying to achieve hemostasis and to decrease blood loss. This is great because the Jada is something new and it's a little bit different in terms of mechanism. We don't actually use it yet at our institution, but we're waiting.
We're waiting to introduce it and to potentially study it because I think one of the things is that it was recently FDA-approved, but we don't really have any studies in terms of comparison. Does it work better than the Bakri? Is the Bakri better? Because I think the Bakri is more cost-effective in terms of price. I think we don't have those studies yet. We are going to introduce that. Tony, do you have it at your institution?
[Dr. Anthony Shanks]
Yes, we do. We've done training with it. The difference is with a Bakri, it's just a balloon that you put in and fill up with saline. Again, like we're always thinking about, we want to minimize going back to these complicated surgeries if you can avoid it. Certainly, we always think about people preserving their fertility. Bakri is just a bigger balloon that goes inside the uterus. You blow it up.
It's nice because you can watch the amount of blood that's coming through to know if you're still having ongoing bleeding. Eventually, after a certain amount of time, 24 hours what I've done in the past, you deflate and you can take it out. The concept of the Jada is if you're thinking about an atonic uterus, you're placing in something, a foreign body, and blowing it up.
It sounds maybe a little counterintuitive. If you're going to explain something to an engineer and say, "What would you actually do to get a uterus to clamp down? Would blowing it up be the way to do it?" That was the concept of the Jada, which is, essentially, it's going to use pressure suction to keep things down. You have to insert this device. I don't really have anything around here on my desk that looks like it, but it's a small--
[Dr. Christopher Beck]
Most people won't be able to see the desk anyway.
[Dr. Anthony Shanks]
Well, a prepared obstetrician would have had something, but you can place it into the uterus and you actually have to hook it up to wall suction. There's metrics that they use to do that. It's been successful when we've done it, but Roxane's right. It's newer, so it doesn't have the studies behind it. Personally, I think it makes intuitive sense. I think just having more options for things that can work would be good because you want to try to avoid some of these certainly hysterectomies and other invasive things.
[Dr. Roxane Rampersad]
Right, because that's where we're going, right? If the medications don't work and tamponade doesn't work is we're taking the patient either to the interventional radiology suite or we're going to the operating room. That's our next big, I think, decision is where we're going.
(6) Triaging Patients to Interventional Radiology or the Operating Room
[Dr. Christopher Beck]
Sure. One of the things I want to talk about with TXA just for some of the IR listeners, TXA is something to keep on your radar if your institution uses it or it's part of their algorithm. If you do end up taking a patient back and you're going to be working in the blood vessels knowing the patient is on TXA can create issues with basically inducing thrombus in areas that we don't want to put it there, so we go in femoral access or radial access. TXA makes people hypercoagulable.
You can have more clot formation in areas you do not want the clot. Now, we're getting to the point where either the balloons aren't working, the meds aren't working, and you're now at a point where you either have to take them back to the OR or you take them back to the IR suite. What's going on in your head as to how patients get triaged to different spots? Just because you're going to the operating room doesn't mean it's hysterectomy, right? There are some other maneuvers you can do, but will you talk about how that decision tree happens?
[Dr. Roxane Rampersad]
I'll tell you, for me, what allows me to decide whether the patients go into the IR or the operating suite is really the amount of blood. Persistent bleeding in someone that's hemodynamically stable, I'm going to take that patient to the interventional radiology suite. If that patient is not hemodynamically stable, they're unstable and they have more brisk bleeding, their vital signs are abnormal, they're hypotensive, then I'm going to the operating room and I'm going to think about more operative maneuvers.
You mentioned there are other things besides hysterectomy. A B-Lynch suture is one of those things that we can do. Essentially, we're compressing the uterus on itself to try to stop the bleeding. We can sometimes ligate the vessels, the uterine arteries going to the uterus, or we can ligate a little bit higher. A hypogastric ligation is the next thing. Then if those things are not working and bleeding ensues and that patient becomes unstable and it's becoming coagulopathic from that blood loss, then we're thinking about hysterectomy is my mind. Tony, what do you think?
[Dr. Anthony Shanks]
I think the word that you mentioned about stability is the big one. We would never want to send a hemodynamically unstable patient off the floor to interventional radiology where they cannot be surgically reopened quickly. I think that would probably be the unsafe thing to do. That's reserved for the person that has maybe that persistent low-level bleed. If you have a Bakri balloon and you continue to see blood come out, the patient's vital signs are otherwise stable, but you're not really addressing the bleeding.
That's a good person for that. I also think certainly C-sections. If you have a complicated C-section and they're hemodynamically unstable, going back in, seeing where you actually closed off your hysterotomy, that makes sense because sometimes you can have those extensions and that's where you're bleeding from. Not necessarily hysterectomy, but just reapproximating those areas first.
[Dr. Christopher Beck]
One of the things I want to dig in on though is you guys are super high-level operators at big institutions, do a lot of those work, but not every OBGYN is created equal or not all resources available. Just not every IR is created equal, not every OBGYN is created equal. Can you speak to that a little bit? Are there some operators who would feel uncomfortable with unstable patients? Sometimes I'll hear from OBGYN colleagues like they're very nervous about taking a patient back because they're like, "Oh, I just feel like it's going to be a hostile pelvis." Things like this come up into, I think, people's decision tree. Can different obstetricians end up in different places?
[Dr. Anthony Shanks]
Yes, I would never want an obstetrician or really any physician do something that they're uncomfortable with. I was specifically thinking about hysterectomies, a cesarean hysterectomy. I think the planning stages are very important because, at our institution, we actually have GYN oncologists. Those are the people that do the most surgery. Typical day for Roxane and myself, we are not in the OR all day.
We're seeing patients. We're doing ultrasound. We like having people that are really good at knowing surgical planes and distorted anatomy because that's what it is at the time of a c-hyst. Planning is great. Certainly, there are going to be times when the instability happens and they're not there like it happens. You want to make sure your labor and delivery is covered by staff that is capable of doing that. What do you think, Roxane?
[Dr. Roxane Rampersad]
We take a lot of transfers, and so this comes up definitely. For most obstetricians out in smaller areas and small institutions, I think the thing that they worry about mostly is their blood bank, is that they are not equipped to transfuse someone sometimes more than six units. It's really unfathomable to me because we have this big blood bank and we have massive transfusion protocols. I think that's what most of those obstetricians are thinking about.
[Dr. Anthony Shanks]
Sure.
[Dr. Roxane Rampersad]
They may have the balloon tamponades, but they may not have interventional radiology also. For them, hysterectomy is the-- The end-point is removing that. Then we often get a lot of those patients transferred to us because they can still have ongoing bleeding even after hysterectomy, and so they need to come to these quaternary centers like what we have. It's definitely something to think about when you're in a smaller area and a smaller hospital.
[Dr. Anthony Shanks]
In Indiana and many states have these levels of care where you have the tertiary hospital and everything funnels up. It's up to individual states to figure out what is safe to say at different places. I feel like radiology plays a big role in some of these cases because when we talk about the four T's, those are things that are going to happen at the moment. They can happen anywhere.
As our C-sections rise and we have the placenta accreta spectrum, which I'm sure we'll talk about, in anticipation of those cases, those are the ones I think that you can refer them to the centers within your state that are actually experts at that. That way, you have time to get the blood available and all that. The blood bank thing is definitely, I think, future states. I've been just hearing talks about shortages with things and then not being able to give O-negative blood for some of these massive transfusions. It'll be something to keep an eye on down the road.
(7) The Importance of Massive Transfusion Protocols
[Dr. Christopher Beck]
How important is having a massive transfusion protocol for y'all's practice? It seems like that's a cornerstone of managing this issue.
[Dr. Roxane Rampersad]
It's definitely key for us. We take care of a lot of high-risk patients. I think Tony mentioned the placenta accreta spectrum. We have a fair amount of that because our cesarean section rates are increasing, so we see a lot of previas and a lot of placenta accreta spectrum. It's very important. I think we keep that in mind every time we have patients that fit in that high-risk category that are coming in for delivery. This patient's likely to bleed. We're going to have to type and cross this patient. Likely, we may need to activate massive transfusion protocols. Very, very important, I think, for us. Because we're a referral center and we get a lot of transfers, it's important.
[Dr. Anthony Shanks]
I also think there are these Venn diagrams on how to be a good educator these days. You have to have your content knowledge. We've all gone to learn about our specialty. If you wanted to impart education, you have to know pedagogy and how to actually teach adult learners. When we talk about protocols, I feel like with our current state of medicine where things are so specialized and you just have to be able to reflexively go down these fast pathways, especially in fast-paced specialties, that way of teaching is so important.
Massive transfusion protocols are really protocols for any clinical condition. I feel like it's so important. I think medical students now, certainly residents, I'm sure residents 50 years ago in terms of how they learned that, they had book knowledge that they had and then they applied it. Now, they did not have a pocketbook of protocols that we have and continually update all the time.
[Dr. Christopher Beck]
How about dipping into the interventional radiology side? Do you guys both have access to interventional radiology 24/7, 365?
[Dr. Roxane Rampersad]
We do. At our institution, we name our activations differently. A Level 1 activation is what trauma uses for a patient that comes in and needs IR. We use that same level of activation though for our mom just because our moms are younger and these procedures are life-saving. Even though our patients are hemodynamically stable, we'll use that same Level 1 activation in our institution. It gets everyone mobilized. People are in the suite quicker. We're lucky also because, in our tower, interventional radiology has a suite two floors down. We can bring that patient down into the IR suite really quickly.
[Dr. Christopher Beck]
Tony, how about y'all?
[Dr. Anthony Shanks]
Yes, it's very similar. That's on there. I do feel with interventional radiology, we do rely on them. Again, we are only going to send stable bleeding patients, but it's not like we have-- I personally have not been in their suite, so I don't know what it looks like when it's over there. I maybe have done it once when I was back in St. Louis, but I almost feel like there are colleagues, but they're a little bit separate. It just goes back that we don't want to send that unstable patient to make that journey.
[Dr. Christopher Beck]
Sure, there's no hybrid suites in which y'all do any collaborative practice with balloon occlusions and C-sections in the same suite or anything?
[Dr. Roxane Rampersad]
We've done some balloon occlusions for a patient with a placenta accreta spectrum. I think the data has not panned out. I think most people no longer think it's evidence-based to start with these balloon occlusions. I will say that we have a couple of our oncologists that really like that. Patients will go down to the suite and then come back up and then we inflate them if we need to, but we are not using them, I think, preoperatively.
[Dr. Anthony Shanks]
Oh, I'm curious, Roxane. Preoperative. What about stents, ureteral stents? Are you guys using that a lot?
[Dr. Roxane Rampersad]
I think it depends. It depends on the GYN oncology surgeon. I think it's rare, but they are some, depending on what that imaging looks like on MRI or what we think on ultrasound that may want those ureteral stents placed prior to the surgery. It's such, I think, a surgeon preference. You definitely see different practices based on the surgeon.
[Dr. Christopher Beck]
The GYN surgeons, are they putting them in themselves or they get help with urology?
[Dr. Roxane Rampersad]
No, they're putting in themselves.
[Dr. Christopher Beck]
Okay, that's what I thought.
[Dr. Anthony Shanks]
At her institution. At ours, we have urologists that'll put in stents. Again, these are the ones you are anticipating having problems.
[Dr. Christopher Beck]
Sure, right.
[Dr. Anthony Shanks]
Your placenta accreta spectrum is not necessarily the ones that happen in the moment.
[Dr. Christopher Beck]
Of course. Okay. Actually, I'll leave it to Tony. Where do you want to take it next in terms of like you have a patient that's either going to the operating room or going to IR suite and, either way, you can get a good outcome?
[Dr. Anthony Shanks]
Well, I'm curious. Obviously, we know definitively, hysterectomy is going to happen. If someone has a uterine artery embolization via our great colleagues in the VIR suite, what do you tell them about future pregnancies and what they should be worried about?
[Dr. Christopher Beck]
Oftentimes like in my experience when-- so I work at a big obstetrical hospital in New Orleans. OB does a lot of deliveries. It's not an uncommon problem. To be honest, this conversation doesn't really happen at the moment. It's all emergent. We're coming in in the middle of the night or the middle of the day and everything's happening very quickly. Afterwards, a lot of the talk is just like, "Hey, you're okay. You're through this. You're healthy. You're happy."
There's no good data to steer them in the right direction, so I'll kind of defer to some of the uterine artery embolization for fibroid data. I'll just say that, "This didn't help." What we did for that emergency isn't going to help you to get pregnant, but it's not a form of birth control. You certainly will have an option for pregnancy, but it's not doing you any favors in terms of fertility.
[Dr. Roxane Rampersad]
That's interesting, Chris. We differentiate what is used, I think, for our patients, at least by our radiology colleagues. They'll use gel foam often, I think, for our patients who desire future pregnancies. I'm told that there's an increased risk for bleeding with gel foam. We tend to use gel foam if patients desire future fertility. Then something were permanent, it sounds like when we think they're done with childbearing. You're right. We don't often know. When we don't know, everyone gets gel foam here at least at our institution.
[Dr. Anthony Shanks]
You're right, Chris. We see them afterwards. You guys help us out. If successful, upwards 90% of the time. Then afterwards, they're going to ask, "Can I still get pregnant?" The answer is yes, but you're right. Looking at this, there is the UAE data after fibroids as well as postpartum hemorrhage. I still think those patients will be watched very closely to make sure that growth is fine in their subsequent pregnancies. I think being hyper-alert, not just with the UAE but what other procedures were done, was there a C-section? Was there any type of manipulation of the inside of the uterus? Am I going to be worried about adhesive placenta down the road? I think I'll be considering that.
[Dr. Christopher Beck]
Right. Going back to the gel foam, I thought that might be kind of in the weeds for you guys. In terms of embolization material, every operator has their own algorithm when they're kind of looking at postpartum hemorrhage, really hemorrhage and trauma in general. I think if you poll a lot of interventional radiologists, most people are going to use gel foam in the uterine arteries. Unless you saw a pseudoaneurysm or an AV fistula or something that was a little bit more of an indicator that you had a bad vascular injury.
I think sometimes those will be treated with coils and then maybe followed up with some gel foam. I think, by and large, that people will just go to gel foam. We're very comfortable with it in the trauma setting. It's quick, it's easy, it's cheap. I think most people use gel foam. Maybe they're thinking about fertility, but I think a lot of people, that's just their default to treat it, whether you're in the liver or the uterus.
[Dr. Roxane Rampersad]
That's a great point. It came up because one of our fellows was concerned, I think, because I think one of the permanent embospheres was used in a prior patient. I think it came up as, "What should we tell her about? Is there a risk for placenta accreta spectrum in the future? Is there a risk for infertility in the future?" I think it got a lot of people thinking and talking. It was great because both our radiology colleagues and our high-risk OB colleagues kind of came together. I think what we were told is that for them, just like you mentioned, I think gel foam is probably going to be the default. There is this potential increased risk for a re-bleeding, I guess, is what I would say.
[Dr. Christopher Beck]
Yes, so gel foam temporary. Sometimes patients can re-bleed. Anecdotally, we don't publish our data. We don't do so many that it would warrant a publication. Usually, gel foam lock it in with gel foam. Then it allows the patient to give themselves a chance to heal and then it gives you guys a chance to do your thing. Then rarely are we taking people back either to the operating room after uterine artery embolization or back to the angio suite.
[Dr. Anthony Shanks]
That's what I was going to ask. If they fail a uterine artery embolization and they're still having ongoing bleeding, I think the next step would be going in if you have not already done that, looking at your C-section scar if it happens to be a C-section preparing for a possible hysterectomy. In your experience, how often have you had to do it more than once on the same patient?
[Dr. Christopher Beck]
Uterine artery embolization?
[Dr. Anthony Shanks]
Yes. Do you ever go back in?
[Dr. Christopher Beck]
Never had to take him back in. I say that. There was one time we took a patient back to the angio suite where we did, so we went. I didn't have a CTA beforehand, which isn't my standard practice to get a CTA. I'll just take them from wherever they're located to the IR suite. We'll do angiography of the uterine arteries. I didn't see anything, which is not uncommon, still embolized with gel foam.
Then the patient was hemodynamically stable, but it was still downtrending like it was an arterial bleed. I took them back to the angio suite, did a flush aortogram, and it was actually a bleed coming off. Basically, a different branch that was applying like a round ligament artery. It was off like the external of the inferior epigastric artery. It was really kind of on me. I missed the bleed.
If you play the odds, if you embolize the uterine arteries, you're going to be successful in 90% plus of the patients. They weren't responding. We got a CTA, showed the bleed, and so I knew where to go in on the next round. Some practitioners will actually do a flush aortogram to get a lay of the land and help direct their catheterization after that. My practice previously had been to just go straight to the uterine arteries and embolize those, whether I saw anything or not.
[Dr. Anthony Shanks]
My experience just from the IR colleagues is that the success rates are very high. That's the exception.
[Dr. Christopher Beck]
We're like fighter pilots. We think the success of all of our stuff is very high. If you ask fighter pilots how often they hit their targets, it's like double what they actually had.
(8) Placenta Accreta Spectrum: The Utility of Ultrasound and MRI
[Dr. Anthony Shanks]
Now, we're talking. I'm a huge Top Gun fan, so I'm ready for this podcast to start talking about Maverick. Well, because we've talked about interventional radiology, when I think about the anticipation of a postpartum hemorrhage, I think it's worthwhile to talk about placenta accreta spectrum and then, specifically, the diagnosis, ultrasound, and MRIs. Again, like Roxane, we worked together, so I know what it was before. Are you guys using MRIs routinely? Certainly, everyone's getting ultrasounds. We can talk about what we look for, but what about MRIs?
[Dr. Roxane Rampersad]
We're not using them routinely, but there are some cases that we are using them. That's so controversial because I think as MFMs, all the MFMs think we just need to stick with the ultrasound. Our oncology folks sometimes are pushing for that MRI even though I feel like a lot of times-- and no disrespect, but I think that they overcall the MRI because I think no one wants to miss, obviously, a placenta accreta spectrum. I think maybe when it's helpful is when we think it's accreta and we think there's bladder invasion and we have to prepare for that. Maybe in those cases, it's helpful, but we don't routinely use MRI. Do you guys use routine MRI?
[Dr. Anthony Shanks]
We have a pediatrician, Dr. Brandon Brown. We do a lot of MRIs for fetal indications. He actually has grant funding to offer patients. We were getting a lot of MRIs with ultrasound. We actually had something looking at our own thing. There are so many studies that compare the predictive values of ultrasound and MRIs. I find those studies helpful just to remind me what to look for that are on there.
I feel like the ultrasound criteria, the things that we look for will look for placental lakes, hypervascularity behind the bladder. I always tell a med student back in the days when we used to make bladder flaps, "You'd never do that if there were a bunch of vessels behind it." If you see a bunch of vessels behind it, you should definitely be concerned that retroplacental clear space is another one. If you see bulging into the bladder, that's bad.
Their MRI colleagues kind of made their cutoffs that are on there. I feel like not routinely. I don't think that routinely. Like you're mentioning, there probably are going to be some select cases. Certainly, if the person that is going to operate on it, if it'll help their surgical planning, by all means. We're fortunate to have the ability to offer that to our patients. I'm sure that's not the case everywhere.
[Dr. Roxane Rampersad]
I think part of it too is, is MRI with gadolinium the best sort of imaging, and is that what we should be doing? We often don't use gadolinium in pregnancy, but the group in San Diego, right? They use a lot of gadolinium. A lot of the studies with MRI or using MRI comes from that group. Tony, I was just wondering if you guys are using gadolinium with your MRIs, or are you guys going without contrast?
[Dr. Anthony Shanks]
Yes, so it's up to what Brandon does. I'm pretty sure it's without contrast for these indications. I'd have to double-check with him to be honest.
[Dr. Christopher Beck]
Who's Brandon? Is he the GYN--
[Dr. Anthony Shanks]
Brandon Brown. He's a pediatrician with a special interest, which I feel is kind of nice that you have a dedicated person. We have that ability because we use MRIs not necessarily for placental issues, but for a lot of our fetal conditions to really kind of delineate surgical planning for them. We now have fetal interventionalists. I'm sure that'll be kind of a bigger thing that we'll be able to offer our patients.
(9) Placenta Accreta Spectrum Management
[Dr. Christopher Beck]
Got you. All right, so whether you use ultrasound or MRI, do you guys want to kind of just talk a little bit more broadly about accreta spectrum and how you guys handle that?
[Dr. Roxane Rampersad]
We suspect placenta accreta spectrum when patients have previas. That's the first thing. When we see a previa, we start looking at that interface. We look for that loss of that myometrial interface that Tony mentioned. We look for these lacunae in the placenta and then we look at the vascularity at the bladder interface. Some of those things can clue us in that maybe this patient has placenta accreta.
Once we diagnose placenta accreta spectrum, then we have a multidisciplinary team that we mobilize to start talking about these cases and then for surgical planning. It's a group made up of our high-risk group e-docs and our GYN oncologists and then people who have an interest in imaging. We take that patient through their pregnancy. We bring them in for antenatal steroids because most of these patients are delivered early.
We bring them in. We do that surgical planning, get them typed and crossed, and then we get them to the operating room. Usually, I think with this multidisciplinary approach, we're more successful, I think, than someone coming off the streets with an undiagnosed placenta accreta spectrum. I think you can definitely see a difference in blood loss and a difference in morbidity.
Knowing ahead of time and having patients being imaged is definitely helpful, especially when they have a history of a prior cesarean section. I think we'll have Tony tell us his experience too. When patients have a prior cesarean section and they have that previa and once their cesarean section starts to increase in terms of numbers, that risk can be as high as 60%. It's a pretty significant risk actually. It's really important for us to try to keep our cesarean rates down if we can.
[Dr. Anthony Shanks]
There's a very important study. It came out in 2006. Silver is the primary author. It really enforced the implications of having a previa in addition to that C-section. Because if you have a manipulation of your uterus, a myomectomy, something that disturbs that endometrial layer, that knit-a-box layer, that's going to lead to adhesive placenta. It makes sense. The more C-sections you have, your risk is going to go up.
This study that Silver and their group, it was over 30,000 patients that they looked at. They stratified it with whether you had a previa or not. If you did not have a placenta previa and let's see you're going in for your fourth C-section, so you've had three prior C-sections going in for your fourth, your risk of an accreta was 2%. If you're going in for your fourth C-section, you had three prior C-sections, and you had a previa, your risk is over 60%.
That's a huge difference just based on where that placenta is. To me, that makes sense. If you have a fundal placenta that's far away from the scar, okay, that's probably less risky than one that's right there that could potentially grow into it. Even before you've laid that probe on the patient to look at an ultrasound to see if it's got some of these clinical characteristics, your clinical history, just taking that will clue you in how worried you should be.
[Dr. Christopher Beck]
Are both of you guys doing all your own ultrasound imaging? Is it farmed out to the radiology department or is it all in-house? By in-house, I mean inner department of the OBs.
[Dr. Roxane Rampersad]
Ours are done by our MFMs and then our radiologists get involved when we have to do MRI.
[Dr. Christopher Beck]
Okay, how about you, Tony?
[Dr. Anthony Shanks]
That's the same way. We're very ultrasound-based. These are our own patients. I think relying on radiology, they probably handle some GYN scans certainly overnight with that, but for anything obstetric-related and, certainly, these placenta ones will come to us.
[Dr. Christopher Beck]
Got you. I know that now we can't see anybody. Tony, I'll leave it to you to where you want to take it next.
(10) Offsetting Postpartum Hemorrhage: The Future State of Technology
[Dr. Anthony Shanks]
All right, so let's think future state. We've covered, Roxane, what things are like now. What are we working on with Jada and everything? We have the protocols. Specifically, with postpartum hemorrhage, what do you think we need to be cognizant of? Where do you think things are going? What do you think we could potentially do to offset this in the future?
[Dr. Roxane Rampersad]
Gosh, Tony, that's a really good question and blew my mind here. I don't know besides [chuckles] tamponade and what else we can do. You know what? Actually, let me take that back. I think one of the things that's really exciting that potentially could help us are these devices that engineers are looking at that are wearable, that potentially could let us know about the hemodynamic state before we're behind the eight ball because that's the issue, right, is that oftentimes when we recognize it, that patient could be already behind the eight ball and we're trying to catch up.
I think that would be an amazing thing. Patients would come in. They would be laboring or they could be in the operating room. They would wear some sort of optical device that's looking at that volume and hemodynamic states. That could clue us in, "Hey, your patient is going to be in trouble." Start doing these things potentially. Maybe you need to start thinking about transfusion ahead of time, or maybe you need to start thinking about ligating vessels or being more expedient with your surgery. That, I think, could be something in the future that could really help us.
[Dr. Anthony Shanks]
Yes, I love to think about these moonshots. I think that's how you get these big developments, not just in medicine but in anything. It's usually something that's a little bit outside of the box. I love the idea of personalized medicine. That's just one aspect of it. Certainly, in the most acute of settings that you can keep track of that person's vital signs before they get too sick.
I think in terms of the etiology for these postpartum hemorrhages, we've had such a focus on creating a diagnosis and preparation. Boy, I wish there was a way to prevent it. If there was some way, maybe after a delivery that you could apply something on the inside of a non-pregnant uterus that can reestablish a stable wall internally. Again, pie in the sky. That may be something 50 years down the road. Somebody will be able to figure out, but I think that would be cool.
[Dr. Christopher Beck]
That's nice. Let me ask you guys this. A lot of our audience says interventional radiology, vascular surgery, interventional cardiology. Are there any things that you wish your interventional radiology colleagues knew or any references that you wish that they had at their disposal to help you take care of these patients? Does anything come to mind in terms of articles or ACOG guidelines that are available?
[Dr. Anthony Shanks]
Yes, so there was a New England Journal of Medicine article that came out last year. It's Bienstock. Dr. Bienstock is the primary author, but it has a couple of people that we know. Dr. Eke, Dr. Hueppchen. It's a great review with where our current state is. I think that's a great reference to have, but I think an interventional radiologist always having the most up-to-date ACOG postpartum hemorrhage is a great thing to hold on to. It gets updated every few years, but you'll intuitively know what obstetricians are thinking about in dealing with these cases. They'll always have areas unlike uterine artery embolizations using radiology to diagnose things. You'll know what we are supposed to be thinking about.
[Dr. Christopher Beck]
Got you. Roxane, anything to add?
[Dr. Roxane Rampersad]
Yes, I was going to say, one of the things that is really helpful is really collaboration. OBs and MFMs love collaboration. I feel like collaborating with our IR colleagues in radiology and making protocols so we know what's new on our side, what's new on your side, and coming together, I think, works really well. We do it at WashU and I think we do it really well. We have built protocols together. There's people in radiology that are really interested in postpartum hemorrhage. I think that is really good and really helpful for us when we collaborate and we know what you're thinking and what we're thinking. That would be my big plug.
[Dr. Christopher Beck]
Okay, excellent. All right, guys, anything that we left? Any stone left unturned? Anything that we didn't cover?
[Dr. Anthony Shanks]
No, I think this was a nice review. This was fun.
[Dr. Christopher Beck]
All right, good. Glad you guys enjoyed it. To our audience, thank you for listening. If you enjoyed the podcast but want more, please check out the show notes on this episode. I'm going to work hard with Roxane and Tony and make sure that we can upload or at least a link to all the articles that we talked about. Those can be found at https://www.backtable.com/
Special thanks to all the people at BackTable who make those show notes happen. It takes an effort. What else? Oh, we're offering some free CME. I think this podcast will be a part of that. If you want to get some CME, go ahead and click on the green link and that'll take you through the process. We really appreciate your support and we'll catch you next time on the BackTable podcast. Roxane, Tony, thanks for coming on.
[Dr. Roxane Rampersad]
Thank you, guys. It was fun.
[Dr. Anthony Shanks]
Thank you.
Podcast Contributors
Dr. Roxane Rampersad
Dr. Roxane Rampersad is a professor and practicing OBGYN with Washington University School of Medicine in St. Louis.
Dr. Anthony Shanks
Dr. Anthony Shanks is a professor of clinical obstetrics and gynecology with the Indiana University School of Medicine.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2022, November 15). Ep. 4 – IR/OB Collaboration in Treating Postpartum Hemorrhage [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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