BackTable / OBGYN / Podcast / Episode #4
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).
BackTable, LLC (Producer). (2022, November 15). Ep. 4 – IR/OB Collaboration in Treating Postpartum Hemorrhage [Audio podcast]. Retrieved from https://www.backtable.com
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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.
To set the stage, Drs. Rampersad and Shanks explain the definition of PPH based on the American College of Obstetricians and Gynecologists (ACOG) guidelines. They further describe the differences between early / acute versus late blood loss, in addition to the most common etiologies using the “Four T’s” pneumonic: tone, trauma, tissue, thrombin. Drs. Rampersad and Shanks then describe their approach to the workup and management of PPH. The group discusses topics such as uterine massage, oxytocin, hemabate / methergine, tamponade (e.g. Bakri balloon, the JADA System), embolization, and hysterectomy.
The physicians then describe the role of cross-specialty collaboration between OBGYN and IR, specifically in the management of PPH. When highlighting the role of IR, Dr. Beck describes how he counsels patients for uterine artery embolization (UAE), and he provides an anecdote regarding a repeat UAE. He also shares his perspective with utilization of gel foam versus coils. The group then transitions to describe diagnosis and management of placenta accreta spectrum (PAS), its association with PPH, and the role of radiology in this disease process.
Lastly, Drs. Rampersad and Shanks allude to what the future may hold for PPH, including more personalized medicine and potential technologies to prevent PAS. The group ends the episode by providing IR colleagues with insight to what may strengthen the collaboration between OBGYN and IR in order to provide optimal care for patients with PPH.
Silver RM, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226-32. doi: 10.1097/01.AOG.0000219750.79480.84. PMID: 16738145.
Bienstock RM, Eke AC and Hueppchen NA; Postpartum Hemorrhage. New England Journal of Medicine 2021 Vol. 384 Issue 17 Pages 1635-1645. Accession Number: 33913640 DOI: 10.1056/NEJMra1513247.
ACOG Postpartum Hemorrhage:
[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.
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