Podcast Transcript: IR/OB Collaboration in Treating Postpartum Hemorrhage

[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.