USF-TGH doctors combine technology and teamwork for safe delivery

The hospital’s new hybrid operating room, allowing interventional and open procedures in the same place, helped reduce high-risk patient’s blood loss

Reyna Miranda didn’t know much about the high-tech, carefully orchestrated rehearsals that preceded the birth of her son last week.  The baby boy she held in her arms was proof enough that all had gone well. “He’s a miracle,” she said.

Miranda, 36, of Ruskin, had a rare but increasingly common complication of pregnancy known as placenta accreta. During normal childbirth the placenta detaches from the uterus. In women with placenta accreta, the placenta — fed by an extensive network of delicate blood vessels — grows too deeply into the uterine wall.

Last Wednesday, teams led by three USF Health physicians – Dr.  Mitchel Hoffman, Dr. Valerie Whiteman and Dr. Bruce Zwiebel — performed a four-stage procedure in Tampa General Hospital’s new hybrid operating room that allowed Miranda to safely deliver a healthy baby while significantly reducing the primary risk of placenta accreta: life-threatening bleeding.

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L to R: Dr. Bruce Zwiebel, Dr. Mitchel Hoffman and Dr. Valerie Whiteman with Reyna Miranda and baby Jordan Roldan Miranda.

When severe placenta accreta is detected by ultrasound during pregnancy, the standard treatment is a cesarean section delivery followed by hysterectomy, or surgical removal of the uterus. Before delivery, arterial catheters may be placed by an interventional radiologist to partially shut down, or embolize, blood flow to the uterus immediately after delivery, reducing the risk of massive blood loss. This involves moving the patient, hooked up to the precisely-placed catheters, to a labor and delivery operating room.  Massive hemorrhage often still occurs before, during or after the hysterectomy. Sometimes the patient must be rushed back to interventional radiology to further embolize the bleeding vessels. Valuable time slips away during the transfers.

The spacious hybrid OR is equipped with all the technology needed to efficiently perform interventional and open surgical procedures in one place.   Tampa General has primarily used it for cardiovascular cases since opening the suite in January.   Miranda was the first obstetric patient to be treated there.

“The patient benefitted from having all the expertise in the same room… without the added risk of moving,” said Dr. Whiteman, associate professor of obstetrics and gynecology and director of the Division of Maternal-Fetal Medicine, USF Health Morsani College of Medicine.

On average, a woman may lose three to five liters of blood during such a complex delivery and hysterectomy, but Miranda lost only a fifth of that during the five-hour case.

“This was the most ‘bloodless’ cesarean hysterectomy for an accreta I have ever seen,” Dr. Whiteman said.

Mom and baby

Miranda snuggles with her baby boy. A team of skilled USF-TGH physicians and new specially-equipped hybrid OR helped to significantly reduce Miranda’s blood loss for a complication of pregnancy known as placenta accreta.

Here, briefly, is how the multi-part procedure worked:

-          First, Dr. Zwiebel, an interventional radiologist, threaded catheters from Miranda’s groin into the uterine arteries so he could later block the blood supply to the pelvis and uterus.

-          Dr. Whiteman, a perinatologist, performed the C-section to deliver the 5-pound, 1-ounce baby boy. The placenta was left attached to the uterus and the incision was closed.

-          Then, Dr. Zwiebel injected tiny particles, or embolization agents, through the previously placed catheters to close off blood supply to the extensive network of blood vessels within and around Miranda’s uterus.  This highly-specialized process, aided by state-of-the art high-resolution imaging, helped reduce the risk of hemorrhage during the hysterectomy.

-          Finally, Dr. Hoffman performed the hysterectomy, made even more challenging by the blood vessel-laden placental “mass” that had replaced the lower uterus much like a tumor.  Dr. Hoffman, a specialist in gynecological cancers, has worked on many pelvic tumor cases with Dr. Zwiebel, who embolizes the tumor and adjacent tissue to help Dr. Hoffman operate more safely and effectively.

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Tampa General Hospital’s new high-tech hybrid operating room, open in January, allows open and interventional procedures to be performed in the same place, enhancing efficiency and patient safety. It is similar to the state-of-the-art hybrid OR at the USF Health Center for Advanced Medical Learning and Simulation, the first of its kind for training in the world.

A team of 20 doctors and other healthcare professionals practiced for Miranda’s multidisciplinary surgical care plan several days before her arrival.

“This case was a great example of how technology and a team approach can be used to markedly improve a patient’s surgical outcome,” said Dr. Hoffman, professor and director of the Division of Gynecologic Oncology, USF Health Morsani College of Medicine.

“It was a great team effort across the specialties of interventional radiology, neonatology, obstetrics and gynecology, and anesthesiology,” said Dr. Zwiebel, associate professor and vice chair of clinical affairs at USF Health Radiology and chief of staff at Tampa General. “It was well rehearsed before the procedure and went off without a hitch.”

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L to R: Dr. Hoffman, Dr. Zwiebel and Dr. Whiteman led teams that performed a complex multi-part procedure involving a C-section followed by a hysterectomy.

Placenta accreta has been associated with abnormalities in the lining of the uterus caused by C-sections or other uterine surgery leaving a scar.  Miranda fit the high-risk profile; she had two previous C-sections and the condition was detected by ultrasound at four months.

The increasing incidence of placenta accreta has paralleled the rise in C-section rates, researchers say. As many as 90 percent of patients with the condition require blood transfusions.  The American College of Obstetricians and Gynecologists reports maternal mortality rates as high as 7 percent.

Drs. Hoffman, Whiteman and Zwiebel, and other USF physicians, authored a 2010 paper in the American Journal of Obstetrics and Gynecology reporting on the significant hemorrhage and urinary tract problems associated with non-emergency hysterectomy for placenta accreta.

Photos by Eric Younghans, USF Health Communications
Susan Shulins, Tampa General Hospital, contributed to this story