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Tampa General-USF doctors use technology, teamwork for special delivery

TAMPA — The birth of Jordan Roldán-Miranda this week at Tampa General Hospital was preceded by a flurry of rehearsals.

Where would everybody stand? How would they maneuver around equipment? Where would they put Jordan? How would they keep his mother from losing enough blood to kill her?

Reyna Miranda had placenta accreta, a life-threatening condition in which part of the placenta — the mass of delicate blood vessels that sustain the fetus — grows too deeply into the wall of the uterus. The biggest danger? Moments after giving birth, Miranda could quickly begin losing as much as a gallon of blood.

Doctors have a general recipe for dealing with such cases — deliver the baby by caesarean section, then perform a hysterectomy. This is even more complicated than it may sound.

The potential for massive blood loss means doctors may need to shut down blood flow to the uterus just after the baby's birth and before the hysterectomy. The entire treatment plan means rushing patients from one specially equipped unit of the hospital to another, as valuable minutes slip away.

Tampa General-University of South Florida doctors, however, decided to do something remarkably different: Keep the patient in one place.

Miranda, 36, of Ruskin was the first obstetrics patient to be treated in the hospital's new "hybrid operating room," a huge, high-tech space which had been used primarily on heart and vascular patients since opening in January.

On Wednesday, in this room, a team led by Dr. Valerie Whiteman delivered her baby by C-section.

Then Dr. Bruce Zwiebel and his team immediately came in and used the room's state of the art surgical equipment and high-resolution imaging machines to "embolize," or block the flow of blood, to the uterus. It's a sophisticated procedure to get around the placenta with its mass of blood vessels so tangled, one doctor described it as a "Medusa head."

His work completed, Zwiebel then handed off the room to Dr. Mitchel Hoffman, a specialist in gynecological cancers, to perform the hysterectomy. Though Miranda did not have cancer, the team had to treat the uterus and placenta like a tumor — a fragile time bomb that could pour blood if handled the wrong way.

Counting her delivery and hysterectomy, Miranda lost about a liter of blood in five hours — a fifth of what is sometimes seen in similar cases.

"By having all this technology we were able to reduce the blood loss," said Whiteman, who is USF's interim director of the maternal-fetal division.

A team of 20 doctors began planning for Miranda's arrival days earlier. Placenta accreta is thought to be related to abnormalities in the lining of the uterus, typically due to scarring after a C-section or other uterine surgery.

The incidence of placenta accreta has increased, paralleling the rise in caesarean delivery rates, researchers say. As many as 90 percent of patients with the condition require blood transfusions. Maternal mortality rates have been reported as high as 7 percent, according to a 2012 report from the American College of Obstetricians and Gynecologists.

Miranda was a prime candidate for the condition: She had two previous C-sections, and ultrasounds showed there was a problem at about four months.

Hoffman, a USF professor and division director of gynecologic oncology, said doctors at TGH had been following a long-term obstetrics study in Australia that showed coordinated planning, including the use of the embolization procedure after delivery, resulted in much better outcomes for the patients. But in that study, he said, the procedures still happened in different hospital operating rooms.

The new hybrid operating room is part of a three-phase project for the cardiovascular program. But obstetricians thought about how they, too, might take advantage of the room's special features. No similar operating room has been used in birthing centers at other local hospitals.

Zwiebel, a USF associate professor of radiology who also is the hospital's chief of staff, said it made sense. "We can do anything in this room," he said.

On Friday morning, Miranda was less impressed by talk of the high-tech surgery than she was by a swaddled baby Jordan, who was born Wednesday morning, five weeks short of full term, at 5 pounds. Speaking through an interpreter, she said she hadn't been scared until doctors inserted a catheter in her. That's when she knew this wouldn't be like her other five deliveries.

She works from 7 a.m. to 7 p.m. at a tropical fish farm, separating the fish when they come in from the Philippines and sorting them for sale. She said the work kept her mind off the complicated pregnancy she was experiencing.

Baby Jordan was healthy but has one unusual characteristic: He has a sixth finger on his tiny left hand. Miranda said her brother back in Mexico had an extra thumb on each hand, so she assumes it runs in the family.

Her husband, Jorge, asked her if she wanted to have the sixth finger surgically removed. She said no.

"This is how he was born," she said. "He's a miracle."

Jodie Tillman can be reached at jtillman@tampabay.com or (813) 226-3374.

Tampa General-USF doctors use technology, teamwork for special delivery 03/08/13 [Last modified: Friday, March 8, 2013 10:06pm]
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