Maternal Hematology: The Value of Interdisciplinary Care (TAB #34)

HELEN: Welcome to Talking About Blood. I’m Helen Osborne, host of this podcast series and a member of the advisory board for The Blood Project. I also produce and host my own podcast series about health communication called Health Literacy Out Loud. Today, I’m talking with Dr. Tabea Sutton, who is a clinical fellow in maternal hematology at Mount Sinai Hospital and the University of Toronto in Canada. After her medical residency in internal medicine and hematology, Tabea developed a strong interest in caring for people during transitional life stages, especially during pregnancy, childbirth, and the interface between pediatric and adult medicine. Those are fascinating times and gaps. Welcome, Tabea. I can’t wait till I have our discussion.

TABEA: Hi, Helen. Thank you very much for having me at your podcast.

HELEN: You are a clinical fellow in maternal hematology. Please do tell, what is that? And is that something that just you are doing or does that happen everywhere?

TABEA: So maternal hematology, sometimes we also call it fetomaternal hematology or obstetric hematology. It’s a discipline where we care about women who have either a pre-existing hematologic disorder and they are pregnant or diseases that are part of hematology that do specifically occur in pregnancy. And it has gotten more attention recently because the field is growing very much, but it’s not yet a fully established discipline itself.

HELEN: Well, who are listeners? Just let me tell you who’s listening. It may be hematologists, perhaps been in practice a long time or newer in the field. It may be scientists or medical folks earlier in their careers and people just interested in everything to do with blood. Can you give an example of those interfaces of that maternal hematology? You talked about it from two different ways.

TABEA: One thing is the women who have a pre-existing hematologic diagnosis, which could be bleeding disorders, hemoglobinopathies. And those women more and more plan to have families. And those pregnancies often are high risk and need a good interdisciplinary care from obstetric, but also from us hematologists being part of it to make sure that they get a good care during that very vulnerable period in their life when they’re pregnant. That’s one thing. And the other thing is diseases that do only occur in pregnancy, but they’re hematologic diseases. For example, alloimmunization. So this is an antibody transfer between mom and the fetus from blood group incompatibilities, which is a pregnancy-specific disorder, which is also part of hematology.

HELEN: Thank you. So you talked about the two different ways. You used some terms in there that I’d really like to explore a little bit more, terms and concepts. You talked about people with pre-existing bleeding disorders who now are dealing with family planning, but they’re at higher risk. Is that something in more recent days, or is that something that’s been going on a long time?

TABEA: Well, I think those women had families before, but due to medical progress, their life expectancy rose. Also, their quality of life rose. So maybe a few years ago, those women did decide on not having a family. But nowadays, let’s take sickle cell disease, where women have better life expectancy and better quality of life. And we start talking about curative therapies as well. They more and more decide on having a family. So I think patient numbers are rising a lot recently.

HELEN: That’s very interesting because of the advances of science and medicine in many spheres that people did not have the babies. Are there other, so you talk about sickle cell disease, other diseases?

TABEA: Yeah. So we do also care about women having bleeding disorders. We care about women who had thromboembolic diseases. There is women having myeloproliferative diseases. Sometimes we see women who have the diagnosis of a lymphoma in pregnancy. So it’s pretty broad. It actually covers most of the topics that we care about in hematology also outside of pregnancy. Many of them do also occur during pregnancy.

HELEN: Fascinating. Now, something else you talked about that I’d want to explore more. You talked about interdisciplinary aspect of this. Your focus is internal medicine and hematology, but you’re not an OB or GYN, correct?

TABEA: That’s correct. No, I’m not. I’m a trained hematologist.

HELEN: So it’s not just you. You know your hematology. Maybe the OB doesn’t know that as much. How do you all work together for this one person’s care and the care of the baby?

TABEA: Yeah, so I think that’s a key element in a good care of a pregnant woman, that the different disciplines in complex medicine work together. So it’s not even only obstetric me. It’s also sometimes we need anesthesia being part of the care team. We might need the pain service being part or mental health support. Pediatrics is often part of it. So it’s very important that there are several people who are actually taking care of the woman. Here at Mount Sinai, we have a very advanced model, I feel like. So we see the women in a clinic together, obstetric and hematology. So it’s a clinic happening on the same day. So obstetric is here and hematology is here. And then the woman has an appointment with both. And actually, we sit in the same room for preparing, not for the visit with the patient itself, but we prepare in the same room, which gives us very, very short ways to talk to each other.

HELEN: Tell me, just make it more vivid for me. So the patient who’s pregnant is not in the room, but you and the OB are in the same physical space. How would you go about preparing? Because the woman who’s pregnant is going to see both of you that day, but see you separately, correct?

TABEA: So maybe she already saw hematology, but she has not yet seen obstetric. And I might be worried because she has swelling on her legs. So I can reach over to obstetric who sits just on the table next to me and I say, hey, obstetric, I saw Mrs. Smith. I’m a bit worried she has swollen legs. I think it’s not a deep vein thrombus, but could she have preeclampsia? And then obstetric can say, okay, we’ll have a look. We’ll see what we think. So these very little barriers for interdisciplinary discussion is very, very helpful that we share a bit of common language. We ask Obstetrics, hey, what do you think? I’m not sure. What do you think? Could it be something from your discipline? So that’s very helpful.

HELEN: Thank you. I’m getting a better picture of that. But you said many people are involved. It could be anesthesia. It could be pediatrics. It could be pain management. Are you around all those people or just the two main people for that person’s care?

TABEA: So currently, it’s the two of us like having a bit of leading care and being present. It is also just from an organizational standpoint, a huge effort to have more disciplines there. But ways are very short. So anesthesia is close by, but so far, they’re not sitting at the same space as we are. But we try to keep ways very short to have easy interdisciplinary discussions on what do you think? How high is the risk for this woman getting an epidural? Could she bleed?

HELEN: And I’m just thinking of this from an organizational or a group process. Does one of you take the lead? You know, does one of you say, this is what I think and this is what we’re going to do? Or is it kind of a group think? And where is the woman involved in making those decisions? Because it sounds like it’s very much of a team effort.

TABEA: It is. So in the end, I would say obstetric is always the lead because they’re going to deliver the baby. But we never had that moment where we did not agree. I think if we have not the same opinion, it needs even further discussions that everybody’s on the same point. In the end, we were always agreeing on what our recommendations are. In the end, it’s a very personal topic delivering a baby. So the woman is highly involved on how she plans to deliver, what are her wishes, and we are just counseling her. But I think the proximity of hematology and obstetric it’s also essential that we give consistent messages to the woman, that not one discipline is saying this and the discipline is saying something else, that we are a team and we had a discussion and we give consistent recommendations for them that they’re reassured that the team is all on the same page. But in the end, the woman has lots to say in the whole discussion.

HELEN: Okay, that’s great. I would be very reassured. I know when I go for care for whatever it is, I had this provider over there and that provider over there and they’re not quite saying the same thing to me. It’s up to me to make sense out of all of it. It sounds as like you came up with that model to do it up front. You’re going to use the same language, make recommendations, and I don’t know at what point the woman’s involved, but it sounds like you’re so respectful of her point of view in that. How did this interdisciplinary model come about?

TABEA: Well, Sinai has a long tradition for it. They have it with lots of other disciplines as well. There is a clinic for cardiology. There’s a clinic for rheumatology. And I’m not fully sure how many years they have been practicing it, but it has been growing and growing. And as the progress in medicine is going on and care becomes so much more complex, they just realized how efficient and how successful that model is to provide good care for high-risk women.

HELEN: Oh, I can certainly see that there. So if you continue the story, just keep giving another clinical example. So this woman at high risk, how might this change what happens in practice, the fact that you’re using such teamwork?

TABEA: So let’s say we follow a woman who has sickle cell disease in pregnancy. She goes and sees her obstetrician. She might tell her obstetrician, I have a bit of back pain. I’m tired, which could be just pregnancy-associated symptoms. But maybe they’re a bit worried and they call us and say, hey, hematology, could you please see that woman? And then we might do a CBC and see, oh, her hemoglobin is low. And then we can have a discussion with obstetric. Is it necessary to transfuse her? Or should we try to avoid transfusion because of side effects where obstetrics might not be aware of, but we are. So this is super helpful just to be so close and have a discussion about it.

HELEN: It sounds so super helpful. I’m trying to think of what to ask. Is there a downside to this?

TABEA: I think for the quality of care, there is no downside. I think not every center in the world will be able to have that model. I think it’s an outstanding model for big obstetric clinics. I’m also thinking, what do we do for hematologists in smaller clinics where they have to take care about women having blood disorders.

HELEN: So tell us more about that. I mean, I’m intrigued because you have this great setup that has been sanctioned by your administration, apparently, for both of you to spend time and be in the same space. What would you recommend for centers that do not have all this availability?

TABEA: I feel like we have to continue our effort to improve education in that field and to also motivate our hematology colleagues. And that might be a message I want to give here at the podcast to stay interested in topics like obstetrics. So when we go into specialization, we sometimes lose a bit of curiosity to keep on being interested in other disciplines, maybe when we start to focus a lot. So I want to encourage my colleagues to be interested in the care of women who are pregnant, to be interested on what is obstetrics doing, to ask questions about women, about fertility, about family planning in everyday life, and that we try to improve the education for hematologists, that they actually feel comfortable in those topics.

HELEN: I mean, you must have some colleagues who are just hematologists, maybe doing this a long time. Is that a question that comes up for a woman in her 20s or something about family planning? Is that part of a routine hematology conversation?

TABEA: Hard for me to speak for all my hematology colleagues

HELEN: Right i am putting you in the spot. I wish we could clone you worldwide.

TABEA: hope it is a question they’re asking but i might guess not everyone is because i feel we ask questions where we are comfortable about the discussion we need to have afterwards and that’s what i wanted to say if we can improve the education in pregnancy-associated topics, maybe in hematology, then more people would actually ask the woman, let’s say in a sickle cell clinic, saying, do you plan on having a family? And then it’s very important she might have been trying for two years and did not become pregnant. And then it’s important for us to know these aspects and to counsel her.

HELEN: So it sounds like the practicing clinicians need to have some level of confidence that is not in their absolute main practice.

TABEA: Very well said. Yeah, that’s what I feel.

HELEN: Okay. And then the other issue, I’m not sure we kind of got to the end of this one, was about in a rural clinic, in a small clinic, you would say there’s a woman who has sickle cell disease and now she is pregnant. What would you recommend without all the wonderful access that you have to your colleagues?

TABEA:: So I think it’s good to have a good network and to know your own strength as a hematologist. So if you’re comfortable and maybe you have access to resources or you have a colleague who is knowledgeable and you can ask, then I’m very happy that those colleagues provide care to those women. And very often there is no one else. So you’re the only hematologist maybe in a local hospital. So it’s important that you take care of those women and not to be afraid to do something wrong and then not to give her care.

HELEN: Is there some kind of a resource where hematologists might go looking to learn more about hematology and pregnancy or something? Is there some support when people might feel pretty overwhelmed and alone in this treatment pickle here?

TABEA: Not yet, like fully structured. It’s a bit distributed everywhere. There is a bit of guidelines and resources, but I think that’s one of the main challenges of obstetric hematology or maternal hematology, that we have less guidelines and evidence-based practice because there’s less studies being conducted with pregnant women. So that’s actually a bit of challenge we’re facing. Where do you get good resources, good guidelines? If you cannot base it on your own experience, if you’re in a center where you don’t have a high patient number of pregnant women.

HELEN: Well, I hope that you’ll be involved in writing some of those papers and guidelines. That would be wonderful to do. You talked about other life transitions. We focused on maternal and pregnancy. I’ve long been interested in that interface between pediatric and adult care. How does a child go from going to the doctor with his or her parent to being responsible for their own care on their own? Tell us a story as that relates to your role in hematology.

TABEA: So the so-called transitioning, which means giving care from a pediatric care team to an adult care team is another challenge we face in medicine. It has some common aspects to maternal hematology. You need a good amount of understanding and patience for everything that is around that individual. So transitioning is challenging for the young, for the adolescents. It needs often good understanding from the care providers on the adult side. So we are very convinced that the patient needs to take care of its own appointment and be on time and manage well. And this is a huge challenge for the adolescents when they move from pediatric hospitals where they’re very closely cared and lots of efforts are done to accommodate them well into that adult world. So that’s very, very different. Just the systems are very different. The individual, usually the transitioning from being an adolescent to an adult takes years, in my opinion. But the care team changes from one day to another. And that’s the challenge.

HELEN: I’ve actually done a health literacy outlet podcast on that transition from pediatrics to adult care. And there’s more factors involved. You not only have the patient, but you have the parents or the caregiver. And what I learned from that is sometimes one of the teams doesn’t really want to let go, or the parents don’t really want to let go and turn over responsibility. So there’s a whole, it’s not just you and a fellow provider coming to terms. There’s a whole team having to change how they’re providing care and not being the focal point as much anymore. That’s what I learned from the health literacy perspective. Is that what you’re finding out too?

TABEA: Yeah, and maybe building a bit the bridge back to maternal hematology is that concept of being responsible for two patients is giving us adult hematologists sometimes a bit insecurity. So for pediatrics, it’s always the patient and the parents. And the parents are so important that they are, let’s say, part of the patient. And in obstetric hematology, we do not only care about the patient, but she’s carrying a baby, a fetus. So that’s a patient as well. And sometimes if we want to apply a therapy, there is even conflicting interest of the fetus and the mom. So for who is it better? Does it have an impact on the fetus? So those transition periods are actually somehow comparable for me. That’s why I actually like both very much, why they’re so fascinating for me.

HELEN: I can hear that from you, how much you like all that. For the listeners, I told you who they were, their different levels of their knowledge and experience in the medicine and science. What would you want practicing physicians to know, those newer in the sciences or health careers, and just the public? What do you think they’d want to know about this?

TABEA: I think what I want to give as a message is to stay interested. It’s very rewarding to care about pregnant women. It’s a very vulnerable time in life. And I would say like pregnancy and childbirth is for everyone the way how we came into the world. So it’s a very important period for everyone. And really to be part of that care as physicians and to improve that care for these very, very vulnerable women.

HELEN: So I’ve learned so much from you. I really have, and I love how you’re approaching this. It’s not just your expertise in medicine and the sciences, but it’s also your willingness to work as a team. And the team are your fellow clinicians, also the patient or patients, parents or caregivers, and making this all happen within a working system. I hope that there are resources for people to learn more, both about the interdisciplinary aspect of this, as well as specific to maternal hematology.

TABEA: Absolutely. So we do have a bit, a society is a little bit ahead of us. So there’s a society for maternal cardiology, and they have a curriculum with lots of resources. And they’re a little bit a step ahead, but we are trying to make these resources available for people that we actually can improve education, interest of physicians, and to make them feel more comfortable and therefore to improve the care.

HELEN: You’re working on increasing education, interest, and ultimately improving care. Tabea, thank you so much for all you’re doing and for inspiring all of us who are interested eager to know more about blood and being a guest on Talking About Blood.

TABEA: Thanks for having me, Helen.

HELEN: As we just heard from Dr. Tabea Sutton, it’s important to know not only about the care each of us can provide, but the care that we as colleagues and teams can provide along with the people we’re caring for. To learn more about thebloodproject.com. and explore its many resources for professionals, trainees, and patients, go to thebloodproject.com. I invite you to also listen to my podcast series about health communication at healthliteracyoutloud.com. Please help spread the word about this podcast series and The Blood Project. Thank you for listening. Until next time, I’m Helen Osborne.