Dionne: So People magazine recently featured the actor musician Mandy Moore, and in it, she revealed to the world that she will not get an epidural for her second baby because she has a rare blood disorder called ITP, and therefore, she will be going through her labor unmedicated…like the answer testers.

 

Maleeha: Okay, Dionne, this story really hit me because it’s definitely a sensational headline, and it made the issue seem very cut and dry. In reality, I think there are a lot of options. Lots of options. So let’s take this catchy headline today and let’s break it down, because the decision is definitely not all or nothing.

 

Dionne: Yeah. On this episode of The IVY Drip, we’ll talk about ITP or immune thrombocytopenic purpura, and similar blood conditions and whether you really can get an epidural or not. We’ll also discuss how women with these conditions can best prepare to have a smooth delivery.

 

INTRO: This is The IVY Drip, a podcast designed to give you the dish on health topics you need to know but didn’t know to ask. We are your hosts, Dr. Maleeha Mohiuddin and Dr. Dionne Ibekie. We’re both Harvard trained anesthesiologists and besties. Join us as we explore hot topics that are rarely discussed but can have a huge impact on your life.

 

Maleeha: OK, so to start us off, in case you’re not familiar with what an epidural is, I think it’s  relevant to explain exactly what it is, where it’s performed, and how it’s performed. I definitely had an epidural for my pregnancies, didn’t you, Dionne?

 

Dionne: Oh, there’s no way I would not have an epidural.

 

Maleeha: Yeah, I mean, this is kind of a big decision for a lot of women. I think it’s a big decision that Mandy’s making for her that you’re paying.

 

Dionne: It is. So let’s talk about it. An epidural is a procedure where the goal is to get Mamas comfortable from the waist down by numbing a lot of their contraction pain associated with labor. That way, ideally, you can rest and be more comfortable so that when it’s time to push, you are relaxed and ready. To do this, though, we have to place a sterile needle in your back. Yep. A big ol needle in your back. But thank God we go through residency training for this so we know how to use it.

 

Maleeha: Okay, so this is a spiel that I’m gonna say. I say to all my patients, okay, give it to us. Shoot. Yeah. So the whole procedure is sterilely. Done. Okay. We use the needle I inserted into the back, again, sterile, and find this particular space called epidural space. Okay. Once I reach that space, I’m going to thread a very soft, tiny, thin catheter, and that little flimsy catheter attaches to a pump, and I take the needle out so there is nothing sharp that stays in your back. Okay. And the pump delivers medication, this numbing medication throughout the duration of your labor. And it’s actually pretty comfortable. The medicine gives you that great magical relief that you’ve been wanting. And also the catheter, you can’t really feel it. It’s quite tiny and very thin. I say it’s a thin like a fishing wire. Okay. Usually placing an epidural is pretty straightforward. It takes about anywhere from five to 15 minutes. Unless there are some particular issues involved, it can take longer.

 

Dionne: So why does all this matter, and what does this have to do with Mandy?

 

Maleeha: Well, one word, I think, is bleeding. And like I said, we make a small hole in your back that’s just outside a very important area called your spinal column. And so before we can do that or enter that area, we really need to make sure your blood counts are okay, specifically, platelets, because platelets help stop bleeding by forming clots.

 

Dionne: Yeah. So every time you nick yourself, it’s those platelets that rush up and form the clots to stop the blood loss. We need platelets. They’re like spackle. We need lots of them and ones that are functional. Meaning that they work.

 

Maleeha: Yeah. So when they’re low, when the platelets are low, patients are at increased risk for bleeding. Okay. And if they drop to really critical values, patients can bleed out or really bleed, which is very dangerous, especially for any woman in labor, because as you can imagine, either you’ve seen personally or you’ve seen in the movies, women bleed a lot during labor. Anywhere from half a liter to a full liter is a normal amount of blood loss. So we’re really checking blood work a lot to make sure that everything is going smoothly and safely.

 

Dionne: I just thought that this could be a whole another episode, because bleeding and pregnancy is such an important topic, and it comes up a lot in the media, too. So that’s just something I want to bring up. Maleeha, I think we need to do an episode on that. But back to epidurals, specifically bleeding. With epidurals, it’s important for us to mitigate that risk, because, like you said and you pointed out, it’s close to the spinal column, and it’s a very small space that we enter with a needle. And if there is excessive bleeding in that space, it can lead to a rare, this is a rare complication, but neurological, severe neurological issues like paralysis. It’s rare, but it can happen. And that’s what we want to avoid. And that’s why platelets and conditions like thrombocytopenia and ITP are important.

 

Maleeha: Okay, so let’s go back to yeah, let’s go back to Mandy Moore. She has ITP. So let’s talk about this acronym. What is ITP?

 

Dionne: I like the way you did that. Right? You kind of rap or something. Are you trying to make it pop? So ITP stands for immune thrombocytopenic, purpura, and it’s basically a condition where you have low numbers of platelets, and this disease is caused by an immune reaction against your own platelets. Your body is destroying its own platelets, essentially.

 

Maleeha: Yes, exactly. And so patients with ITP. When you don’t clot well, you bruise really easily. So patients can have bruises all over their skin. They might bleed, their gums might bleed when they brush their teeth. And that’s where the name part of the name comes from purpura. Purpura, meaning purple discoloration of the skin. And the unique thing about this condition too, is that patients with ITP can have super fast drops in their platelet counts, which is why we check blood counts repeatedly.

 

Dionne: OK, so now it all makes sense. Let’s put all the pieces of the puzzle together. Mandy Moore has ITP and therefore can’t get an epidural and will go without pain relief for her labor. I mean, pretty black and white decision, right?

 

Maleeha: Yeah, not really. In fact, there are a lot of treatment options depending on your circumstance. So we got to get a little academic here, because I want you to know this is not just coming from Dionne and me. Right. There is a whole society, the Society for Obstetric Anesthesia and Perinatology, or SOAP, for sure. They put out this consensus statement on neuraxial procedures in obstetric patients with thrombocytopenia, which is this exact situation, patients with low platelets. The society is amazing. Honestly, to me. I know you’re not a Harry Potter person yet, but it sounds like a group of wizards that get together. And that’s actually how I think of them, because they’re all crazy smart and they may or may not have wands, but basically they get together and they put out these guidelines that all anesthesiologists can follow safely, such as in this situation.

 

Dionne: So, yeah, the wizards, according to their statement, which is based on clinical data, anesthesiologists are able to safely place epidurals on patients with a certain threshold of platelets that even women with ITP meet. Your OB is always tracking your platelets, whether you have ITP or not, because low platelets can happen to any pregnant woman.

 

Maleeha: Dionne, I feel like you dealt with this yourself, didn’t you, during one of your pregnancies?

 

Dionne: Yeah, I did. So it wasn’t ITP like you said. But I did have something called gestational thrombocytopenia. And that’s more of a condition that occurs in pregnancy where your platelets drop. But in this situation, your platelets resolve postpartum.

 

Maleeha: Meaning they go back to normal.

 

Dionne: Exactly. They get back to normal. The exact cause is unknown, but like everything else in pregnancy, it’s probably hormone induced. But guess what, guys? I had an epidural.

 

Maleeha: Not surprising.

 

Dionne: There’s no way I would not have an epidural.

 

Maleeha: Yeah, I’m not surprised that you got an epidural, but what were some of your considerations? And was it scary, like did you really have to weigh it out? Were you nervous about it?

 

Dionne: So I wouldn’t say that I was scared because I had the advantage of being a physician. Lucky me. However, I was very adamant that I needed an epidural. I already had the experience of my first pregnancy. I knew what contractions felt like, and I didn’t last very long with the first one, so I knew I was going to last very long with this one. What we did was schedule an induction, meaning that we weren’t going to allow me to go into spontaneous labor, but instead she was going to induce my labor with medications. That allows my OB to give me medications called steroids. And the steroids taken days before helped to boost my platelet count. That allowed for my platelet numbers to meet the threshold that was required for me to get my epidural. So I was very thankful and happy for that.

 

Maleeha: Awesome. Yeah. So then steroids are an option, but it sounds like you really do have to have some kind of discussion and plan that out in advance.

 

Dionne: Yeah, I mean, the experience I had is the experience of many women with thrombocypenia, including people with ITP. According to SOAP, ITP patients can also receive pulse steroids to boost or stimulate platelet production. Additionally, they can also receive IVIG or IV immunoglobulins to help increase their platelet count as well. So ITP patients do not have to automatically rule out epidurals from their labor plan. We are equipped with ways to optimize their platelet count to allow the anesthesiologist to safely perform the procedure and prevent harm.

 

Dionne: So could Manny Moore actually have gotten an epidural then? There’s no way we could answer that without knowing her specific history. However, we’re sure she made the right choice for her and made it with her will OB, and that is what’s important.

 

Maleeha: Yeah. So the main takeaway here, and you know how I love takeaways.

 

Dionne: Yes, you do.

 

Maleeha: There are many options, and there’s a whole group of anesthesiologists who have specialized training and obstetrics so that they can advise and get involved in making a plant that fits your needs.

 

Dionne: And even when an epidural is not possible, there are other forms of pain relief we can offer a laboring woman. No need to go completely on natural. However, that’s a whole episode’s worth of information, so you’ll have to tune in for the next one. Wink, wink.

 

Maleeha: Yes, information is power. It’s good to know your options and utilize all your resources. On that note, thank you for joining us. We hope this helped allay some of your fears. Just know that if you have questions related to pain relief during labor, especially the epidural, you can always ask your OB for a referral to the anesthesiologist. You have all those prenatal visits. It’s the perfect time to just ask them on one of those visits and they will direct you to us. So we would be happy to see you and address all your concerns.

 

Dionne: For more IVY Drip, check out our website at theivdrip,co and email us with your stories, comments and questions at info@theivydrip co. We love to hear from you all. And don’t forget to subscribe to our podcast and spread the love now for the random tip of the day.

 

Maleeha: Okay, tip of the day. It’s related to what we just talked about. I would say have a little meal or something to snack on prior to requesting your Epidural. Because once Epidural is in, we only allow for sips of water and some ice chips. I don’t know about you, but I actually had a little snack of, like, pita chips and hummus at 2am. before getting my epidural. And it worked.

 

Dionne: I had Thai food, so I had a whole meal

 

Maleeha: At 2am, that hat was hard for me.

 

Dionne: It wasn’t at 2 am, luckily it was at a godly hour, but good for you. I had food, food.