HJNO Nov/Dec 2024

48 NOV / DEC 2024  I  HEALTHCARE JOURNAL OF NEW ORLEANS   Healthcare Briefs Doctors Grapple with How to SaveWomen’s Lives Amid ‘Confusion and Angst’ over New Louisiana Law By Lorena O'Neil Reprinted with permission from The Louisiana Illuminator , lailluminator.com. When a woman starts bleeding out after labor, every second matters. But soon, under a new state law, Louisiana doctors might not be able to quickly access one of the most widely used life- saving medications for postpartum hemorrhage. The Louisiana Illuminator spoke with several doctors across the state that voiced extreme con- cern about how the rescheduling of misoprostol as a controlled dangerous substance will impact inpatient care at hospitals. Misoprostol is pre- scribed in a number of medical scenarios — it’s an essential part of reproductive health care that can be used during emergencies, as well as for miscarriage treatment, labor induction, or intra- uterine device (IUD) insertion. But because it is used for abortion, misopros- tol has been targeted by conservatives in Louisi- ana — an unprecedented move for a medication that routinely saves lives. A controlled dangerous substance has extra barriers for access, which can delay care. “My fear is that someone could eventually die,” said Dr. Tara Morse, an OB-GYN who practices at Touro Infirmary in New Orleans. “And that’s not why we all went into medicine. Our goal is to pre- vent everything and be able to use every drug at our disposal.” Every hospital has its own system for obstet- ric hemorrhage care. Some use rolling carts or kits in birthing rooms with easily accessible med- ications and equipment in case of hemorrhage after delivery. Misoprostol is a pill often used in early stages of post-delivery bleeding, especially for patients with hypertension or asthma who might have adverse side effects from using other hemor- rhage medications that are usually administered by needles or an IV. Misoprostol is also used as a precautionary measure in case doctors think a patient is at risk for hemorrhaging. In May, Gov. Jeff Landry signed legislation reclassifying misoprostol and mifepristone as Schedule IV controlled dangerous substances, despite more than 200 doctors signing a letter against the measure. The law goes into effect on Oct. 1, and doctors and pharmacists are scram- bling to come up with postpartum hemorrhage policies that will comply with the law while still providing proper medical care for women. Some hospitals have already preemptively pulled misoprostol from their obstetric hemor- rhage carts and kits because controlled danger- ous substances need to be stored and accessed differently from other medications. “It is causing a lot of confusion and angst just not understanding, just not knowing — they’re still trying to figure out what to do,” said an OB-GYN who asked that her name not be used because she had not received clearance from her hospital. She said she’s heard of the medication being pulled off carts at some hospitals. “The physician community that I work within is certainly anxious about what the changes to the normal process will be,” said Dr. Stacey Hol- man, division director at Touro’s maternal child services. She added how “frustrating” it is that it’s become routine in Louisiana to have an unclear law attempting to dictate medical practice creat- ing stress on health care providers. “It’s an unnecessary barrier and really critical to the regular everyday care that we provide to our patients,” she said. “We’re trying to fix something that is not bro- ken and that is absolutely safe,” Holman said. Holman said she is not aware of misoprostol being proactively removed from any of Touro’s obstetric hemorrhage carts. But come Oct. 1, “It won’t be in our carts anymore because it [will be] a controlled substance and has to go through the pathways of the pharmacy.” Alternate drugs are available, but Holman pointed out Touro sees an increased number of hypertensive patients in her community who aren’t able to use one of the primary alternatives. Hypertensive patients are also at increased risk for maternal morbidity and mortality. “My job is to save the mom’s life, not type out orders on a computer,” Morse said of what the new protocols might look like if doctors have to put in physician’s orders before obtaining the medicine, versus adding the order afterward as is often the case now. Morse, who occasionally works at rural hospitals in the state, said she’s very worried about how this will impact those facilities — especially ones without in-house pharmacies on nights and weekends. “I’ve been [at a rural hospital] trying to get a simple headache medication released, and it’s taken 45 minutes,” Morse said. Sometimes doc- tors have to call a remote pharmacy and leave a voicemail, she said, playing phone tag to get access to vital medication. “In these [hemorrhage] situations, you don’t have 45 minutes,” Morse said. While hospitals in New Orleans are attempt- ing to find workarounds for the new law, there are some rural doctors who aren’t even aware the reclassification of misoprostol and mifepristone is happening. One physician in northwest Louisiana who spoke with the Illuminator hadn’t heard that misoprostol was becoming a controlled danger- ous substance until a reporter told her about it. “What? That’s terrifying,” the doctor said. “Take it off the carts? That’s death. That’s a matter of life or death.” The physician said that if a pregnant patient came into her hospital bleeding out with no IV access, she would automatically use misopros- tol as an option. Other medications and tools are not as easily accessible in rural hospitals because they require more resources, whether that’s because they are more expensive or require the use of syringes. Not to mention the more time a patient has to wait for access to medicine, the more blood she loses. “Blood is always in short supply,” the doctor said of her hospital. “Misoprostol can prevent the need for transfusion.” The doctor said the pending law likely explains why pharmacists had been “pushing back” when she prescribed misoprostol for outpatient miscar- riage management. They’ve been calling her to request clarification on why she prescribed the medication, and one pharmacy refused to fill the prescription. She had to send that patient to a dif- ferent pharmacy. Her patients often travel hours to see her, and she regularly has to call in miso- prostol to help them manage care at home. On Aug. 22, 50 doctors signed a letter to the Louisiana Department of Health and Sur- geon General Ralph Abraham asking for addi- tional guidance on how to safely prescribe and