HJBR Nov/Dec 2024

46 NOV / DEC 2024  I  HEALTHCARE JOURNAL OF BATON ROUGE   Healthcare Briefs 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 hospi- tals 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 Surgeon General Ralph Abraham asking for additional guidance on how to safely prescribe and admin- ister misoprostol and mifepristone once the new law goes into effect. They specifically asked for help on the use of misoprostol in the inpatient setting, and “how to ensure it will be readily and quickly available in commonly used obstetric hemorrhage carts.” “This is a nationally recognized guideline to emergently treat life-threatening postpartum hemorrhage and it is critical that providers are aware and have access to medication without delay,” the doctors wrote, requesting Abra- ham’s advice be communicated well in advance of October 1. They had not heard back as of Monday. The Louisiana Department of Health, the state Board of Pharmacy and Attorney General Liz Mur- rill did not return requests to explain how they plan to educate health care providers and assist them in making sure care for Louisiana women is not disrupted. A provision in the new law calls for doctors to be educated on how to comply. “This is a bad drug to be a controlled sub- stance,” says Dr. Jennifer Avegno, director of the City of New Orleans health department and an emergency room physician. “We are putting women’s lives at risk by denying them immediate access to a life-saving drug.” Avegno adds, “The OB providers that I’ve spo- ken to are very concerned and very upset about the way this will change their practice, and I don’t blame them.” She likened the situation to delay- ing a patient in anaphylaxis access to an EpiPen or removing medicine from a crash cart in an emergency room. “When you need to give blood to a crashing patient, do you want it right there or do you want to have to call somebody to have them walk it down from the blood bank?” said Avegno, who thinks the new law could lead patients to lose more blood. “Ultimately it will be OK,” Avegno said, adding that doctors will use heroic measures to stop as many tragic outcomes as they can. “But for some people, having that delay or being forced to take a drug that is not the best indication for them will worsen outcomes.” Louisiana is among the worst states in terms of maternal mortality and morbidity, and Black women are disproportionately at risk of dying due to complications with pregnancy or childbirth. But the state has successfully been reducing death rates due to postpartum hemorrhage. “The state has done really good work on reduc- ing maternal mortality through hemorrhage over the last several years by very deliberate mecha- nisms,” Avegno said. “And [with this new law] we run the risk of backsliding.“ Dr. Jane Martin, a maternal fetal medicine spe- cialist in New Orleans, agrees. “The frequency of severe maternal morbidity