Love's labor pays off for mother, baby

By Karen Blakeman
Advertiser Staff Writer

Julie Apina hadn’t planned to become pregnant.

She was 37 years old and both of her daughters by a previous marriage had been delivered by Caesarean section. The youngest was born prematurely, taken from her womb after the placenta grew to block the cervix and bleeding began. None of those factors boded well for a third shot at pregnancy.

Baby Tiare was born healthy on Wednesday afternoon as doctors raced to prevent Julie Apina from bleeding to death from a placenta attached to the uterus wall. Deborah Booker • The Honolulu Advertiser

But Apina was pregnant, and she couldn’t help being happy about it. Her husband, Siate Apina, was worried but happy — his doubts assuaged by the prayers of friends and family, and those he said with his wife. The only person who wasn’t happy was Apina’s doctor.

“She said she didn’t want to handle this type of problem pregnancy,” Julie Apina said. “That was a real turn-off.”

So in the autumn of last year, Apina made the first of what would seem like an endless series of decisions: She chose to keep the baby and get a new doctor. She chose Melanie Lau, a gynecologist and obstetrician who delivered babies at the The Queen’s Medical Center.

Apina had consulted with Lau before and trusted her.

Lau trusted Apina, too. Once apprised of the challenges they faced, Lau trusted Apina to make choices based on the information.

The first piece of information came when Lau sent her for an ultrasound test in the 16th week. The baby was well. But the placenta was blocking the cervix, and unless the situation righted itself before the baby came to term, it might have to be taken early, as the baby born 11 years before had been.

The next month, the ultrasound showed the placenta in the same position. But Norman Sato, the Queen’s physician who analyzed the ultrasound, spotted another worrisome situation: the possibility of placenta accreta. The placenta that nourished Apina’s baby might be growing into the wall of her womb.

Lau knew what could happen to women with this condition. After the birth, as the placenta was removed, the mother was likely to suffer a massive hemorrhage.

“They bleed like stink,” Lau said.

A woman who had her baby delivered by another doctor at Queen’s a few months earlier had had a similar accreta. She bled profusely, undergoing transfusion after transfusion as doctors tried to stop the bleeding with clotting agents and gave her an emergency hysterectomy. Nurses said the woman survived the surgery.

Lau needed something more effective than the clotting agents used on that woman.

While Apina went through a series of tests, none of which confirmed or ruled out the condition, Lau researched. She discussed

Apina’s condition with an Arizona specialist who came to Queen’s to update doctors on gynecological intensive care. The news wasn’t good.

“After she talked to him, she told me if I had accreta, my chances of surviving might be 50-50,” Apina said.

Doctor and patient decided to try to find proactive ways of dealing with the possibility of accreta. Lau sent Apina to talk to Dr. Ryan Matsuo, an interventional radiologist who thought he had a way of stopping the profuse bleeding with balloon angioplasty.

The procedure involved placing tiny balloons in the arteries that fed the uterus, entering through the femoral artery near the top bend of the leg, threading the catheter from one side of her body, up through her aorta and down the other side. The two balloons would partially block blood flow to the uterus, slowing the bleeding.

Apina took her husband and her father, a retired pediatrician, with her to see Matsuo. They listened carefully as he explained the options and their consequences. The options boiled down to two, Apina said: Matsuo could put the balloons in just after the baby was born or just before.

Because Apina would begin to bleed after the delivery and continue to do so while Matsuo inserted the balloons, waiting until after the birth might well result in her death.

Because he would have to use radiation to see where he was threading the balloons, Plan B would expose the child to radiation. With each moment that passed, the baby’s chances of developing leukemia or lymphoma later in life would increase. The average time for procedure was 7 to 10 minutes. If it took longer than 11 minutes, problems with the child were likely.
“Plan B,” Apina said.

“Plan B,” said her husband.

“Good choice,” said her father.

Matsuo would insert the balloons just before the C-section birth, deflate them and inflate them if and when the bleeding started. Apina, Lau and Matsuo set the date for angioplasty and delivery for Thursday, April 4.

On Wednesday, Apina’s uterus began to contract and she began to bleed. At 3 p.m., she called Lau from her home in Waipahu.

“Take an ambulance,” Lau said. “Hurry.”

“My husband is home,” Apina said. “I want him to drive.”

Siate Apina’s hand shook and he forgot his wallet. But he turned on his flashers, sucked in his breath, leaned on the horn and used the shoulder of the road as a passing lane. The Apinas arrived at Queen’s at 3:20. Lau, Matsuo and the rest of the team Lau had assembled were ready.

Siate was banished to the waiting room. He didn’t even have a chance to tell Julie he loved her.

Matsuo installed the balloons using only 4.5 minutes of radiation time, and Apina was taken to the operating room.

Lau opened Apina’s uterus and delivered a screaming, 7 pound, 10 ounce baby girl with long dark hair and a very long name: Tiare Marie Harue Kehaulani Apina. Then she lightly massaged the placenta.

“Inflate the balloons,” Apina heard her doctor say. The accreta was confirmed and bleeding was profuse, but when Matsuo inflated his balloons it slowed and stopped.

Apina didn’t require a transfusion; she lost only a liter of blood, a fraction of what often streams from accreta patients as they undergo repeated transfusions.

Yesterday, Siate Apina drove back to the hospital.

His prayers had been answered: he took his healthy wife and baby home.

CORRECTION: An earlier version of this story erroneously described Julie Apina's placenta problem. Also, a reference to the death after surgery of another pregnant mother was incorrect.