HOW Collaborative president Associate Professor Giselle Kidson-Gerber.
A network of dedicated Australian clinicians is bridging a critical gap between haematology and women’s health that has stemmed from a lack of crossover between disciplines and a reluctance to include pregnant women in research.
Called the Haematology in Obstetrics & Women’s Health (HOW) Collaborative, the group grapples with complex issues that require a multidisciplinary approach like managing haematological malignancies or thromboprophylaxis during pregnancy.
Its members – haematologists, obstetricians, anaesthetists and midwives among others – do this by collaborating on research, education and advocacy, and share their expertise through position statements and at major meetings.
Co-founder and president Associate Professor Giselle Kidson-Gerber says the lack of randomised controlled studies has limited guidance in the space, leading to variation in practice and uncertainty over how to optimise patient outcomes.
“It’s hard to do research in women who are pregnant. Some people find it very scary, particularly haematologists who are used to dealing with more black and white, and then the extra person brings in a lot of grey,” she tells the limbic.
“But clinical trials are so important. They give you access to medication, we know you often get better outcomes, you get much more monitored care. So are there reasons not to exclude them and how can we change the thinking around that?”
Another way to increase data is to measure what’s already happening. Associate Professor Kidson-Gerber, who is head of clinical haematology at Prince of Wales Hospital in Sydney, says even haematologists who have only a few patients who fit the research criteria should get involved because collectively they can make a difference.
The high-impact research happening locally
Current research projects being run by the group include assessing the birth outcomes of women who receive low-dose enoxaparin (Clexane) prophylactically throughout pregnancy.
“There used to be a pattern of having inductions, but then we realised we probably don’t need to have inductions, and nearly all those women could still access an epidural and not have excess bleeding. So we’ve done a retrospective study which we’re working up to publish now, and now we’re thinking of setting up a prospective study,” Associate Professor Kidson-Gerber says.
There’s also been increased interest in the heavy menstrual bleeding space. The team is about to conduct a prospective study looking at menstrual losses in patients in Australia and New Zealand on direct oral anticoagulants, comparing dabigatran – the DOAC used in New Zealand – with apixaban.
Their research will also look into the outcomes of women of childbearing age with myeloproliferative neoplasms, particularly in pregnancy.
Associate Professor Kidson-Gerber says while there are already overseas data sets available, there are questions over their generalisability.
“It’s interesting, some of the clinics overseas are amazing, they have a very specialised service, but then they tend to see the worst of the worst,” she says.
“Do all women with essential thrombocythaemia have a high rate of miscarriage and abruption and these terrible foetal losses? In my experience, the answer is no. So we want to be able to give patients the bigger picture.”
A research team is also looking at the outcomes of pregnant women with inherited bleeding disorders to determine whether the postpartum haemorrhage rate has improved following an Australian guideline change to using tranexamic acid.
Advocacy and sharing expertise
The collaborative has also been involved in guidelines for thrombocytopenia management in pregnancy, sickle cell disease in pregnancy, and haematological malignancies in pregnancy, often collaborating with other groups and societies.
“We don’t have the level of data to be able to say with confidence, ‘This is what you should do’. But we are writing guidelines which are really practical within the limits of the information that we have,” Associate Professor Kidson-Gerber says.
“When it’s grey, we’ll often say it’s grey.”
With manpower critical to its research and advocacy efforts, the collaborative is expanding its membership nationally and has launched a new website [link here].
Associate Professor Kidson-Gerber says members can get access to previous education content, discounts at meetings and linked in with the research arm.
National MDTs are also being considered as another way to share knowledge.
The collaborative holds symposiums, with an education symposium to be held ahead of ISTH in Paris, and conference sessions at major meetings like Blood and the Society of Obstetric Medicine of Australia and New Zealand’s ASM.