Summary
A woman walks into a clinic, she’s eight months pregnant: tired, pale, anemic. Many of the woman’s symptoms are typical in pregnancy, and this isn’t her first pregnancy. Her last pregnancy ended early with an emergency C-section at 32 weeks. No one dug much deeper afterward. But this time, her obstetrician happens to flip through an old chart and finds a diagnosis so rare, most doctors will never encounter it. In this episode, follow a multidisciplinary team’s race against time to design a complex care plan that, despite many challenges, keeps mother and baby safe.
Dr. Jerome Federspiel
Assistant Professor of Obstetrics and Gynecology in the Division of Maternal Fetal Medicine at the Duke University School of Medicine
Jerome (Jeff) Federspiel is an Assistant Professor of Obstetrics and Gynecology in the Division of Maternal Fetal medicine at the Duke University School of Medicine. He received his Medical Doctorate and a Doctorate of Philosophy in Health Policy from the University of North Carolina, completed his residency in obstetrics and gynecology at Johns Hopkins, and his fellowship in Maternal Fetal medicine at Duke. Dr. Federspiel’s clinical and research interests center on improving care for patients with hematologic or cardiovascular complications complicating pregnancy.
Transcript
DDx SEASON 12, EPISODE 5
More Than a Bleed: A Complex Care Plan for a Safe Delivery
Dr. Raj Bhardwaj: This season of DDx is produced in partnership with and sponsored by Sanofi.
HOOK
Dr. Bhardwaj: A 28-year-old woman walks into a clinic. She’s eight months pregnant. Tired. Pale. Anemic.
But here’s the thing—she’s always tired. She’s a student. She has two young kids.
This isn’t her first pregnancy. Her last one ended early—an emergency C-section at 32 weeks. No one dug much deeper afterwards.
But this time, her obstetrician happens to flip through an old chart and sees something.
A word most doctors never encounter. A diagnosis almost no one had flagged as urgent. Until now.
Dr. Jeff Federspiel: Conditions like this, if we don’t take action ahead of time, can certainly be incredibly scary. They can be life threatening or even lead to the loss of life.
Dr. Bhardwaj: This is DDx, a podcast from Figure 1 about how doctors think. I’m Dr. Raj Bhardwaj.
If you work in healthcare, you’ve felt it—that moment when communication breaks down.
Maybe a physical therapist catches something, but it doesn’t make it back to the physician.
Or a nurse sees a red flag, but the rest of the team doesn’t hear about it. Those gaps?
They can get in the way of giving patients the care they deserve.
This season on DDx, we’re going inside hemophilia treatment centers—places where teamwork isn’t optional. It’s what holds everything together.
You’ll hear stories from people who do this work every day—how collaboration really works, what it looks like in real time, and what happens when it breaks down.
These aren’t hypotheticals. These are real patients, real decisions—and real consequences.
In this episode, you’ll hear from Dr. Jeff Federspiel, a high-risk obstetrician at Duke University.
Dr. Federspiel is trained to see both sides of a complicated pregnancy—from maternal care to blood disorders.
In this episode, he takes us inside a case where a rare diagnosis nearly upended a delivery—and how teamwork kept everything on track.
CHAPTER 1: A CLUE IN THE CHART
Dr. Federspiel: She was already 35 weeks when she came into our care. And the reason she came to see us was because it had been identified by her OBGYN team that she had a really rare bleeding disorder.
Dr. Bhardwaj: The diagnosis had been there for a while—dysfibrinogenemia. A rare bleeding disorder.
Her liver makes fibrinogen, a protein needed for clotting, but it doesn’t work properly.
Unlike hemophilia, where you’re missing a clotting protein, dysfibrinogenemia means the protein is there—it just doesn’t work right.
And that can lead to bleeding too much or clotting too easily, or both.
With rare conditions, the path to a diagnosis is almost never straightforward.
People move, life shifts, care teams change—and sometimes the full picture only comes into focus later than anyone would hope.
Dr. Federspiel: And because she had transitioned from different providers, because she had moved along the way, her OBGYN team discovered this really late in her pregnancy, this now being her fourth pregnancy, and they knew that she needed to receive care in a referral center like Duke with this unusual bleeding disorder.
Dr. Bhardwaj: Dr. Federspiel specializes in high-risk pregnancies involving bleeding disorders. When he saw her bloodwork, alarm bells went off.
Dr. Federspiel: What I noticed right away was that her fibrinogen level was really low. It runs between 130 and 140. And levels typically in pregnancy are more like 400 to 500 during delivery and after delivery, if her levels were to fall much more, she could have a significant bleeding complication.
Dr. Bhardwaj: Fibrinogen is a protein the body uses to form blood clots—and in pregnancy, levels naturally rise to help protect against bleeding during and after delivery.
So when hers stayed low, it meant her body might not be able to stop a hemorrhage if one began.
Dr. Federspiel: I felt nervous. I felt like we needed to make sure that we delivered a really well-choreographed complex care plan, and that we didn’t have much time to figure it out because the patient was coming to us at 35 weeks.
Dr. Bhardwaj: So the question isn’t just how to deliver this baby safely. It’s also about how to walk the tightrope between two kinds of risks—bleeding and clotting—and do it with perfect timing.
Dr. Federspiel: So when thinking about a patient who has a disorder like this, we wanna make sure we give them just enough support to help them stay safe and avoid bleeding without erring in the opposite direction. Giving them so much product back that they’re at risk of clotting. And that can be a difficult, difficult balance to hold.
CHAPTER 2: BUILDING THE PLAN
Dr. Bhardwaj: She needed a team. Fast.
Dr. Federspiel: It was really important to figure out who would need to be involved in care and planning for delivery. We were at the end of the third trimester, and we needed to have safe plans in place, to avoid the possibility of really scary bleeding events for both mom and baby.
Dr. Bhardwaj: There wasn’t much time—and no room for error. Because this wasn’t just a high-risk pregnancy.
It was something far more rare.
Dr. Federspiel: These aren’t the kind of conditions that you see every day. Even in a place like Duke where we take care of a lot of patients with complex medical needs, we still see a case of a bleeding disorder like this one a few times a year, not on a daily basis by any means.
Dr. Bhardwaj: Usually there’s a clear set of steps. A protocol.
But what do you do when there isn’t?
Dr. Federspiel: This was a case where we didn’t have a playbook, so we had to write one. We don’t practice medicine in a vacuum. We have teammates for a reason, and I’m really lucky to work with some really smart people across the range of specialties that help pregnant people here at Duke.
Dr. Bhardwaj: So Dr. Federspiel started doing what any good teammate would— he picked up the phone.
Dr. Federspiel: I made a lot of phone calls.
Dr. Bhardwaj: Hematology’s first up.
They calculate how much fibrinogen this patient might need—just in case.
Dr. Federspiel: I called the hematologist who this patient had seen just a few days before I had seen her. We talked about his thinking about balancing bleeding risk versus clotting risk and potentially how we could use a combination of fibrinogen levels, but also a technology called thromboelastography, which is a way of looking at how well the blood is clotting.
Dr. Bhardwaj: Anesthesiology reviews the risk of an epidural.
Dr. Federspiel: I called our anesthesiologist and spoke to them at some length about the decision to place an epidural and someone with a bleeding disorder. It’s always something which understandably gives them anxiety as well.
Our anesthesiologists really deeply understand literature about epidural safety. And you can really speak thoughtfully about balancing risks and benefits.
Dr. Bhardwaj: Pediatric hematology plans for the baby.
Dr. Federspiel: We also reached out to our pediatric hematology colleagues, our blood and bleed disorder specialists for children, to have them weigh in on how we should approach those first hours and days of life for testing and precautions for the baby.
Our pediatric hematology colleagues just really think well beyond what I could think about how the early life of an infant can be impacted by a condition like this. The precautions we should take. Things as simple as, should we give a vitamin K injection after birth, which could help prevent bleeding in general, but is also an invasive procedure being done to an infant whose clotting system we don’t understand entirely yet.
Dr. Bhardwaj: Pharmacy gets the clotting factors stocked.
Dr. Federspiel: Our pharmacists are wizards at problem solving, figuring out how to make sure that we have adequate supplies of even very expensive medicines available to us for cases like this. And our blood bank similarly is really, fanatically devoted to keeping our patients safe. They’re people who, like us, work 24/7 and they’re always available to us to help make sure that we have the products we would need to treat a patient who had a bleeding complication like this.
Dr. Bhardwaj: Lab medicine preps for fast turnaround.
Dr. Federspiel: We reached out to our laboratory medicine colleagues to make sure that they were prepared for a case in which we would need information quickly, particularly if there was an emergency situation.
And to replace fibrinogen, we also need to have fibrinogen products.And certainly our colleagues in laboratory medicine, just deeply understand how their tests work in a way that’s so impressive and really understand how to solve problems about getting test results to a patient quickly when it’s really important.
Dr. Bhardwaj: This isn’t just collaborative care. It’s logistical choreography— with people’s lives in the balance.
CHAPTER 3: THE DELIVERY
Dr. Bhardwaj: It’s 9 in the morning when our patient arrives at labor and delivery.
Dr. Federspiel: We planned to deliver her pregnancy a little bit earlier, around 37 weeks because she had that low fibrinogen level and because she had that history of a placental abruption before which can really put both mom and baby in harm’s way in a hurry.
Dr. Bhardwaj: The plan’s in place. Orders are written. Bloodwork is drawn.
A real-time clotting test is sent. It’s a blood test that shows not just how much clotting protein is there, but whether it’s actually working.
Dr. Federspiel: And that test came back reassuring. Even though the fibrinogen level was a little bit lower that we would have liked, her blood clotting function was still holding its own, doing okay.
Dr. Bhardwaj: And then … the team moves forward with her induction. Labor takes about 36 hours.
Everyone’s on alert.
Twelve hours in, she asks for an epidural.
Dr. Federspiel: Of course, our obstetric anesthesiologist had been following her case the whole time she had been in the hospital, had been watching her laboratory tests the whole time, and they reviewed her fibrinogen levels. Her clotting function looked normal, they could safely place the epidural and they did.
Dr. Bhardwaj: She pushed for two hours, surrounded by specialists who were all bracing for something to go wrong.
Dr. Federspiel: This was a case that we had put an awful lot of preparation in and I think a lot of us were waiting with bated breath to make sure that she and her little one did well.
Dr. Bhardwaj: And then, finally—a baby.
Dr. Federspiel: Baby came out pink and squealing. Very normal, very robust. Nothing out of the ordinary at all.
Dr. Bhardwaj: The room fills with relief.
Dr. Federspiel: She had delivered normally, and she needed nothing further during her hospitalization before she went home. It felt really wonderful to know that she was safe and the little one was safe as well.
CHAPTER 4: LESSONS
Dr. Bhardwaj: This story is about what didn’t happen. There was no hemorrhage.
No code.
No crash cart. Just a plan.
One built not by a single doctor, but by a team—each specialist holding a piece of the risk, and a piece of the solution.
Dr. Federspiel: Our hematology colleagues, our obstetric anesthesiology colleagues, laboratory medicine, pharmacy, and transfusion medicine colleagues all really do uniquely work so closely together on the care of patients with conditions such as this. And it’s really amazing, inspiring, to work in a place in which everyone shares that sense of mission.
Dr. Bhardwaj: For clinicians listening: Even if a diagnosis is rare, the patient isn’t.
She’s tired. She’s bruising. She’s anemic.
You don’t need to know the disorder by name to know something’s off—and you don’t need to fix it alone.
Dr. Federspiel: If you have a patient who has a bleeding disorder and they’re thinking about becoming pregnant, you may not know that maternal-fetal medicine doctors are also happy to meet with patients before pregnancy to talk about the potential risks of bleeding disorders in pregnancy, but also how we can work together to help achieve a healthy outcome.
Dr. Bhardwaj: In medicine, the biggest victories are sometimes invisible. No transfusion.
No bleeding.
Just a healthy mom. And a healthy baby.
And a room full of people who planned for every moment that might have gone wrong—so that, in the end, nothing did.
SHOW CLOSING
Dr. Bhardwaj: Thanks to Dr. Jeff Federspiel for speaking with us.
This is DDx, a podcast by Figure 1. Figure 1 is an app that lets doctors share clinical images and knowledge about difficult-to-diagnose cases.
I’m Dr. Raj Bhardwaj, host and story editor of DDx.
Head over to figure1.com/ddx where you can find full show notes, speaker bios and photos.
This season of DDx was produced in partnership with and sponsored by Sanofi. Thanks for listening!