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High Risk Pregnancy Management
Maternal Fetal Medicine fellows receive clinical instruction in high-risk pregnancy management through a series of activities designed to allow them progressively greater and greater responsibility, while at the same time carefully ensuring close faculty supervision. The 12-month core MFM clinical experience is achieved by serving a four month block in each year of the Fellowship. Clinical MFM activities will occupy the third block the first year. High-risk pregnancy management training in the middle of the second year is augmented by two months of inpatient clinical rotations in Obstetric Anesthesia and Critical Care followed by a two-month outpatient rotation in the CAFC at Mercy Medical Center. The third year of the fellowship begins with a four-month block on the MFM service.
The MFM service manages all inpatient (antepartum, intrapartum and postpartum) obstetric care. During this intensive clinical experience, the fellow also participates in the Center for Advanced Fetal Care as well as in a weekly outpatient High-Risk Clinic. Our inner-city patient population is high risk. Twenty percent of our deliveries are of women with no prenatal care, 12% are substance abusers and 2.3% are HIV positive. Nearly 20% of our deliveries arrive via the state-wide perinatal transport system and result in high proportions of very low birthweight and extremely low birthweight infants, complex maternal medical admissions, and maternal intensive care admissions. Frequent collaborative care for pregnant patients of the R Adams Cowley Shock Trauma Center, co-located on the UMMC campus, and a state-wide referral for ultra high-risk maternal surgery associated with unavoidable high maternal mortality rates are all important features of our program, in which all of our fellows play an important clinical role. Each fellow, under the direction of members of the Division of Maternal Fetal Medicine, is exposed to the full breadth and depth of the subspecialty and enabled to meet the relevant objectives of Guide to Learning in Maternal-Fetal Medicine, ABOG 2007, Sec IX, XI, and XIV.
This three-year experience allows the fellows continuity of patient care as they act as the first line for resident consultation and teaching. MFM faculty, in accordance with ABOG, CREOG and CMS requirements, are always physically present or immediately available in these clinical settings for overall supervision and teaching of both the fellows and resident staff. Interaction with both residents and MFM faculty takes place freely, allowing the fellow an opportunity to grow as a teacher and mentor to the resident housestaff, while carefully assuring close MFM faculty supervision and availability.
The fellows play a central role in determining management decisions for all patients in whose care they are involved. Labor & Delivery is staffed by members of the MFM division for four out of five weekdays. When an OB-GYN generalist covers Labor & Delivery, the MFM Fellow is backed up by a designated and scheduled faculty member who is physically available when called. The faculty covering Labor & Delivery, both MFM and generalists, are physically present on Labor & Delivery or the Mother-Baby Unit, and have no other concurrent clinical or administrative responsibilities.
Case discussions are held at each morning (7:30 a.m. for residents, fellows and attendings) and each evening (5:00 p.m. for fellows and attendings) during shift change. All perinatal in-patient cases are presented and discussed in a round table format that involves students, residents, fellows, and faculty. At this session, the fellow prepares the teams for potential future problems and assures continuity of planning and care. In addition, on the one day a week (Tuesday) when an OB-GYN generalist is the attending physician on Labor & Delivery, the fellowship program director attends the morning sign-out session. The fellows' clinical rotations are timed so that third year fellows are on clinical rotations during the critical July - August period for new interns and advancing residents. This allows fellows the opportunity to develop their skills as teachers and mentors to the residents during a highly stressful period in the academic year.
The fellowship training and resident training complement and enrich one another and do not compete with each other, complying with Sec I, para A, subparagraph 2 of the General and Special Requirements for Graduate Medical Education in the Subspecialty Areas of Gynecologic Oncology, Maternal-Fetal Medicine, and Reproductive Endocrinology and Infertility ABOG 2010.
Additional clinical experience is acquired by the performance of two types of night calls. The fellows cover the "high-risk" call for MFM consults and maternal transports. This is an at home "on the beeper" type of call during which the fellow acts as first point of telephone contact for both maternal transports and in-house consultation. This "high-risk" call is shared among the entire MFM faculty. Except for those nights (about 10/month) on which an MFM attending is scheduled for the in-house call, first call for this coverage falls to the fellows in rotation. The fellow is required to communicate with the on-call MFM attending for all consult and transport decisions. Should the fellow be required to come into the hospital, the fellow works in close consultation with the in-house attending and covering MFM attending. The need for the presence of the MFM attending is determined jointly by the fellow, the in-house attending, and the MFM attending. On occasion, the fellow is called in to lend a hand in a busy Labor & Delivery as an experienced fully trained general OB-GYN physician. When the fellow is called upon to evaluate or manage complicated patients beyond the level of expertise or comfort of the in-house attending, the MFM attending joins the in-house team. If the fellow's presence in-house is required overnight, the following day's schedule is adjusted to comply with the ACGME and ABOG duty hour requirements as outlined in Section 1, paragraph G,4 of the General and Special Requirements for Graduate Medical Education in the Subspecialty Areas of Gynecologic Oncology, Maternal-Fetal Medicine, and Reproductive Endocrinology and Infertility, ABOG 2010.
In addition to the above core clinical rotations and activities, the each fellow participates in a High-Risk Pregnancy Clinic for one half-day a week during each research or didactic month throughout the entire Fellowship. Each clinic is staffed by a MFM fellow and faculty member. Residents see patients at two of the three weekly clinics as well. The MFM faculty member is physically present for the entire clinic and has no additional duties at that time.
Maternal Fetal Physiology
The weekly fellow specific learning sessions, the five clinical conferences, and daily case discussions are geared to teaching the fellow both the principles and clinical application of maternal fetal physiology. In addition, the program director provides the fellows a reading list including the ACOG Clinical Expert series, and the ABOG MOC articles relevant to maternal fetal physiology as well as other selected publications of current and historical interest. This reading list is revised annually, and is supplemented by division members at the Friday morning session, for matters of immediate clinical application.
The Department of Obstetrics Gynecology and Reproductive Sciences at the University of Maryland School of Medicine is fortunate to have a dedicated core of basic scientists whose main interest is reproductive physiology with a strong emphasis on maternal-fetal circulatory physiology. Fellows gain knowledge through a combination of seminars and elective laboratory research in the Division of Perinatal Research laboratories by ongoing clinical and teaching interaction with members of the Division of Human Genetics as well as members of the MFM Division.
These divisions include principal investigators on NIH and NICHD awards, including an NIH/NSF Specialized Cooperative Centers Program for Studies in Reproductive Research Grant. This center includes a long-standing funded baboon colony and numerous active perinatal experimental programs using the pregnant baboon model. The Center for Studies in Reproduction, (CSR) headed by Eugene D. Albrecht, PhD, is a well-established interdepartmental center drawing members from nine departments. Fellows are invited and encouraged to attend the research division's seminars.
Since our previous review, each fellow has spent an Introduction to Basic Science Research month under the direction of Loren Thompson, PhD, in the small animal model research of chronic hypoxia lab. The fellows' investigations into the pregnant guinea pig model of reduced fetal oxygenation have been productive in terms of learning and publications.
Genetics and Teratology
Miriam C. Blitzer, PhD, clinical biochemical geneticist and recently appointed executive director of the ABMG, Carol L. Greene, MD, pediatric medical geneticist, provide clinical consultation and teaching resources to the division. The MFM Division also includes the Perinatal Genetics Counseling Service whose master's degree level genetic counselors, Amanda Scaffe, Stephanie Ashley and Lauren Doyle, work closely with the fellows at UMMS. Jessica Scott does so as well during the Mercy Medical Center rotation.
The Division of Human Genetics faculty, genetic counselors and students in the Masters for Genetic Counseling Program are also valued contacts for the division and provide didactic teaching to the fellows on a regular basis. As described above, an Interdisciplinary Genetics Conference is held each Monday at 12:30 p.m., led by Dr. Greene. Clinical geneticists and genetic counselors from throughout the Baltimore region meet and discuss both antepartum and pediatric genetic cases. The fellows, while learning clinical genetics and dysmorphology, also bring a valuable MFM viewpoint to a primarily genetic and pediatric audience. The fellows attend this meeting during the research/didactic months, and clinical situation allowing, the MFM clinical rotation as well.
The fellow has the opportunity to spend time in the maternal serum screening laboratory under the direction of Dr. Blitzer, or to observe pediatric genetics or dysmorphology clinics under the direction of Dr. Greene. An elective research rotation in the maternal serum screening laboratory is available for interested fellows under the direction of Dr. Blitzer.
The first year of our fellowship was, at the time of our last review, redesigned so that the initial four months, which had previously been clinical, became didactic. The third of these months is an introduction to perinatal genetics research. The fellow, under the direction of Division Head and Associate Program Director for Clinical Fetal Medicine, Chris Harman, MD, begins the lifelong learning of the principles and techniques of genetic counseling, genetic ultrasound, genetic testing, amniocenteses, CVS and fetal therapy. By the completion of the fellowship, the fellow is enabled to meet the objectives of the Guide to Learning in Maternal-Fetal Medicine, ABOG 2007, Sec VII, VIII, and XIV.
The Center for Advanced Fetal Care at UMMC is one of 20 North American centers receiving fetal medicine referrals at a high enough level to meet membership requirements for the North American Fetal Therapy Network. The management of these cases includes direct fellow involvement in the care of fetal patient for intrauterine surgery, placental laser therapy and fetal transfusions. During the previous year, 31 intrauterine transfusions, 17 laser treatments of TTTS, five cardiotoxic injection for discordant twin anomalies, six bipolar and two unipolar cord coagulations for TRAP, two thoracentesis and two amnioinfusions for gastroschisis took place. One case each of bipolar cord coagulation for discordant twin growth, laser treatment of TRAP, cord ligation for discordant twin anomalies, cord ligation for discordant twin growth, EXIT procedure for CCAM, pericardiocentesis for CHD, and urinary bladder shunt placement for LUTO were performed as well.
Maternal medical treatment for fetal therapy was undertaken eight times for fetal SVT, eight times with indomethacin for TTTS, and twice with IVIG for NAT, and once with dexamethasone for CHB.
Case audit and the CAFC genetics database and invasive testing database are supervised by Dr. Harman, with full access given to the fellows for clinical and research purposes. Individual fetal diagnosis and treatment discussions are included in the weekly neonatal-perinatal conference.
The fellows may take a postgraduate course HGEN 728 - Clinical Genetics, as one of their required GME courses. Additional relevant courses in genetics provided through the University of Maryland, Baltimore may be elected or audited by the fellows as well.
In cooperation with the Maryland Institute for Human Virology, directed by Dr. Robert Gallo, and co-directed by Dr. Robert Redfield, the Department of Obstetrics, Gynecology, and Reproductive Sciences cares for pregnant women with HIV in a multidisciplinary clinic that meets weekly in the Penn Street-Western clinic offices. Care of these women, in collaboration with the department's certified nurse midwifery division is overseen by a MFM divisional faculty member Lindsay Alger, MD. The fellow is expected to participate in this clinic, which is contemporaneous with the High-Risk Clinic in which all cases of maternal infectious disease are reviewed. Lindsay S. Alger, MD, is a member of the Infectious Disease Society for Obstetrics and Gynecology, and was a committee member of the AIDS Clinical Trial Group (ACTG) and The Obstetrics Working Group of the ACTG. Dr. Alger has also served as an ad hoc reviewer for the National Institute on Drug Abuse.
Dr. Alger is a tremendous resource for the fellows in all area of perinatal infection. She is responsible for developing and implementing infectious disease policy and protocol in both the prenatal and intrapartum/post-partum arenas. She works closely with the fellows on the clinical MFM service and presents lectures and seminars to the fellows and the department as a whole.
The Institute for Human Virology offers regularly scheduled seminars, both clinically, and research oriented, which the fellow may attend. Fellows may also attend a series of lectures on infectious disease topics relevant to maternal-fetal medicine given by the Division of Infectious Diseases in the Department of Medicine.
Fellows gain additional knowledge regarding the role of infectious disease in fetal malformation by participating in evaluations performed in the CAFC, where antenatal imaging, and polymerase chain reaction studies are applied to the evaluation of the at risk fetal patient. Last year, 23 amniocentesis and two cordocenteses were performed for the diagnosis of possible fetal viral or parasitic infections and two fetal blood transfusions were performed for parvovirus infections.
In addition, the fellows care for or provide consultation to gravidas across the spectrum of infectious disease during the clinical MFM rotations described above. Likewise, neonatal complications of maternal infectious disease are presented and discussed in the combined Neonatology-Perinatology conferences held each Monday.
The University of Maryland Medical Center is one of two NICU's designated by the State of Maryland as a Level IV nursery. The 40-bed NICU, under the direction of Cynthia Bearer, MD, Ph.D., Chief, Division of Neonatology is staffed by ten neonatologists. Alison J. Falck, MD, is the Director of the Neonatal-Perinatal Medicine Fellowship which trains three fellows per year. Both divisions meet for a joint Neonatal Maternal-Fetal Medicine conference held each Monday at 4:00 p.m. Cases of mutual interest, such as newly identified fetuses with genetic or structural abnormalities and antepartum admissions at risk for preterm birth or in need of early induction, are presented by members of the MFM team to our neonatology colleagues. Likewise, the neonatology teams provide the obstetricians with updates on recently delivered NICU admissions.
This conference, attended by the MFM and neonatology faculty, fellows, on-service residents and students, provides the MFM fellows with information about many more cases than they can actually see. Both NP and MFM fellows present formal lectures alternately on topics of mutual interest on a monthly basis. This conference is formatted on a monthly basis to clinical pathological conference. Both NP and MFM fellows present relevant antepartum, intrapartum, and postpartum aspects of each case. Additional histopathologic, diagnostic and clinical input is provided from members of the pathology, diagnostic imaging and pediatric surgery services.
This weekly conference provides the MFM fellow the opportunity understand the etiology, diagnosis, management, prevention and consequences of the full spectrum of neonatal complications. The fellow is expected to round on high-risk service neonates admitted to the NICU. Certification in NRP/NALS is required as well.
The Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of Maryland has responsibility for all fetal evaluation and obstetric ultrasound within the University of Maryland Medical System. We have an extensive referral base of neighboring and statewide hospitals. The Center for Advanced Fetal Care at University of University of Maryland Medical System (CAFC) provides the majority of these examinations and has completed the ALUM accreditation process. Obstetric ultrasounds are also performed on the Labor & Delivery unit, the private faculty offices and perinatal outreach sites. The resources of the ultrasound program includes Dr. Harman, Director of the CAFC, MFM division members, and sonographers with advanced training in obstetric ultrasound, fetal echocardiography, first trimester ultrasound, vaginal ultrasound and other specific techniques. This team provides over 9,000 obstetric scans and Doppler studies per year to which the fellows have access.
The Center for Advanced Fetal Care at Mercy Medical Center, provides an additional training site for the fellow. The CAFC at Mercy Medical Center, under the direction of Robert Atlas, MD, with additional staffing by Drs. Kopelman, Kush and Atkins one day a week each, performs an additional 9200 scans per year and has completed the ALUM accreditation process as well.
As noted previously, the initial four months of the fellowship are now didactic. The first three of these months will be an introduction to the theory and practice of ultrasound technique, ultrasound and perinatal genetic research. This expanded experience is augmented in the second year with a two month clinical rotation through CAFC at Mercy Medical Center where the fellows apply the principles of targeted ultrasound and hone their skills in recognition of fetal anomalies, genetic testing, and genetic counseling. The fellow on the UMMS MFM service also participates in the CAFC scanning and procedures, as well as bedside sonography of Labor & Delivery and gravid and post-partum inpatients. The third year ultrasound experience consists of an additional two month concentration in fetal echocardiography. The experience in obstetric imaging is designed to provide the fellow with, first, basic skill and initial knowledge and, later, increased skill and advanced knowledge of obstetric imaging and antenatal diagnostic techniques, ensuring compliance with The Guide to Learning in Maternal-Fetal Medicine, ABOG 2007, Sec VII, and XIV. The CAFC also refers selected cases to the UMMC diagnostic imaging service for MRI evaluation of the anomalous fetus (19 cases in 2009), and for evaluation of abnormal placentation.
The equipment at both sites includes state-of-the-art color Doppler and 4-D units. Digital image storage facilities include patient specific storage, with diagnostic code recall, full reproduction and publication capability and online teaching files.
Specific skills in which the Fellows are trained include:
- First Trimester
- Nuchal translucency screening (all division members are certified by the Fetal Medicine Foundation or the SMFM)
- Cervical length
- First trimester Doppler
- Chorionic villus sampling
- Conventional first trimester transabdominal and transvaginal scans and multiple gestation embryo reduction
- Second Trimester
- Cervical length
- Fetal blood sampling
- Fetal echocardiography
- Selective reduction of anomalous twins
- Fetal transfusion
- Referrals for maternal serum screening
- Ultrasound screening for aneuploidy
- Primary scans for obstetric dating, anatomic survey and placental localization
- Third Trimester
- Fetal evaluation
- Biophysical profile
- Integrated fetal Doppler and biophysical testing
- Fetal blood sampling
- Fetal transfusion
- Invasive fetal procedures (thoracentesis, paracentesis, bladder drainage, etc.)
- 3D and 4D ultrasound
- Multi-vessel Doppler panel
- Multiple clinical protocols involving ultrasound evaluation of the IUGR fetus, endovaginal ultrasound for placental localization and vasa previa, ultrasound guidance for external cephalic version, intrapartum managements of twins and triplets births and in-utero endoscopic micro-laparoscopic techniques and laser therapy of twin-twin transfusion syndrome.
The Division of Obstetrical Anesthesia in the Department of Anesthesiology provides 24-hour coverage in Labor & Delivery and the IMC. In concert with MFM faculty and fellows, the obstetric anesthesia attending physicians and residents provide bedside care to critically ill patients on Labor & Delivery, in the Labor & Delivery recovery room, the IMC, and in consultation on all intensive care units throughout the UMMS.
A one-month rotation in obstetric anesthesia, focusing on obstetric techniques, evaluation of the critically ill obstetric patient, maternal and fetal physiology in relationship with anesthesia, as well as the full range of anesthesia techniques, takes place in the second year of training. MFM fellows receive training in obstetric anesthesia and function as a member of the Obstetric Anesthesiology team. They participate in clinical care of patients, daily rounds and didactic sessions under the direction of the Division of Obstetric Anesthesia faculty.
At the conclusion of this rotation, the fellow should be able to understand the effects of analgesics and anesthetics employed during Labor & Delivery and to manage the complications thereof, fulfilling the objectives of Guide to Learning in Maternal-Fetal Medicine, ABOG 2007, Sec XII.
The second year fellow rotates through the Surgical Intensive Care Unit (SICU) for a one-month rotation under the direction of William C. Chiu, MD, Medical Director, Surgical Intensive Care Unit, Program Director, Surgical Critical Care Fellowship. Certification in ACLS is required as well.
We are the perinatal referral unit for the R Adams Cowley Shock Trauma Center, which is attached to and fully integrated within the University of Maryland Medical System. This unique association allows the fellow the opportunity to, under the supervision of the MFM attending, participate in the management of these complex patients, initially in a consultation when they are in the Shock Trauma Unit, and later as the patient is transferred to the care of the obstetric service. As indicated, members of the MFM division may perform surgery for conditions associated with massive hemorrhage, such as placenta percreta or giant uterine AVM in the Shock Trauma operating suites order to take advantage of their unique equipment and consultative services.
The Shock Trauma Center conducts a regular series of didactic sessions, many of which cover conditions and complications that are listed under either anesthesia, obstetric complications or medical and surgical complications of the educational objectives in the Guide to Learning in Maternal-Fetal Medicine which the fellow may attend.
Management of the critically ill obstetric/postpartum patient is the responsibility of the MFM team. With increasing experience, the MFM fellows assume primary bedside responsibility for the critical obstetric patient, with the close supervision of the attending MFM staff. Under the direction of Maternal-Fetal Medicine faculty, fellows participate in the care of gravid or post-partum patients who require critical care services on Labor & Delivery, in our IMC unit, or in the several intensive care units within UMMS. Members of the Obstetric Anesthesia Service are fully involved in the care of these complex patients and serve as an invaluable clinical and teaching resource for the fellows.
The fellows acquire knowledge of perinatal pathology through many of the previously listed activities, which assure exposure to placental and funic abnormalities. All placentas are reviewed and studied in detail. In addition, Chen-Chi Sun, MD, of the Department of Pathology has a major interest in the pathology of reproduction with many collaborative reports with division members on fetal and placental issues.
Through the Center for Advanced Fetal Care, the fellow becomes fully versed in developmental abnormalities, infection, aberrant growth, placental dysfunction, hydrops and CNS abnormalities as causes of perinatal injury and intrauterine fetal death, with particular focus on in-vivo placental Doppler, and structural abnormalities. Once a month, the combined neonatology-perinatology conference is dedicated to a clinical pathological conference format with strong input from Dr. Sun and her colleagues. The fellows are participants in these conferences, presenting clinical review and correlation for each case.