This article originally appeared in Pathways, a magazine
published for physicians and the community by UMass Memorial Medical
Center.
Obstetricians have always been responsible for two patients at a time -
mother and fetus. Clinically, however, there was little they could do for the
fetus until the 1900s. In fact, most of the medical advances in the field of
maternal-fetal medicine (MFM) have occurred in just the past three or four
decades, spurring recognition of MFM as a board-certified subspecialty of
obstetrics and gynecology in 1974.
As knowledge of the complexity of maternal-fetal health problems has
increased, and new diagnostic tools and treatments have become available,
outcomes for patients that are high risk have improved. It is rare that a mother
with complications in a current or previous pregnancy, or a fetus at risk of
chromosomal abnormalities, cannot benefit from maternal-fetal medicine
subspecialty care.
Karen Green, MD, started the UMass Memorial Maternal-Fetal Medicine program
28 years ago when she came to what was then Memorial Hospital directly from her
MFM fellowship. "At that time, Memorial Hospital had a neonatal intensive care
unit (NICU) and a neonatologist who saw high-risk patients, but no one had any
high-risk obstetrical training," she recalled. Today, she continues to care for
patients in the Division of Maternal-Fetal Medicine at UMass Memorial, the only
such program serving Central Massachusetts. Each year, the program handles an
estimated 300 maternal transports from community hospitals and performs more
than 6,000 targeted fetal ultrasound exams.
"The specialty and the program have grown exponentially for several reasons,"
she said. Chief among them is that "the number of patients at risk is a fairly
substantial portion of the OB population, and the range of complications during
pregnancy is increasing due to delayed childbearing and the rise in multiple
gestations.
"With increasing maternal age come fertility problems, with fertility
problems come assisted reproduction, and with assisted reproduction come
multiple gestations, which are inherently high-risk," Dr. Green added. "Plus,
older women are more likely to have medical problems of their own that can
complicate pregnancy," she noted, citing such conditions as hypertension and
diabetes, and thyroid and cardiac disease. In addition, a woman who has had a
previous abnormal pregnancy - characterized by preeclampsia, preterm delivery or
fetal abnormality, for example - or who develops health issues with a current
pregnancy is among the high-risk patient population Dr. Green and her colleagues
see.
UMass Memorial has extensive diagnostic and therapeutic options for the
obstetrical, medical or surgical complications of pregnancy. Diagnostic tools
include comprehensive ultrasound, fetal echocardiography and fetal MRI to detect
structural abnormalities such as congenital heart disease, spina bifida, and
abnormalities of the limbs, kidney, bowel and certain areas of the brain.
Maternal serum screening, including alpha fetoprotein, along with amniocentesis
also are available. Treatment options range from medical management to
intrauterine interventions such as blood transfusions.
Couples at risk of a pregnancy affected by a hereditary condition or
chromosomal syndrome may take advantage of preconception and prenatal genetic
counseling.
Whenever possible, a UMass Memorial genetic counselor meets with couples
prior to pregnancy to discuss the chance they face of having a child with a
genetic condition or birth anomaly. This allows the discussion of the pros and
cons of various prenatal screening and diagnostic tests. It also enables review
of the family's health history for possible hereditary conditions, including
diseases commonly carried by otherwise healthy persons, such as cystic fibrosis
(carried by one in 25 Caucasians) and sickle cell (carried by one in eight
African-Americans).
For couples with an increased chance of having a child with a particular
hereditary condition, there is the option of pre-implantation genetic diagnosis
(PGD). PDG utilizes in vitro fertilization to create embryos that are tested for
the genetic condition; those embryos without the condition are then
implanted.