Caring for high-risk moms and babies

A Q&A with maternal-fetal medicine specialist Dr. James Bofill

What is a maternal-fetal medicine specialist?

Maternal-fetal medicine specialists are a type of obstetrician-gynecologist (OB-GYN) who are experts in managing complicated pregnancies. Maternal-fetal medicine specialists work with the expectant mother’s referring OB-GYN to provide customized care.

What makes an expectant mother high risk and in need of care by a maternal-fetal medicine specialist?

We see three main groups of patients. First, I care for women with complicated pregnancies, and some of these complications are quite common. Some expectant moms have advanced maternal age, type 2 diabetes, chronic hypertension, lupus or myriad disorders that may have a deleterious effect on their pregnancy.

The second group of patients are those whose local obstetrician might be concerned that their ultrasound has demonstrated a fetal anatomic defect or abnormality. Those patients are typically referred to us for a detailed or “targeted ultrasound”, where we carefully study the pregnancy with ultrasound and determine if there are issues. Lastly, our referrals will also include patients who have had a difficult outcome in a prior pregnancy.

It’s incredibly important for high-risk patients of any age to optimize their health prior to initiating a pregnancy. We offer pre-conception counseling so that a patient can discuss any medical issues she had prior to pregnancy. We also have a genetic counselor at our Fetal Center who can speak to the patient if there are any genetic issues in her family. Unfortunately, in the U.S., only about 45 percent of pregnancies are planned. This means that, in most cases, we will try to optimize the patient’s health as soon as the pregnancy is recognized.  

What are some of the risk factors for unborn babies?

It is well known that patients who have poor control of diabetes during early pregnancy are at much higher risk for the fetus to have malformations. Similarly, those patients who initiate a pregnancy with very poor control of their high blood pressure are much more likely to have a fetus that exhibits poor growth; we call this fetal growth restriction. It is also important to know that patients who carry a set of twins are at a higher risk for difficult pregnancy outcomes compared to the patient who carries only one fetus. It is crucial for us to determine if twins share the same placenta or if each baby has his or her own.

We also must be on the lookout for complications particular to the process of twinning. When we find that a fetus or a set of twins has any of these issues, we step in with specialized management plans to optimize the pregnancy outcome. Significant considerations would include when and where to deliver these pregnancies. We will occasionally find situations where the infant will require the specialized care of our colleagues from the pediatric subspecialties, such as cardiology or pediatric surgery, immediately after delivery. We coordinate these deliveries so the infant will have the optimal attention that he or she will require at birth. We also make certain that the parents have a chance to meet with their pediatric subspecialists prior to delivery so that their questions regarding the management of the infant will be answered.

How do you monitor the pregnancies of older, high-risk moms and their babies?

We do our best to address the issues associated with advanced maternal age as early in pregnancy as we possibly can. We offer counseling early on to make these moms aware of their options for genetic testing if they so desire. Down syndrome screening and testing are easily available. We also counsel the mom that she is at increased risk for such things as gestational diabetes and the hypertension disorders of pregnancy.

Later in pregnancy, we will repeat ultrasonography to ensure the fetus is growing well. Additionally, with patients of advanced maternal age, we will perform weekly fetal testing (BPP or NST); this allows us to allow the pregnancy to continue normally if the testing is normal and modify our testing if there are concerns. On rare occasions, the testing may be very worrisome, and we can intervene with delivery if required. With our testing, the real question we are asking is, “Would the fetus be safer in the mom’s uterus or in the nursery?”

If a developing baby has medical problems, can you address these problems prior to delivery?

It all depends on the situation. We have had many cases where the fetus has had a severe rhythm disturbance of the heart, which can lead to heart failure. We treat these developing babies by giving their mothers medicine, which crosses the placenta and may be able to regulate the cardiac rhythm and hopefully extend the pregnancy to term. We have also successfully treated fetuses with thyroid disorders in a similar manner.

We have found many cases where a twin pregnancy has the so-called twin-to-twin transfusion syndrome. When we identify these cases, we arrange for the patient to travel to one of the national centers, where a laser procedure may be accomplished to correct or mitigate the abnormality.

However, in most cases, our major contribution is to identify a major structural defect and to bring these issues to the attention of the pediatric subspecialists. Then, we make a plan to manage the pregnancy and make appropriate plans for delivery. Sometimes, the patient will need to travel to UMMC in Jackson to deliver so that the pediatric subspecialists can care for the infant immediately after delivery.

We also have subspecialists in our Biloxi clinic, including Dr. Aimee Parnell, a fetal and pediatric cardiologist. A fetal cardiac defect is the most common defect that we encounter, and it happens in just under 1 percent of pregnancies. We freely consult with Dr. Parnell and other pediatric subspecialties. Other pediatric specialties offered at the Biloxi clinic include pulmonology, neurology and orthopedics.

The UMMC Center for Telehealth delivers online access to additional pediatric medical specialties. Through telehealth, pediatric experts can examine and treat patients online using live, two-way audio/visual technology as easily as if they were in the same exam room.

Children’s of Mississippi manages the Gulf Coast’s only Level III neonatal intensive care unit (NICU) at Memorial Hospital in Gulfport. The unit provides around-the-clock care to newborns with special needs and has been recently updated with 11 semi-private rooms with 23 NICU beds where critically ill or premature infants receive advanced levels of treatment.

How do high-risk moms obtain an appointment?

We generally take patients by referral. Patients can ask their obstetrician for a referral to our clinic.

This interview originally appeared in the October 2021 edition of Gulf Coast Woman, provided by University of Mississippi Medical Center