SSM MATERNITY CARE Summer 2010 Obstetrics SM FOCUS ON MEDICAL NEWS FROM SSM MATERNITY CARE AND THE PHYSICIANS OF SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE ON THE COVER First in the World Maternal-Fetal Medicine Specialist Mike Vlastos, M.D., and Fetal Surgeon Ed Yang, M.D., perform a tracheal occlusion for a fetus with Congenital Diaphragmatic Hernia (CDH). CDH occurs when a hole in the fetus’ diaphragm causes organs from the abdomen to develop in the chest cavity. This often causes the lungs to be fatally small. Dr. Yang and Dr. Vlastos are the first in the world to inject a dissolvable hydrogel in the fetus’ trachea instead of a detachable balloon. The gel blocks the trachea, causing increased pressure and increased lung growth. The gel disssolves within four weeks, so there is no balloon to remove and no airway obstruction in place in the event of an unexpected early delivery. FOCUS ON obstetrics SM Editor In Chief Editor Writer & Designer Sherlyn Hailstone Andrew Sutton Katelyn Ideus President SSM Cardinal Glennon Children’s Medical Center Physician Services Manager SSM Cardinal Glennon Children’s Medical Center Physician Communications Specialist SSM Cardinal Glennon Children’s Medical Center For comments and suggestions, please email FocusOnObstetrics@ssmhc.com. Announcements Publications Myles T, Campise M, Kittur N, Leet T. “Association Between Gestational Weight Gain and Optimal Infant Birthweight Outcomes in Women of Varying Pre-Pregnancy Body Size.” Society for Maternal-Fetal Medicine. 2009 30th Annual Meeting. Am J Obstet Gynecol 2009; 201:6, pg S203, #546 Mostello D, Chang J, Allen J, Luehr L, Shyken J, Leet T. “Recurrent preeclampsia: The effect of weight change between pregnancies.” Obstet Gynecol. 2010 (in press). Artal R, Lockwood C, Brown H “Weight Gain Recommendations in Pregnancy and the Obesity Epidemic.” Obstet Gynecol. Vol. 115, No. 1, January 2010. Fetal Echos now available at SSM St. Clare Health Center To provide close and convenient services to patients, SSM Maternity Care is proud to offer fetal echocardiograms at SSM St. Clare Health Center. SSM St. Clare Health Center St. Francis Building 1015 Bowles Avenue Fenton, MO 63026 Fetal Echo Specialist Renuka Peterson, M.D., sees patients at this location the 2nd and 4th Friday of each month. Renuka Peterson, M.D. Fetal Echo Specialist To make an appointment, please call (636) 496-4641. Earn CME online, on your time! SSM Maternity Care, Saint Louis University School of Medicine and SSM Cardinal Glennon Children’s Medical Center are proud to offer convenient CME credit to physicians through the Online Education Series. Obstetrics on Demand and Fetal Care Institute on Demand offer presentations for 1.0 AMA PRA Category 1 CreditTM. Organizations Raul Artal, M.D. • One of four OB/GYNs from the United States named to consultant to the World Health Organization • President of the Council of University Chairs of OB/GYN • Chair of ACOG Scientific Committee • Associate Editor of Clinical Updates in Women’s Health Care, published by ACOG Now Playing on Obstetrics on Demand Presented by SSM Maternal Fetal Medicine Specialists “Shifting Paradigms Concerning Late Pre-Term Birth” Erol Amon, M.D. “Prenatal Screening for Congenital Heart Defects” William Holcomb, M.D. Now Playing on FCI on Demand Presented by Fetal Surgeon Ed Yang, M.D. “Fetoscopic Treatment of Amniotic Band Syndrome” “Fetal Intervention for Congenital Diaphragatic Hearnia” Cardinal Glennon also offers Pediatrics on Demand, which includes presentations from the Division of Neonatology. www.obstetricsondemand.com www.fciondemand.com www.pediatricsondemand.com Username: ds\r010-online • Password: webcme 1 Meet Our Maternal-Fetal Medicine Specialists raul artal, M.D. Saint Louis University School of Medicine: Professor of Obstetrics and Gynecology; Interim Co-Director of Division of Maternal-Fetal Medicine M.D.: Saint Louis University School of Medicine, St. Louis, MO Residency in Obstetrics and Gynecology: University of Missouri, Kansas City, MO Fellowship in Maternal-Fetal Medicine, Ob/Gyn: Washington University School of Medicine, St. Louis, MO Thomas Myles, M.D. Erol Amon, M.D. Saint Louis University School of Medicine: Professor of Obstetrics and Gynecology; Interim Co-Director of Division of Maternal-Fetal Medicine M.D.: St. Louis University School of Medicine, St. Louis, MO Residency in Obstetrics and Gynecology: Illinois Masonic Medical Center, Chicago, IL Fellowship in Maternal-Fetal Medicine: RushPresbyterian, St. Luke’s Medical Center, Chicago, IL jeffrey greenspoon, m.d. Saint Louis University School of Medicine: Associate Professor of Department of Obstetrics, Gynecology M.D.: University of Southern California, Los Angeles, CA Internship in Obstetrics and Gynecology: Cedars-Sinai Medical Center, Los Angeles, CA Residency in Internal Medicine: Cedars-Sinai Medical Center, Los Angeles, CA Residency in Obstetrics and Gynecology: Cedars-Sinai Medical Center, Los Angeles, CA Fellowship in Maternal-Fetal Medicine: Women’s Hospital, LAC/ USC Medical Center, Los Angeles, CA Dorothea Mostello, M.D. Saint Louis University School of Medicine: Associate Professor of Obstetrics and Gynecology; Director of Diabetes in Pregnancy Program St. Mary’s Health Center: Director, Antepartum and Postpartum Units M.D.: The Johns Hopkins School of Medicine, Baltimore, MD Residency in Obstetrics and Gynecology: University of Colorado Health Sciences Center and Affiliated Hospitals, Denver, CO Fellowship in Maternal-Fetal Medicine: University of Cincinnati, Cincinnati, OH SSM Maternity Care is proud to offer expert care through its affiliations with Saint Louis University Maternal-Fetal Medicine specialists and private specialists. 2 GilAD Gross, M.D. Saint Louis University School of Medicine: Professor and Chairman of Department of Obstetrics, Gynecology & Women’s Health M.D.: Sackler School of Medicine, University of Tel-Aviv, Israel Rotating Internship: Beilinson Hospital, Israel Residency in Obstetrics and Gynecology: Beilinson Hospital, Israel; Case Western Reserve University/ Metro General Hospital, Cleveland, OH Fellowship in Maternal-Fetal Medicine: Harbor-UCLA Medical Center, Torrance, CA Saint Louis University School of Medicine: Professor of Obstetrics and Gynecology; Director of MaternalFetal Medicine Fellowship Saint Mary’s Health Center: Chief of Obstetrics M.D.: Northwestern University Medical School, Chicago, IL Internship and Residency in Obstetrics and Gynecology: Saint Joseph Hospital, Northwestern University Medical School, Chicago, IL Fellowship in Maternal-Fetal Medicine: University of Tennessee Center for the Health Sciences, Memphis, Tennessee OB/GYN Ultrasound Preceptorship: Northwestern University Medical School William Holcomb, M.D. SSM Maternity Care: Maternal-Fetal Medicine Specialist M.D.: Indiana University, Bloomington, IN Residency in Obstetrics and Gynecology: Washington University, St. Louis, MO Fellowship in Maternal-Fetal Medicine: Washington University, St. Louis, MO jaye shyken, M.D. Saint Louis University School of Medicine: Associate Professor of Obstetrics and Gynecology M.D.: University of Missouri School of Medicine, Columbia, MO Residency in Obstetrics and Gynecology: University of Missouri and Clinics, Columbia, MO Fellowship in Maternal-Fetal Medicine: Washington University School of Medicine, St. Louis, MO Mike Vlastos, M.D. Saint Louis University School of Medicine: Assistant Professor of Obstetrics and Gynecology M.D.: Creighton University, Omaha, NE Residency in Family Practice: University of Wyoming, Casper, WY Residency in Obstetrics and Gynecology: Regions Hospital, St. Paul, MN Fellowship in Maternal-Fetal Medicine: Washington University School of Medicine, St. Louis, MO Use Our Maternal-Fetal Medicine Specialists SSM Maternity Care is proud to offer a full range of services at multiple locations in metro St. Louis and surrounding areas. 1. St. Clare Health Center 636.496.5450 1015 Bowles Avenue Fenton, MO 63026 All Services Available Monday & Friday, Afternoons 2. DePaul Health Center 314.344.6495 12277 DePaul Drive, Suite 301 St. Louis, MO 63044 All Services Available Tuesday, Wednesday, Friday, All Day Ultrasound: Monday, Thursday 3. St. Joseph Health Center 636.947.5615 330 First Capitol Drive, Suite 210 St. Charles, MO 63301 All Services Available Tuesday - Friday, All Day 4. St. Joseph Hospital West 636.625.7730 100 Medical Plaza Lake Saint Louis, MO 63367 All Services Available Monday, Tuesday, Thursday, Friday All Day 5. St. Mary’s Health Center 314.768.8730 6420 Clayton Road Richmond Heights, MO 63117 Fetal Evaluation & Treatment Unit Monday - Friday, All Day Outpatient Clinic Monday & Thursday, Morning Wednesday, Afternoon Diversions Andrew Sutton Physician Services Team Leader Brasserie by Niche • www.brasseriebyniche.com Brasserie is a lot like Niche, but without the need for a second mortgage to pay the bill. The space oozes a casual French atmosphere, even down to the audible din bouncing off the tin ceiling. The wine list is limited, yet offers a variety of well-priced wines from France and the United States. My wife, Tricia, and I paired our meal with a 2007 Domaine Cordier Puilly-Fuisse. We started with the country pate, served with grain mustard, crusty bread and house-made pickles. The pate is rich, and the pickles lend a perfect hint of salt. Tricia enjoyed her mixed lettuce salad, sprinkled with dabs of goat cheese and hazelnuts, and finished with a roasted shallot vinaigrette. My frisee and bacon salad was topped with a 6. Southeast Missouri Hospital 573.331.6385 1701 Lacey Street Cape Girardeau, MO 63701 Monday or Tuesday each week, All Day poached egg, dressed with a bacon vinaigrette and served with a side of Lipitor. Tricia glowed as she enjoyed the braised beef short ribs, which fell apart with the slightest pressure. My roasted chicken arrived in its own miniature cast iron pan. Savory chicken thighs are paired with mushrooms and drizzled with just the right amount of jus. The saltiness of the jus and the earthiness of the mushrooms played against each other to create a very enjoyable combination. Expect great service, a lively atmosphere and terrific food. Reservations strongly encouraged. Porter Creek Vineyards • www.portercreekvineyards.com The 2007 Porter Creek George’s Hill Chardonnay comes from very old vines, planted on a steep hillside in the Russian River Valley. Low yields and barrel-aging on the yeast create a very complex wine. Hints of vanilla play on the nose, and the well-placed acidity is complemented by citrus and oak flavors. Very tasty and only $28.00 per bottle. 3 Guest Contributor William Holcomb, M.D. Use all views to detect fetal heart defects T he heart is the most common site of major birth defects. Eight of 1,000 newborns are affected, and at least two in 1,000 have lesions that may present catastrophically in the newborn period. A family history of congenital heart defects, maternal diabetes, extracardiac fetal anomalies and teratogen exposure are all risk factors for fetal heart defects. However, 80 to 90 percent of detected lesions occur in low-risk patients and are diagnosed due to findings on screening sonography, either through first trimester nuchal translucency screening or second trimester evaluation of fetal heart views. Euploid fetuses with an elevated first tremester nuchal translucency measurement have about a 20-fold increased risk for congenital heart defects. Even under the best of circumstances, some fetal heart defects will be missed. But with a focused and systematic approach, about three fourths of them, including the great majority of critical lesions, can be detected. The traditional screening view of the fetal heart is the apical four-chamber view. If properly obtained and carefully interpreted, there is a wealth of information in this view. It’s much more than counting to four. The size, axis and placement of the heart as well as chamber proportion and placement, and mobility of the valves may all provide clues when a defect is present. However, many of the cyanotic heart lesions, such as conotruncal defects, may be associated with a perfectly normal four-chamber view. 4 With very little additional time and effort, the outflow tract views of the heart can be obtained in most patients during the routine anatomy scan. These will reveal such problems as tetralogy of Fallot or transposition of the great vessels, which will escape detection with a four-chamber view alone. Another approach is the use of the transaxial view through the upper thorax, the so-called three vessel view. The normal arrangement of the pulmonary artery, the ascending aorta and superior vena cava can be quickly confirmed with this view. Detection of fetal cardiac abnormalities before birth allows a careful screen for other associated abnormalities. For instance, a heart defect is often the first clue when there is a chromosome abnormality. As many as one in three fetuses with a detectable heart defect has an abnormal karyotype. Once a heart defect is suspected on a screening ultrasound, the parents may be referred to a pediatric cardiologist for detailed assessment of the lesion and discussion of the treatment options and prognosis. This gives parents an opportunity to absorb the information, ask questions and participate more actively in the treatment plan. Most fetal heart defects are well-tolerated by the fetus still in utero, but some lesions can cause progressive cardiac failure or other complications requiring early delivery. Monitoring and management of these situations is only possible with accurate prenatal diagnoses. With certain heart defects, delivery at a tertiary center is optimal for care of the newborn. This can be arranged and carried out in a relaxed, organized manner when the heart lesion is diagnosed prenatally. The family of a fetus with a congenital heart defect is best served by a team including the obstetrician-gynecologist, a Maternal-Fetal Medicine specialist, a pediatric cardiologist, a pediatric heart surgeon and a primary care pediatrician, among many others. The time to assemble this team is well before the birth and that depends on paying close attention to the fetal heart during the routine anatomy screen. In my practice, I have found that the best time to screen is about 20 weeks. For more information on this subject, please visit: Obstetrics on Demand. Watch Dr. Holcomb’s presentation and earn 1.0 AMA PRA Category 1 CreditTM through Saint Louis University School of Medicine. www.obstetricsondemand.com Username: ds\r010-online Password: webcme T he single most important quality of an effective Practice Manager is the ability to multi-task. At first glance, their job seems no different than the ordinary day of any person in a supervisory role, but it is different. It is related to the practice of medicine, so medico-legal liability; ever-changing insurance requirements and regulations; and strict government payor rules all come in to play. Unfortunately, these variables sometimes overshadow the reason we are all there — to provide and ensure quality, ethical care to our patients. At first thought, it may seem the administrator of a large group clinic may be more accomplished at multi-tasking. She will see daily issues stemming from multiple physicians, many staff and higher patient volumes. However, the benefit of this structure is greater staff to delegate to. Delegation itself is key to successful management and to providing high-quality care. It can be as simple as assigning a duty but can escalate to creating a written policy with corresponding organizational structure charts. Use the strengths of your staff to ensure all processes are being completed in an effective way. Many of the best managers I have worked with or learned from have come from the less glamorous role of solo-prac- Practice Management Corner By: Donna Bernard Director of SSM Maternal & Fetal Outpatient Services titioner management. They handle all facets of the practice directly. They assist the staff with the patient who is unhappy with her bill; gather and present data for approval on a previously rejected pre-authorization; and reschedule the day because a physician is running late in surgery. The hands-on work of these managers not only makes them savvy about the inner workings of the medical office, but masters at multitasking effectively. But, when it comes to ensuring the best possible care, no role in the medical practice can be discounted. From the front desk, billers and pre-authorization staff to clinical personnel, nurses and physicians, all are key components to the practice. The quality manager knows a piece of each job and understands how they work together. And, throughout the many tasks of the day, she takes a moment to confirm quality, ethical care for each patient. Joint Commission Alert: High Blood Pressure, Diabetes, Obesity put women at Risk E arly this year, the Joint Commission issued a Sentinel Event Alert in regard to maternal deaths. According to the Center for Disease Control and Prevention, there are 13.3 maternal deaths per 100,000 live births, which is far more than the target of 3.3 maternal deaths per 100,000 live births. Pre-existing medical conditions noted in the alert as contributors included high blood pressure, diabetes and morbid obesity. For 35 years, SSM Maternal-Fetal Medicine Specialist Raul Artal, M.D., has researched and published articles in regard to gestational diabetes and its effect on the mother and fetus. Dr. Artal serves as Director of Ob/Gyn at SSM St. Mary’s Health Center and Professor and Chairman at Saint Louis University School of Medicine. In January, he published “Weight Gain Recommendations in Pregnancy and the Obesity Epidemic,” which detailed recommendations for the care of obese and morbidly obese women. Dr. Artal and his co-authors — Charles Lockwood, M.D., and Haywood Brown, M.D. — suggest a diet tailored to the different classes of obesity and one that provides adequate calories and nutrients to the fetus. The classes are defined as: Class 1: BMI 30-34.9 Class 2: BMI 35-39.9 Class 3: BMI greater than 40 The article suggests “a nutrient-dense caloric intake in the range of 2,000-2,500 cal/d. This caloric intake results in a gestational weight gain of 10 pounds or less and, in some, a net negative weight gain....Although vigorous exercise and weight loss programs are not recommended during pregnancy, some physical activity and modified diets are worthwhile.” “Weight gain in pregnancy has become a major contributor to the obesity epidemic and, most alarming, the rise in diabetes,” Dr. Artal says. “Physicians should encourage their patients not to exceed weight gain recommendations and stay or become active by walking for at least 30 minutes per day.” 5 St. Louis Fetal Care Inst Mike Vlastos, M.D., and Ed Yang, M.D., perform Laser Photocoagulation (FLC) of the placental vascular anastamoses to close the shared blood vessels of Adrian and Aidan S ince its conception in July 2009, the St. Louis Fetal Care Institute has been caring for families as they navigate through what many of them call, the scariest, most overwhelming moments of their lives. Grandparents, aunts, uncles and cousins eagerly await phone calls from the new mother and father after every appointment, hoping to learn the status of the newest, tiniest member of their family – the one they are praying they will meet. For many parents, the Fetal Care Institute provides the one thing they crave the moment they hear there is a problem with their unborn baby. Hope. Through its partnership with high-risk obstetricians at SSM 6 St. Mary’s Health Center, pediatric specialists at SSM Cardinal Glennon Children’s Medical Center and researchers at Saint Louis University School of Medicine, the St. Louis Fetal Care Institute provides accessible, comprehensive care to mothers whose unborn babies have congenital, anatomic and genetic anomalies. Pediatric and Fetal Surgeon Ed Yang, M.D., and MaternalFetal Medicine Specialist Mike Vlastos, M.D., co-direct the Fetal Care Institute, providing state-of-the-art diagnostic services, evidence-based prognostic information and appropriate fetal interventions. As the area’s only formally trained fetal surgeon, Dr. Yang titute: Life-Saving Care n Wells. The Fetal Care Institute corrected Stage III Twin-Twin Transfusion Syndrome in which Adrian was receiving more blood than Aidan, causing harm to both twins. performs open, fetoscopic and needle-based interventions for a wide variety of diagnoses. He spent 15 years in training, learning the risks, processes and diseases, and he continues to conduct research and develop new operations for difficult fetal diagnoses. Dr. Vlastos ensures the safety of the mother, reviews every ultrasound and provides ultrasonographic guidance during fetal operations. “We are here to provide hope for the future of babies and families,” Dr. Yang says. “We provide support not only medically, but emotionally, and we are an outlet for difficult, lifethreatening problems.” Recognizing the anxiety that comes with a referral to the Fetal Care Institute, mothers work closely with Patient Care Coordinators Katie Francis, RNC, CPNP, and Amanda Jones, RN, BSN, who ensure timely appointments and compassionate, coordinated care. Before joining the Fetal Care Institute, Katie spent more than a decade as a Cardinal Glennon transport nurse and nurse practitioner in the Dana Brown NICU at Cardinal Glennon. Amanda joined the team after 10 years in the high-risk labor and delivery unit at St. Mary’s Health Center. “As a mother, it’s difficult to imagine being faced with finding out there is a serious complication during pregnancy,” Amanda says. “From a mother’s point of view, I have instantly loved 7 Comprehensive both of my children even before they were born. It is the strongest bond I have ever felt, and I extend my heart to each of our patients knowing how scared I would feel in their situation.” With the area’s only formally trained fetal surgeon, the St. Louis Fetal Care Institute is proud to provide multiple fetal interventions for appropriate fetal diagnoses. Cardinal Glennon’s Footprints program also supports the family in a variety of ways, including helping develop a birth plan, arranging spiritual services and following families whose babies spend time in the NICU after birth. FETOSCOPIC PROCEDURES For Gina and Dan Pralle, the support has made it possible to get through difficult days. Fetal Intervention • • • • • Tracheal Occlusion for severe pulmonary hypoplasia due to: • Congenital Diaphragmatic Hernia (CDH) • Giant omphalocele • Severe oligohydramnios/anydramnios Laser Photocoagulation for Twin-Twin Transfusion Syndrome Fetal cystoscopy and posterior urethral valve ablation for bladder outlet obstruction Radiofrequency Ablation for Twin Reversed Arterial Perfusion Sequence Amniotic band syndrome OPEN FETAL PROCEDURES: • • • Resection for Sacrococcygeal Teratomas Resection of giant lung lesions Ex Utero Intrapartum Treatment for: • Airway obstruction • Unstable congenital heart defects “They have been so helpful, because we know we can call anytime,” Gina says. “That’s so important in something like this – when all of sudden you have a question that is weighing on you. “On Mother’s Day, we were panicking about a question. We started thinking that if we didn’t do anything and lost our baby we would be horrible parents. Dr. Vlastos called us that day to answer our question. He really put our minds at ease.” Upon referral to the Fetal Care Institute, patients’ travel, accommodations and visit will be arranged. After diagnostic testing, appropriate consultations will be scheduled based on the fetal diagnosis. During the entire process, communication is essential. Dr. Yang and Dr. Vlastos keep the mother and referring obstetrician informed so decisions can be made in regard to the remainder of the pregnancy, delivery and ongoing care. Referring physicians can expect phone calls and weekly letters detailing image reports, ultrasounds and consultations, as they are encouraged to continue providing care when appropriate. At 13 weeks gestation, Gina and Dan were referred to the Fetal Care Institute due to a potential bladder obstruction. At their first visit, Dr. Vlastos confirmed the obstruction, but explained that, due to the small size of the fetus, more testing was needed. At 14 weeks, Gina underwent amniocentesis and sampling of the fetal urine to determine how the fetal kidneys were working. At week 16, Gina and Dan met with pediatric urologist Casimir Firlit, M.D., and pediatric nephrologist Richard Feldenberg, M.D. “We’ve just been gathering information for the last three weeks from each specialist,” Gina says at the couple’s week 16 checkup at the Fetal Care Institute clinic. “So we’re to the point of looking at our options and making a decision on what we want to do. OTHER THERAPEUTIC FETAL PROCEDURES • • 8 Fetal Transfusions Thoracic or vesicoamniotic Shunt Placement “We feel as informed as we can possibly be, thanks to everyone here. They make us stop and think about things, which we are so thankful for because you really get overwhelmed in this kind of situation, and you definitely don’t want to have any regrets.” For some parents, the ultimate decision doesn’t seem like much of a choice. Shortly after referral to the Fetal Care Institute, Molly Mueller underwent in-utero, fetoscopic laser photocoagulation to remove an amniotic band wrapped around her son, Charlie’s, right leg. Without the procedure, Charlie’s leg may not have survived the pregnancy or been viable at birth. In the operating room, Dr. Yang and Dr. Vlastos used laser technology to sever the band and restore blood flow. The Fetal Care Institute also recommended fetoscopic laser photocoagulation to separate the shared blood vessels of Teela Wells’ twin boys, Aidan and Adrian. A fetal ultrasound at 19 weeks showed diamniotic/monochorionic twins with evolving Twin-Twin Transfusion Syndrome (TTTS), which was causing Adrian’s heart to function poorly and Aidan to be 38 percent smaller than his brother, with no amniotic fluid surrounding him and no visible bladder. A fetal echocardiogram suggested Stage III TTTS, which occurs in 15 percent of all monochorionic twin pregnancies, with rapid progression and with a mortality rate as high as 80 percent. scope through Teela’s abdominal wall and into her uterus. The shared blood vessels were closed, and the amniotic fluid was restored to normal. “It was actually my first time ever having surgery, but we did great,” Teela says. “I recovered pretty quickly, and within a week they started to see positive changes with the twins.” Teela delivered her sons at 36 weeks via cesarean section. They were discharged after 11 days in the Level III NICU at St. Mary’s Health Center. “It was a huge relief to take them home,” Teela says. “My mom said I should prepare myself for either one of them or neither of them making it. I am so thankful I came home with two babies.” While Teela’s treatment occurred before birth, not every patient will need intervenMolly Mueller and her son Charlie Taylor tion during pregnancy. Christina Sanunderwent fetoscopic laser photocoagulation tangleo and her fiancé Brad Huson were at 25 weeks gestation for an amniotic band After monitoring Teela and her twins around Charlie’s right leg. referred the Fetal Care Institute at seven closely for several weeks, Dr. Yang and Dr. months. What was thought to be fluid Vlastos recommended proceeding with the laser intervenaround their daughter, Brooke’s, lungs turned out to be contion. During the procedure, they inserted a thin fiber-optic genital diaphragmatic hernia (CDH), in which a hole in the Aidan and Adrian Wells lay in their mother, Teela’s, arms. In-utero they suffered from Twin-Twin Transfusion Syndrome in which blood vessels between the twins resulted in unequal sharing of blood flow. This caused Adrian’s heart to function poorly and Aidan to be 38 percent smaller than his brother, with no amniotic fluid surrounding him and no visible bladder. Dr. Yang and Dr. Vlastos performed Fetoscopic Laser Photocoagulation to separate the blood vessels. 9 Left: The dissolvable hydrogel used during a Tracheal Occlusion. The St. Louis Fetal Care Institute is one of only three centers in the nation to perform Tracheal Occlusions for Congenital Diaphragmatic Hernia (CDH) and the only one in the world to use the dissolvable gel. Above: Dr. Yang and Dr. Vlastos work together to inject the hydrogel into the fetus’ trachea during a Tracheal Occlusion procedure. diaphragm allows organs to develop in the chest cavity instead of the abdomen. During the last six years, Dr. Yang has collected data on 65 fetuses with CDH in order to develop a system to predict outcomes after birth. He can now tell parents how their baby will do based on the location of the fetal liver and the size of the lungs. For babies with the liver in the chest and small lungs, the prognosis tends to be poor. About 40 percent of these babies never get to go home. Their last breath is in the NICU. But for fetuses such as Brooke, whose liver had developed in her abdomen and whose lung growth had not been severely stunted, a positive prognosis meant that Brooke would most likely have a normal life and that the CDH could be fixed after birth. “We are scared more than anything,” Christina says after watching nurses wheel four-day-old Brooke from the Dana Brown NICU to the operating room at Cardinal Glennon. “But I’m excited as well because it has been a long planning process with so many emotions.” In the operating room, Brooke was laid on her right side and Dr. Yang made three tiny incisions in her chest. Using a 3-mm scope, he immediately located the small hole in Brooke’s diaphragm, and within 20 minutes he successfully pushed her intestine and spleen from her chest cavity to her abdomen with 3-mm graspers and needle drivers. He then stitched the hole in her diaphragm closed. 10 “Like Dr. Yang said, ‘It’s the age of Nintendo,’” Christina says. “With a video screen and all of these tiny tools, he is able to fix tiny babies just like my daughter. I think it’s important that parents know that these types of things are not only possible, but available right here where we live.” Unfortunately, not every baby is as fortunate as Brooke. For babies with severe CDH, fetal surgery offers a chance to improve survival and quality of life. While the solution before birth does not fix the CDH, it makes the lungs grow bigger so babies can breathe better. Dr. Yang and Dr. Vlastos occlude the trachea by injecting a dissolvable gel into the fetal lungs. The gel blocks the trachea for three to four weeks. During that time, the lungs continue to make fluid, which increases the pressure within the lungs and results in increased growth. The Fetal Care Institute is one of three institutions nationwide to offer this procedure and the first in the world to use the dissolvable gel instead of a balloon. The gel should be safer since there is no balloon obstructing the airway in the event of an unexpected early delivery. “It’s an amazing phenomenon to be able to intervene in these types of cases,” Dr. Vlastos says. “It’s a dream come true to see the faces of these women giving birth to their children. It doesn’t get any better – this is it.” St. Louis Fetal Care institute T Patient-Focused Care o ensure the health, safety and comfort of each patient, the St. Louis Fetal Care Institute designed a Medical and Ethical Review Board that meets regularly to discuss the scientific and ethical issues related to fetal intervention. The diverse team includes: • Dennis Vane, M.D.: Surgeon in Chief, SSM Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine • Robert Fleming, M.D.: Neonatologist, SSM Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine • Michael Panicola, Ph.D.: Corporate Vice President of Ethics, SSM Health Care • William Holcomb, M.D.: Maternal-Fetal Medicine Specialist, SSM Maternity Care • Pam Lesser, RNC-AWH, MS: Director of Labor and Delivery and Mother-Baby, SSM St. Mary’s Health Center The Review Board evaluates the scientific validity of new fetal operations, discusses ethical dilemmas in difficult cases and considers research proposals. Through extensive conversations, the Review Board ensures the following for each patient: • The intervention is based on scientifically sound evidence. • The intervention provides maximal fetal benefit with minimal risk to the mother. • The intervention is performed with the highest ethical standards of care. • A balanced perspective on the different problems and options is given. “This multidisciplinary approach to ethical and medical issues is important for each patient,” says fetal surgeon Ed Yang, M.D. “We need to make sure that our entire institution supports these different, ethically challenging cases, so we can provide the best possible, coordinated care.” St. Louis Fetal Care Institute Leading-Edge Facilities I n October, the St. Louis Fetal Care Institute will open a new clinic suite at SSM Cardinal Glennon Children’s Medical Center, bringing it closer to pediatric specialists. In anticipation of longer stays for out-of-town patients or those meeting with several specialists, the suite will include two nesting rooms complete with a couch, recliner, TV and computer. There will also be an examination and treatment room for ultrasounds and treatments such as amniocentesis. A monitor on the wall will make sure everyone in the room can see the images. Finally, a conference room large enough for a family and several specialists will provide ample space for consultations. 11 Q&A Mike Vlastos, M.D. Ed Yang, M.D. St. Louis Fetal Care Institute Co-Director St. Louis Fetal Care Institute Co-Director Maternal and Fetal Medicine Specialist Q: Why did you choose this speciality? A: Fun and passion! After four years of rural family medicine and a second residency in obstetrics and gynecology, maternal-fetal medicine has allowed me to work with some of the unique human complications of women and babies during pregnancy. The FUN is in helping women move through pregnancy and meet their child. That first look a mother has of her baby is amazing! The PASSION is found in the knowledge that a complication is present and being integral in assisting women and babies to birth. Q: What is your biggest challenge? A: This is our ultimate challenge: Can we take our present knowledge and technology and then go beyond? Can we think outside of the box and carve out a new paradigm? As we embrace this challenge, there are instances when we share with women and their families the basic human quality of compassion. We will continue to take advances from world leaders, national experts and our experience to help the smallest of patients — the babies in the womb. Q: What about your job inspires you the most? A: This institution is centered around the fetus. Within the bustle of our day, a woman enters an examination room with the understanding that her pregnancy, her fetus, her baby has a unique complication. This woman is looking for help. I aspire to share our understanding of her baby’s situation and to assist her through our established, leading-edge technology, novel approaches, clinical experience and compassion. When necessary, appropriate and possible, our focus is to intervene in ways only a few establishments are capable. 12 Fetal Surgeon Q: Why did you choose fetal surgery? A: I read about it in medical school and said to myself: “That is what I have to do.” I wanted to do something with an unknown frontier, so I could help families who currently didn’t have a solution. Q: How has your formal training in fetal intervention helped you provide better care? A: I have spent 15 years in training at places where fetal intervention is practiced or was invented. This gave me time to understand the risks, the processes and the diseases. This background and experience also gives me the courage to intervene and try to change the future for problems that usually have poor outcomes. Q: What is your main goal for the St. Louis Fetal Care Institute? A: My hope is to lessen the anxiety regarding a prognosis for families. It’s an overwhelming time for them, so we do the work for them. We find the appropriate care and resources so they can feel fully informed when they are making the difficult decisions about how to move forward. For rare, difficult problems, we also strive to provide unique, individual fetal operations, with the hope that we can change that baby’s life. Q: What do you think the future holds for these patients? A: It is difficult given the illnesses of their children, but there are also laughs, smiles and milestones crossed and conquered. I have not had a parent who came back to me and said that they wished we had never tried so hard for their baby. They are happy to meet their children and spend time with them, no matter what. Ed Yang, M.D., Ph.D., FAAP St. Louis Fetal Care institute Co-Directors M.D.: Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, TN Ph.D.: Cell Biology, Vanderbilt University School of Medicine, Medical Science Training Program, Nashville, TN Internship: Department of General Surgery, University of California, San Francisco, CA Residency: Department of General Surgery, University of California, San Francisco, CA Chief Residency: Department of General Surgery, University of California, San Francisco, CA Fellowship: Department of Pediatric Surgery, Children’s Hospital Boston, Boston, MA Mike Vlastos, M.D., FACOG M.D.: Creighton University, Omaha, NE Residency: Family Practice, University of Wyoming, Casper, WY Residency: Obstetrics and Gynecology, Regions Hospital, St. Paul, MN Fellowship: Maternal-Fetal Medicine, Washington University School of Medicine, St. Louis, MO Katie Francis, RNC, CPNP M.S. in Nursing - Pediatric Nurse Practitioner: Saint Louis University School of Nursing, St. Louis, MO Neonatal Intensive Care Unit Nurse: SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO Neonatal/Pediatric Transport Nurse: SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO Pediatric Nurse Practitioner: SSM Cardinal Glennon Children’s Medical Center, St. Louis, MO St. Louis Fetal Care institute Patient Care Coordinators Amanda Jones, RN, BSN B.S. in Nursing: Southern Illinois University Edwardsville, Edwardsville, IL Student Nurse Extern: Belleville Memorial, Belleville, IL Student Nurse/Surgical Technician: SSM St. Mary’s Health Center, Richmond Heights, MO Maternal Transport Nurse: SSM St. Mary’s Health Center, Richmond Heights, MO Clinical Support Nurse: SSM St. Mary’s Health Center, Richmond Heights, MO Staff Nurse Labor and Delivery: SSM St. Mary’s Health Center, Richmond Heights, MO Contact US: Phone: 314.268.4037 Toll-Free: 1.877.776.3385 Email: FetalCare@ssmhc.com : www.twitter.com/stlfetalcare 13 Physician Services Department SSM Cardinal Glennon Children’s Medical Center 1465 South Grand Blvd. Saint Louis, Missouri 63104-1095 Non Profit Org U.S. Postage PAID St. Louis, MO Permit No. 2412