Several thousand babies are born each year are born at Einstein Medical Center Philadelphia and Einstein Medical Center Montgomery. While the vast majority are simple, low-risk births, some patients have more complicated needs. In this podcast, Perspectives’ Sharon Eisenhour talks with maternal-fetal medicine specialists Carlene Quashie, MD, and Adeeb Khalifeh, MD, about how Einstein cares for high-risk pregnancies.
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Sharon Eisenhour: Welcome to Einstein Perspectives, an ongoing podcast series from Einstein Healthcare Network. I’m Sharon Eisenhour, and today I’m speaking with Carlene Quashie, MD, Director of the Division of Maternal-Fetal Medicine at the Einstein Healthcare Network, and Adeeb Khalifeh, MD, Associate Director.
Our guests are specialists in Maternal-Fetal Medicine, the branch of obstetrics and gynecology that focuses on high-risk pregnancies. Einstein Medical Center Philadelphia and Einstein Medical Center Montgomery both provide care for high-risk pregnancies. Einstein Philadelphia boasts the lowest rate of complications in the city for all pregnant patients.
Dr. Khalifeh, tell us what makes a pregnancy high-risk.
Adeeb Khalifeh: So while most of pregnancies are routine pregnancies that usually occur without any major complications, any medical maternal complication that occurs during pregnancy, or any fetal complication, makes a pregnancy at high-risk. Most doctors take care of one patient. We have two patients, and it’s the mother and the baby. So anything that could affect either of them makes the pregnancy a high-risk pregnancy.
Eisenhour: So how are these concerns discovered?
Dr. Khalifeh: So every pregnancy goes through routine prenatal visits and screening tests during the pregnancy So we have a certain amount of knowledge of what should be normal and what is abnormal and what is concerning. So anything that is in the abnormal range will raise flags and will be leading to further testing. And that could lead to a disease process that we discover for the mother or for the baby.
Eisenhour: And so what happens if a pregnancy is considered high-risk?
Dr. Khalifeh: So once a pregnancy is considered high-risk, the general obstetrician then refers the patient to the maternal-fetal medicine specialist, who reviews the complication of the pregnancy, whether it’s for the mother or for the baby, and decides what type of management needs to be followed to really optimize the care of the pregnancy. At times, it involves only the maternal-fetal medicine specialist. But sometimes it’s a multidisciplinary approach where we ask, as well, the opinion of other colleagues, including the cardiologist, endocrinologist or any other medical specialty for that. We have even some multidisciplinary clinics, including the diabetes and pregnancy program, the cardiovascular disease and pregnancy program at Einstein. And these will optimize the care of the pregnancy and lay out the appropriate management until delivery.
Eisenhour: At Einstein, what are the most common concerns that lead to a patient being referred to the maternal-fetal medicine team for high-risk care?
Dr. Khalifeh: In general, the most common medical maternal complication would be hypertensive disorders of the pregnancy and diabetes in pregnancy. Almost 10% of pregnancies are complicated by hypertensive disorders. And around 6 to 7% are complicated by diabetes in pregnancy, whether it’s diabetes prior to pregnancy or diabetes discovered in pregnancy.
Eisenhour: What is the impact of a high-risk pregnancy on lifelong health?
Dr. Khalifeh: A lot of those patients, especially patients that have diabetes or hypertensive disorders, have long-term life implications because even if diabetes was discovered in pregnancy and subsequently has resolved, these women are at increased risk of diabetes later in life. For women that have hypertension, they are at increased risk of cardiovascular disease later in life.
So we’d like to use pregnancy as a window for future health to coordinate the patient’s health care after delivery and make sure that the patient has appropriate follow-up with her primary care physician or with the cardiologist or with the endocrinologist. Delaying diabetes, delaying the complications of diabetes, delaying the cardiac effect of hypertension, all of that will increase life expectancy for the woman and will improve her quality of life. So we try to act as the coordinator, if you want, between delivery and handing over the patient to the physician that will take care of her..
Eisenhour: Dr. Quashie, as an example, how would the plan of care change for a pregnant patient with diabetes?
Carlene Quashie: Well, diabetes is very common in our patient population. So when we see patients with a history of diabetes, ideally, it would be nice for those patients to approach us prior to getting pregnant..
However, many patients get pregnant without coming in for a preconception consult. And at the very beginning, with their first visits, we have to be sure and get some idea as to what kind of control they’re having with the diabetes. So we run a series of tests. We get them nutrition counseling, diabetic education. And from very early on, we start being very aggressive with monitoring the blood sugars up to four times a day and making adjustments with their medication to try to get things under control as early as possible.
Obviously, the reason for doing this is diabetes can have an impact on the development of the fetus. There’s an increased risk of congenital anomalies that could occur because of diabetes. So many of these patients are seen at least once every two weeks. We do a lot more ultrasounds in patients that are diabetic so we can follow the growth of the fetus, the amniotic fluid. We do a special ultrasound, a fetal echo, of the baby’s heart around 23 to 24 weeks — again, looking to make sure that structurally everything is normal.
And then for the rest of the pregnancy, they come in for what we call fetal testing, where we monitor the baby’s heart rate. That gives us a sense that the baby’s getting enough oxygen and everything is stable in the uterus. So there is an aggressive approach that we take to monitoring patients with diabetes. and this allows us to get the best outcome for these pregnancies.
Eisenhour: How would the plan of care change for pregnancy with twins?
Dr. Quashie: Twins are cute, but they can be complicated pregnancies. So one of the first things we try to establish, with those first initial ultrasounds, is what kind of twinning are we dealing with? Because with identical twins, particularly identical twins that share a placenta, they can be a very tricky pregnancy. And we have to keep a very close eye on those fetuses, because there could be sharing of blood vessels between one twin and the other, which sets us up for a complicated high-risk issue called twin-to-twin transfusion. When twins are not sharing a placenta, there’s less of a concern for that, but there’s always a concern for growth issues in twins, making sure that both babies are growing appropriately.
There’s also an increased risk of premature labor with twins because the developing uterus grows very quickly. And sometimes your body gets fooled, thinking that because you have a fuller uterus that it’s now time to contract. But we all know that that’s not what we want to happen in a premature state, so we do have to monitor moms for premature labor as well with twins.
Eisenhour: So what are the strengths of high-risk pregnancy care at Einstein?
Dr. Quashie: I think one of our biggest strengths is that we have many specialties at Einstein that help us take care of high-risk patients, from hematology to rheumatology, cardiology. We depend a lot on the specialists to collaborate with us on individual cases. And we have multidisciplinary meetings to come up with care plans for patients that have other issues besides pregnancy-related issues. Patients may have platelet disorders. Patients may have sickle cell disease. Patients may have lupus.
We also have 24-hour, in-house anesthesia coverage, which is important because we may have to call on an anesthesiologist in a stat fashion to be able to get a baby delivered very quickly.
Another strong point is the use of the intensive care nursery. We have six neonatalogists that are full-time, with an in-house neonatologist 24/7.
All of our ultrasounds are done by sonographers that are specially trained to do high-risk ultrasounds. We currently have seven full-time sonographers and we have five MFM attendings. So I think we have a core team of providers and colleagues that come together to really help us take care of high-risk patients.
Eisenhour: Our thanks to today’s guests, Carlene Quashie, MD, Director of the Division of Maternal-Fetal Medicine, and Adeeb Khalifeh, MD, Associate Director. Both are specialists in Maternal-Fetal Medicine at Einstein Medical Center, Philadelphia. To learn more or to schedule an appointment, call 1-800-EINSTEIN or visit the OBGYN section of the Einstein website at einstein.edu. For Einstein Perspectives, I’m Sharon Eisenhour.