High Risk, High Reward
by Celia Spell
The national birthrate is at a historical low. Almost 60 of every 1,000 women in the United States gave birth in 2018, which is down 2% from 2017 and is now the lowest it has been in 32 years, according to the Centers for Disease Control and Prevention.
Potential reasons for this decline range from changes in the nation’s economic health to society’s increased access to birth control.
But while the national overall birthrate and fertility rate have been declining, the number of women having children in their thirties has increased. As maternal age is one of the most common contributing factors to a high-risk pregnancy, physicians across the state as well as the country are changing the way they approach treatment.
In the past, new parents wouldn’t know about a congenital anomaly or risks associated with their delivery until they went into labor or soon after. By incorporating improved methods of imaging and collaboration among hospitals throughout South Carolina, physicians at MUSC are diagnosing issues earlier and treating patients proactively, which improves outcomes for the mother and her baby.
The Advanced Fetal Care Center, the Center for Placenta Accreta Spectrum and the MUSC Health Care Simulation Center are just a few ways MUSC physicians of different specialties and disciplines are collaborating to better treat their pregnant patients.
High risk brings specialties together
When assessing a woman for potential pregnancy risks, physicians look at a patient’s age, weight and blood pressure as well as any accompanying medical conditions that existed before pregnancy, such as diabetes or heart or kidney problems. They also look at any family history of genetic disorders and monitor for any issues with previous pregnancies. Other conditions can also develop during pregnancy, like gestational diabetes or preeclampsia, which is one reason routine prenatal appointments are important.
Maternal age, especially when a woman is over 40 years old, is a risk factor for pregnancy complications, but it is not necessarily the most significant contributing factor to a high-risk pregnancy. It’s what can accompany age. “It’s the fact that as you get older, your chances of developing conditions like diabetes and high blood pressure go up,” said Eugene Chang, M.D., a maternal fetal medicine specialist at MUSC. “Age can change the risk profile of the average pregnant patient in multiple ways.”
The Advanced Fetal Care Center has been part of the plan for the new MUSC Shawn Jenkins Children’s Hospital and Pearl Tourville Women’s Pavilion for years, but after successful collaboration between maternal fetal medicine specialists and fetal cardiologists at MUSC, Chang and Fetal Cardiology Director Sinai Zyblewski, M.D., partnered to create the center a few years before the opening of the new hospital.
Since its inception in 2015, more subspecialties have joined the group, and the program will continue to grow with its dedicated home in the new children’s hospital. Physicians throughout South Carolina and even further afield should look for potential fetal abnormalities at the patient’s 20-week ultrasound appointment; women with risk factors can then be referred proactively to the Advanced Fetal Care Center and will work with multiple specialists to create a pregnancy plan that addresses all aspects of their care.
The ability to detect any potential complications early on has only grown in recent years, as have potential treatments both in the womb and soon after birth. These advancements have also created the need to counsel families not only on the most up-to-date treatment options available but on those that are currently being investigated.
The Center offers an integrated approach to prenatal and postnatal care. Patients receive comprehensive counsel and care from a multidisciplinary team at the Advanced Fetal Care Center that may have started with pediatric cardiology and maternal fetal medicine specialists but will now include neonatology, urology, neurosurgery, general pediatric surgery and otolaryngology.
Physicians who specialize in treating these various conditions in nonpregnant adults don’t always want to treat the same condition in someone who is pregnant. “It can be almost like a scarlet letter,” said Chang. “Which is why having physicians with dedicated interests in pregnancy in one location is so unique.”
Having the Advanced Fetal Care Center also provides patients with a point of contact. Because MUSC acts as the regional provider for fetal anomalies and high-risk pregnancies, many patients arrive from hundreds of miles away.
“Having a centralized contact provides a nice complement to the physician team and helps families coordinate multiple subspecialties and make decisions about their child’s care,” said Chris Goodier, M.D., a maternal fetal medicine specialist at MUSC who works with Chang at the Advanced Fetal Care Center.
Placenta accreta on the rise
Another way that MUSC is tackling high-risk pregnancies is through the Center for Placenta Accreta Spectrum (CPAS). Usually the placenta rests atop the uterus and detaches during delivery, but in placenta accreta, the placenta attaches firmly into the uterine wall and instead can cause severe bleeding issues and can lead to the need for a hysterectomy. The spectrum is made up of three grades, which are defined by the depth of attachment into the muscular layer of the uterus: accreta, increta and percreta.
The most critical factor when dealing with a patient with placenta accreta is early detection and diagnosis. With the CPAS, MUSC is working with physicians across the state to catch the warning signs early. In a recent study, Chang and Goodier worked with other doctors in the state to validate the Placenta Accreta Index, which uses 2-D and color Doppler sonographic exams to calculate a patient’s risk.
An ultrasound can show some markers for placenta accreta, but the addition of other imaging techniques – for example, fetal MRI – helps physician teams to prepare to receive these patients. If a physician in the community sees anything suspicious on a patient’s ultrasound, they can refer the patient to the MUSC Prenatal Wellness Center for further imaging and care coordination.
Once a placenta accreta diagnosis has been made, a multispecialty team at the CPAS focuses on the planning needed for the patient’s care and the surgical and medical management of her placenta accreta. Each case requires multiple specialists including maternal fetal medicine, gynecologic oncology, anesthesia, neonatology, urology, trauma surgery and nursing.
With a comprehensive team like this, Chang has seen more positive results in his patients’ care. “The good news is the morbidity has definitely gone down and taking care of those patients has been a lot more successful.”
Although improved care is available, rates of placenta accreta have been increasing over time: the American College of Obstetricians and Gynecologists estimates that 1 in 272 pregnancies are affected each year. Risk factors for placenta accreta include accreta in a previous pregnancy and prior caesarian section during delivery as well as other uterine surgeries. The rise in placenta accreta in the U.S. correlates with the rise in C-sections.
In a systematic review in Obstetrics and Gynecology, researchers found that the rate of placenta accreta rose from 0.3% after one previous C-section to almost 7% for women with five or more previous C-sections.
“When I started my residency 20-25 years ago, I saw maybe one case of placenta accreta in those four years,” said Chang. “But now we probably see one a month.”
But while rates of C-section deliveries and the rates of placenta accreta have been rising, it’s unclear if C-sections are completely to blame. According to Goodier, placenta accreta typically occurs in a thin or poorly formed tissue in an area of scarring which allows the placenta to invade or directly attach to the uterine muscle. Other factors, such as a mother’s age, uterine fibroids and infertility can be associated with a risk for accreta, which is one of the reasons he set out to validate the Placenta Accreta Index.
Preparation is key when treating placenta accreta, and that is the main goal of the Center for Placenta Accreta Spectrum at MUSC.
Planning for the unexpected with simulation
South Carolina is divided into four different perinatal regions – Charleston, Florence, Columbia and Greenville – with MUSC staffing both Charleston and Florence. Using these divisions, most patients don’t need to travel too far for their care, unless they have an unusual anomaly that sends them to Charleston.
As part of the state’s Birth Outcome Initiative, there is a mobile simulation training lab called SimCoach that travels throughout the perinatal regions allowing health care providers to gain hands-on practice managing the complications of labor and delivery. Goodier describes it as, “A way for these health care teams to enhance communication, identify obstacles and prepare for all types of obstetric emergencies.”
A few examples of these complications include dystocia, which is when a baby gets stuck in the birth canal during delivery; postpartum hemorrhage, when a new mother bleeds excessively after birth; eclampsia, which is when a pregnant woman experiences seizures; and maternal cardiac arrest, which also allows the team to practice perinatal resuscitation.
In addition to traveling throughout the state working with physician teams, Goodier also works with resident and medical student teams on campus at the MUSC Health Care Simulation Center. He helps to provide exposure to unstable pregnant patients through the use of immersive and procedural scenarios.
These programmed scenarios take place throughout the year in the simulation center and on the labor and delivery floor of the hospital.
“It’s all about exposure, communication and ensuring workflows are in place,” says Goodier. “It’s not meant for you to study; it’s about practicing for patients, especially for rare events.”
Through the development of the Advanced Fetal Care Center as well as the Center for Placenta Accreta Spectrum and the MUSC Health Care Simulation Center, MUSC works with physicians to form a patient-centric process for tackling high-risk pregnancies to improve outcomes for both mothers and babies. Through early diagnosis and intervention, physicians can guide patients through a smoother pregnancy, labor and delivery.
“It’s a scary time for a family to discover their baby has something that requires intervention,” said Chang. “We follow them from start to finish, and I think that’s comforting.”