Baylor delivers for patients with high-risk pregnancies

From prenatal care and testing to newborn care, the James M. and Dorothy D. Collins Women and Children's Center at Baylor University Medical Center at Dallas offers advanced diagnostics and treatments. Physicians from across the region ask the team of maternal-fetal medicine specialists on the center's medical staff to consult on high-risk cases, such as Nickie Haine, and in some cases, assume primary care.

"I like it at Baylor, because everyone takes a lot of time describing options and telling me what is going on," says Haine, 32, who is expecting again after experiencing multiple miscarriages. "It's been a good experience, and they are very competent."

Among the array of services offered to all pregnant women at Baylor Dallas is first-trimester screening for Down syndrome. Also known as trisomy 21, Down syndrome occurs when fertilization results in an extra chromosome 21. Babies born with Down syndrome often have congenital heart defects, mental retardation and other health problems.

In the past, women age 35 or older typically received genetic counseling and diagnostic testing for Down syndrome at a later gestational age. Although older women have a greater risk of delivering a child with Down syndrome, most babies with the condition are actually born to younger mothers.

"We're doing a more accurate test earlier in the pregnancy," says Jon Rosnes, MD, medical director of the Maternal Fetal Medicine Program and member of the medical staff. "It is more accurate than second trimester testing and is recommended by ACOG (The American College of Obstetricians and Gynecologists)."

Rosnes explains that first trimester screening has an 85 percent Down syndrome detection rate, compared with older, second trimester "quadscreens." Quadscreens are tests for four substances — serum alpha-fetoprotein, human chorionic gonadotropin (hCG), unconjugated estriol and serum dimeric inhibin A — which may reveal birth defects. The tests are accurate about 75 percent of the time. With the first trimester screening, fewer women require amniocentesis and invasive procedures, reducing the potential for pregnancy loss while completing a screening test that has a higher detection rate for some chromosomal abnormalities.

First trimester screening includes a blood test, known as serum pregnancy-associated plasma protein A and free b-hCG, and an ultrasound to check for nuchal translucency, a measurement to determine the thickness at the back of the fetus's neck. Extra fluid in this area could indicate Down syndrome or another abnormality. If screening indicates an increased risk for a health problem, additional testing would be offered. This may include genetic counseling (can be done at any time during pregnancy), a detailed comprehensive sonogram, chorionic villus sampling (a biopsy of the placenta at 10 to 12 weeks of gestation) or amniocentesis (performed at 15 to 20 weeks of gestation).

Haine, who wanted to avoid having an amniocentesis if at all possible, has done that after receiving good news from her first trimester screening.

"It was helpful for us to get a sense of how things were going and if there were any problems to be prepared for," she says.

Prior lost pregnancies are one factor that put an expectant mother at high risk for complications. Other factors are medical conditions, such as diabetes mellitus, asthma or hypertension. Taking multiple medications also adds to fetal dangers and women carrying twins, triplets or other multiple births are considered high risk. About 15 percent to 20 percent of patients seeking care at Baylor are at high risk, Rosnes estimates.

Often, maternal-fetal medical specialists recommend that women planning to become pregnant work with their physicians to bring underlying medical conditions under the best control possible before conception. Perinatologists on the medical staff at Baylor Dallas offer preconception counseling to help women reduce risks.

"The key is to maximize [women's health] before they get pregnant, so they have fewer complications," Rosnes says.

While some obstetricians feel comfortable managing medically stable patients, many doctors will refer patients with chronic health issues to the maternal-fetal team at Baylor Dallas.

Patients often return to their regular doctor with a plan of care developed at Baylor.

Physicians on the medical staff at Baylor complete an in-depth assessment, including an evaluation of risk for fetal abnormalities. Diagnostic testing typically includes an ultrasound. The physicians assess fetal growth and offer genetic counseling to anyone with a family history of a genetically inheritable disease.

Throughout the course of pregnancy, physicians on the medical staff at Baylor monitor the patient's health status and may coordinate additional care with other specialists — for instance, working closely with a kidney specialist who is caring for a woman with kidney failure and is undergoing dialysis six days a week.

Sometimes pregnancies that begin normally develop complications and women require hospitalization on Baylor's antepartum unit. For instance, a woman with uncontrolled vomiting may need intravenous fluids. Other situations necessitating hospitalization include pre-eclampsia, preterm labor and poorly controlled diabetes.

"A preterm labor patient may stay two or three days or be here quite awhile," Rosnes says. "It depends on several factors, including how stable the patient is and what the surrounding community can handle."

Physicians on the medical staff at Baylor aim to bring babies into the world at 40 weeks, when they are fully developed. Although sometimes that is not possible, it is the team's goal.

"When you get a patient through, you feel a sense of achievement," Rosnes says.

When it comes time for delivery, Baylor promotes family involvement. Whether the new parents want other children or extended family present, Baylor works to make it happen. Once the baby arrives, he or she stays with mom.

"The bonding experience between mom and baby is extremely important, and we promote rooming in. The baby stays with the parent, with a minimal amount of separation of parents and newborns," Rosnes explains.

Lactation consultants visit with the mother before she leaves the hospital and can offer guidance for successful breastfeeding, even after discharge.

"As an institution, we encourage breastfeeding, if they can, because it's more natural and healthy for babies," Rosnes says.

Although physicians aim to bring pregnancies to term, some babies are born early at a low birth weight and must stay for a time at Baylor's Level III neonatal intensive care unit (NICU).

Frequently, when a community physician suspects a preterm birth is likely, he or she will refer the mother to Baylor for delivery.

"[Pre-term] babies who don't have to be transported do significantly better than babies born outside of the hospital [with a level III NICU]," says Craig Shoemaker, MD, chief of pediatrics and medical director for neonatology at Baylor, adding, "We have expertise in handling very tiny babies."

In recent decades, medical science has improved the survival chances for premature babies. Babies as young as 26 weeks' gestation often survive, with respiratory support and the right care.

"The majority of kids who leave the nursery will be healthy kids," Shoemaker says.

Babies progressing well typically stay until they are near the age when they should have been born. For instance, a child born at 33 weeks may spend a month in the NICU, bringing it closer to the 40-week window that is considered full-term.

As in other maternal-child areas, the Baylor NICU promotes family interaction, teaching parents how to massage their babies, to hold them on their chests, to offer non-nutritive sucking and to diaper and feed the infants as they grow stronger.

"Our goal at Baylor is to get babies to have the best results possible," Shoemaker says.  : :

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• Information about women's services at Baylor Dallas