Comprehensive Model for High Risk Pregnancies
Guiding expectant mothers through challenges and on to a successful birth often requires expertise and collaboration.
Jose Prieto, M.D., medical director of the division of maternal-fetal medicine in the Johns Hopkins All Children’s Maternal, Fetal & Neonatal Institute, leads a team approach to perinatal care from pregnancy through delivery.
“Our perinatology and neonatology programs are combined to provide comprehensive care to mother and baby as one unit,” Prieto says. “Most perinatal groups see patients and give ultrasounds and opinions—we provide expert care. We can begin that care from diagnosis of high risk through birth of the baby or we can work with the referring obstetricians to monitor expectant mothers at high risk.”
Prieto’s perinatal team, including Karen Raimer, M.D.; Rachelle Schwartz, D.O.; and Katherine Apostolakis-Kyrus, M.D., works closely with referring obstetricians at the first sign of prenatal complication.
Expectant mothers are first screened for potential maternal and fetal risks before any treatment recommendations are made. These can be extensive high-risk ultrasonography and various fetal evaluations, such as:
- chorionic villus sampling to determine chromosomal abnormalities, such as Down syndrome
- amniocentesis to determine fetal infection and spina bifida
- cord blood testing to determine blood-related problems
If any abnormality is detected, Prieto’s perinatal team meets with the patient’s obstetrician to determine the most appropriate care plan based on the level of risk to the mother and fetus.
Partnering with Obstetricians
For low-risk complications, the patient may stay with her obstetrician and check in with perinatologists throughout her pregnancy. High-risk complications often include a close partnership between a patient’s referring obstetrician and Johns Hopkins All Children’s perinatologists.
“Within this partnership, we can take care of a full range of high-risk maternal and fetal conditions, from maternal hypertension, diabetes, lupus and cardiac disease to fetal anomalies like spina bifida, congenital diaphragmatic hernia and congenital heart disease,” Schwartz says. “We work closely with neonatologists and other colleague specialties, including pediatric surgeons, pediatric cardiologists and pediatric clinical geneticists. Communication is key, and we work closely together, seeking everyone’s input regarding next management steps to ensure overall quality of care up through delivery.”
Delivery decisions are based entirely on the risk factors involved and communicated clearly with the expectant mother.
“For example, a baby with spina bifida would be delivered by us and then moved immediately to our neurosurgical unit for specialized care,” Schwartz says. “If we don’t believe delivery with us is necessary, we encourage delivery close to home with the regular OB, but they have access to us if necessary.”
Doctors with All Children’s Specialty Physicians provide care throughout the west coast of Florida through affiliations and collaborations with regional and community hospitals.
“We provide integrated teams like this to other hospitals and ambulatory centers we partner with to regionalize perinatal and neonatal care—at least that’s our goal,” Prieto says. “The Institute believes in caring for the right patient in the right place.”
Brandon Regional Hospital is a perfect example of this convenience. Johns Hopkins All Children’s provides perinatal coverage to Brandon and has neonatologists staffed in their neonatal intensive care unit. For most patients, the mother and child are taken care of at Brandon. If higher-level care is needed, patients are transferred to Johns Hopkins All Children’s in St. Petersburg, for those requiring the highest-level care, or a regional NICU.
This collaboration is designed to bring care to communities. For instance, Prieto holds multidisciplinary conferences at Brandon to present high-risk cases to all subspecialists involved in the care of a patient, coordinating care on site rather than bringing the multi-hospital team to Johns Hopkins All Children’s campus. For now, these conferences allow specialists to create a plan they will present to the mother. Soon, these conferences will include the mother as well, engaging her as early as possible in the care plan.
“The newer model is more inclusive of the patient at the front end,” Prieto says, “and will allow her to meet all of the specialists who will eventually be part of her care team—it’s exciting what will come of this.”