High Risk Pregnancy Management
Maternal Fetal Physiology
Genetics and Teratology
Infectious Diseases
Neonatology
Ultrasonography
Obstetrical Anesthesia
Critical Care
Perinatal Pathology

High Risk Pregnancy Management

Maternal Fetal fellows receive clinical instruction in high-risk pregnancy management through a series of activities designed to allow them progressively greater and greater responsibility, while at the same time carefully assuring close faculty supervision and availability. The 12-month core MFM clinical experience is achieved by serving a four-month clinical block in each year of the fellowship. During the first year, an additional month is devoted to Obstetric Ultrasound, Obstetric Anesthesia, and Critical Care each. During the second and third years of the fellowship, a four-month period is spent on the MFM service. The MFM service manages all inpatient (antepartum, intrapartum and postpartum) care. During this intensive clinical experience, the fellow will also participate in the Center for Advanced Fetal Care (our Ultrasound Lab described below in section F) as well as in a weekly outpatient High Risk Clinic. eekly outpatient High Risk Clinic.

This three-year experience allows the fellows continuity of patient care as they act as the first line for resident consultation and teaching. MFM faculty, in accordance with ABOG, CREOG, and HCFA requirements, are always physically present in these clinical settings for overall supervision and teaching of both the fellows and resident staff. Coverage and interaction with both residents and MFM faculty will take place freely to allow the Fellow an opportunity to grow as a teacher and mentor to the resident housestaff, while carefully assuring close faculty supervision and availability. The fellow will play a central role in patient management decisions for all patients in whose care they are involved.

Daily case discussions are held at each A.M. and P.M. change over on Labor and Delivery. Perinatal in-patient cases are presented and discussed in a round table format that involves students, residents, fellows, and faculty. This session under the direction of the Fellow prepares the teams for potential future problems and assures continuity of planning and care. The clinical rotations are timed so that the second year fellow is on clinical rotations during the critical May-June step-up period for the residents. This allows the fellows the opportunity to develop their skills as teachers and mentors to the residents during a highly stressful period in the academic year. The senior fellow's clinical rotations are located mid-academic year. This affords the graduating Fellow a timely clinical experience prior to the written board exams, and protects the final four months of the Fellowship for the critical task of thesis completion.

Additional experience is acquired by the performance of two types of night call. The fellow shall take in-house call approximately three times per month throughout their fellowship. Attending faculty in accordance with ABOG, CREOG, and HCFA requirements, is in house, and always present for consultation and supervision. The Maternal Fetal Medicine fellows shall also be assigned to cover the "high risk" calls for MFM consults and maternal transports. This is an at home "on the beeper" type of call during which the fellow acts as first point of telephone contact for both maternal transports and in-house consultation. This "high risk" call is shared among the entire MFM faculty. Except for those nights on which an MFM attending is scheduled for in-house call, first call for this coverage will fall to the fellows in rotation approximately four times per month. The fellow is required to communicate with the on-call MFM attending for all consult and transport decisions.

In addition to the above core clinical rotations and activities, the fellows shall maintain participation in the High Risk Pregnancy Clinic for one half day a week during each research month for the entire fellowship.

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Maternal Fetal Physiology
The Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Maryland School of Medicine is fortunate to have a dedicated core of scientists whose main interest is reproductive physiology with a strong emphasis on maternal-fetal circulatory physiology. Fellows gain knowledge through a combination of seminars and elective laboratory research in the Division of Perinatal Research laboratories, by structured interaction with members of the Division of Human Genetics, as well as leading members of the Division of MFM whose special areas of interest are fetal medicine.

These divisions include principal investigators on three NIH awards, an American Heart Association National Center, and an NIH/NSF Specialized Cooperative Centers Program for Studies in Reproductive Research Grant. This center includes a long-standing funded baboon colony and numerous active perinatal experimental programs using the pregnant baboon model. The Center for Studies in Reproduction, headed by Eugene D. Albrecht, PhD is a well-established interdepartmental center drawing members from nine departments. Fellows are invited and encouraged to attend their regular meetings and seminars, and participate in ongoing research projects.

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Genetics and Teratology
The University of Maryland Department of Obstetrics, Gynecology, and Reproductive Sciences includes the Division of Human Genetics. Experienced master's degree level genetic counselors, and. pediatric genetic dysmorphologist, provide primary clinical and teaching resources to the division. These individuals also provide clinical and didactic teaching to the fellows on a regular basis. Faculty and students in the Masters for Genetic Counseling program are also valued contacts to the division. Close liaisons with experts in cytogenetics, metabolic disorders and maternal serum analyte testing, and molecular genetics, are maintained through the Program of Human Genetics.

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Infectious Diseases
In cooperation with the Maryland Institute for Human Virology, directed by Dr. Robert Gallo, and co-directed by Dr. Robert Redfield the Department of Obstetrics, Gynecology, and Reproductive Sciences cares for all women with HIV in a multidisciplinary unit that meets weekly in the resident clinic offices. Care of these women, in collaboration with the Department's certified nurse midwifery division is overseen by a MFM divisional faculty member, Dr. Lindsay Alger. The fellow is expected to participate in this clinic, which is contemporaneous with the High Risk Clinic in which all cases of maternal infectious disease are reviewed. Dr. Alger is a member of the Infectious Disease Society for Obstetrics and Gynecology, a committee member of the AIDS Clinical Trial Group (ACTG) and a member of The Obstetrics Working Group of the ACTG. Dr. Alger has also served as an ad hoc reviewer for the National Institute on Drug Abuse. Jan Kriebs CNM, Director of the Nurse Midwifery program is an authority and recognized State resource in management of HIV in woman, with particular emphasis on pregnancy and continuing care.

The Institute for Human Virology offers regularly scheduled seminars, which are both clinically, and research oriented which the fellow may attend. Fellows may also attend a series of lectures on infectious disease topics relevant to maternal-fetal medicine given by the Division of Infectious Diseases in the Department of Medicine.

Fellows gain additional knowledge regarding the role of infectious disease in fetal malformation by participating in evaluations performed in the Center for Advanced Fetal Care, where polymerase chain reaction studies are applied to the evaluation of the fetal patient. Dr. Weiner has a major clinical interest in this area reflected by several publications. Fellows with a particular interest in infectious diseases may choose to spend a 4-week elective on the Infectious Disease Consultative Service working up and rounding on patients with a variety of infectious processes.

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Neonatology
The University of Maryland Medical Center is one of two NICUs designated by the State of Maryland as a Level IV nursery. The 40 bed NICU is staffed by six Neonatologists and supports an active Neonatology Fellowship program. This assures the fellow ample exposure to the complete range of neonatal complications at all gestational ages. The fellow will participate in a one-week course to learn the principles and skills of neonatal intubation and ventilation, drug use, cardiac massage, umbilical catherization, volume replacement, temperature control, and interpretation of management of acid and blood gas status. The fellow shall round on all high-risk service neonates admitted to the NICU. These activities will involve the Fellow in discussion of the etiology, diagnosis, management, and consequences of the full spectrum of neonatal complications. Certification in NALS is required of Fellows as well.

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Ultrasonography
The Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of Maryland has responsibility for all fetal evaluation and obstetric ultrasound within the University of Maryland Medical System. We have an extensive referral base of neighboring and statewide hospitals. The Center for Advanced Fetal Care, and the Antenatal Testing Unit, provides the majority of these examinations and has completed the AlUM accreditation process. Obstetric ultrasounds are also performed on the Labor and Delivery unit, the private faculty offices, and perinatal outreach sites. The resources of the ultrasound program includes Dr. Harman, Director of the CAFCa, four additional board certified MFM specialists, and three sonographers with advanced training in obstetric ultrasound, fetal echocardiography, first trimester ultrasound, vaginal ultrasound and other specific techniques. This team provides over 8500 ob scans/year to which the Fellow will have total access. Fellows, unless they have demonstrated prior training and expertise in ultrasound shall first participate in an intensive 4-week program of didactic sessions and technical tutorials to assure mastery of basic skills and theory. The equipment owned by the Department includes four state-of-the-art color Doppler units, a new 4-D unit, and a number of other excellent imaging instruments. Digital image storage facilities include patient specific storage, with diagnostic code recall, and full reproduction and publication capability. Fellows shall have access to a teaching file of over 8,000 slides. Specific programs in which the Fellows shall be trained include:

First trimester:
Nuchal translucency screening (the division has 4 members certified for screening by the London based Fetal Medicine Foundation) first trimester echocardiography, serial cervical length, first trimester Doppler (investigational), chorionic villus sampling, conventional first trimester transabdominal and transvaginal scans, and multiple gestation embryo reduction.

Second trimester:
Cervical length, investigational Doppler, early and conventional amniocentesis, fetal blood sampling, fetal echocardiography, selective reduction of anomalous twins, fetal transfusion, referrals for triple screening, ultrasound screening for aneuploidy, primary scans for obstetric dating, anatomic survey and placental localization.

Third trimester:
Fetal evaluation, biophysical profile, fetal Doppler, fetal blood sampling, amnioinfusion, various shunt procedures, invasive fetal procedures (thoracentesis, paracentesis, bladder drainage etc.) Clinical investigation in 3-D ultrasound, 10 vessel Doppler panel, and multiple clinical protocols involving ultrasound evaluation of the IUGR fetus, endovaginal ultrasound for placental localization and vasa previa ultrasound guidance for external cephalic version, intrapartum managements of twins and triplets births In -utero endoscopic micro-laparoscopic techniques and laser therapy of twin-twin transfusion syndrome have recently been added to our armamentarium.

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Obstetrical Anesthesia
Andrew Malinow M.D. is the Director of the Division of Obstetrical Anesthesia in the Department of Anesthesiology. He supervises seven fulltime faculty and one to three fellows in OB anesthesia. The division provides 24-hour coverage in Labor & Delivery and three free standing LDRP units on the sixth floor. Integral with MFM faculty and fellows, the obstetric anesthesia attending and fellows provide bedside care to critically ill patients on Labor and Delivery, in the L&D/recovery room and in consultation on all intensive care units throughout the UMMS.

A one-month rotation in obstetric anesthesia, focusing on obstetric techniques, evaluation of the critically ill obstetric patient, maternal and fetal physiology in relationship with anesthesia, as well as the full range of anesthesia techniques, is mandatory. MFM fellows receive training in obstetric anesthesia in parallel to the obstetric-anesthesia fellow. They participate in clinical care of patients supplemented by daily rounds and weekly didactic sessions run by Dr. Malinow.

At the conclusion of these sessions, the fellows shall be able to describe the actions of systemic analgesia/sedation, understand the physiologic responses of the fetus and mother to general and regional anesthesia diagnose and manage complications of anesthesia, and understand the appropriate anesthetic management of medical and obstetrical complications in both routine and high-risk patients.

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Critical Care
Each fellow rotates through the surgical intensive care unit for a one-month rotation to obtain a concentrated experience in critical care during the first year of the three-year Fellowship. Certification in ATLS is required as well.

We are the perinatal referral unit for The Maryland Shock Trauma Center , which is attached to and fully integrated within the University of Maryland Medical System . This unique association allows the fellow the opportunity to, under the supervision of the MFM attending, participate in the management of these complex patients, initially in a consultation when they are in the shock trauma unit, and later as the patient is transferred to the care of the obstetric service.

Management of the critically ill obstetric/postpartum patient is the responsibility of the perinatal care team. With increasing experience, the MFM fellows assume primary bedside responsibility for the critical obstetric patient, with the close supervision by the attending staff. Under the direction of Maternal Fetal Medicine faculty, fellows participate in the care of gravid patients who require critical care services on Labor and Delivery, and in our soon to be opened maternal intermediate care unit. Faculty member Hugh Mighty MD, Department Chair, one of few physicians nationally certified in OBGYN, MFM, and Critical Care Medicine is an especially valuable resource in this area. Members of the Obstetric Anesthesia team are also involved in the care of these complex patients and serve as an additional resource for the fellows.

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Perinatal Pathology
Fellows acquire knowledge of perinatal pathology through many of the previously listed activities, which assure exposure to placental and funic abnormalities. All placentas are reviewed and studied in detail for all births. In addition, Chen-Chi Sun of the Department of Pathology has a major interest in the pathology of reproduction with many collaborative reports with Division members on fetal and placental issues. Through the Center for Advanced Fetal Care, the fellow will become fully versed in developmental abnormalities, infection, aberrant growth, hydrops, and CNS abnormalities as causes of perinatal injury and death with particular focus on in-vivo placental Doppler, and structural abnormalities. Once a month a combined neonatology-perinatology conference is dedicated to clinical pathological conference format with strong input from the individuals mentioned above. The fellows are participants in these conferences, presenting clinical review and correlation for each case.

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