Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices ensuring that you stay at the forefront of your field. I'm Melanie Cole. And joining me today is Dr. Devon Ramaeker. She's the Division Director of Maternal-Fetal Medicine at AHN Women's Institute. She's here today to highlight the program at AHN and Maternal-Fetal Medicine.

Dr. Ramaeker, thank you so much for being with us. And as we begin, I'd like you to speak about the field of Maternal-Fetal Medicine. It's not really been around very, very long. Tell us about this specialty and the trend of rising number of women entering pregnancy with medical issues. Why do you feel that is?

Dr Devon Ramaeker: Well, Melanie, thank you first for having me. Maternal-Fetal Medicine is a unique subspecialty within obstetrics and gynecology that focuses on what's considered high-risk obstetrics or high-risk pregnancies, and that can include both maternal risks and fetal risks. So things, for example, like diabetes in pregnancy or new diagnosis of fetal birth defects or fetal anomalies in pregnancy.

 As I mentioned, this is a unique field within OB-GYN, but a much needed field as many women are entering pregnancy later than what has historically occurred and also with medical diagnoses, like things like diabetes and chronic hypertension or even increased weight and that has really changed the risks that we see in pregnancy.

Melanie Cole, MS: Dr. Ramaeker, as we speak about medical conditions that can affect a pregnancy, and we're looking at high-risk pregnancies and different types of high-risk pregnancies, I'd like you to speak a little bit about some of those conditions, what's considered high-risk, and even medications. You mentioned diabetes and high blood pressure, which come with comorbid conditions and medications to manage those conditions. Can you tie that together with your specialty and tell us how those kinds of pregnancies come to you and what you're seeing generally?

Dr Devon Ramaeker: I think it's confusing for both patients and referring physicians, as there is no clearly defined criteria of what makes someone, or a patient high-risk. And there are varying degrees of risk that occur in pregnancy. So, Most commonly, what we talk about is diabetes and chronic hypertension as they're just the most prevalent diagnosis that we typically manage and see in pregnancy. But it's not limited to those diagnoses and can really be anything like autoimmune disorders like lupus. It can be inflammatory bowel disease like ulcerative colitis, a number of medical diagnoses that we see in pregnancy. Oftentimes when we have those women who have those diagnosis, they are on, medications that may or may not be compatible with pregnancy. That is one of the areas that I think we can be most helpful in is helping both patients and referring physicians navigate that unknown or the uncomfortableness of continuing certain medications in pregnancy.

Melanie Cole, MS: That's an important point. And when we think of those medications, and you mentioned they're not necessarily compatible with pregnancy, can you speak about the risks for the baby that are associated with high-risk pregnancies? What do you typically see if a woman is diabetic before she gets pregnant or gestational diabetes or she's already obese or has high blood pressure or cardio issues? Can you speak about the risks to the baby?

Dr Devon Ramaeker: Yeah. And I want to clarify that a lot of medications are actually compatible with pregnancy. And so, I think the biggest counseling point we can discuss with patients is the benefit of maintaining those medications for optimizing maternal care that will then optimize fetal care. So for instance, in diabetes, we really encourage patients to have optimal glucose control before entering pregnancy because we know that poorly managed or poorly controlled diabetes has significant risks for the pregnancy, including birth defects that largely impact Not exclusively, but more commonly, the heart and spine of the fetus can lead to growth abnormalities, both growing too large or too small, and stillbirth, which is when the fetus passes away during pregnancy. So, it's really optimizing the medications that a patient is on to then optimize their maternal diagnosis that will directly impact the pregnancy in the fetus.

Melanie Cole, MS: That's so important, what you just said, Dr. Ramaeker. Tell us about the services that are available both for normal and high-risk pregnancy through the program at AHN. Tell us about cardio obstetrics and diabetes and perinatal palliative care and even screening fetal echocardiogram.

Dr Devon Ramaeker: Yeah. So, we provide full scope consultative care through Maternal-Fetal Medicine and we have specialty programs within Maternal-Fetal Medicine to manage many common diagnoses. And so as you mentioned, we have a fully developed diabetes and pregnancy program to help patients both with type 1 and type 2 diabetes, but also gestational diabetes, throughout their pregnancy. And we are capable of managing them throughout their pregnancy and in that postpartum period. We take care of moms with cardiac, concerns or cardiac diagnoses, and that may be things like cardiomyopathies or could be maternal congenital anomalies that were corrected when they were children. We have a developed program with the women's cardiology group to care for those women. We have a really robust genetic counseling service. So for patients that are interested in genetic testing during pregnancy, and to be clear, all women are eligible to receive genetic testing, but for those women that may need additional counseling because of a family history of a genetic abnormality or a previous pregnancy with a genetic abnormality, we have a really robust genetic counseling service available for those patients.

We also provide, as you mentioned, screening fetal echocardiograms, and that's to identify even to a higher level or higher degree cardiac anomalies of the fetus during pregnancy. And then, last but definitely not least, is we have also a robust perinatal palliative care program for those patients that do have the unfortunate event of being diagnosed with an anomaly during pregnancy that's considered life-limiting. Some patients will choose the palliative care route for their pregnancy, and we have a great system set up through AHN to help support women through that pregnancy, the delivery, and postpartum.

Melanie Cole, MS: I'd love for you to tell us about your team. You just mentioned so many specialties and how the team prioritizes collaboration with the patient's primary care so that she can work on some of those comorbid conditions and those conditions that might be limiting in her pregnancy. Tell us about your team.

Dr Devon Ramaeker: Well, I'm really thankful for the team we do have. Each of these programs are really headed by a physician within our practice that has a unique interest in those areas. So, for example, Perinatal Palliative Care is led by my colleague, Dr. Bushman. Our Fetal Screening ECHO Program is led by Dr. Aziz. And so, we have the depth within our department where we have been able to develop these specialty programs.

I think the number one thing, though, is that even if these programs didn't exist in their current state, is we try incredibly hard to communicate with the referring practices. And I think that's the foundation for any good practice, especially a consulting practice, is to have that communication with the referring practices and physicians so that we can actually co-manage these patients in a way that feels very individualized for the patient themselves.

Melanie Cole, MS: When do you feel it's important that community physicians refer? It can be one visit for just an opinion, yes, or throughout the pregnancy. Tell us what referral looks like?

Dr Devon Ramaeker: There's a whole scope of referrals. We will see patients even prior to conception, and go over counseling aspects to prepare for a pregnancy. And that can be really for any condition that a woman has. We typically most commonly do those for patients that may have diabetes or have had a prior adverse outcome in pregnancy, but it doesn't have to be limited to just that. And so, we encourage referring practices or referring physicians that if there is a patient that they have in their practice that they know is contemplating pregnancy, and may have a comorbid condition or medical diagnoses that might impact pregnancy, to refer them to us for a preconception consultation.

During pregnancy, we will happily see patients as little or as often as the referring practices think is necessary. And so, what that means is that we may see a patient for a one-time consultation. They may have a medical diagnosis that is relatively well-controlled with minimum medication and that patient may be appropriate for a single consultation. Other patients have more complex care and may need ongoing visits with us throughout the pregnancy for a higher level of co-managed care.

Melanie Cole, MS: What a comprehensive program this is. Dr. Ramaeker, wrap it up for us. Tell us about any research at AHN, trends in the field, and a summary of what you would like referring physicians to know about Maternal-Fetal Medicine and the program at AHN

Dr Devon Ramaeker: In terms of research, there are a number of initiatives happening both specifically within MFM and OB-GYN, more broadly, looking at care delivery models, quality of care that we give in general, and then we have more specific research that's occurring, but generally looking at models of care and quality of care that we provide.

In terms of a broad overview of what we provide as MFM and for referring practices and physicians to kind of take away from this is to just remember that we are there to help patients navigate the complexity of reproduction when they have medical diagnoses, and that we will happily meet with patients at any stage in their reproductive plans to help assist those physicians and these patients navigate their medical diagnosis and how that might impact pregnancy.

Melanie Cole, MS: Thank you so much, Dr. Ramaeker, for joining us today. And to learn more or to refer a patient, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. Please remember to subscribe, rate, and review this podcast and all the other AHN Med Talks podcasts. I'm Melanie Cole. Thanks so much for joining us today.