Dr. Angela Chaudhari (Host): Welcome to Parts and Labor, a roundtable discussion with our Maternal-Fetal Medicine experts here at Northwestern Medicine. My name is Dr. Angela Chaudhari, and I'm a minimally invasive gynecologic surgeon and serves as the Chief of Gynecology and Gynecologic Surgery here at Northwestern Medicine. I will be your host today as we talk about what constitutes a high-risk pregnancy, discuss when you should refer to our Maternal-Fetal Medicine specialists, as well as to discuss some diagnoses that can be co-managed with your general OB-GYN.

On our panel today, we have three highly skilled Maternal-Fetal Medicine specialists from Northwestern Medicine. First up, Dr. LaTasha Nelson, an Associate Professor of OB-GYN and Maternal-Fetal Medicine as well as Co-Director of our Placenta Accreta Program. Next up, Dr. Bethany Stetson, Assistant Professor of OB-GYN and Chief of Obstetrics at the Prentice Women's Hospital here at Northwestern Med. She's also the Associate Fellowship Director for our Maternal-Fetal Medicine Program here. And then, Dr. Kelly Drexler, an Assistant Professor of OB-GYN and MFM, and has had the unique opportunity to both train here a number of years ago, as well as to now come back and be one of our esteemed faculty members.

So, I'm so excited you guys are all here in the studio today to talk a little bit about high-risk pregnancies. I feel like everybody always says, "I'm high risk because dot, dot, dot," right? It might be that they feel like they have some personal reason that they're high risk. But really, who is high risk?

Dr. LaTasha Nelson: You know, I like to tell patients, I personally could make anybody high risk. But the question is, who's higher risk in the capacity that they need to be seen by MFM? And these are the patients that are outside the garden variety OB patient. They may have maternal problems or fetal problems that make them a little bit different, and they need a little bit higher acuity care.

Host: So, are there any specific diagnoses that you guys feel like, "Gosh, we must see those patients?"

Dr. Bethany Stetson: Yeah, I think from my perspective, I think anyone who has a modifiable risk factor is really important for us to see. So, someone, say, cancer in pregnancy, we know that our assistance in helping them with the management of their cancer in pregnancy can improve their outcomes. Those who have, you know, significant hypertensive disorders on multiple medications or things like heart failure, optimizing their care antenatally and even during the pregnancy can improve their outcomes. So, kind of two examples. In addition to diabetes, again, modifiable risk factors that we can adjust through improvement of their own healthcare prior to pregnancy and throughout the pregnancy to hopefully reduce their pregnancy morbidity.

Host: Okay. Well, the number one question I get from friends and patients is advanced maternal age, that horrible term everybody hates, over the age of 35. Are they really high risk?

Dr. LaTasha Nelson: No. You know, I think we kind of look at a lot of that from the insurance standpoint. But we know that as women get older, of course, we have more comorbidities. So, we're really more likely to have medical problems. But typically, we as MFMs don't really start to think about high-risk MFM until we're greater than 40.

Host: Greater than 40. Well, all my friends will be very happy, although I am getting older and my friends too are getting older with me. So, I'm pretty sure they still all qualify. But that's really good to hear, because I feel like out in the community, so many patients imagine that what they bring to the table might actually be considered high risk. How about patients, maybe with not a modifiable risk factor, but maybe on different types of medications? For example, high blood pressure or some of those sorts of things, should they be seeing a high-risk specialist?

Dr. Kathleen Drexler: I think that's a good question. And I think at a minimum, I think there's patients who may have rheumatologic diseases or things where they're on medications that maybe aren't typical for other women of reproductive age who don't have those comorbidities. It's always worthwhile to have them see MFM in consultation. It doesn't necessarily mean they need to follow with us for their whole pregnancy, but certainly something that we can meet with them at some point in the pregnancy to talk about risks, benefits, continuing the medication, stopping the medication, and that sort of thing.

Dr. LaTasha Nelson: I definitely believe that it's even more important to see them before they get pregnant so we can have those conversations and review those medications and optimize their health before they conceive so we can have the best outcome.

Host: Dr. Nelson, I love that so much. That was actually going to be my next question. It's like, when should these patients who are on different types of medications or maybe have these modifiable risk factors, what's the best time to come see you guys?

Dr. Bethany Stetson: So really, I think antenatally is great because we can assess their baseline health. So again, I think something we're going to talk a little bit about, but cardiovascular disease. So, getting that evaluation prior to pregnancy so, if there is any room to optimize, we have that opportunity prior to pregnancy. Same with obesity, for example, do we have any opportunity to reduce the associated morbidity with obesity before, with things like lifestyle management or weight modification before, because we don't want patients to lose weight during pregnancy.

Host: Okay. Let's talk about the first one you mentioned, cardiac disease. I mean, this is something that myself, as an OB-GYN and as a gynecologic surgeon, I feel like I don't know a lot about baseline cardiac disease. That's just like not part of my practice. I work so closely with hospitalists and cardiologists to make sure my patients are optimized for surgery. So, what should our general OB-GYNs be thinking about when we think about cardiac disease and pregnancy?

Dr. Bethany Stetson: Yeah. So, I think you're exactly right. We are not doing this in silos. We are definitely doing this in the multidisciplinary approach. So, generally, there is a cardiologist who has special interests in women's health, specifically in pregnancy who is seeing these patients in addition to us. And then, once they're pregnant, also an OB anesthesiologist, because all of those players have important impact for that patient's care.

I think antenatally, the things that general OB-GYNs should be thinking about is, do you have a cardiac history? So, that can be from a structural standpoint. Did you have a heart defect as a child that was repaired? Yes, you may not perceive that you have issues, but that should still be evaluated, because pregnancy is a very different state than the non-pregnant state. So, the physiologic changes, meaning the doubling of blood volume, the increased cardiac output, that demand on your heart is different. And so, we want to make sure that in its kind of native non-pregnant state that that is optimized. So that way, we can try to anticipate what that will do with the stress of pregnancy.

So on structural issues, is there any rhythm issues? So, patients who have palpitations that have had different devices for the treatment or surgeries related to that, because we know, again, that increased blood volume can dilate that top chamber of your heart, which can lead to kind of extra signals being sent that will lead to arrhythmia. So, if you had that before pregnancy, that can get worse. So, again, optimizing that. And then, medications. So, if it is not a structural issue, but just an intrinsic heart issue, something like a muscle issue for heart failure, are there any medications that we can do to optimize the heart before pregnancy? Or can we tell you that we don't recommend that you get pregnant, this is just too high risk for yourself? And what other opportunities do we have for you to grow your family?

Host: Yeah. So, it sounds like, you know, oftentimes when I still practiced general OB-GYN, we would have patients come in and they would give us these histories of, you know, childhood cardiac condition. And they used to see their pediatric cardiologist for years and then kind of have gotten lost to followup. They're living their life. They don't really continue to follow up with anybody. It sounds like it's pretty important for us as general OB-GYNs to get those patients back into Cardiology before they ever think about getting pregnant and probably into you guys as well for some counseling.

Dr. Bethany Stetson: Yep, absolutely. I think it's wonderful that the pediatric cardiovascular surgeons have done such a great job. And overall, these outcomes are good, but there are underlying things that pregnancy will exacerbate that we need to evaluate. So, I think that's absolutely a great opportunity, is in that reproductive age patient, referring them to their cardiologist for baseline evaluation, assessing whether or not they're interested in pregnancy, and if they are, referring them to us., Because it's not only a risk for themselves, which I feel like we're not always motivated by what is helpful for ourselves. But especially if they have a structural condition, that also impacts their fetus, and there is an increased risk for their fetus to have a structural cardiac anomaly. So, sometimes when you kind of also discuss the impact on the pregnancy and their family, which sometimes is more important to them than themselves, can also be another kind of avenue to encourage that care.

Host: Okay. Well, we got really deep, really fast into cardiovascular disease. And, you know, the good news is the vast majority of patients out there don't have these very serious problems. But it's so good to hear that we really have a resource here at Northwestern for our patients that really need this very high-level care. Let's take a step back to more simple cardiovascular disease, something a measly gynecologic surgeon can understand. How about hypertension? You know, so many women are getting diagnosed with hypertension in their 30s, early 40s, and often thinking about pregnancy and are very, very scared to get pregnant. In fact, so many patients, I feel like, come off of their high blood pressure medications thinking that they're unsafe for pregnancy. So, what should we be doing with these patients? Sending them to you? How do we counsel these patients?

Dr. LaTasha Nelson: So, we should definitely be counseling these patients about what is causing their hypertension. Is this a modifiable risk, like Dr. Stetson said? Are they on the best medication regimen that can control the blood pressure? And are these blood pressure medicines safe in pregnancy? Some patients get really scared when they're on medications and they get pregnant. But actually, there are a lot of medicines that we use that are safe in pregnancy and that we can monitor and get actually good control.

Host: I think when we think about who's listening, so we obviously have some OB-GYNs listening, I'm sure we're going to have some patients listening. And so for patients out there, I mean, for me, I would say the biggest thing is you've got to go talk to your doctor before you get pregnant. Make sure you're going in, getting checked out, getting baseline evaluation. You probably won't need high-risk specialists for just something as simple as hypertension. Probably your general OB-GYN is going to be able to counsel you along the way. Do you guys agree with that?

Dr. Kathleen Drexler: Absolutely.

Dr. Bethany Stetson: Yeah.

Dr. LaTasha Nelson: And I think we should always be preparing. If you have a patient that's of reproductive age, we should always be prepared because you can always get pregnant.

Dr. Kathleen Drexler: Yeah. So, being forward-thinking and not waiting until they're pregnant.

Host: Yeah. You know, I think another area when I meet a lot of women is really around their weight. They think, "How is that going to impact my pregnancy? If I'm a little bit heavy, should I be trying to lose some of that weight? Or will I be okay in my pregnancy?" So, how do you guys think, you know, mild to moderate obesity really impacts pregnancy?

Dr. Kathleen Drexler: I mean, I think we know that there are certain risks that come with pregnancy when you enter pregnancy not at an ideal weight, right? So, coming into pregnancy already being obese does put you at risk for certain things like gestational diabetes and developing preeclampsia. I think obviously the degree of that risk depends on the degree of how much we're talking about in terms of obesity.

I think regardless of where you start, I think it's always important to think about anything you can do prior to getting pregnant to optimize your health is going to reduce your risk, right? So even small reductions in your weight prior to pregnancy can truly alter your risk profile in terms of pregnancy outcomes.

Host: Yeah. Are there any patients who fall into that obesity category that our general OB-GYN should think about referring into MFM? Is there sort of any particular weight or any particular side effect from a weight that you guys think would be important?

Dr. LaTasha Nelson: Well, sometimes, you know, we often get these patients, and there is no magic line. It's the, "What are the comorbidities going along?" You can have a patient who has a BMI of 30, which is technically obese. And they have significant problems, or you can have a patient with a BMI of 40, and they're actually healthy. So, you have to look at the entire picture.

Definitely when we start thinking about operative and surgical risks, those are things that maybe would warrant having at least a conversation with us in terms of helping with delivery planning, delivery timing. We know that when women are overweight, things like getting ultrasound and adequately visualizing baby and making diagnoses can be a little bit more difficult. So, that's another avenue where we could kind of be of help.

Dr. Bethany Stetson: And another thing I think when we get to those higher extremes of obesity, also the consideration of the delivery course. So, having anesthesia consultation as well, just because 90% of pregnant individuals desire neuroaxial anesthesia or an epidural. And because of that, we want to know what is the likelihood of success? What are the complications associated with that, right? So, having those consultations as well to be prepared ahead of time about what you could anticipate.

Host: Well, so, you know, one of the complications of obesity that I think about really that impacts pregnancy really deeply is diabetes. Obviously, type 2 diabetes being one. There's obviously a large group of patients who are type 1 diabetics who are thinking about getting pregnant. What strategies do you guys employ to try to make sure that those patients really have safe pregnancies?

Dr. LaTasha Nelson: Again, the best thing is to see them before they're pregnant. We know that women who go into pregnancy with high hemoglobin A1c levels or poorly controlled diabetes tend to do worse in pregnancy. We know that pregnancy itself increases insulin resistance. So if you start pregnancy and you're kind of that pre-diabetes that everybody talks about, pregnancy itself can tip you over.

Definitely making sure that we're talking to them about modifiable things, diet, exercise. Can we make sure you're on a medication that's safe in pregnancy? A lot of women are on oral meds. In pregnancy, we prefer insulin. So, it may be easier to make that transition prior to pregnancy and get them used to the idea of taking injections and recognizing the utility of insulin and how good it is at keeping those glucose levels in target ranges.

Host: Yeah. Diabetes, I always feel, you know, when I did practice general OB-GYN, it was one of those things where sometimes it went so smoothly and other times it really, really complicated the pregnancy. So, that's so good to hear that, you know, we have the opportunity to send people on for antenatal consultations and that maybe our general OB-GYNs can co-manage some less scary types of diabetes, especially maybe gestational types of diabetes.

And so, you know, I think that that is such an important thing. I think diabetes really scares a lot of patients, especially the idea like the babies could end up in the ICU afterwards because of the sugar problems. So, I know that probably eases a lot of both of our general OB-GYN doctors' minds as well as our patients.

Okay. So as we think about who's getting pregnant, obviously, it sounds like coming to see you guys before is always a good idea. But, you know, there's a lot of patients who are trying to get pregnant and they go in and they see our reproductive endocrinologist, an infertility specialist. And they're maybe on some different medications to get pregnant, they're maybe going through it with IVF, because they've had some difficulties getting pregnant. And we know one of the big risks with IVF and all these assisted reproductive technologies, is twins or even higher order multiples. Now, I assume you guys take care of all of those, right?

Dr. LaTasha Nelson: We do.

Host: So when's the right time? When should a general OB-GYN send those patients to you?

Dr. Kathleen Drexler: I think that's a great question. I think the most important thing that I think referring providers can do is, one, early diagnosis of a multiple gestation is important. And two, the type of multiple gestation, right? So if we're talking about twins, what type of twin pregnancy it is? So, not to get into the nitty-gritty, but how are these twins sharing a placenta? Are they sharing a bag of water, right? Because that increases the complexity and the risk that's associated with the pregnancy, and therefore increases the likelihood that they need to come and see Maternal-Fetal Medicine. Certainly, with higher order multiples, three's a crowd, you know. And so, I think for all of those patients, certainly having MFM hooked in early and often is going to be helpful in terms of being able to make a plan for monitoring, make a plan for delivery, and talk about the different risks. And then, certainly, you know, options for patients if they don't want to continue a multiple gestation and what options there might be to reduce their risk in that regard.

Host: Now, what can you tell those patients, because we all have a little bit of a waitlist to get in, right? And you guys probably prioritize all these different diagnoses. But let's say we do have a patient who gets diagnosed with twins by her reproductive endocrinologist. What is the anticipated first visit with you guys? When would you like to try to see them by?

Dr. Kathleen Drexler: Yeah, that's a good question. I would say, in general, if we're able to establish what type of multiple gestation it is before the end of the first trimester, that is going to be our time frame to get the best information. You know, most reproductive endocrinologists are sort of sending patients out to their primary OBs by the six to eight-week mark, which they may or may not at that point have a full understanding of what the twin pregnancy or triplet pregnancy is. And so, if ideally by the end of the first trimester, if we have a clear understanding of what type of multiple gestation we're dealing with, ideally, about that time is when we'd like to see them to start talking about surveillance for complications and things of that nature.

Host: So, it sounds like it's very reasonable to see their general OB-GYN first and then wait to get an appointment with you guys and that they don't need to feel like by six or eight weeks, they need to be in your office.

Dr. Kathleen Drexler: And I would say the most traditional way in which, you know, patients who have complicated multiples or higher order multiples end up in our care is oftentimes that they are released to their general OB-GYN. They have that, you know, first-trimester ultrasound somewhere between 10 and 14 weeks, and that is when it is identified that they have a higher risk multiple pregnancy. So usually, we're seeing them somewhere around the 14 to 16-week mark.

Host: That makes me feel so good, because so many patients will call and say, "I just can't get in. I just can't get in. I need to get in by eight weeks." And the answer probably is they don't really need to see anybody by eight weeks. They already got their first ultrasound. We know things are moving forward. They need to be eating right, taking care of themselves, taking those medications that they talked to you about before they ever got pregnant, if they needed to. And then, really taking their time and recognizing pregnancy is not a race get to 40 weeks, that actually you'll have plenty of time to see those specialists to make sure you're staying safe.

Dr. Bethany Stetson: Definitely.

Dr. LaTasha Nelson: Absolutely. And that's kind of what we do in MFM, is planning. You know, people think that patients come to us and we automatically envelop them into our practice, and that's not true. Oftentimes, we can, at that first visit, map out the things that are going to be different about this pregnancy and spell those things out. Set forth timings for ultrasound and fetal surveillance, and they don't necessarily need to stay with us. But we can kind of co-manage and make those plans for the providers.

Host: You know, that actually touches on another point, Dr. Nelson. Do you guys see patients off of main campus? Because, you know, we have so many patients out in our suburban practices that are really looking, you know, for maybe a one time consultation. Where can they see you guys at?

Dr. LaTasha Nelson: Well, twice a week, we are at Lake Forest on the North Shore. On Tuesdays and Thursdays, we see patients in consultative services. We have some patients that are our patients here in the city that live on the North Shore, and it's just a little bit easier for them to see us there. We do ultrasound and basically are able to provide all the services there that we can provide here in the city.

Host: Got it. And I assume some of the patients that you co-manage choose to deliver downtown. Do some deliver at the other hospitals in town?

Dr. LaTasha Nelson: Absolutely. Some patients who we see at Lake Forest will go on to deliver at Lake Forest.

Host: Fantastic. So, I just think like that really has opened up our ability to provide service and care sort of across the Chicagoland area, which is really, really great. You know, I just wanted to touch on a couple of programs. Dr. Yi is one of your partners, and I know she runs a pretty amazing Infectious Disease Program. She's one of our biggest researchers on campus.

But, you know, there is a whole program here at Northwestern that's really designed for patients who are affected by different types of infectious disease, such as HIV, hepatitis C, syphilis, toxoplasmosis. And so for those providers out there listening, there are some really great options downtown here for care of these patients, because it can be sort of very scary or complicated both for patients and providers to care for some of those things.

You know, Dr. Nelson, I know that you also run a Placenta Accreta Program here downtown. Can you tell me a little bit about that program and who should be sent to it?

Dr. LaTasha Nelson: So, placenta accreta is a spectrum of disorders that deal with abnormal invasion of the placenta. So, typically, after delivery, the placenta should peel off of the uterine wall, and we go on with our lives. But sometimes that placenta is embedded a little deeply. And patients who have complex medical history, multiple surgeries, prior history of placental issues, we oftentimes will do an ultrasound. And although this is typically a pathologic diagnosis, there are markers that we can see on ultrasound that can make us more and less concerned. So, for instance, patients with placenta previa, meaning the placenta is covering the entrance to the uterus, we can sometimes see abnormal blood supply or vasculature that would go along. And in extreme circumstances, we can actually see the placenta growing outside of the uterus, and that gets kind of scary, but those patients should be sent here.

Host: So for our providers listening, as they're like trying to get appointments in with you guys, trying to get their patients in with you, what all do they need to be sending? What's really important for you guys to have to care for these patients?

Dr. Bethany Stetson: I would say the biggest thing is what is their gestational age, right? So, we can triage how quickly we need to get them in, right? Because if there is a misunderstanding of a patient's complex cardiac history and it's found in the third trimester, we need to expedite that and we will do that. So, I think gestational age is one thing that's really important. The other thing is what is the diagnosis that we're working with? And that's multifold. One, again, for when do we need to see them? And two, where do they need to be seen? So, should they go to the Women's Infectious Disease Clinic, which is on X day, or do we need to schedule them a time to see Dr. Nelson because our concern is placenta accreta? So, it helps us for triaging location provider as well as timing of the disease process.

Dr. LaTasha Nelson: I like for doctors to tell me, what is your question? You know, it sounds silly, but I would never want a patient to come to me and I'll have to guess, or I'm trying to figure out and I kind of totally missed the whole reason they were being sent to me. So, having that provider spell out what is your question, what do you need help with?

Dr. Kathleen Drexler: Now, I think it's important to identify, are you asking us for a consultation, meaning you want us to evaluate the patient's situation, make recommendations, but anticipate they'll continue their care with their primary OB provider? Or are you anticipating that they're going to assume care with MFM for the remainder of their pregnancy?

Host: All such important stuff. You know, it is funny because oftentimes when patients go to see high-risk doctors, they might have something very different in their brain than actually what their general OB-GYN is actually thinking about, right? And so, I think that is so important. You guys might get a whole lot of questions about, "I was exposed to sushi in my first trimester," right? And actually, really what's going on is they have a low-lying placenta and the doctor's really worried about it, right? And, you know, so those I think are really, really good points.

You know, I have really enjoyed talking with all of you. You guys have such an amazing group of doctors, and we're really so lucky to have you here at Northwestern as our consultants for our very highest risk patients. You know, I really want to thank you all for being here. Is there anything else you guys would like to add, either for those patients who imagine that they are high risk or our referring providers?

Dr. Bethany Stetson: I mean, I think the biggest thing is just creating that rapport with your providers. And the general OB-GYNs in the Chicagoland area at Northwestern are truly amazing physicians. I mean, I think we feel fortunate every day. They help us care for our patients. They help deliver many of our patients. And I think if you have a question, we are here. But overall, we trust the care that they're providing. And I think patients need to hear that as well. We truly value their care. And we're here to help and guide in those more complex situations. But overall, cautiously optimistic that everything is going to go well.

Host: Fantastic. Anything else to add?

Dr. LaTasha Nelson: I definitely agree with Dr. Stetson. While we do do total OB, meaning everything from the diagnosis of the pregnancy to delivery, it is not our goal to add to our practice. We're doing okay.

Host: What I'm hearing is these guys are very busy, which means I have to let them get back to the labor and delivery floor now. So, we're going to wrap up. I just want to thank each of you for being here today to talk with our referring providers, with our patients that are out there that have so many questions about potentially getting pregnant or being pregnant right now. So, thank you guys so much for your time.

Dr. Bethany Stetson: Thanks.

Dr. Kathleen Drexler: Thank you.

Dr. LaTasha Nelson: Thanks for having us.