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Maternal-fetal experts smooth the way for the most challenging pregnancies

October 04, 2017
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Jamila Jackson with her daughter, Zoe.

Jamila Jackson thought she would never have children.

In her early 30s, the  mortgage underwriter from Diamond Bar developed uterine fibroids — a type of benign tumor that grows in the muscles of the uterus. To treat them she underwent uterine artery embolization, which reduces blood flow to the uterus and makes pregnancy nearly impossible.

“Back in 2012, the doctor told me I wouldn’t be able to have kids,” Jackson, now 37, says. “When I got pregnant four years later, it was a big surprise.”

Because of her medical history, Jackson’s obstetrician-gynecologist realized she would need specialized care beyond the capabilities of most community hospitals, so Jackson was referred to the maternal and fetal medicine (MFM) experts at UC Irvine Medical Center— a leading center in the region for care of high-risk pregnancies.

From the moment Jackson first met Dr. Jennifer Jolley, her new obstetrician, in the ultrasound suite, she knew she was in good hands. “Dr. Jolley gave me such amazing support and personal care,” she says. “If I could, I would go to her for an earache.”

Specialization and collaboration

Like all her colleagues in the UCI Health High-Risk Pregnancy Program, Jolley is a perinatologist — an OB-GYN with specialized training in caring for mothers and babies in high-risk pregnancies.

But what’s special about UCI Health is that each perinatologist also maintains her or his own unique subspecialty interests. Some specialize in caring for specific medical conditions of the mothers, while others are experts in diagnosing and treating fetuses in utero or multiple gestations. They all work collaboratively to ensure the safety of both mother and baby prior to conception to after delivery.

“Together we represent a wide range of expertise,” explains Dr. Carol Major, director of the Division of Maternal and Fetal Medicine at the UC Irvine School of Medicine.

“My expertise is in diabetes in pregnancy, while Dr. Tamera Hatfield excels in caring for pregnancies complicated by various malignancies. Dr. Afshan Hameed is board-certified in both perinatology and cardiology and has expertise to manage pregnant patients with complex cardiac issues. And Dr. Jolley and Dr. Manuel Porto specialize in prenatal diagnosis and fetal therapy.” Dr. Judith Chung excels in managing women with multiple gestations, while Dr. Julianne Toohey has expertise in management of mood disorders in pregnancy.”

This expertise in fields beyond pregnancy plays an important role in maternal fetal medicine because high-risk pregnancies are often caused by complications with pre-existing chronic health issues.

“Modern medicine is getting very good at maintaining life for a long time,” Major says. “Many of our patients are women with chronic medical conditions like heart disease, diabetes, or maybe they’ve had a kidney transplant or they’re on dialysis. These are women who, in the past, might have been told they couldn’t or shouldn’t get pregnant. But now they can and do, and therefore they’re faced with a whole new set of complications.”

Subspecialization is also important for recognizing the potential for complications with mothers taking certain medications during pregnancy for pre-existing health issues.

“If a woman has high blood pressure, we’re not only going to help keep the condition under control, but we’ll also look at the medications she is taking,” Major says. “Taking ACE inhibitors for high blood pressure, for example, can put the fetus at risk. Knowing which medications are safe or should be avoided during pregnancy is essential.”

Setting lifesaving standards

premature birth rates no longer fallingIn a perfect world, every woman would know whether she had risk factors that might complicate her pregnancy and would consult a high-risk pregnancy specialist like those at UC Irvine Medical Center before getting pregnant. Of course, that’s not how it usually happens. In fact, even women who get all the standard prenatal tests and exams may not realize they have certain risk factors before a problem develops.

Placenta accreta is one of those problems. It happens when the placenta embeds itself into the uterine wall. If a placenta accreta isn’t detected before a woman gives birth, it can put her at risk of potentially life-threatening hemorrhage — uncontrolled blood loss — during delivery. Many standard labor and delivery departments aren’t equipped with the resources needed to effectively deal with a severe hemorrhage when it does happen. This is why hemorrhage is currently the leading cause of maternal death in the United States. Related: Angie Tran-Bloom's ordeal with placenta accreta ›

Major says the best way to keep women safe is by diagnosing accreta before they deliver, and making sure those who do have the condition deliver their babies at a tertiary care center such as  UC Irvine Medical Center with quick access to a large blood bank, surgical backup and interventional radiology. Doctors know that accreta can develop when there’s scar tissue in the uterus from a previous C-section or other surgery, but otherwise it’s hard to predict. Recognizing accreta on an ultrasound requires specialized expertise.

In addition to being a place where women with placenta accrete can give birth safely, UC Irvine Medical Center is also a participant in a state of California pilot program called the California Maternal Quality Care Collaborative (CMQCC). Through this program, UCI Health perinatologists have helped to establish standards for recognizing and treating both placenta accreta and preeclampsia — another hard-to-predict condition, which is caused by high blood pressure during pregnancy. California’s program is considered a model for the rest of the nation. Related: UC Irvine Medical Center only area hospital to fully meet national standards for maternity care ›

“We’re teaching community hospitals how to manage hemorrhage, how to stabilize patients and possibly transfer them to a facility like ours,” Major says. “With the CMQCC we have been able to create standards — hemorrhage protocols, blood pressure protocols. And as a result, maternal mortality in the state has since dropped by 50 percent in certain groups of high-risk patients.”

Navigating interconnected risk factors

Jackson was referred to the UCI Health high-risk pregnancy program because of her history of fibroids, but Jolley ultimately diagnosed a number of other inter-related risk factors.

“Jamila had increased risk for placenta accrete due to her previous uterine arterial embolization, plus gestational diabetes, chronic hypertension and fetal growth restriction (small baby),” Jolley says. “Then at 33 weeks we diagnosed her with preeclampsia, which has an increased risk of developing in women with high blood pressure and diabetes.”

At that point, Jackson was admitted to the hospital for round-the-clock monitoring. She ended up being admitted to UC Irvine Medical Center’s perinatal unit for four weeks until her baby was born.

“We wanted to give her baby the longest possible time in utero to mature,” Jolley says. During her stay the hospital staff set up space for the baby’s father so he could be with her the whole time.

“My boyfriend stayed 30 days in hospital with me, and I just had so much support,” Jackson says. “I had to take my hands off the wheel and let someone else guide it, and everyone was so sweet.”

In February, Jackson gave birth to a baby girl named Zoe.

“Jamila was so calm and remained optimistic during her hospitalization,” Jolley says. “We knew all along she would need a cesarean delivery due to the location of her residual fibroids, and we were lucky she did not have placenta accrete to further complicate delivery.”

Despite being born three weeks early, Zoe arrived healthy and happy, and Jackson took her home after just three days of recovery.

“Now that we’re home, I love having all my family over to hang out and cook and spend time with Zoe,” Jackson says. “Family time is just so valuable now. I couldn’t be happier with my experience at UC Irvine Medical Center.”

NICU: A special place for the tiniest patients

For many women with high-risk pregnancies, carrying the baby for a full 40 weeks might not be possible. In some cases the baby may come early due to prterm labor. In others, the perinatologists may decide that delivering the baby early is the safest choice for both mother and child.

Premature babies and those who need ongoing medical care stay in a specialized facility called the neonatal intensive care unit (NICU). The UC Irvine Medical Center NICU is one of the most advanced in the region. It’s a Level III unit, meaning it meets the most rigorous standards set by the state and is capable of caring for infants born as early as 23 weeks gestation. For these tiniest of preemies, the unit has a section designated the “petite suite.”

“When babies are born extremely premature, before 28 weeks, they can face many challenges and they need constant specialized care,” says Dr. Jennifer Jolley. “Their lungs are not be fully mature, so they need respiratory support. They have a risk for bleeding in the brain that could lead to neurodevelopmental dealys, and have an increased risk for other complications with other organs.”

For any baby staying in the NICU, safety and support is paramount to all — and that includes parents and loved ones. The 45-bed facility, which is staffed around the clock by dedicated primary care nursing teams, has includes private rooms where parents can visit 24 hours a day and sit in special “kangaroo” chairs that allow parents to hold their infant with skin-to-skin contact.