David A. Nagey, MD, PhD

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 A perinatologist, or maternal-fetal medicine specialist, can play a number of roles in the care of the complicated obstetric patient - from performing imaging and prenatal diagnosis to consultation concerning vexing or unusual medical or obstetric problems. My job (and I think I've got the best job in the world) involves traveling around Maryland on a set schedule seeing patients referred by other obstetricians, writing up a consult such as that attached, and then presenting the patient(s) back to the referring physicians at a conference for which they get an hour of CME credit through the state medical society. I also carry an 800-number pager to answer quick consults. Last year I did over 400 in-person consults away from Hopkins (I don't count the consults there), answered over 600 telephone/pager consults and provided over 1000 person-hours of CME/CEU credit - and I'm having a blast because I'm learning all the time!

What types of cases require a perinatologist to be consulted?

Any time the obstetrician wants another opinion, or thinks the patient needs to hear it another time, or wants to speak with someone who is used to dealing with unusual obstetric situations, the maternal-fetal medicine specialist can be useful.

Do you usually work with the patient directly or with her physician?

Whatever the referring physician prefers - usually with the patient FOR the referring physician for difficult problems.

OBGYN.net: Does the woman/patient continue care with the Perinatologist or with her OB/GYN?

 Almost always with the referring OB/Gyn. An exception would be the patient requiring neonatal surgery soon after delivery. In those cases we often co-manage but delivery takes place where the pediatric surgeons are. (for us Johns Hopkins)

Once a women has had a difficult pregnancy does she always need special care when pregnant in the future?

Everyone deserves special care, and the woman with a prior poor outcome more so - but most women can get that care from their own OB - who might then choose to consult a maternal-fetal medicine specialist (or not).

This is an area most women know Nothing about and as you so well know, are very frightened to find themselves in a non-normal pregnancy. I think this will help them understand so much about what is happening and what to expect while in the care of their OB/GYN and their Perinatologist.
 
 Thank you so much Dr. Nagey for sending this presentation to us. I see a wonderful service for many women coming out of publishing this article/interview.

Articles

OBGYN.net Interview with David Augustus Nagey, MD, OBGYN.net Editorial Advisor, Pregnancy & Birth

What does a perinatologist do?

39 year old para 0500 referred because of her horrid obstetric history felt due, at least in part, to placental floor infarction which was found with her last placenta. She has a history of left leg and thigh phlebitis. She took INH for six months in 1991 for a PPD conversion.
 
 Obstetric History:
 '86 - 28w FDIU 
 '87 - 20w FDIU 
 '88 - 20w FDIU
 '89 - 20w FDIU 
 '96 - 27w FDIU
 
 LMP: xx/yy/97 -> 14 5/7w
 
 initial visit data: ee/ff/97: 60" 173# 8w
 sonogram(s):
 rr/ss/97- 9 0/7w -> 14 4/7w
 uu/ww/97 - 12 5/7w -> 14 3/7w
 
 Workup to date includes an upper limit normal aPTT at 34 sec, normal creatinine clearance and uric acid, negative anti-cardiolipin IgG, negative lupus anticoagulant screen (normal aPTT, normal dilute Russell Viper Venom ratio). Thyroid function testing is normal.
 
 Impression:
 IUP 14 5/7 weeks
 multiple 2nd trimester fetal losses
 placental floor infarction - at least with her last pregnancy
 
 Suggestions:
 Monthly sonograms for growth.
 Protein S and C and resistance to activated Protein C (Factor V Leiden), fasting homocysteine level and (though I don't know exactly how I will respond to a positive), anti-leukocyte antibodies.
 
 I heartily endorse your plans to admit her at ~24 weeks to do daily monitoring and a weekly amniotic fluid index.
 
 Thank you for allowing me to share in the care of this lady.
 
 
 David A. Nagey, MD, PhD
 pager (800) 803-8060
  
    

I saw her at the outlying clinic about one month later and the requested labs were reviewed. This included normal Protein

C and S; normal resistance to activated Protein C; normal fasting homocysteine level and negative anti-leukocyte antibodies (whew!). Further, her creatinine clearance was 115 ml/min.

A glucose challenge test at about this time was positive, as was her 3-hour GTT (she had been tested and was not diabetic in prior pregnancies). She was well controlled on diet alone.

She was followed regularly until 24 weeks when she was admitted to The Johns Hopkins Hospital with a plan to provide close fetal surveillance and to deliver her at no later than 28 weeks. After starting her weekly betamethasone shots it became necessary to institute insulin. Her subsequent glucose values were normal without significant fluctuation. Twice daily NST's were (surprisingly) reactive from the outset and twice-weekly biophysical profiles yielded reassuring information. Weekly AFI's were normal. Fetal growth was assured by sonograms every 3 weeks.

She was begun on mini-dose heparin at 26 weeks (by one of my partners though in retrospect I think it was a good idea).

At 28 weeks we had a normally growing, reactive and healthy appearing fetus. My partners restrained me from delivering her. We continued our prior management.

At 32 weeks, with my partners out of town at the SPO, I performed a low transverse cervical cesarean because of a transverse lie and a failed external cephalic version attempt. The baby

was a 1445-gram male with Apgars 8 and 9. He required hood oxygen for 2 days then was discharged to a pediatric convalescent hospital at approximately 7 days of age. He went home at approximately one month of age and has done well since.

39 year old para 0500 referred because of her horrid obstetric history felt due, at least in part, to placental floor infarction which was found with her last placenta. She has a history of left leg and thigh phlebitis. She took INH for six months in 1991 for a PPD conversion.

Author | David A. Nagey, MD, PhD

Articles

What does a perinatologist do?

The Carlyle Crenshaw Perinatal Health Initiative Of The Johns Hopkins Hospital