The fellows' clinical case load serves as the focus for education in maternal-fetal physiology. Each case is the subject for review of appropriate physiology (normal and pathological), and review of management based on an understanding of the physiology. Case load content is reviewed to offer direction in the assignment of appropriate patients to meet the breadth of the fellows' educational needs.
Genetics and Teratology
Fellows receive training in the area of genetics and teratology through management of patients with Dr. Edith Cheng and/or the genetics counselors. The clinical experience includes genetic counseling of couples at risk for conception with autosomal conditions requiring complex DNA mutational analyses.
The cases are chosen to introduce the fellow to the concepts of traditional Mendelian inheritance as well as nontraditional mechanisms, such as those involved in mitochondrial inheritance and anticipation, as seen in disease involving expansion of trinucleotide repeats. Fellows experience the complexity of such cases by completing the actual step-by-step preparations required for prenatal diagnosis:
- reviewing medical records and completed molecular studies for diagnosis confirmation
- arranging transport of tissue/DNA from appropriate individuals
- counseling the couple
- follow-up of the results
In the past year, we have completed prenatal diagnosis in pregnancies at risk for congenital adrenal hyperplasia, agammagloblinemia, X-linked myotubular myopathy, cystic fibrosis, hemophilia, and alpha- and beta-thalassemias.
Fellows also receive experience in the management of patients with genetic disorders by following such patients with Dr. Edith Cheng. Past and present patients include women with cystic fibrosis, Gaucher's disease, sickle cell anemia, and Ehlers-Danlos syndrome Type IV.
For fellows pursing the infectious disease focus, there is a three-week course in July of the first year, which is an intensive lecture and seminar series in infectious diseases. Clinical rotations on the pediatric and adult infectious disease consult services and a month in the clinical microbiology laboratories provide in depth exposure to infectious disease diagnosis and treatment.
Fellows spend three months in the Maternal/Child HIV Clinic and have the option to work up to one-half day/week in the Harborview Medical Center or UW Medical Center HIV Clinic and the Harborview Sexually Transmitted Diseases Clinic. During clinical obstetrical rotations, fellows learn to manage pregnant women with antepartum, intrapartum, and postpartum infections, and fellows are preferentially assigned prenatal diagnosis patients with possible fetal infection.
The Ob/Gyn departmental conference schedules include many Grand Rounds and other lectures on infectious disease topics, and fellows are encouraged to attend the weekly clinical infectious disease and biweekly HIV-clinical conferences and sexually transmitted diseases research conferences. In addition, several fellows in the past have chosen to take courses offered in HIV (Interdisciplinary 520 Acquired Immunodeficiency Syndrome) and virology (Microbiology 540 Virology).
For fellows entering the program without clinical rotations as residents through the Neonatal Intensive Care Unit, a one-month elective rotation as house staff in the NICU is encouraged to better understand the care and complications of preterm infants. All Ob/Gyn faculty and fellows who take day or night call in Labor and Delivery must have current certification in the American Heart Association Neonatal Resuscitation course.
Additional exposure to neonatology occurs through the Ob/Peds/Anesthesia conference, through participating in NICU rounds to follow-up on infants born to mothers under their care, and through regular consultation with faculty neonatologists about complicated obstetrical and neonatal management situations.
Dr. Christine Gleason, Director of Neonatology, has extensive experience in laboratory research studying the effects of cocaine and alcohol in the developing fetal sheep brain and hopes to collaborate with perinatal faculty and fellows in the laboratory. A fellowship in Neonatology at the University of Washington was established in July of 1999.
During an average experience, the fellows should have the following experience in a setting of direct supervision. This total does not include experience on Labor and Delivery, the Antepartum service, and fetal testing using biophysical profiles.
- 168 suspected anomalous fetuses (Prenatal Diagnosis Ultrasound Clinic)
- 198 routine ultrasound scans (1/2 day per week)
- 150 cervical lengths
- 616 Total (average)
Prenatal Diagnosis Ultrasound
During their clinical rotations, perinatal fellows spend one half day per week in the prenatal diagnosis clinic for one year. Each week they see three to four patients that are referred secondary to being at risk for or suspected to have an anomalous fetus based on an outside ultrasound. The fellow is responsible for performing the ultrasound examination, counseling the patient about the significance of any findings, developing a management plan for the remainder of the pregnancy, and performing any diagnostic tests (amniocentesis and fetal umbilical blood sampling) that are necessary. The fellows are supervised by one of the perinatal faculty (Drs. Michael Gravett and Jane Hitti) with the assistance of a certified genetic counselor and a registered diagnostic medical sonographer. Many of the patients seen in this clinic are referred for the remainder of their pregnancy care which is provided by the fellow.
For one half day per week until proficient, fellows are assigned to scan 3–4 patients having routine (16–20 week) ultrasound. This activity is supervised by one of the perinatal faculty plus a registered diagnostic medical sonographer and is designed primarily to enhance the fellows' ultrasound experience in a mostly normal population and to allow them to increase their experience with patients with multiple gestations.
Early Ultrasound and Transvaginal Ultrasound
During their rotation through the Prematurity Prevention Program, fellows get the opportunity to scan early pregnancies, (~20/rotation) and gain experience with cervical length ultrasound exams (~70/rotation). These exams are supervised by the perinatal faculty and a registered diagnostic medical sonographer.
The Obstetrical Anesthesia service at the University of Washington Medical Center consists of five faculty physicians with fellowship training in obstetrical anesthesia, headed by Heathcliff Chadwick, MD, and an obstetrical anesthesia fellow. Maternal-Fetal Medicine fellows work closely with the obstetrical anesthesia staff and fellow in developing delivery plans early in pregnancy for complicated patients and in caring for critically ill patients on Labor and Delivery.
Obstetrical anesthesia teaching rounds are held four days per week from 7:00 to 9:00 AM. The first hour is spent reviewing management of cases from the previous 24 hours and planning management of current patients. The second hour is a didactic lecture on topics in anesthesia and obstetrics.
MFM fellows are encouraged to participate in these teaching rounds. In addition, anesthesia management of complicated patients is discussed in the weekly Obstetrics/Pediatrics/Anesthesia conference. If MFM fellows desire further anesthesia experience, elective time in the operating room or intensive care unit is available.