Educational Objectives | Didactic Conferences | Clinical Facilities | Special Areas | Research | Department Fellows
Select a topic, or simply scroll down the page:
| High Risk Pregnancy Management | Infectious Diseases | Obstetrical Anesthesia |
| Maternal Fetal Physiology | Neonatology | Critical Care |
| Genetics and Teratology | Ultrasonography | Perinatal Pathology |
A. High Risk Pregnancy Management
Maternal Fetal Medicine fellows receive clinical instruction in high-risk pregnancy management through a series of activities designed to allow them progressively greater and greater responsibility, while at the same time carefully assuring close faculty supervision and availability. The 12-month core MFM clinical experience is achieved by serving a four month block in each year of the Fellowship. Clinical MFM activities will occupy the second block the first year. High risk pregnancy management training in the second year is augmented by month-long inpatient clinical rotations in Obstetric Anesthesia, and Critical Care and a 2 month outpatient rotation in the CAFC @ MMC. The third year of the Fellowship, will end with four month blocks on the MFM service.
The MFM service manages all inpatient (antepartum, intrapartum and postpartum) obstetric care. During this intensive clinical experience, the Fellow also participates in the Center for Advanced Fetal Care (our Ultrasound Lab described below in section F) as well as in a weekly outpatient High Risk Clinic. This portion of the MFM fellowship is designed so that each fellow, under the direction of members of the Division of Maternal Fetal Medicine, is exposed to the full breadth and depth of the subspecialty and thereby fulfilling the terminal objective of Guide to Learning in Fetal-Fetal Medicine, ABOG 1996, Sec VIII, and X.
This three-year experience allows the fellows continuity of patient care as they act as the first line for resident consultation and teaching. MFM faculty, in accordance with ABOG, CREOG, and CMS (HCFA) requirements, are always physically present or immediately available in these clinical settings for overall supervision and teaching of both the Fellows and resident staff. Interaction with both residents and MFM faculty takes place freely, allowing the fellow an opportunity to grow as a teacher and mentor to the resident housestaff, while carefully assuring close faculty supervision and availability. The fellowship training and resident training shall complement and enrich one another and not compete with each other as out lined in the General and Special Requirements for Graduate Medical Education in the Subspecialty Areas of Gynecologic Oncology, Maternal-Fetal Medicine, and Reproductive Endocrinology and Infertility ABOG 2005, Sec I, para A, subparagraph 2.
The fellows play a central role in management decisions for all patients in whose care they are involved. Daily case discussions are held at each AM and PM shift changeover on labor and delivery. Perinatal in-patient cases are presented and discussed in a round table format that involves students, residents, Fellows, and faculty. At this session the fellow prepares the teams for potential future problems and assures continuity of planning and care. In addition, on those days when an Ob-Gyn generalist is the attending physician on L&D, the fellow meets with an MFM attending to review all cases and assure appropriate supervision.
The clinical rotations are timed so that upper level year fellow are on clinical rotations during the critical June – August period for the new interns and advancing residents. This allows the fellows the opportunity to develop their skills as teachers and mentors to the residents during a highly stressful period in the academic year.
Additional experience is acquired by the performance of two types of night call. The fellows cover the "high risk" call for MFM consults and maternal transports. This is an at home "on the beeper" type of call during which the fellow acts as first point of telephone contact for both maternal transports and in-house consultation. This "high risk" call is shared among the entire MFM faculty. Except for those nights on which an MFM attending is scheduled for in-house call, first call for this coverage falls to the fellows in rotation. The fellow is required to communicate with the on-call MFM attending for all consult and transport decisions. Should the fellow be required to come into the hospital, the fellow works in close consultation with the in-house attending and covering MFM attending. The need for the presence of the MFM attending is determined jointly by the fellow, the in-house attending, and the MFM attending. On occasion the Fellow is called in to lend a hand as in a busy L&D as an experienced fully trained general OB-GYN physician. When the fellow is called upon to evaluate or manage complicated patients beyond the level of expertise or comfort of the in-house attending the MFM attending joins the in-house team. If the fellows presence is required in-house the following day’ schedule is adjusted to comply with the ACGME and ABOG duty hour requirements as outlined in Section 1, paragraph G,2 of the General and Special Requirements for Graduate Medical Education in the Subspecialty Areas of Gynecologic Oncology, Maternal-Fetal Medicine, and Reproductive Endocrinology and Infertility ABOG 2005.
In addition to the above core clinical rotations and activities, the fellows participate in the High Risk Pregnancy Clinic for one half day a week during each research or didactic month throughout the entire Fellowship.
The Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Maryland School of Medicine is fortunate to have a dedicated core of scientists whose main interest is reproductive physiology with a strong emphasis on maternal-fetal circulatory physiology. Fellows gain knowledge through a combination of seminars and elective laboratory research in the Division of Perinatal Research laboratories, by ongoing clinical and teaching interaction with members of the Division of Human Genetics, as well as members of the Division of MFM.
These divisions include principal investigators on NIH and NICHD awards, including an NIH/NSF Specialized Cooperative Centers Program for Studies in Reproductive Research Grant. This center includes a long-standing funded baboon colony and numerous active perinatal experimental programs using the pregnant baboon model. The Center for Studies in Reproduction, (CSR) headed by Eugene D. Albrecht, PhD is a well-established interdepartmental center drawing members from nine departments. Small animal model research of chronic hypoxia (or reduced fetal oxygenation) is ongoing under the Direction of Loren Thompson PhD as well. Basic science researchers attend the MFM divisional research meetings and fellows are invited and encouraged to attend the research division’s seminars. A schedule of the last years CSR seminars is attached.
The University of Maryland Department of Obstetrics, Gynecology, and Reproductive Sciences includes the Division of Human Genetics. Experienced master’s degree level genetic counselor, A. Higgs, Miriam C. Blitzer PhD a clinical biochemical geneticist and Dr. Carol Greene, a pediatric medical geneticist, provide clinical and teaching resources to the division.
These individuals also provide clinical and didactic teaching to the Fellows on a regular basis. Faculty and students in the Masters for Genetic Counseling program are also valued contacts for to the division. Close liaisons with experts in cytogenetics metabolic disorders and maternal serum analyte testing, and molecular genetics, are maintained through the Program of Human Genetics. This program has a graduate teaching program, which includes monthly seminars, which the Fellows are invited to attend. The Fellows also attend a weekly Multidisciplinary Genetics Conference supervised each Monday by Dr Greene.
The first year of our program has been redesigned so that the initial four months, which had previously been clinical, will be didactic. The second of these months will be an introduction to perinatal genetics during which the fellow will learn principles and techniques of genetic counseling, genetic ultrasound, genetic testing and amniocenteses, fetal therapy, and CVS in the Centers for Advanced Fetal Care at UMMC. The fellow will spend time in the maternal serum screening laboratory under the direction of Dr. Blitzer and will observe pediatric genetics clinics under the direction of Dr. Greene. An elective research rotation in the maternal serum screening laboratory is available for interested fellows under the direction of Dr. Blitzer.
Case audit and the CAFC genetics database and invasive testing database are supervised by Dr. Harman, with full access given to the Fellows for clinical and research purposes. Individual fetal diagnosis and treatment discussions are included in the weekly neonatal-perinatal conference mentioned in para V. c. above.
The Fellows are required to take a postgraduate course HGEN 728 - Clinical Genetics, as one of their required GME courses. Additional courses in genetics provided through the University of Maryland may be elected or audited by the Fellows as well.
In cooperation with the Maryland Institute for Human Virology, directed by Dr. Robert Gallo, and co-directed by Dr. Robert Redfield, the Department of Obstetrics, Gynecology, and Reproductive Sciences cares for pregnant women with HIV in a multidisciplinary clinic that meets weekly in the Penn St.-Western clinic offices. Care of these women, in collaboration with the Department’s certified nurse midwifery division is overseen by a MFM divisional faculty member, Dr. Lindsay Alger. The fellow is expected to participate in this clinic, which is contemporaneous with the High Risk Clinic in which all cases of maternal infectious disease are reviewed. Dr. Alger is a member of the Infectious Disease Society for Obstetrics and Gynecology, a committee member of the AIDS Clinical Trial Group (ACTG) and a member of The Obstetrics Working Group of the ACTG. Dr. Alger has also served as an ad hoc reviewer for the National Institute on Drug Abuse. Jan Kriebs CNM, Director of the Nurse Midwifery program is an authority and recognized State resource in management of HIV in woman, with particular emphasis on pregnancy and continuing care.
The Institute for Human Virology offers regularly scheduled seminars, which are both clinically, and research oriented which the Fellow may attend. Fellows may also attend a series of lectures on infectious disease topics relevant to maternal-fetal medicine given by the Division of Infectious Diseases in the Department of Medicine.
Fellows gain additional knowledge regarding the role of infectious disease in fetal malformation by participating in evaluations performed in the Centers for Advanced Fetal Care, where antenatal imaging, and polymerase chain reaction studies are applied to the evaluation of the at risk fetal patient. In addition the Fellows care for or provide consultation to gravidas across the wide spectrum of infectious disease during the clinical MFM rotations described above. Likewise, neonatal complications of maternal infectious disease are presented and discussed in the combined Neonatology-Perinatology conferences held each Monday.
This training in both maternal and fetal aspects infectious is designed to fulfill the terminal objective of Guide to Learning in Fetal-Fetal Medicine, ABOG 1996. Sec XI.
The University of Maryland Medical Center is one of two NICU’s designated by the State of Maryland as a Level IV nursery. The 40 bed NICU is staffed by six neonatologists and supports an active neonatology fellowship program. This assures the MFM fellow ample exposure to the complete range of neonatal complications at all gestational ages. Certification in NALS is required thereby fulfilling the terminal objective of The Guide to Learning in Fetal-Fetal Medicine, ABOG 1996, Sec XII.
The fellow is expected to round on all high-risk service neonates admitted to the NICU. In addition, the topics listed in Section XII.C of The Guide to Learning in Maternal Fetal Medicine are covered in formal and informal presentations at a weekly joint conference with the Neonatology Division. These activities involve the fellow in discussion of the etiology, diagnosis, management, and consequences of the full spectrum of neonatal complications.
The Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of Maryland has responsibility for all fetal evaluation and obstetric ultrasound within the University of Maryland Medical System. We have an extensive referral base of neighboring and statewide hospitals. The Center for Advanced Fetal Care at University of University of Maryland Medical System (CAFC) provides the majority of these examinations and has completed the AlUM accreditation process. Obstetric ultrasounds are also performed on the Labor and Delivery unit, the private faculty offices, and perinatal outreach sites. The resources of the ultrasound program includes Dr. Harman, director of the CAFC, MFM division members, and five sonographers with advanced training in obstetric ultrasound, fetal echocardiography, first trimester ultrasound, vaginal ultrasound and other specific techniques. This team provides over 10,400 obstetric scans/year to which the fellows have access.
The Center for Advanced Fetal Care at Mercy Medical Center (CAFC @ MMC), provides an additional training site for the fellow. The CAFC @ MMC performs over 3200 scans per year and has completed the AlUM accreditation process as well. (See Sec VI. B above.)
Previously, unless they have demonstrated prior training and expertise in ultrasound, Fellows, have participated in a 4-week program of obstetric ultrasound to assure mastery of basic skills and theory. In order to achieve this goal with all fellows the first year of our program has been redesigned so that the intial four months, which had previously been clinical, will be didactic. The first three of these months will be an introduction to theory and practice of ultrasound technique, perinatal genetic and ultrasound research. This expanded experience is augmented in the second year with a two month clinical rotation through CAFC @ MMC where the fellows apply the principles of targeted ultrasound and hone their skills recognition of fetal anomalies, genetic testing, and counseling. The fellow on the MFM service also participates in the CAFC scanning and procedures, as well as bedside sonography of L&D and on-service inpatients. The third year ultrasound experience will consists of a two month concentration in fetal echocardiography.
The experience in obstetric imaging is designed to provide the Fellow with basic skill and initial knowledge and later increased skill and advanced knowledge of obstetric imaging and antenatal diagnostic techniques fulfilling the terminal objective of Guide to Learning in Fetal-Fetal Medicine, ABOG 1996, Sec VI, and VIII.
The equipment at both sites includes state-of-the-art color Doppler and 4-D units, and a number of other excellent imaging instruments. Digital image storage facilities include patient specific storage, with diagnostic code recall, and full reproduction and publication capability and online teaching files.
Specific skills in which the Fellows are trained include:
First trimester:
Nuchal translucency screening (all division are certified for screening by the London based Fetal Medicine Foundation or the SMFM), cervical length, first trimester Doppler, chorionic villus sampling, conventional first trimester transabdominal and transvaginal scans, and multiple gestation embryo reduction.
Second trimester:
Cervical length, Doppler, amniocentesis, fetal blood sampling, fetal echocardiography, selective reduction of anomalous twins, fetal transfusion, referrals for maternal serum screening, ultrasound screening for aneuploidy, primary scans for obstetric dating, anatomic survey and placental localization.
Third trimester:
Fetal evaluation, biophysical profile, fetal Doppler, fetal blood sampling, amnioinfusion, various shunt procedures, invasive fetal procedures (thoracentesis, paracentesis, bladder drainage etc.) Clinical investigation in 3-D and 4-D ultrasound, 10 vessel Doppler panel, and multiple clinical protocols involving ultrasound evaluation of the IUGR fetus, endovaginal ultrasound for placental localization and vasa previa ultrasound guidance for external cephalic version, intrapartum managements of twins and triplets births and in-utero endoscopic micro-laparoscopic techniques and laser therapy of twin-twin transfusion syndrome.
Andrew Malinow M.D. is the Director of the Division of Obstetrical Anesthesia in the Department of Anesthesiology. The division provides 24-hour coverage in Labor & Delivery and the IMC. In concert with MFM faculty and fellows, the obstetric anesthesia attending physicians and residents provide bedside care to critically ill patients on Labor and Delivery, in the L&D recovery room, the IMC, and in consultation on all intensive care units throughout the UMMS.
A one-month rotation in obstetric anesthesia, focusing on obstetric techniques, evaluation of the critically ill obstetric patient, maternal and fetal physiology in relationship with anesthesia, as well as the full range of anesthesia techniques, is mandatory. MFM fellows receive training in obstetric anesthesia and function as a member of the Obstetric Anesthesia team. They participate in clinical care of patients, daily rounds, and didactic sessions under the direction of the Division of Obstetric Anesthesia faculty.
At the conclusion of this rotation sessions, the Fellows shall be able to describe the actions of systemic analgesia/sedation, understand the physiologic responses of the fetus and mother to general and regional anesthesia diagnose and manage complications of anesthesia, and understand the appropriate anesthetic management of medical and obstetrical complications in both routine and high-risk patients, thereby fulfilling the terminal objective of Guide to Learning in Fetal-Fetal Medicine, ABOG 1996, Sec XI.
Each fellow rotates through the Surgical Intensive Care Unit (SICU) for a one-month rotation to obtain a concentrated experience in critical care. Certification in ACLS is required as well.
We are the perinatal referral unit for The Maryland Shock Trauma Center, which is attached to and fully integrated within the University of Maryland Medical System. This unique association allows the fellow the opportunity to, under the supervision of the MFM attending, participate in the management of these complex patients, initially in a consultation when they are in the shock trauma unit, and later as the patient is transferred to the care of the obstetric service. In addition, The Maryland Shock Trauma Center conducts a regular series of didactic sessions, many of which cover conditions and complications that are listed under either anesthesia or obstetric complications or medical and surgical complications of the educational objectives in the Guide to Learning in Maternal-Fetal Medicine.
Management of the critically ill obstetric/postpartum patient is the responsibility of the MFM team. With increasing experience, the MFM fellows assume primary bedside responsibility for the critical obstetric patient, with the close supervision of the attending MFM staff. Under the direction of Maternal Fetal Medicine faculty, fellows participate in the care of gravid patients who require critical care services on Labor and Delivery, and in our maternal intermediate care unit. Faculty member and Department Chair, Hugh Mighty MD, one of few physicians nationally certified in OBGYN, MFM, and Critical Care Medicine is an especially valuable resource in this area. Members of the Obstetric Anesthesia team are also involved in the care of these complex patients and serve as an additional resource for the fellows.
I. Perinatal Pathology
In order to fulfill the terminal objective of The Guide to Learning in Fetal-Fetal
Medicine, ABOG 1996,Sec. V. the fellows acquire knowledge of perinatal
pathology through many of the previously listed activities, which assure exposure
to placental and funic abnormalities. All placentas are reviewed and studied
in detail. In addition, Chen-Chi Sun MD of the Department of Pathology has a
major interest in the pathology of reproduction with many collaborative reports
with Division members on fetal and placental issues. Through the Centers for
Advanced Fetal Care, the fellow becomes fully versed in developmental abnormalities,
infection, aberrant growth, hydrops, and CNS abnormalities as causes of perinatal
injury and death with particular focus on in-vivo placental Doppler, and structural
abnormalities. Once a month the combined neonatology-perinatology conference
is dedicated to clinical pathological conference format with strong input from
Dr. Sun and her colleagues. The Fellows are participants in these conferences,
presenting clinical review and correlation for each case.
|
Email this Page
Print this Page © 2008 University of Maryland Medical Center (UMMC). All rights reserved.
UMMC is a member of the University of Maryland Medical System, 22 S. Greene
Street, Baltimore, MD 21201. 1.800.492.5538 TDD: 1.800.735.2258
Physician Referral: 1.800.373.4111
