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MOMENTS IN MEDICINE
Fall | Winter 2009

Amazingly Ordinary

Clara & Margaret

At first glance, there is nothing that seems especially out of the ordinary about Margaret Ingebretsen’s delivery. In a scheduled induction, Ingebretsen delivered a beautiful 8 pound, 14 ounce baby girl on June 29, 2009. Baby Clara was monitored in the NICU for several hours before she and her mother were reunited in her room later that day. After getting the green light from their physician, Ingebretsen and Clara returned home the very next day.

What is extraordinary about this seemingly ordinary birth, are the complex circumstances that surrounded the pregnancy and fetus and the special care Ingebretsen received that led to a healthy delivery.

Ingebretsen’s problems began early on.

At 20 weeks into her pregnancy, an ultrasound detected possible kidney problems with Ingebretsen’s fetus. Ingebretsen, who lives in Okinawa, Japan, with her husband and three other children, was advised to get a second opinion by a maternal fetal specialist. Ingebretsen decided to return to her hometown of Omaha where she made an appointment with Carl Smith, MD, a maternal fetal medicine specialist at the Olson Center for Women's Health at the University of Nebraska Medical Center (UNMC).

Further testing, including another ultrasound, revealed abnormalities of the kidney involving a left multicystic dysplastic kidney, cysts on her right kidney and two ureters. Ingebretsen was also diagnosed with gestational diabetes, a condition that can be life-threatening to both the mother and the fetus if not managed carefully.

“Achieving a positive outcome for mother and baby for all of our high-risk maternity patients is our goal for every pregnancy,” says Dr. Smith, who is also chair of the department of Obstetrics and Gynecology at UNMC. “For this to happen, our job is to ensure mother and baby receive the appropriate interventions during their pregnancy, they deliver at the right time, in the right way and in the right environment.”

It was determined from the outset that Ingebretsen and her fetus would need close monitoring as well as delivery in an acute care environment that could support potential complications during and after pregnancy. So Ingebretsen and her three children moved in with her mother who lives in Omaha and prepared for a long visit. Ingebretsen home-schooled her two school-aged children so she could remain under the close supervision of Dr. Smith and his colleagues. Ingebretsen visited Dr. Smith every two weeks for a physical examination and ultrasound of the fetus.

Carl Smith, MD

A multicystic dysplastic kidney means that the kidney is covered with multiple cysts, which vary in size, and interfere with the kidney’s ability to function normally. One of the biggest concerns, says Dr. Smith was ensuring that the kidneys, which are responsible for producing amniotic fluid, were producing enough amniotic fluid for proper lung development. With very little function remaining of the left kidney, Ingebretsen’s tiny fetus had to rely primarily on her right functioning kidney to produce enough amniotic fluid.

At the same time, Ingebretsen’s diabetes was managed by Lynn Mack-Shipman, MD, an endocrinologist at The Nebraska Medical Center’s Diabetes Center. The diabetes staff also provided on-going education and training on proper management of her condition throughout the pregnancy.

“There were a lot of things that could have gone wrong,” says Ingebretsen, “but the staff and doctors did such a good job that I always felt like things were really under control.”

Despite the numerous doctors’ visits, labs and ultrasounds Ingebretsen had to endure, she says it wasn’t that bad because all of her visits were coordinated in convenient blocks of time at the Women’s Olson Center. “It was all very convenient,” recalls Ingebretsen. “I never had to go anywhere else. I would come in for my appointments and they would all come to me.”

“Achieving a positive outcome for mother and baby for all of our high-risk maternity patients is our goal for every pregnancy.”
Carl Smith, MD

Dr. Smith is one of three maternal fetal medicine specialists who practice at The Nebraska Medical Center with expertise in managing high-risk pregnancies. His partners include Teresa Berg, MD, and Paul Tomich, MD, also maternal fetal medicine specialists.

High-risk pregnancies can occur for a number of reasons, including factors such as pre-existing medical conditions of the mother; medical complications that arise during pregnancy; pregnancy complications or premature delivery due to age or past pregnancy issues; as well as abnormalities of the fetus.

Left to Right:
Teresa Berg, MD, Carl Smith, MD, Paul Tomich, MD

“We work collaboratively with a patient’s family physician or obstetrician to provide consultative support or, in some cases, the referring physician may ask us to follow the patient throughout her pregnancy, delivery and post-partum care,” says Dr. Smith.

“The primary difference between our specialty and obstetricians, is that we have additional training and experience in caring for women with complicated pregnancies, which can make a big difference in a positive outcome,” says Dr. Berg. “Some doctors practice only maternal medicine and some practice only fetal medicine. But we do both, which allows us to ensure both mother and baby are receiving the most optimal care.”

This additional training includes two to three years of maternal-fetal medicine fellowship, in addition to four years of an obstetrics and gynecology residency. This provides these doctors with special expertise in dealing with obstetrical, medical and surgical complications of pregnancy including the use of diagnostic or therapeutic procedures during pregnancy such as comprehensive ultrasound, chorionic villus sampling, genetic amniocentesis, fetal surgery or treatment. Doctors are also trained to manage women with medical or surgical disorders such as heart disease, high blood pressure, pre-eclampsia, diabetes or other endocrine disorders, kidney or gastrointestinal disease and infectious diseases. In addition, they deal with healthy women whose pregnancy is at markedly increased risk for an adverse outcome due to abnormal blood tests, twins or multiple births, recurrent pre-term labor and delivery, premature rupture of membranes, recurrent pregnancy loss and suspected fetal growth restriction.

A number of medical advances has contributed to increasingly positive outcomes for high-risk mothers and their babies over the years, resulting in diminishing maternal mortality as well as decreased mortality rates for premature infants. “It is a rare event for a mother to die during or after birth,” says Dr. Smith. “We are also seeing increasingly better outcomes for premature infants.”

The introduction of improved screening capabilities, such as high resolution ultrasound, has been a key advancement that has revolutionized the care and outcomes for mothers and premature infants by allowing for better prenatal diagnosis of fetuses with abnormalities, notes Dr. Smith. “Thirty years ago we couldn’t see any detail in the fetus’s anatomy,” he says. “Ultrasound now allows us to assess the growth of the fetus, the rate of blood flow through the vessels, potential structural problems, as well as the function of organ systems within the fetus.” With this information, better care and preventive measures can be provided during pregnancy. Delivery in the appropriate environment is also more likely, which ensures the necessary medical expertise and technology are available during and after delivery should complications arise. Ultrasound has also taken the place of a number of diagnostic invasive procedures that had traditionally been performed on the fetus, providing a safer and risk-free alternative to these tests.

“Some doctors practice only maternal medicine and some practice only fetal medicine. But we do both, which allows us to ensure both mother and baby are receiving the most optimal care.”
Teresa Berg, MD

Better information and knowledge about the effectiveness of drug therapies in treating premature labor, improved ventilator technology, as well as the widespread use of steroids to strengthen lungs and help keep young airways open are additional advancements that have improved infant outcomes. “Today, we expect most premature infants to leave the nursery as a normal baby,” says Dr. Smith.

Another significant change in high–risk deliveries is an increasing number of doctors are scheduling delivery at major medical centers that specialize in maternal and neonatal care such as The Nebraska Medical Center. The Nebraska Medical Center is one of just two hospitals in the city that also provides neonatal surgical support. “Studies have shown that premature infants who are delivered under the care of a tertiary care hospital that can provide the full range of acute care services to the mother and baby fare much better,” says Dr. Smith. “Over the years, it has become clear that babies who need to be in a NICU do better when the mother is transported to the facility containing the NICU before delivery, rather than delivering the baby at a remote site and then transferring the baby,” says Dr. Smith. “The mother is far safer and a better incubator than even the best-equipped NICUs.”

“Given the complications that could have happened, this was definitely a success story.”
Margaret Ingebretsen

The level of care for premature infants has also been raised at The Nebraska Medical Center with a new state-of-the-art Newborn Intensive Care Unit (NICU) that was updated approximately three years ago. The newly expanded NICU is designed to embrace a family-centered environment tailored to support the developmental needs of premature infants. It has perfected the environmental variables and science of nursing care to provide optimal support for the babies’ needs.

“During my residency in the early 1990s, the minimum gestational age was 26 to 28 weeks,” says Dr. Berg. “Now we can deliver babies as early as 23 to 24 weeks with good survival rates. In addition, the mortality rates today for premature infants are the same for babies delivered at 32 weeks as they are for babies delivered at 38 and 39 weeks.”

The newly-remodeled NICU
provides a family-centered environment.

The maternal fetal medicine group also provides outreach education and clinics throughout Nebraska. “Part of our mission is to educate other doctors and nurses about high risk pregnancies, what to look for, preventive measures, how to manage more common problems and when to refer to a specialist,” says Karla Haggar, RN, BSN, perinatal outreach coordinator for the group. The physicians hold monthly clinics in Hastings and Kearney, Neb., which are typically packed full from 8 a.m. to 5 p.m. “This is a really convenient service we provide for these patients, as it allows them to continue to be followed by their hometown family practitioner or obstetrician while receiving the extra consultative care they need from our specialists on a monthly basis.”

“Over the years what we have found is that the key to achieving positive outcomes,” says Dr. Smith, “is reaching these women early, providing education, delivering in the appropriate medical facility and preparing parents and family for caring for a baby with special needs. This is what we try to accomplish every day. Taking care of complicated patients with various problems and still having a positive outcome is challenging, interesting and very rewarding.”

“Given the complications that could have happened, this was definitely a success story,” says Ingebretsen. Clara is scheduled for surgery to remove part of her non-functioning kidney and the extra uterer in November. If all goes well, doctors expect Clara to be just fine since the body is capable of functioning with just one kidney. Ingebretsen and her family will then return to Japan after Christmas where Ingebretsen says she is looking forward to reuniting with her husband and returning to an ordinary life.

Because sometimes ordinary isn’t so bad after all.

Next article in the Fall | Winter 2009 issue of One Thousand And One:
Finely Tuned