Maternal-fetal Medicine Fellows Research Articles

Revisiting the challenges of training Maternal Fetal Medicine fellows in chorionic villus sampling

More than a decade ago, researchers described a survey of Maternal Fetal Medicine fellows that showed that chorionic villus sampling training was limited for Maternal Fetal Medicine fellows in the United States. Prenatal screening and diagnosis have rapidly evolved since then and include the introduction of noninvasive aneuploidy screening that uses cell-free fetal DNA. Yet, chorionic villus sampling remains the only method available for first-trimester genetic diagnosis. This study evaluated the chorionic villus sampling training of Maternal Fetal Medicine fellows with respect to availability, competency standards, and education methods. In November 2015, an electronic survey was sent to Maternal Fetal Medicine fellows and fellowship directors of accredited Maternal Fetal Medicine fellowship programs in the United States. Fifty-eight percent of fellows (179/310) and 46% of program directors (35/76) responded. Ninety-five percent of Maternal Fetal Medicine fellows think that invasive diagnostic testing is essential to their training; 100% of fellows have amniocentesis training; and 65% have chorionic villus sampling training. The median number of chorionic villus sampling procedures that are expected during a fellowship in those who trained was 10. Eighty-eight percent of fellows and 89% of program directors state that chorionic villus sampling training could be better; 89% of fellows and 97% of directors would like access to simulated models. Barriers to training included lack of patients (71%) and lack of proficient attending supervisors (43%). Since the last survey, >10 years ago, chorionic villus sampling training has declined further. A decrease in the number of procedures that are performed is the leading barrier to this training.

Physician Satisfaction With Clinical Pharmacist Services in an Obstetrics and Gynecology Teaching Clinic

Objective: To evaluate physician satisfaction with clinical pharmacy services in an obstetrics teaching clinic. Study Design: A 35-question survey was created to evaluate demographics and provider satisfaction with clinical pharmacy services using 5-point Likert scale and open response questions. Surveys were administered to all clinic attendings, maternal fetal medicine fellows, and OB/Gyn residents in June 2014 via Survey Monkey. Results: Thirty-one physicians (83.8%) completed the survey. The first set of questions utilized a 5-point Likert-type scale ranging from “poor” (1) to “excellent” (5) and evaluated respondents’ impressions of the clinical pharmacists’ clinical knowledge and professional behavior. The median score was 5 (“excellent”) on all items in the survey, and many demonstrated an average response of 4.81 to 4.9 or higher, demonstrating that almost all respondents chose “excellent.” The next set of questions assessed the clinical pharmacist’s role with the clinic’s multidisciplinary team and asked respondents to answer questions based on a 5-point Likert-type scale ranging from “strongly disagree” (1) to “strongly agree” (5). The majority of responses to questions in this section were between 4.19 and 4.84. Reasons for referring patients to the clinical pharmacist were smoking cessation, asthma management, psych medication use/issues, adherence/polypharmacy, medication reconciliation, counseling on medication safety in pregnancy, insulin/heparin administration, and substance abuse. Conclusions: Overall, the survey identified a positive response and high level of physician satisfaction with clinical pharmacy services. Clinical pharmacy has the capacity to enhance pregnancy care and should be more routinely integrated into the prenatal care team.

Obstetric hemorrhage survey: Attitudes and practices of maternal-fetal medicine fellows

To evaluate experiences related to obstetric hemorrhage and suspected abnormal placentation among first year maternal-fetal medicine fellows. A cross-sectional anonymous survey was administered at the Society for Maternal-Fetal Medicine fellow retreat in March 2013. Fellows were asked about management strategies that reflected both their individual and institutional practices. There was a 56% response rate (55/98). In cases of postpartum hemorrhage due to uterine atony, there was variable use of the uterine tamponade device. The median incremental time for balloon deflation was every 5 hours (IQR = 2-12). Compared to the east coast, fellows from the west coast performed more hysterectomies (mean±SD; 2.9±2.4 vs. 1.2±1.2, p = 0.004). During a peripartum hysterectomy, 29% of fellows used a handheld cautery device such as Ligasure® or Gyrus®. Fifty-six percent responded that their institution never recommend planned delayed hysterectomies for abnormal placental implantation. There is wide variation in practice among first year maternal-fetal medicine fellows in management of peripartum hysterectomy and postpartum hemorrhage.

Practices and education surrounding anticipated periviable deliveries among neonatal-perinatal medicine and maternal-fetal medicine fellowship programs.

To explore national practices of periviable decision-making and care, and to determine and compare trainee education in this domain, within neonatal-perinatal medicine (NPP) and maternal-fetal medicine (MFMP) fellowship programs. A 75-item survey was sent to NPP and MFMP program directors in the United States. In all, 79 of 168 surveys were completed (47%). MFMPs reported offering active interventions for bigger or more mature fetuses (versus NPPs). Variability exists in estimated frequency of simultaneous antenatal counseling by both specialties (range 0 to 90%) and of inter-specialty communication before consultation (range 5 to 100%). One-quarter of MFMPs reported no fellow education regarding periviable deliveries, versus 2% of NPPs (P=0.002); 40% of MFMPs teach fellows about periviable ethics, versus 63% of NPPs (P=0.05). NPPs more frequently utilize role modeling (P=0.01) and simulation (P=0.01) as learning methods. NPPs and MFMPs report different, often asynchronous, practices and fellow education regarding antenatal counseling and resuscitation at periviability.

Delaying Maternal-Fetal Medicine (MFM) Fellowship

INTRODUCTION: Gender and generational value shifts have resulted in vast workforce changes in obstetrics, with some obstetricians returning to training after a time gap. We aim to characterize recent MFM trainees and fellowship graduates, focusing on the delayed decision to return for fellowship training. METHODS: An electronic survey was sent to fellowship programs and their departments. RESULTS: There were 71/267 (27%) respondents who delayed fellowship training. Generation X (born 1965-80) had a significantly greater proportion of obstetricians who delayed training (49/71; 69%) compared to the total study group (76/196; 39%, P<0.001). Of those who delayed fellowship, 39% (n=28) were prior community practitioners, 31% (n=22) were university-based practitioners, 18% (n=13) had military/loan repayment obligations, and others were involved in administration/research. Explanations for the delay included family (n=20; 28%), initial lack of interest (n=16; 21%), and military service (n=13; 18%). There were 21 (30%) respondents who returned to training without citing personal difficulties. However, 50 (70%) of the delayed trainees cited the following challenges in returning to training: less autonomy (n=32; 64%), financial constraints of a trainee's salary (n=29; 58%), and family obligations (n=21; 42%). No respondents regretted returning to fellowship training. CONCLUSION: MFM trainees from Generation X were more likely to delay training. While there were definite personal challenges to returning to training, no one regretted the decision. This group is an underutilized resource that may help build stronger bridges between the generalist and MFM communities.

Current Implementation of Universal Cervical Length Screening for Preterm Birth Prevention in the United States [19

INTRODUCTION: To evaluate the incidence of implementation of universal cervical length (CL) screening for preterm birth (PTB) prevention among institutions with Maternal-Fetal Medicine (MFM) fellowship training in the United States. METHODS: In January 2015, we conducted a national survey of institutions with MFM Fellowship Programs regarding implementation of universal CL screening, defined as CL screening of women with singleton gestations without a prior spontaneous PTB. We also identified whether a transabdominal ultrasound (TAU) or transvaginal ultrasound (TVU) was used for screening. Results were compared by geographical regions. We also assessed if a low obstetrical volume (annual deliveries<3000) affected implementation of TVU CL screening program. RESULTS: We identified 78 MFM fellowship programs, of which 100% responded to the survey. Fifty-three programs (68%) had implemented a CL screening program, with 25 programs (32%) using TVU while the rest (36%) used TAU for CL screening. The Midwest had the highest percent of CL screening (94%), with the highest use of TVU (50%). The South had the lowest percent of CL screening (58%) (OR 0.52 [0.19–1.46]) and the lowest use of TVU (12.5%) (OR 0.22 [0.05–0.78]) compared to rest of the United States. Lower annual obstetrical volume did not affect the likelihood of implementing a program using TVU (7.6%) compared to programs having higher obstetrical volume (24.3%) (OR 0.73 [0.24–2.17]). CONCLUSION/IMPLICATIONS: Universal CL screening has been implemented by over two thirds of institutions with MFM Fellowship Programs. Of these programs, approximately half screen by TAU and half by TVU.

Web-based comparison of historical vs contemporary methods of fetal heart rate interpretation

Contemporary interpretation of fetal heart rate patterns is based largely on the tenets of Drs Quilligan and Hon. This method differs from an older method that was championed by Dr Caldeyro-Barcia in recording speed and classification of decelerations. The latter uses a paper speed of 1 cm/min and classifies decelerations referent to uterine contractions as type I or II dips, compared with conventional classification as early, late, or variable with paper speed of 3 cm/min. We hypothesized that 3 cm/min speed may lead to over-analysis of fetal heart rate and that 1 cm/min may provide adequate information without compromising accuracy or efficiency. The purpose of this study was to compare the Hon-Quilligan method of fetal heart rate interpretation with the Caldeyro-Barcia method among groups of obstetrics care providers with the use of an online interactive testing tool. We deidentified 40 fetal heart rate tracings from the terminal 30 minutes before delivery. A website was created to view these tracings with the use of the standard Hon-Quilligan method and adjusted the same tracings to the 1 cm/min monitoring speed for the Caldeyro-Barcia method. We invited 2-4 caregivers to participate: maternal-fetal medicine experts, practicing maternal-fetal medicine specialists, maternal-fetal medicine fellows, obstetrics nurses, and certified nurse midwives. After completing an introductory tutorial and quiz, they were asked to interpret the fetal heart rate tracings (the order was scrambled) to manage and predict maternal and neonatal outcomes using both methods. Their results were compared with those of our expert, Edward Quilligan, and were compared among groups. Analysis was performed with the use of 3 measures: percent classification, Kappa, and adjusted Gwet-Kappa (P< .05 was considered significant). Overall, our results show from moderate to almost perfect agreement with the expert and both between and within examiners (Gwet-Kappa 0.4-0.8). The agreement at each stratum of practitioner was generally highest for ascertainment of baseline and for management; the least agreement was for assessment of variability. We examined the agreement of fetal heart rate interpretation with a defined set of rules among a number of different obstetrics practitioners using 3 different statistical methods and found moderate-to-substantial agreement among the clinicians for matching the interpretation of the expert. This implies that the simpler Caldeyro-Barcia method may perform as well as the newer classification system.

415: Barriers and facilitators to research by maternal fetal medicine fellows

415: Barriers and facilitators to research by maternal fetal medicine fellows

688: How many procedures does it take? Success of a CVS training program for maternal fetal medicine fellows

688: How many procedures does it take? Success of a CVS training program for maternal fetal medicine fellows

A guide on how to build a novel home-made part task training simulator for cervical cerclage training.

Cervical cerclage is a experience demanding procedure and which is difficult for most of the residents and maternal fetal medicine fellows to have the first experience on real patients. In this study we presented an in-expensive and easy to build model for cervical cerclage training.

Attitudes and Knowledge of Maternal-Fetal Medicine Fellows Regarding Noninvasive Prenatal Testing.

Using cell-free DNA in maternal serum to detect fetal aneuploidy has been shown to have high sensitivity and specificity. The purpose of this study was to assess attitudes and knowledge of Maternal-Fetal Medicine (MFM) fellows regarding noninvasive prenatal testing (NIPT). A 13 question survey was sent via listserv to US-based MFM fellows. One hundred sixteen fellows responded, a 42.3% response rate, with >75% reporting they are comfortable ordering NIPT. Most (82%) preferred that a patient discuss options with a provider or genetic counselor. Three common methods used to learn about NIPT were: formal educational activities (n = 78, 69%), self-review of the literature (n = 76, 67%), and discussions with peers (n = 73, 65%). On questions related to trisomy 21, accuracy was >70%. However, accuracy was lower regarding use in twin pregnancies (42%) and monosomy X screening (50%).

I am not sure?

I Am Not Sure? Paul E. Levin It was a beautiful Friday morning, a few weeks into the summer. My schedule appeared lighter than usual and I even envisioned leaving work a bit early. Maybe a challenging bike ride before dinner. I was sitting in the chairman’s office having our weekly meeting. One of our junior faculty members called . . . he needed help. He was on call and a 32–year–old pregnant woman with a displaced femoral neck fracture had just been transferred to our emergency department (ED). Ms. B tripped in her kitchen last evening. She was unable to stand and was brought to the local ED by ambulance. My colleague was concerned that he wouldn’t be able to successfully reduce the fracture. The long–term prognosis of the hip joint depended on a successful reduction of the femoral neck fracture. In addition, there was an ongoing debate in the orthopaedic literature related to the urgency of operative care to prevent osteonecrosis of the femoral head. I reviewed the x–rays, didn’t anticipate a problem and let him know that I would come to the operating room (OR) to assist. “No”, he responded, “I am not comfortable caring for this patient”. I immediately left the office, went to the hospital and assumed care of the patient. Clearly, my plans for a bike ride were gone, but I had the opportunity to help a woman in need of expert orthopaedic care. Ms. B had been admitted to the obstetrical service. She was a 32–year–old woman of Haitian descent who had recently immigrated to the United States. She had very limited English comprehension and her primary spoken languages were French and Creole. She was alone, in a hospital in a foreign country. She was 24 weeks pregnant with her first child and had no other co–morbidities. Her pregnancy had ben progressing uneventfully. When I first met Ms. B she was lying on a stretcher in an observation unit on the obstetrical floor. She appeared frightened. Two orthopaedic residents were present and obtaining consent for surgical repair of the hip. In their minds there was nothing to discuss, the patient had a displaced femoral neck fracture and needed to have surgery immediately. In their minds, no other options were available and obtaining consent would be straightforward. I introduced myself, sat down on a lab stool by the bed and began a conversation. I needed to meet the patient, understand who she was and discuss treatment. I am not sure that obtaining an informed consent is ever “straightforward” when [End Page 14] a doctor is explaining to a patient that they require emergency surgery. This discussion surely would not be easy or straightforward. We utilized a telephone interpretation service. Every question and response required the transfer of the handset between the patient and physician. Ms. B was in pain and frightened. She immediately expressed concern about her pregnancy and her baby. I arranged for her to meet all of the physicians who would possibly be involved in her care and the care of her baby. Each consultant could explain their area of expertise and potential involvement in the care of Ms. B and her child. She met and had an opportunity to talk with the obstetrician on call, a maternal fetal medicine (MFM) fellow and a neonatologist. I supplied the orthopaedic information. I explained the severity of the injury, the risks of osteonecrosis either with or without surgery as well as concerns over non–union and traumatic arthritis of the hip. Undoubtedly, in a healthy 32–year–old woman who wasn’t pregnant, early surgical intervention would be the most appropriate management in hopes of preserving a normal hip joint. We also discussed the possibility of treating her without surgery. She would be administered pain medication, which were known to be safe during pregnancy, and allowed to begin to ambulate with a walker or crutches. I explained potential problems without surgery and what options would be available to treat any problems that developed with her hip after the child was born. Of course, hip fractures in pregnant woman are very rare, and as a result treating a...

Training needs in operative obstetrics for maternal-fetal medicine fellows

Objective: To define residual operative obstetric training needs for first-year maternal-fetal medicine (MFM) fellows. Methods: We administered a web-based survey to all 100 first-year fellows. We used descriptive statistics to report frequency data for 13 procedures, and logistic regression to estimate odds ratios for comfort in doing and teaching selected procedures. Results: Response rate was 86% (n = 86). Fellows who completed residency in the Northeast/Midatlantic (n = 26) were less likely to report comfort doing or teaching low forceps deliveries (OR 0.21, 95% CI 0.05, 0.78; and 0.20, 95% CI 0.04, 0.85, respectively), while those completing fellowship in the West (n = 13), reported more comfort performing breech extraction of a second twin (OR 6.84, 95% CI 1.24, 51.50); fellows completing residency in the Southeast formed the referent group. Fellows reporting completion of the three selected procedures >5 times each during residency were significantly more likely to report comfort doing and teaching them as fellows. Type of residency program (community/academic) was not significantly associated with reported comfort. Conclusion: The wide range of operative obstetric experience fellows reported gaining in residency varies by region. Additional research is needed to understand competency and teaching ability for procedural skills, and many MFM fellows may need additional procedural experience.

Umbilical Cord Blood Banking

Dr. Martin is Maternal-Fetal Medicine Fellow, and Dr. Badell is Assistant Professor, Department of Gynecology and Obstetrics, Emory University School of Medicine, 550 Peachtree St NE, Atlanta, GA 30308; E-mail: [email protected]. The authors and all staff in a position to control the content of this CME activity, and their spouses/life partners (if any), have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This activity expires on August 14, 2015.

Spontaneous and indicated preterm birth subtypes: interobserver agreement and accuracy of classification

The purpose of this study was to estimate interobserver variability and correct classification of preterm birth into spontaneous and indicated subtypes. This was a cross-sectional study in which a trained obstetric nurse, maternal fetal medicine (MFM) fellow, and MFM faculty member independently reviewed discharge summaries and full medical records to classify preterm birth into "spontaneous" and "indicated" subtypes. Consensus classification was obtained with a senior faculty member and was considered the correct classification. Proportions of correct classification by both discharge summary and full medical record review and by level of reviewer were compared with the use of the χ(2) test. Interobserver variability was estimated with the use of Fleiss' kappa. Of 132 preterm births, 58.8% were spontaneous. Interrater agreement for classification of preterm birth subtype based on the full medical record review was substantial (0.79; 95% confidence interval, 0.76-0.80). Interrater agreement was slightly less, based on discharge summary classification alone (Kappa, 0.73; 95% confidence interval, 0.71-0.79) compared with a full medical record review, but this difference was not significant (P = .3). Correct classifications for research nurse, MFM fellow, and MFM faculty member were 85%, 95%, and 93%, respectively, for the full medical records and 85%, 93%, and 92%, respectively, for the discharge summaries alone. There was no significant improvement in correct classification based on full medical record review compared with discharge summary alone for any level of reviewer (P > .6). There is substantial, but imperfect, agreement between reviewers for classification of preterm birth into spontaneous and indicated subtypes. Incorrect classification may occur 5-15% of the time, even with experienced research personnel. Discharge summaries that are populated with pertinent clinical data may streamline accuracy for research efficiency.

Development of a Targeting Task Trainer for Ultrasound-Guided Needle Procedures

INTRODUCTION: Ultrasound-guided needle procedures are difficult skills to master considering the decrease in the need for invasive testing with the emergence of cell-free fetal DNA testing. Because these procedures will continue to be needed in the foreseeable future, simulation will need to take on a larger role in the training. METHODS: Three models using wooden dowels, drinking straws, and wooden balls as ultrasound targets were constructed and used in three distinct targeting tasks. Targeting tasks were devised that required participants to hit targets in the same ultrasound plane (dowel) while following a restrictive path (straw) and outside the initial ultrasound plane (ball). Completion time and targeting errors were recorded for residents (11), maternal-fetal medicine fellows (three), and maternal-fetal medicine (three) attendings. Performance was compared between those with experience in needle-guided procedures (fellows and attendings) and those without experience (residents) using a Mann–Whitney U test. RESULTS: All attendings felt the tasks would allow the practice of targeting skills and aid in training. There were no differences between the experienced and inexperienced groups on either the dowel or straw tasks. Experienced health care providers performed significantly better than inexperienced group in the ball task (P<.05). CONCLUSIONS: We describe training tasks that can aid in the training of ultrasound-guided needle procedures. Although the dowel and straw tasks did not discriminate, the ball task clearly showed benefit of prior experience. Although the ball task is likely to be helpful in training, other tasks with good discriminatory ability need to be devised.

Preferences in cesarean delivery surgical technique: a survey of maternal–fetal medicine fellows

Objective: Our goal was to (1) describe self-reported cesarean delivery (CD) surgical techniques of Maternal–Fetal Medicine (MFM) fellows and (2) determine whether preferences were congruent with recommendations using US Preventive Services Task Force (USPSTF) criteria.Methods: MFM fellows were queried regarding their preferred CD technique via online survey. Preferences were compared to evidence-based recommendations using standard recommendation language and quality of evidence as outlined by the USPSTF. Categorical variables were compared by Chi-square analysis or Fisher’s exact test, with p < 0.05 considered statistically significant.Results: Of 233 active MFM fellows in August 2012, 167 completed the survey, resulting in a response rate of 71%. Statistically significant differences of preferences were noted when stratified by year in fellowship (blunt tip needles), gender (thromboprophylaxis, skin incision, fascial extension, uterine closure suture) and geographic region of fellowship (fascial extension, skin closure). CD techniques preferred by MFM fellows were congruent with recommendations designated as high or moderate level of certainty with regard to prophylactic antibiotics, uterine incision extension, uterine atony prevention and placenta removal, while incongruent with regards to pre-operative vaginal preparation and blunt needle preference.Conclusion: Among MFM fellow respondents, variation exists in preferred CD technique and vis-à-vis evidence-based recommendations.

Dilation and evacuation training in maternal-fetal medicine fellowships

Many maternal-fetal medicine (MFM) specialists provide dilation and evacuation (D&E) procedures for their patients with fetal or obstetric complications. Our study describes the D&E training opportunities that are available to MFM trainees during their fellowship. National surveys of MFM fellows and fellowship program directors assessed the availability of D&E training in fellowship. Univariate and multivariate comparisons of correlates of D&E training and provision were performed. Of the 270 MFM fellows and 79 fellowship directors who were contacted, 92 (34%) and 44 (56%) responded, respectively. More than one-half of fellows (60/92) and almost one-half of fellowship programs (20/44) report organized training opportunities for D&E. Three-quarters of fellows who were surveyed believe that D&E training should be part of MFM fellowship, and one-third of fellows who have not yet been trained would like training opportunities. Being at a fellowship that offers D&E training is associated with 7.5 times higher odds of intending to provide D&E after graduation (P= .005; 95% confidence interval, 1.8-30). MFM physicians are in a unique position to provide termination services for their patients with pregnancy complications. Many MFM subspecialists provide D&E services during fellowship and plan to continue after graduation. MFM fellows express a strong interest in D&E training; therefore, D&E training opportunities should be offered as a part of MFM fellowship.

Cervical Insufficiency and Cerclage

Dr. Herrera is Maternal-Fetal Medicine Fellow, and Dr. Lewis is Assistant Professor, Hofstra School of Medicine, Department of Obstetrics and Gynecology, St. Luke's-Roosevelt Hospital Center, 1000 10th Avenue Suite 10C, New York, NY 10019; E-mail: [email protected]. All faculty and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This activity expires on February 14, 2015.

Long-term trends in applicants for maternal-fetal medicine fellowship positions.

To examine long-term trends in applicants for Maternal-Fetal Medicine (MFM) fellowship positions specifically following the prolongation of fellowship training in 1997 from 2 to 3 years. We conducted a review of the data from the National Residency Matching Program (NRMP) from 1992 to 2013 in order to compare the numbers of total applicants with those who matched. There was a significant decline in the number of applicants per year between 1997 and 2001. In the subsequent 12 years, the number of applicants exceeded the number of positions with nearly all programs being filled per year. After reaching a nadir of 60 fellowship positions in 2000, the numbers of programs and positions increased gradually to levels now equal to before prolongation of training. These findings should be helpful as pursuit of fellowship training is being considered earlier in residency and as the balance between generalists and subspecialists in obstetrics and gynecology is being more closely evaluated.