Intern Ready: Ob/Gyn

Before Your First: Day With Fetal Therapy

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Fetal therapy is a subspecialty of maternal-fetal medicine focused on treating fetal disease before birth — from prenatal cures (anemia, TTTS) to improving outcomes (myelomeningocele, CDH), optimizing conditions at birth, and transplacental therapy (SVT, congenital heart block). In this episode, Dr. Michelle Kush walks us through the major fetal therapy procedures you may encounter as an OB/GYN resident and what your role will be.

Topics Covered:

  • What Is Fetal Therapy? – Subspecialty of MFM treating fetal conditions before birth. Contact the fetal therapy team at 844-543-3825.
  • Fetal Anemia and Intrauterine Transfusion
    • Busiest fetal transfusion center in the Mid-Atlantic (600+ transfusions to date).
    • Most common indications: alloimmunization, parvovirus infection, hydrops/hereditary spherocytosis.
    • Performed on L&D once fetus reaches viability, with betamethasone course completed.
    • Risks: preterm labor, PROM, fetal bradycardia, emergent delivery (<1%).
    • General care path: arrive → H&P → OB anesthesiology → NPO, IVF, continuous fetal monitoring → transfusion (usually in triage room) with OR, anesthesiology, and NICU on standby.
    • Post-transfusion: Continuous monitoring (fetus is paralyzed — change mother's position for decels). Advance to clears at 1 hour if no contractions and reassuring tracing. Earliest discharge at 2 hours if Category I tracing and fetal movements have returned.
    • Twin-to-Twin Transfusion Syndrome (TTTS)
      • Occurs in monochorionic pregnancies — unequal sharing of volume between donor and recipient twins.
      • Fetoscopic laser ablation of placental vascular anastomoses offered for Stage 2+ (or progressing Stage 1), performed 16–26+6 weeks.
      • Risks: preterm labor, PROM, membrane separation, demise of one or both fetuses, bleeding, maternal transfusion (<2%).
      • Pre-op: consents in the Center, H&P, OB anesthesiology, NPO, IVF, Foley catheter prior to OR.
      • Post-op: magnesium 2 g/hr (titrate up by 0.5 g/hr for >6 contractions/hr). POD 1: stop mag, remove Foley, AM CBC, regular diet, ultrasound in Center, may discharge home.
      • Myelomeningocele (MMC) Closure
        • Performed 24–26 weeks for isolated anomaly with normal genetics (open or fetoscopic approach).
        • MOMs trial showed: less hindbrain herniation, decreased/delayed shunt placement, improved ambulation at 30 months.
        • Maternal risks: preterm delivery, PROM, uterine incision complications.
        • Admit night prior. Morning of: A-line placed, indomethacin at 6 AM, magnesium started, Foley placed.
        • Post-op: highest risk for pulmonary edema — strict I&O, incentive spirometry is a must, continuous fetal monitoring, epidural for pain, SCDs in place. If concerns: see the patient, listen to lungs, check I&O, and CALL.
        • POD 1: AM labs (CBC, CMP), continue indomethacin/heparin/SCDs/IS. Remove A-line if all agree. Mag and Foley discontinued. Transition to PO pain control (Tylenol, Dilaudid, gabapentin, Flexeril, abdominal binder).
        • Fetal Arrhythmias and Transplacental Therapy
          • Most common admission: fetal SVT (FHR >180 bpm for more than 10% of observation time).
          • Indications for transplacental therapy: tachycardia ≥180 bpm with biphasic DV, tachycardia ≥280 bpm regardless of duration, or SVT with fetal hydrops.
          • May need 24 hours of continuous monitoring to determine if transplacental therapy is needed. Risk for hydrops and fetal death.
          • Most commonly treated with flecainide; additional agents include digoxin and amiodarone.
          • Maternal baseline: EKG and CMP with ionized Ca, then continuous cardiac monitoring while initiating. Must have normal EKG indices (PR ≤0.2 sec, QRS ≤0.12 sec, QTc ≤0.47 sec).

            • About the Speakers:

            Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

            Guest Speaker: Michelle L. Kush, MD – Assistant Professor, Maternal-Fetal Medicine, Center for Fetal Therapy in the Department of Gynecology and Obstetrics at Johns Hopkins.

            Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

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            Intern Ready: Ob/GynBy Lucy Brown, M.D.