Society for maternal-fetal medicine (SMFM) special report: the maternal-fetal medicine subspecialists' role within a health care system.

A maternal-fetal medicine (MFM) subspecialist has advanced knowledge of the medical, surgical, obstetrical, fetal, and genetic complications of pregnancy and their effects on both the mother and fetus. MFM subspecialists are complementary to obstetric care providers in providing consultations, co-management, or transfer of care for complicated patients before, during, and after pregnancy. The MFM subspecialist provides peer and patient education and performs research concerning the most recent approaches and treatments for obstetrical problems, thus promoting risk-appropriate care for these complicated pregnancies. The relationship between the obstetric care provider and the MFM subspecialist depends on the acuity of the maternal and/or fetal condition and the local resources. To achieve the goal of promoting early access and sustained adequate prenatal care for all pregnant women, we encourage collaboration with obstetricians, family physicians, certified midwives, and others, and we also encourage providing preconception, prenatal, and postpartum care counseling and coordination. Effective communication between all obstetric care team members is imperative. This special report was written with the intent that it would be broad in scope and appeal to a diverse readership, including administrators, allowing it to be applied to various systems of care both horizontally and vertically. We understand that these relationships are often complex and there are more models of care than could be addressed in this document. However, we aimed to promote the development of a highly effective team approach to the care of the high-risk pregnancy that will be useful in the most common models for obstetric care in the United States. The MFM subspecialist functions most effectively within a fully integrated and collaborative health care environment. This document defines the various roles that the MFM subspecialist can fulfill within different heath care systems through consultation, co-management, and transfer of care, as well as education, research, and leadership.

The patient-centered medical home and accountable care organizations: an overview.

PURPOSE OF REVIEW: As the crisis regarding the cost of medical care in the United States continues to spiral out of control, new models of care are being touted as a means to fix the economics of healthcare. This review will examine newly proposed models of healthcare. RECENT FINDINGS: The patient-centered medical home (PCMH) and accountable care organizations (ACOs) are two models that have leapt to the forefront of healthcare reform. The PCMH or medical home is a model predicated upon a primary care provider who will provide and coordinate comprehensive healthcare for the patient across the continuum with care that is evidence based and patient centered. The PCMH provides coordinated care, allowing for more appropriate utilization of resources resulting in improved care and outcomes while decreasing costs. The ACO agrees to be accountable for the overall care, quality and cost of the patients enrolled. The model links patient care to quality, safety and improved outcomes. This coordination reduces the costs of care, thus making it economically appealing to the patients, the providers, the ACO and the payer, whether it be government or private. SUMMARY: Healthcare reform will require implementation of new models of care. The PCMH and ACO are two such models. Although both models have their share of supporters as well as detractors, both will play a significant role in the next chapter of healthcare reform in this country.

Antenatal diagnosis and perinatal management of extremely giant fetal cervicopharyngeal teratoma resulting in impossible fetal intubation: a case report.

We report the case of an extremely large giant neck teratoma diagnosed on routine sonogram and confirmed by 3-D and 4-D sonography and MRI in a 19-year-old primigravida at 18 weeks. Rapid growth, polyhydramnios, premature contractions and premature rupture of membranes necessitated delivery at 28 weeks. Under general anesthesia, with a multidisciplinary team attendant, efforts by the otolaryngologist to establish an airway during an EXIT (ex utero intrapartum treatment) procedure failed as did subsequent attempts by the neonatologist, leading to an early neonatal death. Although a team approach will increase the likelihood of success in securing the airway during EXIT procedures, it cannot be a guarantor in cases of giant neck teratoma.

Cocaine body packing in pregnancy.

Ingesting multiple packets of drugs ("body packing") is a well-described method of smuggling. Although older reports suggested that body packers were mostly young men, the demographics of this group may be changing because children, older patients, and pregnant women may be involved. Pregnant patients represent a challenge in management, particularly in the event of package rupture. Modification of standard management protocols, which were developed for nonpregnant body packers, may be necessary to address the anatomic and physiologic changes of pregnancy. We report the case of a pregnant cocaine body packer who required a perimortem cesarean section after the rupture of a cocaine packet. The care of the pregnant body packer is discussed.

Maternal death after second-trimester genetic amniocentesis.

BACKGROUND: We report a maternal death after a second-trimester amniocentesis. CASE: An uncomplicated amniocentesis was performed using sterile technique and ultrasound guidance. A refrigerated amniotic fluid specimen demonstrated negative leukocyte esterase activity, negative Gram stain for bacteria and white blood cells, and normal glucose and interleukin-6. The patient died from Escherichia coli sepsis and disseminated intravascular coagulation 40 hours after the amniocentesis. The autopsy showed normal- appearing needle entries into the skin and uterus without evidence of bowel adhesion or a needle track through the bowel. CONCLUSION: Genetic counselors and obstetric care providers should be aware of potential serious maternal morbidity and mortality that may occur subsequent to uncomplicated amniocentesis.

The effect of a single remote course versus weekly courses of antenatal corticosteroids on functional residual capacity in preterm infants: a randomized trial.

OBJECTIVE: There are no randomized data on the effect of repeat courses of corticosteroids during pregnancy on newborn pulmonary function. Our objective was to compare the effect of a single remote course of antenatal steroids (AS) with weekly courses of AS on functional residual capacity (FRC) and respiratory compliance in preterm infants. STUDY DESIGN/METHODS: Pregnant women 25 to 33 weeks' gestation, who remained undelivered 1 week after their first course of antenatal corticosteroids (two 12-mg doses of betamethasone) were randomized to weekly courses of corticosteroids versus weekly placebo until delivery or 34 weeks' gestation. FRC was measured with the nitrogen washout technique and respiratory compliance with the single breath occlusion technique within 48 hours of life. RESULTS: Thirty-seven infants (mean gestational age at delivery approximately 32.5 weeks) were studied. Maternal and infant demographics were similar. There was no significant difference in FRC (28.5 vs 27.5 mL/kg) or respiratory compliance between the infants who received a single remote course of antenatal corticosteroids and those who received weekly courses of corticosteroids until delivery. There was no significant difference in admission head circumference or birth weights between the groups. CONCLUSIONS: Our results demonstrate that weekly repetitive courses of AS do not significantly increase FRC or respiratory compliance in preterm infants when compared with a single remote course of steroids given at a mean gestational age of 29 weeks.