High-Tech Management of
Dwight Cruikshank, MD
Medical College of Wisconsin Obstetrician/Gynecologist;
Chairman, Obstetrics and Gynecology;
Named one of the “Best Doctors in America®” 2004 by Best Doctors, Inc.
High-risk obstetrics emerged as a subspecialty in the late 1970s when Dr. Dwight Cruikshank became one of the first physicians in the country to complete a fellowship in maternal-fetal medicine. Since that time, great progress has been made in identifying and treating high-risk pregnancies. Dr. Cruikshank discusses these pregnancies, which account for 6 to 8 percent of all pregnancies.
Q. What makes a pregnancy high risk?
A wide range of factors contribute to high-risk pregnancies, but they generally fall into the following categories:
- The mother has a chronic condition that increases her risk in pregnancy. The classic example is diabetes. Other examples are high blood pressure, lupus, heart problems or any major illness.
- Poor outcome in previous pregnancies, especially a pre-term birth. This category also includes women who experienced preeclampsia, a type of high blood pressure that develops during pregnancy.
- There is something wrong with the baby. The baby may have a birth defect or a metabolic condition that requires therapy in the uterus or immediately after birth.
- Multiple gestations, which are becoming more and more common.
- A family history of hereditary diseases and birth defects or advanced maternal age (35 or older), which increases the risk of chromosomal abnormalities.
Q. What can be done to treat or manage high-risk pregnancies?
Early diagnostic testing is a big part of what we do to identify high-risk pregnancies and to determine contributing factors and treatment options. Testing includes assessments, screenings, ultrasound, amniocentesis, chorionic villus sampling, umbilical cord sampling, and more. Determining if something is wrong with the baby is the main reason we feel all pregnant women, no matter what their age, should have an ultrasound exam at about the 18th week of gestation. With this test, we can establish if there are any structural abnormalities in the fetus. We can also verify the gestational age of the baby. That's one of the biggest problems in obstetrics. We can get near the end of a pregnancy and not really know when the baby is due. The ultrasound also finds multiple gestations earlier, when they occur in women who got pregnant without medical intervention.
We can test for chromosomal abnormalities and genetic disorders with amniocentesis, a test where a sample of the amniotic fluid that surrounds the fetus is removed and analyzed. Amniocentesis is usually performed around the 16th week. Froedtert & Medical College of Wisconsin also offers chorionic villus sampling and nuchal skinfold measurements, which can detect abnormalities as early as 10 weeks of gestation. Most of the time the results are normal and we can offer reassurance to the mother.
With any of the tests, if it's suspected there is something wrong with the baby, the parents are referred to our Fetal Concerns Program. This program is dedicated to the early diagnosis and treatment of complications in the baby. For instance, we are seeing more babies with congenital heart disease. In a case like that, Fetal Concerns offers complete coordination of care – counseling for the parents and the involvement of a neonatologist, cardiac surgeon, pediatric cardiologist – whatever may be needed, all before the baby is born.
If a mother has experienced a previous pre-term birth, there are tests we can perform to determine if she is again at risk. With bed rest and medication, we can prolong her pregnancy. Bed rest is often prescribed for multiple births to prolong gestation. Preterm birth is the biggest problem with multiple births and contributes to a higher mortality rate than singles.
If a woman has a chronic condition, we optimally want it to be managed before she conceives. For instance, we want a diabetic to have her blood sugar under control, because high blood sugar in the first trimester of pregnancy greatly increases the risk of birth defects. Of course, any condition we diagnose is monitored throughout the pregnancy. We also know now that all women should take a folic acid supplement before they conceive, because it reduces the risk of neural tube defects, such as spina bifida.
Q. Do these approaches help improve outcome?
Absolutely. And now, more often than not, there is something we can do. A good example is a woman who is at risk of delivering at 28 weeks. If we can prolong that pregnancy for just two weeks, we get a much better outcome. Being prepared and providing early, coordinated care is very important. Since Froedtert & Medical College of Wisconsin works in cooperation with Children’s Hospital of Wisconsin, we’re the only hospital in southeastern Wisconsin – really in the whole state – that can offer this high level of coordinated care for the mother and baby. Our birth center is in the Children’s Hospital building, so if something is wrong with the baby, it can be attended to immediately.
Q. What does the future hold for treating high-risk pregnancies?
With all the wonders of the U.S. Human Genome Project and developments in molecular genetics, the future is in gene therapy. We're now identifying abnormal genes for more and more diseases. Someday, we'll be able to identify an abnormal gene in the fetus for something like cystic fibrosis, take it out and replace it with a normal gene. That's coming and it's going to happen in my lifetime.