January 28, 2025 • 21 mins
Recent advancements in maternal and fetal healthcare are leading the way to improved outcomes. Join us as Dr. Katherine Bianco, a Clinical Professor of Obstetrics and Gynecology at Stanford University, sheds light on the evolving landscape of obstetric care. Explore the challenges and innovations within maternal health, particularly in lower- and middle-income countries, and learn how personalized risk management strategies can effectively address disparities faced by underrepresented populations. Discover the vital role that advancements in prenatal screening and genetic testing play in ensuring healthier outcomes for mothers and their babies.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
(bright music)
- Welcome to Stanford Medcast,
the podcast from StanfordCME that brings you
the latest insightsfrom the world's leading
physicians and scientists.
If you're joining us for the first time,
be sure to subscribe on Apple Podcasts,
Amazon Music, Spotify,
(00:22):
or YouTube to stay updatedwith our newest episodes.
I am your host, Dr. Ruth Adewuya.
Joining me today is Dr. Katherine Bianco.
Dr. Katherine Biancois a clinical professor
of obstetrics and gynecology
at Stanford University School of Medicine
and the director of theMaternal Heart Program
(00:42):
at Stanford Children's Healthand Stanford Healthcare.
An expert in managinghigh-risk pregnancies,
she is deeply invested in research
related to genomic abnormalities
and their impact on pregnancy outcomes.
Her clinical focus spansprenatal screening,
maternal heart conditions,
and labor and delivery management.
(01:02):
With medical training
from the Central University of Venezuela
and a residency at YaleSchool of Medicine,
she brings a wealth of knowledge
and a unique perspective tothe field of maternal medicine.
Can you start by tellingus what motivated you
to pursue a career inobstetrics and gynecology?
What inspired your focus
(01:22):
on high-risk pregnanciesand birth defects?
- I think it's a complex answer.
My mom is an OB/GYN.
I saw my first delivery whenI was 10 in the Red Cross
back in Caracas, Venezuela.
She used to volunteer for the Red Cross.
It wasn't the most amazing,
because in lower andmiddle income countries,
you don't have anesthesia
during the process oflabor and deliveries.
(01:44):
It was a lot of yelling, soI was a little traumatized,
but I think that really stick to me
how to make this experiencebetter for women in the future.
I love biology and chemistry
and I was intriguedabout early development.
So when I went to medicalschool in Caracas, Venezuela,
I felt the joy to see a baby being born.
I think it's a privilegethat you have to be invited
(02:06):
into a delivery room and be a participant
in such a magical moment fora woman and for a family.
I made my residency in New Haven
and then I decided to deepen my knowledge
and do a medical genetics fellowship
and a maternal fetal medicine fellowship
because I really wanted tounderstand from the beginning,
and all the way to themolecular level root cause
(02:26):
or abnormalities (indistinct)the fetal compartment
and the placenta compartment
and how that modified maternalhealth and reproduction.
- This full circle vision's so powerful
and so inspiring whereyou started your journey
and how this traumatic birth experience
that you witnessed whenyou were 10 years old
(02:47):
and expending all of your time
and effort to ensure
that future traumatic events don't happen.
To anchor the conversationfor our listeners,
we were talking aboutobstetric emergencies.
What are some of common types
and what unique challengesdo they present?
- As we talked about obstetric emergency,
we need to put in a contextof where do you practice.
(03:08):
If we're talking aboutUS and European society,
we see the leading sources of emergency
will be maternal collapsefor cardiovascular event
or a clot in the lungs,
pulmonary emboli or such.
However, to postpartum hemorrhageis less likely for the US
(03:28):
to ending in a mortalitythat happen in middle
and lower resources income country.
Just to give you a littlesense how quickly can happen
and how emergent it is,
you have a birth and asyou are delivering a baby,
you have these big uterinearteries that are connecting
to this (indistinct)where in any given moment
(03:50):
it's gonna be giving you500 cc bleeding a minute,
so 10 minutes you lost five liters.
That's your limit.
That's how the emergency goes
and how quickly you have torespond and be on the go.
Bleeding is the biggest for us.
Other things could becardiovascular collapse,
but also there are patients that labor
(04:11):
for a long time that rupture membranes
and they can become infected.
They can develop somethingthat we call chorioamnionitis.
High fever, (indistinct)baby's not looking good,
we've gotta deliver.
Then that can lead to sepsis
and if you're not quickenough in recognizing,
then mom becomes verysick, RDS, hypertensive,
and then we lose the mother.
That's another emergency.
(04:33):
Sometimes the placenta can separate.
It's called an abruption.
And when that happens canlead to a lot of bleeding
to the point that themother can go into DIC,
and if we don't correctthe (indistinct) factor
and we don't deliver on time,
we can also have a maternal collapse.
Those are things that canhappen rather quickly.
Other emergencies could be, like,
(04:53):
for some reason we are delivering the baby
and we have a shoulder dystocia.
This is rather common these days
'cause we have such an increase of BMRI.
We definitely have anincrease gestational diabetes.
When these pregnancy don't have
a good (indistinct) controls,
babies tend to be large,
but the way that they gettheir fat distribution
(05:15):
is more in the shoulders.
So the abdominal diameter is bigger
or larger than the head circumference.
So the head comes out butthe shoulders get stuck
and you got about three minutes to try
to get the baby delivered vaginal.
We talk about very quickly.
- Yeah.- Newborns in an emergency
(05:37):
and run a protocol to tryto get the baby out intact.
- Reflecting on what you just shared,
it's striking how the context of care,
whether in a researchrich setting like the US
or in lower income countries,
drastically influences both the management
and outcomes of obstetric emergencies.
(05:58):
Your point about postpartum hemorrhage
being a critical concern globally
yet leading to fewer fatalities in places
with access to rapid interventions
and protocols highlights justhow pivotal resources are.
Diving deeper into this topic,
out of the emergencies you mentioned,
how are the priorities andresponse strategies different
(06:18):
when looking at lower andmiddle income countries?
- Sometimes is relatedwith the access to care
and bringing out cares
and if the patients don't have the ability
to be seen in the outpatientclinic because they're...
I will use the example of my country.
The entire time I was there,
the obstetric clinic was on a strike,
so those patients neversaw any prenatal care.
(06:39):
They just show up to have a baby.
You never know that youhave a high blood pressure
and then you seize.
So eclamptic seizure is quite devastating
and it's quite frequent.
You'll see those more in lower income
because ability to not only recognize
but to have antibiotics and proper care.
- It's striking to see how limited access
to prenatal care can resultin severe complications,
(07:00):
especially in lower income settings.
Your example about the impact
of strikes on prenatalcare is a reminder of
how critical consistent medical support is
for preventing emergencies.
On that note, much of yourresearch explores factors
affecting women's reproductive health.
Can you highlight someadvancements in this field,
(07:21):
particularly in prenatalscreening and diagnosis,
that are making significantdifference in clinical practice?
- I will tell you geneticshas ambushed our field
to the point...
And like anything in medicine,
I think, will be coming frommore invasive to less invasive.
Back in the day if you were35 and above years old,
(07:42):
you automatically werereferred to somebody like me,
high-risk obstetric,
and you will be having anamniocentesis after 16 weeks.
We had ultrasounds
and if you really wanted itto have prenatal diagnosis,
that was the way to go.
So nowadays with genetics andthe whole genome sequencing
and all the understanding that we have,
within two or three weeksyou go to your doctor,
(08:04):
you are able to see(indistinct) pregnancy,
most likely a heartbeat.
You're taking a blood test.
So the need to have an invasive procedure,
it went away.
We continue offering this
because you can't saywithout 100% and say,
okay, this baby doesn'thave a genetic condition.
There's now the ability witha blood sample to test mom
(08:26):
and the partner for autosomalrecessive conditions.
More and more the non-invasiveprenatal testing is able
to give us those information.
Before it was always yougotta have amniocentesis.
- Is there any use casescenario where someone has done
some of these genetic testing
and it would stillnecessitate an amniocentesis?
(08:47):
- We definitely still emphasizing
that if you get a test back,
a non-invasive prenataltesting result positive,
you for sure should havea prenatal diagnosis
'cause you wanna make sure that is real.
We have learned thatsometimes your non-invasive
prenatal testing comes back positive,
what is happening is there is a phenomenon
(09:08):
that the placenta cancarry the genetic component
that you are testing for,
but the baby has been rescued from that.
So that's (indistinct).
But there is another levelwhere the baby doesn't have it,
the placenta doesn't have it,
so where is this DNA signal coming from?
Then we have discovered thatyou went through the process
(09:29):
of taking a test.
Does my baby have Down syndrome?
Guess what, your babydoesn't have Down syndrome,
but you do have cancer.
That material, that extra genetic material
that is making the noise in your testing
is coming from someplace.
You have a tumor thatmight have a test location,
that might have an extrasignal in chromosome 21,
and you're picking that.
(09:49):
- These advancements innon-invasive testing are incredible
'cause it seems to offer quicker insights,
but they also provide thatmuch needed peace of mind
for expecting parents.
Of course, as you mentioned,crucial to follow up
with confirmatory tests toensure everything checks out.
Switching gears a bit,
you mentioned the role ofcardiology in pregnancy earlier.
(10:10):
Could you dive a bit deeper into
how maternal heart conditionscan affect pregnancy outcomes
and what's your typical approach
to managing these complex casesto ensure the best outcomes
for both mom and baby?
- We have this multidisciplinary approach.
We have a very systematic way
to understand these pregnanciesbecause they're very complex
(10:32):
and you have high (indistinct) mortality.
We have prospective studiesfor the last 10 years
that has helped us tounderstand with more granularity
what that means.
Definitely it all goes downto personalizing your patient
because not every single cardiac condition
(10:53):
is same for everybody.
We're trying to useinternational inertial scores
to guide us how severe isthis material condition
and how severe is gonna be the chance
of the patient having anadverse prenatal outcome.
Let's use a example,
a patient that have Mafan's.
That is a genetic condition
and you tend to have an aorta dilatation,
(11:15):
but we know that you're gonnahave an aorta dilatation,
with medication that canbe controlled and easy.
You're not in a critical dilatation level.
You can carry no problems.
That put you in a different risk category.
But if we have a patient that was born
with a congenital heart effect,
let's just say left ventricle hypoplasia,
you pretty much have asingle heart chamber pumping,
and you reach (indistinct)and you're having a baby,
(11:37):
most likely you already have something
that we call Fontan circulation
that is very complex theway that is compensated
because you only have onechamber of your heart.
So a lot of those patients canrun very low in oxygenation
and that can carry all kindof complications for the baby
and for mom.
So depends on your cardiac condition
(11:58):
leads to the risk that you're gonna face.
I have more than one pregnant patient
that we have recommendinterruption pregnancy.
The mortality is so highthat you're not make it.
Risk mitigation is a big thing.
So we emphasize and we workvery hard with the cardiologist
to send the patientsbefore they get pregnant
and they can't emphasizeenough to have a preconception,
(12:19):
meaning have a conversationbefore you get pregnant
because if there are thingsthat actually will modify,
it would definitely willmodify their outcome.
It plays a very heavy rolein our field to decrease,
to mitigate risk and todecrease adverse outcome.
- That sounds like a reallycomprehensive approach
and it's clear how essentialpersonalized risk assessment is
(12:43):
in managing these complex pregnancies
and highlighting preconception planning
and working closely with cardiologists
to assess risk factors before pregnancy
is such a critical pieceof improving outcomes.
This brings me to your research on genetic
and genomic abnormalitiesin the human trophoblast,
which seems to tie into theidea of early risk detection.
(13:07):
How are these abnormalities linked
to adverse pregnancy outcomes
and could you share someof the latest advancements
that you've seen in this field?
- Let's use the example
that we were talking about, preeclampsia,
that is, hypertension in pregnancy.
It's something I've beenstudying for the longest time
because there's many hypotheses.
You can approach this asa vascular abnormality.
(13:29):
You can approach this asa autoimmune abnormality.
People talk about inflammation.
What we have learned,there is an interactive
between the maternal compartmentand fetal compartment.
When these trophoblast cellscome to invade the arteries,
there is a stop.
The theory is called a shallow invasion.
So they're not able to invadeas they proper should be.
(13:50):
The placenta keeps growing,
the trophoblast (indistinct)
the baby keeps growing
and then mom develop thesehigh blood pressures.
You can even have an eclamptic seizure,
and it very, you know, highmortality, high morbidity.
When I was in the labstudying my other focus,
I was looking at genetic abnormalities,
understanding trisomy 21.
(14:11):
I was working with trophoblast blast cells
and I was looking at theinvasion of the cells,
but with the question,
can genetics do somethingto trophoblast cell?
My trophoblasts were trisomal,
and we know that in trisomy pregnancy,
like, for trisomy 13 or 18
and some of the trisomy 21s,
they develop preeclampsia.
Having this abnormalchromosome expression,
(14:34):
or gene expression linked toalso hypertension disorders.
It's a fascinating (indistinct)if you think about it
because it really keepsthe pregnancy going
and keeps the proper fetaldevelopment and growth
and it's all based in thisworld that is the placenta.
- This is such afascinating area of study.
The way you explain ithighlights just how critical
(14:56):
trophoblast cells areto a healthy pregnancy.
It's also fascinating tohear about the interaction
between the maternaland fetal compartments
and how if disrupted can lead
to complications like preeclampsia.
The idea that chromosomalabnormality can influence
these processes addsanother layer of complexity.
(15:17):
- And I will tell you I love the placenta.
You see how the incidence of C-sections
and repeat C-section going up
and maternal mortality also goes up.
That prompted to a lot of people
to start looking and looking.
One of the things is a condition
that now is well established called PAS,
that is placenta accreta spectrum,
which it means that thisplacenta, these trophoblasts,
(15:39):
that they behave like cancer.
Maybe the uterine (indistinct)
you had a previousC-section, leaving a scar,
and they get attached to this scar,
and they sometimes stay inthe endometrium and that's it,
but sometimes theypenetrate to the myometrium
and sometimes they keepgrowing into the bladder,
the bowel, everywhere.
Every time that you'redoing the C-section,
you get the baby out and youcan't get the placenta out,
(16:02):
and if you pull the placenta,
then you're (indistinct) toall this area with placenta.
Nowadays, this is becoming more
and more an entity thatis being recognized.
So I would say it isdefinitely (indistinct)
to say it is not diagnosed.
So one of the things that we'redoing now is are they, like,
the NIPT for trisomy 21,
are there non-invasive biomarkers
(16:24):
that we can get in the mother blood sample
that can help us to understand.
So one thing that we'redoing cool right now,
we are collecting samplesto understand better
what pathways aredisrupted when this happens
in order to see can wediagnose this at 20 weeks?
- That sounds like reallygroundbreaking work.
(16:45):
The ability to detect PAS earlier
using noninvasivebiomarkers would definitely
be life-changing for so many women,
especially those who may not have access
to advanced care centers.
As you said, knowing inadvance could really change
how clinicians approachthese cases, ensuring safety
and better outcomes forboth mothers and for babies.
(17:06):
I'd love to explore your work
in addressing disparities inmaternal and fetal health,
especially amongunderrepresented populations.
Could you share some ofthe unique challenges
that you've encountered
and what changes you believethe healthcare system could
implement to bettersupport these communities
and improve outcomes?
- I love it that we got to this topic
(17:28):
because I would say I'm the director
of EEI in the department
and one of the liaison for the department
and the dean office
in the Office of FacultyDiversity and Development.
I'm going in my 10 year at Stanford
and I did a lot of this work at UCSF too.
What is fascinating to me ishow much progress (indistinct)
(17:48):
and particularly at Stanford,
and when you think about health disparity,
you can't just have one (indistinct)
it's a whole thing.
But let's just try tofocus on just women health,
in particular what we've been
sounding the alarm in the last few years,
and California has beenthe pioneer on this
through the same (indistinct).
We wanna demystify thatrace is a biological factor.
(18:13):
We need to call it.
There is racism.
The racism is causingour black moms are dying
in accelerated rate ascompared with (indistinct).
First thing that youhave to do is educate,
bringing awareness, sowe hold round tables,
we hold (indistinct) we show data,
we start looking into ourpatients and our outcome.
(18:34):
For instance, the areathat we provide here
for the most part is heavilyrepresented by more Latinx,
where we also see complications as well.
We have learned that youhave to bring the language
of preference to the care
to narrow the gap inthis health disparity.
So we have implementedall kind of approaches
to really be able toprovide translation service
(18:56):
to these patients inperson, by video, by phone,
but most important,
understanding the valueof culture (indistinct).
This will be not only forour non-white Hispanics,
but also for our black mothers.
Understanding the patientbackground, cultural background.
The other thing that we are doing
is doing implicit bias training.
(19:17):
So we have training available
and we are actually followingone of the California
initiative where all the prenatalunits, prenatal hospital,
wherever you provideprenatal care in California,
you need to do an implicitbias training every two years.
I think bringing awareness is fundamental.
- As we come to the endof our conversation,
(19:39):
I'd love to hear yourthoughts on how you approach
shared decision making with your patients,
especially given thecomplexity of the diagnoses
and the high-riskconditions that they face.
What strategies do you use to ensure
that your patients are fully involved
and empowered in their care decisions?
- Make the pPatient beparticipatory of the discussions
(20:00):
that you provide theinformation, your assessment,
and then ask the patient,
can you repeat to me what Ijust said in your own words?
What do you think of what I just say?
If I do a lot of that,I do a lot of modeling.
You'll be surprised.
The patients are, for the most part,
they have a pretty good information
(20:20):
and ability to repeat to you.
What is your understanding?
What are your expectation?
How do you think this is working?
I feel this era in medicine,
when you used to tell thepatient this, this, and this,
and it's because I'm the doctor
and you're the patient, that's over.
Of course, if it were,like, in an emergency,
there's not a lot of discussion here.
We just have to explainyou what we have to do.
(20:41):
But if you, let's say Ihave a lot of patients
that have to spend days, weeks,
months in the antepartum service.
We have a lot of opportunityto have conversations there.
I like to approach it in a way, like,
there's short-term goals,intermediate goals,
and long-term goals.
- What really stoodout to me in everything
that you've shared is yourdedication to staying connected
(21:03):
to the latest research and advancements.
It's really clear thatyour continuous learning
and integration of newinsights into your practice
is making a real impact notjust in advancing the field,
but also in bringing the most up-to-date
care to your patients.
- I would tell you medicineis no longer something
that you do alone.
You need your peers.
(21:23):
You need to be nice in the sandbox.
I would never practicehigh-risk obstetrics on my own.
You need a village.
These patients need a lot of care.
(bright music)
- This episode was broughtto you by Stanford CME.
To claim CME forlistening to this episode,
click on the claim CME link below
or visit medcast.stanford.edu.
(21:45):
Check back for new episodes
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(bright music)
(bright music)
- Welcome to Stanford Medcast,
the podcast from StanfordCME that brings you
the latest insightsfrom the world's leading
physicians and scientists.
If you're joining us for the first time,
be sure to subscribe on Apple Podcasts,
Amazon Music, Spotify,
(00:22):
or YouTube to stay updatedwith our newest episodes.
I am your host, Dr. Ruth Adewuya.
Joining me today is Dr. Katherine Bianco.
Dr. Katherine Biancois a clinical professor
of obstetrics and gynecology
at Stanford University School of Medicine
and the director of theMaternal Heart Program
(00:42):
at Stanford Children's Healthand Stanford Healthcare.
An expert in managinghigh-risk pregnancies,
she is deeply invested in research
related to genomic abnormalities
and their impact on pregnancy outcomes.
Her clinical focus spansprenatal screening,
maternal heart conditions,
and labor and delivery management.
(01:02):
With medical training
from the Central University of Venezuela
and a residency at YaleSchool of Medicine,
she brings a wealth of knowledge
and a unique perspective tothe field of maternal medicine.
Can you start by tellingus what motivated you
to pursue a career inobstetrics and gynecology?
What inspired your focus
(01:22):
on high-risk pregnanciesand birth defects?
- I think it's a complex answer.
My mom is an OB/GYN.
I saw my first delivery whenI was 10 in the Red Cross
back in Caracas, Venezuela.
She used to volunteer for the Red Cross.
It wasn't the most amazing,
because in lower andmiddle income countries,
you don't have anesthesia
during the process oflabor and deliveries.
(01:44):
It was a lot of yelling, soI was a little traumatized,
but I think that really stick to me
how to make this experiencebetter for women in the future.
I love biology and chemistry
and I was intriguedabout early development.
So when I went to medicalschool in Caracas, Venezuela,
I felt the joy to see a baby being born.
I think it's a privilegethat you have to be invited
(02:06):
into a delivery room and be a participant
in such a magical moment fora woman and for a family.
I made my residency in New Haven
and then I decided to deepen my knowledge
and do a medical genetics fellowship
and a maternal fetal medicine fellowship
because I really wanted tounderstand from the beginning,
and all the way to themolecular level root cause
(02:26):
or abnormalities (indistinct)the fetal compartment
and the placenta compartment
and how that modified maternalhealth and reproduction.
- This full circle vision's so powerful
and so inspiring whereyou started your journey
and how this traumatic birth experience
that you witnessed whenyou were 10 years old
(02:47):
and expending all of your time
and effort to ensure
that future traumatic events don't happen.
To anchor the conversationfor our listeners,
we were talking aboutobstetric emergencies.
What are some of common types
and what unique challengesdo they present?
- As we talked about obstetric emergency,
we need to put in a contextof where do you practice.
(03:08):
If we're talking aboutUS and European society,
we see the leading sources of emergency
will be maternal collapsefor cardiovascular event
or a clot in the lungs,
pulmonary emboli or such.
However, to postpartum hemorrhageis less likely for the US
(03:28):
to ending in a mortalitythat happen in middle
and lower resources income country.
Just to give you a littlesense how quickly can happen
and how emergent it is,
you have a birth and asyou are delivering a baby,
you have these big uterinearteries that are connecting
to this (indistinct)where in any given moment
(03:50):
it's gonna be giving you500 cc bleeding a minute,
so 10 minutes you lost five liters.
That's your limit.
That's how the emergency goes
and how quickly you have torespond and be on the go.
Bleeding is the biggest for us.
Other things could becardiovascular collapse,
but also there are patients that labor
(04:11):
for a long time that rupture membranes
and they can become infected.
They can develop somethingthat we call chorioamnionitis.
High fever, (indistinct)baby's not looking good,
we've gotta deliver.
Then that can lead to sepsis
and if you're not quickenough in recognizing,
then mom becomes verysick, RDS, hypertensive,
and then we lose the mother.
That's another emergency.
(04:33):
Sometimes the placenta can separate.
It's called an abruption.
And when that happens canlead to a lot of bleeding
to the point that themother can go into DIC,
and if we don't correctthe (indistinct) factor
and we don't deliver on time,
we can also have a maternal collapse.
Those are things that canhappen rather quickly.
Other emergencies could be, like,
(04:53):
for some reason we are delivering the baby
and we have a shoulder dystocia.
This is rather common these days
'cause we have such an increase of BMRI.
We definitely have anincrease gestational diabetes.
When these pregnancy don't have
a good (indistinct) controls,
babies tend to be large,
but the way that they gettheir fat distribution
(05:15):
is more in the shoulders.
So the abdominal diameter is bigger
or larger than the head circumference.
So the head comes out butthe shoulders get stuck
and you got about three minutes to try
to get the baby delivered vaginal.
We talk about very quickly.
- Yeah.- Newborns in an emergency
(05:37):
and run a protocol to tryto get the baby out intact.
- Reflecting on what you just shared,
it's striking how the context of care,
whether in a researchrich setting like the US
or in lower income countries,
drastically influences both the management
and outcomes of obstetric emergencies.
(05:58):
Your point about postpartum hemorrhage
being a critical concern globally
yet leading to fewer fatalities in places
with access to rapid interventions
and protocols highlights justhow pivotal resources are.
Diving deeper into this topic,
out of the emergencies you mentioned,
how are the priorities andresponse strategies different
(06:18):
when looking at lower andmiddle income countries?
- Sometimes is relatedwith the access to care
and bringing out cares
and if the patients don't have the ability
to be seen in the outpatientclinic because they're...
I will use the example of my country.
The entire time I was there,
the obstetric clinic was on a strike,
so those patients neversaw any prenatal care.
(06:39):
They just show up to have a baby.
You never know that youhave a high blood pressure
and then you seize.
So eclamptic seizure is quite devastating
and it's quite frequent.
You'll see those more in lower income
because ability to not only recognize
but to have antibiotics and proper care.
- It's striking to see how limited access
to prenatal care can resultin severe complications,
(07:00):
especially in lower income settings.
Your example about the impact
of strikes on prenatalcare is a reminder of
how critical consistent medical support is
for preventing emergencies.
On that note, much of yourresearch explores factors
affecting women's reproductive health.
Can you highlight someadvancements in this field,
(07:21):
particularly in prenatalscreening and diagnosis,
that are making significantdifference in clinical practice?
- I will tell you geneticshas ambushed our field
to the point...
And like anything in medicine,
I think, will be coming frommore invasive to less invasive.
Back in the day if you were35 and above years old,
(07:42):
you automatically werereferred to somebody like me,
high-risk obstetric,
and you will be having anamniocentesis after 16 weeks.
We had ultrasounds
and if you really wanted itto have prenatal diagnosis,
that was the way to go.
So nowadays with genetics andthe whole genome sequencing
and all the understanding that we have,
within two or three weeksyou go to your doctor,
(08:04):
you are able to see(indistinct) pregnancy,
most likely a heartbeat.
You're taking a blood test.
So the need to have an invasive procedure,
it went away.
We continue offering this
because you can't saywithout 100% and say,
okay, this baby doesn'thave a genetic condition.
There's now the ability witha blood sample to test mom
(08:26):
and the partner for autosomalrecessive conditions.
More and more the non-invasiveprenatal testing is able
to give us those information.
Before it was always yougotta have amniocentesis.
- Is there any use casescenario where someone has done
some of these genetic testing
and it would stillnecessitate an amniocentesis?
(08:47):
- We definitely still emphasizing
that if you get a test back,
a non-invasive prenataltesting result positive,
you for sure should havea prenatal diagnosis
'cause you wanna make sure that is real.
We have learned thatsometimes your non-invasive
prenatal testing comes back positive,
what is happening is there is a phenomenon
(09:08):
that the placenta cancarry the genetic component
that you are testing for,
but the baby has been rescued from that.
So that's (indistinct).
But there is another levelwhere the baby doesn't have it,
the placenta doesn't have it,
so where is this DNA signal coming from?
Then we have discovered thatyou went through the process
(09:29):
of taking a test.
Does my baby have Down syndrome?
Guess what, your babydoesn't have Down syndrome,
but you do have cancer.
That material, that extra genetic material
that is making the noise in your testing
is coming from someplace.
You have a tumor thatmight have a test location,
that might have an extrasignal in chromosome 21,
and you're picking that.
(09:49):
- These advancements innon-invasive testing are incredible
'cause it seems to offer quicker insights,
but they also provide thatmuch needed peace of mind
for expecting parents.
Of course, as you mentioned,crucial to follow up
with confirmatory tests toensure everything checks out.
Switching gears a bit,
you mentioned the role ofcardiology in pregnancy earlier.
(10:10):
Could you dive a bit deeper into
how maternal heart conditionscan affect pregnancy outcomes
and what's your typical approach
to managing these complex casesto ensure the best outcomes
for both mom and baby?
- We have this multidisciplinary approach.
We have a very systematic way
to understand these pregnanciesbecause they're very complex
(10:32):
and you have high (indistinct) mortality.
We have prospective studiesfor the last 10 years
that has helped us tounderstand with more granularity
what that means.
Definitely it all goes downto personalizing your patient
because not every single cardiac condition
(10:53):
is same for everybody.
We're trying to useinternational inertial scores
to guide us how severe isthis material condition
and how severe is gonna be the chance
of the patient having anadverse prenatal outcome.
Let's use a example,
a patient that have Mafan's.
That is a genetic condition
and you tend to have an aorta dilatation,
(11:15):
but we know that you're gonnahave an aorta dilatation,
with medication that canbe controlled and easy.
You're not in a critical dilatation level.
You can carry no problems.
That put you in a different risk category.
But if we have a patient that was born
with a congenital heart effect,
let's just say left ventricle hypoplasia,
you pretty much have asingle heart chamber pumping,
and you reach (indistinct)and you're having a baby,
(11:37):
most likely you already have something
that we call Fontan circulation
that is very complex theway that is compensated
because you only have onechamber of your heart.
So a lot of those patients canrun very low in oxygenation
and that can carry all kindof complications for the baby
and for mom.
So depends on your cardiac condition
(11:58):
leads to the risk that you're gonna face.
I have more than one pregnant patient
that we have recommendinterruption pregnancy.
The mortality is so highthat you're not make it.
Risk mitigation is a big thing.
So we emphasize and we workvery hard with the cardiologist
to send the patientsbefore they get pregnant
and they can't emphasizeenough to have a preconception,
(12:19):
meaning have a conversationbefore you get pregnant
because if there are thingsthat actually will modify,
it would definitely willmodify their outcome.
It plays a very heavy rolein our field to decrease,
to mitigate risk and todecrease adverse outcome.
- That sounds like a reallycomprehensive approach
and it's clear how essentialpersonalized risk assessment is
(12:43):
in managing these complex pregnancies
and highlighting preconception planning
and working closely with cardiologists
to assess risk factors before pregnancy
is such a critical pieceof improving outcomes.
This brings me to your research on genetic
and genomic abnormalitiesin the human trophoblast,
which seems to tie into theidea of early risk detection.
(13:07):
How are these abnormalities linked
to adverse pregnancy outcomes
and could you share someof the latest advancements
that you've seen in this field?
- Let's use the example
that we were talking about, preeclampsia,
that is, hypertension in pregnancy.
It's something I've beenstudying for the longest time
because there's many hypotheses.
You can approach this asa vascular abnormality.
(13:29):
You can approach this asa autoimmune abnormality.
People talk about inflammation.
What we have learned,there is an interactive
between the maternal compartmentand fetal compartment.
When these trophoblast cellscome to invade the arteries,
there is a stop.
The theory is called a shallow invasion.
So they're not able to invadeas they proper should be.
(13:50):
The placenta keeps growing,
the trophoblast (indistinct)
the baby keeps growing
and then mom develop thesehigh blood pressures.
You can even have an eclamptic seizure,
and it very, you know, highmortality, high morbidity.
When I was in the labstudying my other focus,
I was looking at genetic abnormalities,
understanding trisomy 21.
(14:11):
I was working with trophoblast blast cells
and I was looking at theinvasion of the cells,
but with the question,
can genetics do somethingto trophoblast cell?
My trophoblasts were trisomal,
and we know that in trisomy pregnancy,
like, for trisomy 13 or 18
and some of the trisomy 21s,
they develop preeclampsia.
Having this abnormalchromosome expression,
(14:34):
or gene expression linked toalso hypertension disorders.
It's a fascinating (indistinct)if you think about it
because it really keepsthe pregnancy going
and keeps the proper fetaldevelopment and growth
and it's all based in thisworld that is the placenta.
- This is such afascinating area of study.
The way you explain ithighlights just how critical
(14:56):
trophoblast cells areto a healthy pregnancy.
It's also fascinating tohear about the interaction
between the maternaland fetal compartments
and how if disrupted can lead
to complications like preeclampsia.
The idea that chromosomalabnormality can influence
these processes addsanother layer of complexity.
(15:17):
- And I will tell you I love the placenta.
You see how the incidence of C-sections
and repeat C-section going up
and maternal mortality also goes up.
That prompted to a lot of people
to start looking and looking.
One of the things is a condition
that now is well established called PAS,
that is placenta accreta spectrum,
which it means that thisplacenta, these trophoblasts,
(15:39):
that they behave like cancer.
Maybe the uterine (indistinct)
you had a previousC-section, leaving a scar,
and they get attached to this scar,
and they sometimes stay inthe endometrium and that's it,
but sometimes theypenetrate to the myometrium
and sometimes they keepgrowing into the bladder,
the bowel, everywhere.
Every time that you'redoing the C-section,
you get the baby out and youcan't get the placenta out,
(16:02):
and if you pull the placenta,
then you're (indistinct) toall this area with placenta.
Nowadays, this is becoming more
and more an entity thatis being recognized.
So I would say it isdefinitely (indistinct)
to say it is not diagnosed.
So one of the things that we'redoing now is are they, like,
the NIPT for trisomy 21,
are there non-invasive biomarkers
(16:24):
that we can get in the mother blood sample
that can help us to understand.
So one thing that we'redoing cool right now,
we are collecting samplesto understand better
what pathways aredisrupted when this happens
in order to see can wediagnose this at 20 weeks?
- That sounds like reallygroundbreaking work.
(16:45):
The ability to detect PAS earlier
using noninvasivebiomarkers would definitely
be life-changing for so many women,
especially those who may not have access
to advanced care centers.
As you said, knowing inadvance could really change
how clinicians approachthese cases, ensuring safety
and better outcomes forboth mothers and for babies.
(17:06):
I'd love to explore your work
in addressing disparities inmaternal and fetal health,
especially amongunderrepresented populations.
Could you share some ofthe unique challenges
that you've encountered
and what changes you believethe healthcare system could
implement to bettersupport these communities
and improve outcomes?
- I love it that we got to this topic
(17:28):
because I would say I'm the director
of EEI in the department
and one of the liaison for the department
and the dean office
in the Office of FacultyDiversity and Development.
I'm going in my 10 year at Stanford
and I did a lot of this work at UCSF too.
What is fascinating to me ishow much progress (indistinct)
(17:48):
and particularly at Stanford,
and when you think about health disparity,
you can't just have one (indistinct)
it's a whole thing.
But let's just try tofocus on just women health,
in particular what we've been
sounding the alarm in the last few years,
and California has beenthe pioneer on this
through the same (indistinct).
We wanna demystify thatrace is a biological factor.
(18:13):
We need to call it.
There is racism.
The racism is causingour black moms are dying
in accelerated rate ascompared with (indistinct).
First thing that youhave to do is educate,
bringing awareness, sowe hold round tables,
we hold (indistinct) we show data,
we start looking into ourpatients and our outcome.
(18:34):
For instance, the areathat we provide here
for the most part is heavilyrepresented by more Latinx,
where we also see complications as well.
We have learned that youhave to bring the language
of preference to the care
to narrow the gap inthis health disparity.
So we have implementedall kind of approaches
to really be able toprovide translation service
(18:56):
to these patients inperson, by video, by phone,
but most important,
understanding the valueof culture (indistinct).
This will be not only forour non-white Hispanics,
but also for our black mothers.
Understanding the patientbackground, cultural background.
The other thing that we are doing
is doing implicit bias training.
(19:17):
So we have training available
and we are actually followingone of the California
initiative where all the prenatalunits, prenatal hospital,
wherever you provideprenatal care in California,
you need to do an implicitbias training every two years.
I think bringing awareness is fundamental.
- As we come to the endof our conversation,
(19:39):
I'd love to hear yourthoughts on how you approach
shared decision making with your patients,
especially given thecomplexity of the diagnoses
and the high-riskconditions that they face.
What strategies do you use to ensure
that your patients are fully involved
and empowered in their care decisions?
- Make the pPatient beparticipatory of the discussions
(20:00):
that you provide theinformation, your assessment,
and then ask the patient,
can you repeat to me what Ijust said in your own words?
What do you think of what I just say?
If I do a lot of that,I do a lot of modeling.
You'll be surprised.
The patients are, for the most part,
they have a pretty good information
(20:20):
and ability to repeat to you.
What is your understanding?
What are your expectation?
How do you think this is working?
I feel this era in medicine,
when you used to tell thepatient this, this, and this,
and it's because I'm the doctor
and you're the patient, that's over.
Of course, if it were,like, in an emergency,
there's not a lot of discussion here.
We just have to explainyou what we have to do.
(20:41):
But if you, let's say Ihave a lot of patients
that have to spend days, weeks,
months in the antepartum service.
We have a lot of opportunityto have conversations there.
I like to approach it in a way, like,
there's short-term goals,intermediate goals,
and long-term goals.
- What really stoodout to me in everything
that you've shared is yourdedication to staying connected
(21:03):
to the latest research and advancements.
It's really clear thatyour continuous learning
and integration of newinsights into your practice
is making a real impact notjust in advancing the field,
but also in bringing the most up-to-date
care to your patients.
- I would tell you medicineis no longer something
that you do alone.
You need your peers.
(21:23):
You need to be nice in the sandbox.
I would never practicehigh-risk obstetrics on my own.
You need a village.
These patients need a lot of care.
(bright music)
- This episode was broughtto you by Stanford CME.
To claim CME forlistening to this episode,
click on the claim CME link below
or visit medcast.stanford.edu.
(21:45):
Check back for new episodes
by subscribing to Stanford Medcast
wherever you listen to podcasts.
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