Maternal-Fetal Medicine Fellowship Program
The Maternal-Fetal Medicine fellowship program is conducted in a large tertiary care center that houses the largest obsetrical service of the Harvard medical complex. During the last fiscal year, there were almost 9,000 deliveries, 1,020 admissions to the high-risk antepartum service, and 380 maternal transports. Facilities include a 27-bed antepartum unit, 24 labor-delivery-recovery rooms, 4 dedicated operating rooms, a neonatal intensive care unit with 52 beds, an ambulatory high-rsik facility and an Antenatal Diagnostic Center with ultrasound equipment, electronic fetal heart-rate monitoring capabilities, genetic counseling, and high-risk consultative services. Close multidisciplinary relationships exist among neonatology, obstetrical anesthesia, pathology, medicine, and surgery departments within the BWH and with selected services at the Children's Hospital Medical Center and the Joslin Diabetes Clinic. The genetics and dysmorphology service is well developed. Division faculty and other selected subspecialists closely supervise all services in which fellows are actively involved.
During six months of their first year each fellow cares for faculty and service patients on the antepartum inpatient unit. Although these patients account for only 25% of the total deliveries in the hospital, they are responsible for over 50% of the antepartum admissions. This disproportion results because of the very high-risk profile of diabetics from the Joslin Clinic and from the large referral base of the high-risk practice.
Typically, the antepartum experience for each fellow will include caring for patients with complications related to insulin-requiring diabetes (40), preterm premature rupture of the membranes (75), preterm labor (160), third-trimester bleeding (55), hypertension/preeclampsia (75), multiple gestations (30), intrauterine growth retardation (15), and miscellaneous other diagnoses. Forty-eight percent of patients on the antepartum unit deliver infants weighing less than 2,500 grams. In addition to inpatient responsbilities, first- and second-year fellows also take in-house call on the labor and delivery floor every seventh or eighth night, and they take labor and delivery call for the Joslin obstetrical service from home an additional three days a month. Fellows on call work closely with a faculty member.
During six months of each year of the fellowship, fellows attend the prenatal clinic at the Joslin Diabetes Center. Staff in this clinic see an average of 40 pregestational insulin-requiring diabetic pregnancies each year. During the first year of the fellowship, each fellow also spends six months attending the Special Obstetrics Clinic. This resident clinic enrolls 100 patients per year with a wide variety of medical and obstetrical complications.
Second-year fellows participate in the outpatient consultation services provided by the Antenatal Diagnostic Center (ADC). Patients with a current or anticipated pregnancy complication are seen by the fellow under the supervision of a member of the Maternal-Fetal Medicine staff. About 400 consultations are provided annually, many of which derive from recently diagnosed fetal conditions such as anomalies, arrhythmias, isoimmunization, and nonimmune hydrops. The fellow is responsible for the initial assessment of the patients and for ordering and performing diagnostic and therapeutic maneuvers, including amniocentesis, percutaneous umbilical blood sampling (PUBS), and intrauterine transfusions. In addition, the ADC is responsible for a maternal serum marker screening program for over 2,500 women. Fellows obtain experience in counseling women with abnormal serum markers as well as advanced maternal age. Over 1,400 women are seen yearly for genetic counseling and amniocentesis. Fellows have the opportunity to perform significant numbers of genetic amniocenteses in the ADC.
Abundant informal and formal learning opportunities exist for fellows. A board-certified or board-eligible maternal-fetal medicine subspecialist conducts formal bedside rounds on inpatient service with the first year fellow and two residents every day. During the first-year of training, fellows prepare a weekly multidisciplinary conference attended by obstetricians, neonatologists, geneticists, ultrasonogographers, and interested medical subspecialists. In addition, a monthly clinical conference is held at the Joslin Clinic to discuss aspects of diabetes and diabetic pregnancy, and twice-weekly the Special Obstetrics Clinic begins with a clinical conference supervised by a maternal-fetal medicine subspecialist. Ob/Gyn Grand Rounds are presented weekly throughout the academic year, often on topics of interest in maternal-fetal medicine. Fellows have the opportunity to attend an annual postgraduate course in maternal-fetal medicine that is sponsored by the BWH Department of Obstetrics and Gynecology and Harvard Medical School. A basic science and clinical correlation series, offered jointly by the Division of Maternal-Fetal Medicine and the Joint Program in Neonatology provides yet another learning opportunity. In addition, didactic lectures with appropriate reading materials are given weekly.
Fellows are required to take a minimum of six weeks of ultrasound and six weeks of genetics as "electives". These rotations may be done in either the first or the second year. Other clinical electives typically include obstetrical anesthesia, neonatal intensive care, adult intensive care, and additional rotations in genetics, dysmorphology-teratology, and ultrasound.
Fellows have 85% of their time available for research in the second year. This block is intended as an individualized, in-depth research experience. Fellows select a research project based on their needs and long-term goals. Research supervisors provide close mentoring.
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