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In This Issue...
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Health
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Dominican’s Neonatal Unit Uses Latest Technology, Advances to Help At-Risk Babies
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Dominican’s Neonatal Unit Uses Latest Technology, Advances to Help At-Risk Babies
By Linda Fridy
[Editor’s Note: The first installment in this series appeared in the last edition of The Post (MCP: Dec. 12, 2006). That story can be found at www.TheMidCountyPost.com. The following is the second and final part of the series.]
Twenty-first century parents may think that medical advances have taken the worry out of pregnancy and birth. However, new procedures bring a new set of concerns, and some mysteries remain unsolved. When labor veers from the birthing-class model, Dominican Hospital’s Neonatal Intensive Care Unit uses leading edge treatment and technology to give hope to the most frail of patients.
Nearly three decades ago, the first “test-tube” baby was greeted with awe and skepticism. Since then, in vitro fertilization has become commonplace. Unfortunately, preterm birth rates have also increased in that time, up 30 percent since 1980 according to the March of Dimes. And with the Centers for Disease Control announcing this fall that revised figures blame premature births for about one-third of infant deaths, the need for specialized care is even clearer.
Dominican Hospital’s Level III Neonatal Intensive Care Unit, or NICU, is the only one in Santa Cruz County and serves birthing centers at Sutter’s Surgery and Maternity Center, along with Watsonville Community Hopspital. Working in partnership with Stanford, Dominican’s NICU offers much of the latest equipment and breakthroughs to help premature and other at-risk babies improve their odds for a normal, healthy life.
Julie Hum has been a neonatal nurse at Dominican for 21 years, watching the unit progress from a Level II for more stable infants to caring for all but those who require specialized surgery.
“It’s been so wonderful for the babies not to be so far away,” she said. “That’s the best part â€" knowing families can get care in the community.”
In her two-plus decades of experience, Hum has seen improved outcomes for smaller and younger babies.
“Many more of them are surviving than they used to. It used to be that 26-week babies just didn’t make it, and now they do,” she said.
Doctors and nurses agree that advances in ventilators and monitors have made a huge impact, allowing them to see the smallest changes.
“We monitor heart rates and breathing continuously, so we know if breathing becomes irregular or oxygen levels are outside acceptable parameters,” said Dr. Magdy Ismail, medical director of Dominican’s NICU. “It has to be picked up every single time.”
New mother and Aptos resident Bina Mirchandani, whose preterm son spent 6-1/2 weeks in Dominican’s NICU, recalled monitors going off to alert the nursing staff.
While the response was often as simple as tickling the baby’s toes to stimulate respiration, she realized how easy it would be to miss a problem.
“Those heart-rate dips, you wouldn’t know they were happening without (the monitors),” she said.
While monitors have become more advanced, they have become less invasive as well, Ismail noted. Micro blood sampling has also reduced blood draws from tiny patients who need every drop.
Catching Problems Early
For more than half a century, doctors have known that premature babies are likely to develop vision problems, but it is only in the last two years or so that a digital camera has been available to allow doctors to catch early signs of retinopathy. If unnecessary blood vessels are detected, the NICU will make the necessary adjustments to the amount of oxygen these babies are exposed to, Ismail said.
The babies’ eyes are photographed in the NICU and images are transmitted live to a specialist at Stanford for review.
“We work with the best pediatric ophthalmologist from far away,” Ismail said, explaining that the doctor can give immediate feedback and ask for different views if needed.
Sometimes problems can be spotted even before birth. When that happens, local doctors can call in a Stanford perinatologist for help with high-risk pregnancies and births.
Dr. Mark Taslimi leads the Perinatal Diagnostic Clinic adjacent to Dominican Hospital three days a week, with another perinatologist covering a fourth day. He sees expectant mothers by referral for second opinions or “any time the medical professional they are seeing feels like the complexity of the problem is too much for [him or her] to handle themselves.”
He, too, praises advances in technology for helping improve babies’ chances. He points to ultrasounds and fetal MRI (magnetic screen imaging) as improved methods to identify and diagnose areas of concern. The MRI is particularly advanced.
“You put an adult in an MRI and tell them to hold still. Fetuses â€" they don’t listen,” he said. “Now we can get rapid MRI with pretty clear images.”
Doctors have also successfully conducted in-utero blood transfusions and even surgeries. However, Taslimi warns that this leading edge procedure is still very risky.
“The woman can go into labor and deliver a premature baby that has just had surgery,” he said.
Causes for Concern
Some babies arrive in the NICU for many reasons. Mirchandani’s water broke unexpectedly only 25 weeks into her pregnancy, and full-term babies can develop infections if they pass stool in the womb. Yet other conditions provide warning flags for doctors.
Mothers who develop diabetes or high blood pressure and swelling known as preeclampsia (formerly toxemia) must be carefully monitored. And of course, multiple fetuses greatly increase chances of a preterm birth.
“About 50 percent of twins are born premature, and 100 percent of triplets and above are premature,” said perinatologist Taslimi.
He noted that many of these are caused in the United States by vitro fertilization practices particular to this country. These are practices that do not legally limit the number of eggs placed in the womb.
“In Europe, doctors are not allowed to implant more than two eggs,” he said, adding that preterm birth rates are lower in Europe, as well.
Specialized Care Comes at a Price
When an at-risk baby arrives in the NICU, the only thought is caring for the patient. No one considers insurance or ability to pay. Maintaining this level of care is not cheap, however.
One unit that allows the medical team to stabilize a baby, then monitor and protect it costs about $40,000, NICU Medical Director Ismail said. In addition, a ventilator is completely re-circuited before it is used for another baby.
Providing this kind of equipment, round-the-clock care, ongoing training from Stanford and other vital services costs the hospital more than $3,000 per patient a day, said Susan MacMillan of Dominican’s financial office.
“Some very, very ill babies are much more,” she said.
About half of the patients are covered by managed care programs like Blue Cross or HMOs, while the other half is MediCal or self-paid, MacMillan explained. Those patients pay at a much lower rate.
“When you have 50 percent of our coverage coming from [sources that only pay] $1,400 a day that doesn’t cover our costs,” she said.
Of course, the hospital isn’t the only one juggling costs. Parents faced with a bill of nearly $100,000 for their baby’s month in the NICU can be worried and overwhelmed. That’s one reason the NICU team includes social workers, who can help parents wade through the paperwork and questions. They also point parents to public programs that can help with the costs.
While the health of mothers and babies should be compelling enough to promote prenatal care, the bottom line also benefits from efforts to prevent and minimize at-risk babies.
Looking Toward the Future
With more than 10 percent of births coming preterm, finding a way to keep babies inside the mother for a full 40 weeks would make a huge difference in newborn health.
“The next horizon is to get control of labor for the sake of preventing premature births,” Taslimi said, an area where science has not made “an iota” of progress recently.
Researchers have uncovered some triggers for labor, however.
“In the human species, the fetus starts its own labor,” Taslimi explained.
A complicated chemical reaction of hormones, adrenaline and steroids triggers changes in the placenta. Confounding scientists is the fact that women’s bodies have a backup system.
“There are so many cascades,” he said. “If one doesn’t work, [the labor process] goes to another.”
Currently, all doctors can do is slow the process.
“The medication we are using today to slow down a labor works to a reasonable extent for up to 48 hours,” he said.
That time frame can mean a great deal to the fetus, because doctors can introduce a substance that stimulates maturation of the lungs, significantly increasing a baby’s chances, he explained.
The other area Taslimi is excited about is genetic mapping that will allow doctors to tailor medication to a patient’s natural responses. He gave the example of a prescription for epilepsy that causes birth defects in 10 percent of babies whose mothers take it. If doctors can identify the trait that causes a reaction, they can direct these women to other medications before they are pregnant.
“The science in this area is just beginning for all patients. In a pregnant woman, it is 10 times more important because we have this very vulnerable organism, the fetus,” he said. “In the future, we can tailor medication to a person’s genetics at the first prescription.”
Research will likely continue to find more and better ways to help at-risk mothers and babies. Unfortunately, Taslimi reports that the need for specialists in his field outstrips the number of qualified doctors.
Only 25 to 30 physicians nationwide pass the board exams for maternal fetal medicine each year, he said, which does not keep up with the number of doctors retiring or reducing hours.
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