Podcast Transcript: Understanding Fetal & Maternal Interventions: Procedures & Outcomes

[Dr. Anthony Shanks]
The reason why you were featured was because you're a fetal interventionalist. For people that are watching this or listening to this, they may not know what that is. Can you tell us what a fetal interventionist is, and maybe share what that story was that they made the video of?

[Dr. Hiba Mustafa]
Yes. The naming has been variable across different institutions. Fetal interventionist, or fetal surgeon, or fetal therapist, some people would call it, is a person who finished certain type of training. I'll talk about the routes you can go to that training. It focuses on pregnancies, high-risk pregnancies, in which they encounter certain complications during pregnancy related particularly to the fetus.

If the fetus has a certain condition, abnormality, that affects either their survival or causes severe morbidity after birth, then the fetal interventionist or the therapist might be able to intervene in certain ways, certain time of pregnancy if they are eligible. Most importantly, if benefits outweigh the risks, to either improve survival or hopefully reduce the morbidity of that condition.

[Dr. Anthony Shanks]
Hiba, could you tell us about your training and when exactly you got interested in focusing on something that is so specialized?

[Dr. Hiba Mustafa]
Yes. I'm OB/GYN. Residency, OB/GYN residency. I did my maternal fetal medicine fellowship. Maternal fetal medicine, people know it as high-risk OB specialists. You focus whether it's mom or the baby have like some certain complications in pregnancy. After the maternal fetal medicine or MFM fellowship, I did the fetal surgery fellowship. OB/GYN residency is four years, MFM fellowship is three years, and then extra two years for fetal surgery fellowship.

There's another route for it. People might go, which is through the surgical route. You do pediatric surgery, and then you do two years of fetal surgery fellowship. Might be a little bit different of what type of procedures you do, like how extensive, how big of a spectrum you can do if you go through the surgical route versus if you go through the MFM route kind of thing.

[Dr. Anthony Shanks]
With your own journey, when in residency, did you decide MFM? When within MFM, did you decide fetal interventionist versus just MFM?

[Dr. Hiba Mustafa]
No, actually, I think it started in residency. I was a resident in New York, Mount Sinai, New York, and then there was a person who came from CHOP, and they did a lecture to the residents. The lecture was about the twin-twin transfusion syndrome. Basically, if the patients that they did laser on and they ended up coming back to us, they wanted us to send the placentas back to them to do dye test. Basically, during this condition, there's like vascular connections between twins, and with the laser, you can burn these vascular connections.

They wanted to look at the placentas after birth and inject dyes into those vessels just to see if they missed any vessels or how it's looking. I was just a resident full of energy, full of hopes and dreams. Then this person comes and talks about something that, to me personally, appeared so fascinating and so intriguing. That's when I think I want to be a fetal surgeon. I think why it was fascinating more to me that I wanted to take it as a career rather than other people. I was a person who was really into ultrasound.

This is uncommon among OB/GYN residents that they allocate part of their residency time on ultrasound because they're exhausted, they're doing so many rotations. I actually spent a lot of electives, a lot of my off time. If I have nothing to do, I'll go to the ultrasound unit. Something about ultrasound that always I loved to learn more about. Of any fetal interventionist, ultrasound is the biggest portion of their career kind of thing. I think just my love to the ultrasound made this field just more fascinating to me. I thought I can be like that person who was giving the lecture one day.

(2) Maternal Fetal Medicine Fellowships & Post-Fellowship Training

[Dr. Anthony Shanks]
You know me for the audience members. I'm big into education, both medical student and residency. People listening to this, they've done residency. They know that process of applying it and matching. Then, for those that specialize in, we know what that application process looks like in the training. You did another-- just it continues to be specialized. How did you identify where to train, and what did the training actually look like after MFM fellowship?

[Dr. Hiba Mustafa]
For those people who are really into fetal intervention, it's definitely a good thing to do your MFM fellowship in a place that does offer that. However, like after finishing my MFM fellowship, I did realize it's not necessarily true. That's how many MFM fellows approach me. When we go to SMFM or I go to any meeting, those who are interested into the field, they come and they say, "Oh, I do my training in somewhere that they don't offer fetal intervention. Is that a disadvantage to me or not?"

I say absolutely not a disadvantage because those places who are like have a big program and they offer fellowships, et cetera, it's more focused on the team that does the fetal surgery. Usually they have a fetal intervention fellow who come to those cases, and the MFM fellows involvement might not be as big even if you get involved because you're not planning to take this as a career. They might not invest a lot of time, if that makes sense, rather than investing more time into their fetal intervention fellow.

Yes, there is definitely advantage from seeing those cases, managing them pre-op, managing them post-op, but I don't want this to hinder MFM fellows from embarking on this step just because they did their fellowship somewhere that it does not do fetal intervention. Otherwise, I always say, "Go do electives at those places, and attend meetings, and listen to lectures, and read about these topics. Learn the pathophysiology and the offerings and the techniques, et cetera, because your main training going to come during your fetal surgery fellowship."

That's the time where people will be really focused on training you, letting you do it with your own hands, and letting you scan, and letting you make decisions. Yes, it's great if you do your MFM fellowship somewhere who offers it, but never feel disappointed if you match into a place that doesn't necessarily offer it because your main goal when you go to MFM fellowship is MFM. That's why I always say when you go to OB/GYN residency, even if you like MIGS or Gynaec or whatever, focus on being an OB/GYN resident.

Learn the whole field, learn the whole spectrum, learn everything about L&D. Even if you don't like so much being on L&D, but eventually when you become more of a senior resident, you can spend more electives and research on the place that you like to end up with. Similarly, for MFM fellowship, you entered MFM for an MFM. Learn the whole spectrum of MFM because you're going to manage those patients as a whole.

I have a patient whom I'm managing her for fetal reasons, but I have to manage her diabetes and hypertension and everything else. Basically, if you end up in a fellowship that does not offer it, don't feel disappointed. You're going to do still great. You're still going to end up matching hopefully, into fetal surgery fellowships or find a place that's willing to train you and help you grow kind of thing.

[Dr. Anthony Shanks]
What does the landscape look like? I'm familiar with how many maternal fetal medicine fellowships there are in the country, and you don't have to have a very specific number. What does it look like? How many places both in the US and internationally are training people for this?

[Dr. Hiba Mustafa]
Very few. Probably people know this, or maybe they don't know, this is not a ACGME-approved fellowship. There's no certain guidelines or how should it look like. The way it looks is per institution. The amount of years you do per institution, the cases that you do in your first year or second year, and how much research they require you to do is purely per institution. Even those institutions who offer the fellowship, generally they offer it for two years. Some of them decide to do, I'm not going to take another fellow until my fellow finishes the two years.

Some of them know they would take a fellow every year. Some of them they lose their funding because this is not like residency or MFM fellowship is not federally funded. The institution they have to find funds for that position. They might lose funds over certain years, so they don't offer it. Basically, generally, generally the people or the institutions who've been out there, it's Texas Children, Baylor in Texas, UT Houston, which is Memorial Children in Texas as well. Children Hospital of Philadelphia, they have been on and off.

This year they're taking a fellow, but they've been not taking for a few years, for example. Then you have Cincinnati Children, also on and off. They took a fellow today who used to be my resident, but certain years they might not take. However, there are places who want to take a fellow, for example, to train and keep them as partners, for example. I always say, like, "Don't feel like those places who offer fellowship would be your only options. Absolutely not. Go to the meetings, show yourself, show that you are a person who are interested into this field."

Present yourself as a person who, if they're willing to take a fellow one day or help train someone to become their partner, you are available. Don't feel like those places and websites generally, for MFM Fellowship, OB/GYN residency, we go to Google, and we look on the website. This is not something you necessarily will see on websites. This is more of a verbal communication you know someone. You heard someone is offering a fellowship kind of thing. Always be there, present yourself, show your enthusiasm and interest, and people will reach out to you.

[Dr. Anthony Shanks]
You mentioned ACGME, which has oversight and accreditation. In terms of informing what is taught at the residency level, we have things like CREOG and APCO that can provide information. At the fellowship level, we have the Society of Maternal-Fetal, SMFM. What are the organizations that help inform what to teach in terms of what you have to learn as a fellow in fetal interventions?

[Dr. Hiba Mustafa]
There are no organizations, unfortunately. There are educational resources. SMFM has like a few publications, for example, on maternal-fetal surgery and fetal anesthesia. They have some practice bulletins and opinions out there, but there are no organizations who say you have to train for laser or an MMC, or fetal. For example, some people who offer this fellowship, they only do laser FYI. When you go somewhere and they offer you a position or a fellowship, you should ask, "What am I being trained for?"

Many places would say we only do twin-twin transfusion, for example. We don't do fetal. We don't do MMC. The thing with MMC and fetal-- so MMC is myelomeningocele or spina bifida repair. Fetal is a procedure that is done for congenital diaphragmatic hernia, which is like a balloon tracheal occlusion. These two procedures, you require pediatric specialty support. You need a neurosurgery. You need a spina bifida clinic. For fetal, you need a place with very strong ECMO, with very strong pediatric surgery services.

If you don't have the pediatric specialty support, that's why many places don't do fetal, don't do MMC repair while they do lasers because for that one, you really just need NICU a neonatology care kind of thing. There's no guidelines. It depends purely on the person who's offering the fellowship, but you should just basically, during your interview, have a clear expectation. What are you being trained for? What is the expected number of cases you're going to get in your first or second year? What is their vision of how much like independence you're going to have?

NAFTNET did a survey a few years ago. NAFTNET is the North American Fetal Network. All the fetal surgery centers are part of that network. They did a survey a few years ago, and they found the people who finished the fellowship and they went into careers, they felt very comfortable doing laser procedures and other smaller procedures such as coagulation and RFA, and intrauterine transfusion. Many of them did not feel independent to do, for example, fetal or spina bifida repair, just because of the nature of these cases are less and the main surgeon might be the main person who's doing them kind of thing. Just FYI.

(3) Conditions That Fetal Interventionalists Treat