Spring 2009 Vol. VII, No. 3
The Doctor Who Delivers before the Delivery
AUB alumnus Dr. Alfred Khoury graduated with his MD from AUB in 1978, and today is the director of Maternal Fetal Medicine and chief of staff at INOVA Fairfax Hospital in Fairfax, Virginia. For ten years his mentoring of obstetrics and gynecology (Ob/Gyn) residents from the Middle East, most of them from AUB, has been, he says, one of the most satisfying aspects of his career. He shares his thoughts on the critical advancements he has seen in the field of maternal fetal medicine, some troubling challenges, and his hopes for molecular genetics.
Dr. Khoury, can you tell us a little about your background and what led you to become a physician?
You also have a testing center and a large antepartum unit. How do these facilities help your patients?
One of the biggest problems in obstetrics is the premature birth of the baby. We have a 40 bed antepartum unit where we admit patients with problems such as preterm labor, incompetent cervix, preeclampsia, heart failure or severe uncontrolled diabetes to name a few. Unfortunately, some of the problems we encounter are the result of the advances in Ob/Gyn. With the advent of reproductive technologies such as IVF (in vitro fertilization), the number of multiple pregnancies has increased exponentially, which in turn greatly raises the risk of preterm delivery. Statistics show us that triplets achieved by natural means occur at the rate of 1 in 6,000, while those achieved through IVF are much more frequent.
We have had noticeable advances in ultrasound and genetic diagnosis. These allow us to diagnose abnormalities of the fetus early in the course of the pregnancy. Unfortunately, however, our ability to diagnose problems has outstripped our abilities to cure a lot of these problems. We can diagnose a baby in the uterus with thalasseamia major, a blood condition common in the Mediterranean region, but we are not capable of treating or curing the fetus before birth.
I do not want to give the impression that we have not made major strides in our capabilities to care for the mother and the fetus. Our diagnostic capabilities of congenital abnormalities while the fetus is still in the womb have been extremely useful and helpful. With the development of specialized care centers that have the full range of medical and surgical specialties, babies with these abnormalities have a much better outcome once they are diagnosed early and arrangements are made for the neonate to receive an expedited and full range of treatments immediately after delivery. The early diagnosis of the abnormalities also allows the parents to be aware of the situation early, to be educated about the condition of their baby, and to receive both emotional and psychological support prior to delivery.
Where have you seen improvements in your field in the last 25 years?
The past 50 years have seen great advances in our ability to make delivery safer for the mother and the fetus. The death rate for the mother and newborn secondary to pregnancy has declined tremendously. We still have disparities in death rates due to pregnancy between rich and poor countries, and there is a great deal of work to be done to close that gap.
In terms of my particular field of fetal maternal medicine, we have seen significant improvements in ultra sound, genetic diagnosis of inherited diseases, and in the management of some of the diseases that are peculiar to pregnancy. However, the biggest improvement in neonatal outcomes has been due to advances in the neonatal intensive care unit. A large part of the credit goes to our neonatal colleagues who make us look good time and time again. In the case of prematurity and preeclampsia, two diseases that are only seen in pregnancy, we have improved our capabilities in managing and treating those patients but have not been successful in finding the causes of these two conditions or in preventing/curing them.
What about advances in treating patients with medical problems while pregnant?
We have made major strides in our knowledge for treating these patients. However, we have to keep striving to make our specialty more knowledge-based rather than skill-based. This is the path we have to take to solve a lot of the remaining problems in the science and practice of the field. Patients with diabetes, if managed properly, can now have an excellent outcome. Fetuses that have blood incompatibility with their mother are now given blood directly into the umbilical cord while still in the uterus and are delivered healthy. We also now see mothers with heart, liver, and kidney transplants who carry the pregnancy to term and whose fetuses are born healthy.
Is there any way in which the way medicine is practiced now has produced poor outcomes in your pregnant patients?
The increase in the c-section rate to levels of 40-50 percent at some institutions has raised the possibility of a life threatening condition called placenta accreta. In these cases the placenta grows into the muscle of the uterus and at the time of delivery can cause a life threatening hemorrhage for the mother. At the beginning of my career, when c-sections were fewer, we saw one in every year. Now we see about two to three a month.
Another problem that we see is caused by aggressive surgery for cervical cancer, where large portions of the cervix are removed, causing an increased incidence of incompetent cervix which can lead to pregnancy loss or preterm delivery.
What has your role been in the residency program?
About ten years ago we came to an agreement with the George Washington University Department of Ob/Gyn to have two residents a year admitted to the program from the Middle East. Most of these residents have come from AUB. One of the most satisfying aspects of my career has been the opening of doors for those residents (from the Middle East) to come, achieve, and excel. It has been a true pleasure to see that these residents have been stellar in both their academic and professional performance. They have consistently been the highest achievers in their in-service exams and have had the highest percentage of all residents passing the specialty boards. The ratio of the residents who have been admitted to very competitive fellowships has also been highest among those who have come from AUB.
What do you see in the future of OB?
We will soon be able to determine chromosomal abnormalities by a maternal blood test rather than by invasive tests which carry a risk of pregnancy loss. More importantly, however, I hope that the causes of pre-term delivery and preeclampsia are better understood so that the number of premature births and the number of mothers dying will be decreased markedly. I also hope to see the field of molecular genetics advance to reach a level of sophistication that will enable physicians to treat the genetic and metabolic inherited diseases inside the uterus. This would result in a healthy baby rather than a termination of the pregnancy.
Do you work with healthy young women, and if so what do you offer them?
The specialty has developed population based testing that identifies lethal structural and genetic abnormalities which gives the patient the option to end the pregnancy early. Two good examples are the Nuchal translucency test for Down’s syndrome and the alphfetoprotein test for spina bifida and abdominal wall defects. Our testing for diabetes in pregnancy has had an impact in advising patients about their increased risk for developing diabetes later in life and making the necessary adjustments to their life style to delay or prevent the occurrence of the disease.
What about the new vaccine for cervical cancer?
This is a vaccine for the HPV virus, a major contributing factor in causing cervical cancer. I think we will see the effect of this vaccine in the coming years as more young women receive it. Unfortunately, this is an expensive treatment, which will preclude a large number of poor women from receiving it. There is also some social resistance to it as some see it as promoting
sexual activity in young women.
We still have disparities in death rates due to pregnancy between rich and poor countries, and there is a great deal of work to be done to close that gap.