Recently, Spokane perinatologist Dr. Cherie Johnson, who specializes in high-risk pregnancies and births, drained a cyst on the kidney of a babywhile it was still in its mothers uterus. Advanced technology is enabling physicians to perform such in-utero procedures, which sometimes can be life saving.


Because of advances in infertility treatment, ultrasound technology, and medicine in general, perinatologists, who work with high-risk pregnancies, are handling more multiple births than ever. They also are working with a growing number of women who are delaying childbearing until their late 30s and 40s.


Perinatologists are scarce, however, in part due to the high insurance premiums they pay and the additional schooling they have.


I had a good mentor who showed me how rewarding this field could be, she says. There are many trials and tribulations, but theyre balanced with rewards: a healthy mom and a healthy baby.


In Spokane, the medical hub for the Inland Northwest, there are believed to be only two perinatologists: Johnson, whose practice is at Deaconess Medical Center, and Dr. Rodney Briggs, at Sacred Heart Medical Center. Despite a staggering workload, Johnson says shes content with the career path she has chosen.


Briggs declined to be interviewed for this story.


Johnson delivers about 175 high-risk births a year, compared with obstetricians here, who handle about 150 mostly normal deliveries a year, says Dr. Robert Hartman, whos president of the Spokane County Medical Society and an obstetrician. On average, 5,845 babies are born in Spokane County each year, reports the Washington state Department of Health Center for Health Statistics.


Many of the pregnancies handled by perinatologists involve complications such as diabetes, high blood pressure, and weak cervices in the mother. Some complications require mothers to be hospitalized or on bed rest for 100 days or more. All such cases touch Johnson as if they were her first delivery.


I love deliveries. Every one is a wonderful celebration of life, she says. The nurses tease me because sometimes I celebrate more than the families do.


A changing field


In her office in Deaconess main building, Johnson works with eight staff members, including two ultrasound technicians and two fetal-monitoring specialists. Her practice, Northwest High-Risk Obstetrics, operates out of the hospitals former chapel.


On Johnsons otherwise bare walls hangs a drawing depicting the Nativity and a photograph taken in 1947 of Deaconess newly remodeled birthing rooms, complete with solid-wood furnishings and all the comforts of home.


Johnson, 43, speaks in comforting tones, referring to the babies she delivers as pumpkins and to the women who carry them as the mamas. Johnson also speaks with passion for her job, to which she dedicates 80 to 100 hours a week.


The work of a perinatologist is different, though, than it was when someone snapped that old photograph. In fact, it has changed since Johnson opened her practice here 10 years ago.


Advancements in ultrasound technology have been tremendous during the past decade, she says. Were able to see more and provide closer following of the babies.


When a birth defect is detected in an unborn baby, the mother usually is referred to a perinatologist. Johnson obtains amniotic fluid from the mother through an anmiocentesis to check for complications such as cystic fibrosis and chromosomal abnormalities.


Using a variety of techniques, some doctors in the U.S. now perform corrective in-utero surgery on a fetus diagnosed with certain complications, such as spina bifida and hernias of the diaphragm.


Experimental fetal surgeries are being done to correct hydrocephalus, which is an abnormal increase in the amount of brain fluid, causing enlargement of the head and damage to the brain. Doctors are also performing in-utero surgeries to correct gastroschisis, a condition in which a fetuss bowel develops outside of its body.


Before Johnson drained the cyst on the kidney of the fetus in the recent in-utero procedure, the fetus was being poisoned by its own waste, she says. Shes also able to perform in-utero blood transfusions on fetuses.


Such techniques were considered the stuff of science fiction just a few decades ago. Hartman, the medical society president, chuckled as he recalled the ultrasound technology of the early 1980s.


We could say, Theres an 80 percent chance that youre having twins, he says. It was almost like a weather forecast.


Says Johnson, It used to be you could tell if the head was up, or the head was down, or if the baby was breech, but now you can see the babys eyelashes and its uvula.


Newer technology, including three-dimensional and four-dimensional ultrasounds, also can detect cysts in fetuses brains, and they enable doctors to diagnose kidney damage, heart failure, and cleft palate syndrome, Johnson says.


Meanwhile, assisted reproduction has had its own effects in perinatology, she says. It has increased on an exponential path, and women who couldnt become pregnant before, for example some diabetics, now are having babies.


The Centers for Disease Control, in Atlanta, says that in the early 1900s, out of every 1,000 live births in the U.S. each year, six to nine women died of pregnancy-related complications, and about 100 infants died at childbirth or before their first birthdays. By the end of the 20th century, the maternal-mortality rate had dropped drastically to less than 0.1 death per 1,000 births, and the infant mortality rate had fallen to 7.2 deaths a year. The CDC attributes those improvements to better nutrition, advances in medicine, improved access to health care, better disease monitoring, and higher standard-of-living levels.


As society has changed and medicine has advanced, however, some at-risk women who are choosing to have children or women who have delayed childbearing until much later ages face increased risks of pregnancy complications, says the nonprofit American College of Obstetricians and Gynecologists. In more mature mothers, especially those older than 35, conditions such as high blood pressure and diabetes are more common before they become pregnant than in younger women, the organization says. Those conditions mean the older mothers are more likely to need inpatient hospital care before giving birth to safeguard the babys, as well as their own, health.


Fertility decreases with age, so older mothers often must use fertility drugs or undergo in-vitro fertilization to become pregnant, the American College of Obstetricians and Gynecologists says, and in-vitro fertilization often means multiple gestations, Johnson says. She has worked with several women who have carried twins and triplets and has delivered two sets of quadruplets and one set of quintuplets.


Its very fun to deliver multiple births, Johnson says. Its challenging to take that pregnancy as far as you can.


Steep insurance premiums


Handling higher-risk pregnancies means that a doctor has higher liability- and malpractice-insurance rates. The annual insurance premiums for a perinatologist typically range from $60,000 to $120,000, Johnson says. A regular obstetrician-gynecologist in Washington pays $34,000 to $59,000 a year in insurance premiums, reports the American College of Obstetrics and Gynecology. The organization considers Washington one of the nine most expensive states for OB-GYNs, in part because there isnt a law capping noneconomic damages in medical-liability cases.


An insurance environment such as Washingtons makes it hard to attract perinatologists to Spokane, Hartman says. High premiums are driving physicians incomes down so when a physician retires, its very hard to find someone to take their place, he says.


On top of higher premiums, perinatologists training requires three years of high-risk pregnancy experience on top of four years of medical school and four years of residency as an OB-GYN. Johnson studied medicine at the University of California at Irvine and completed a high-risk pregnancy fellowship at Thomas Jefferson University, in Philadelphia. The combination of extra schooling and hefty insurance premiums makes members of the medical community shake their heads when they consider the difficulty in recruiting perinatologists.


We need more perinatologists, and we have to look at the problems in our society that make it tough for a great town like Spokane to recruit them, Hartman says. I suspect Dr. Johnson could add two doctors to her practice and still feel pressed for time.


Johnson recently offered an employment contract to a perinatologist whos interested in moving to Spokane and joining her practice. That doctor hasnt decided whether to join her, but Johnson says she hopes he will accept her offer.


Although the demands of her job are substantial, in an interview Johnson repeatedly directed her comments about perinatology back to her patients. Even in the hardest of cases, such as when a mother died of a brain aneurysm in her seventh month of pregnancy, Johnson recalls the positive outcomes. The womans family made a plaster cast of one of her hands for the baby, who survived, and the babys sibling.


The mama never woke up, Johnson says. They made a plaster mold of her hand so the baby and the other child could place their hands in hers whenever they wanted to or whenever they felt lonely.