sMater | Glenn Gardener 3 | In-utero Treatments

The final episode in the three-part maternal fetal medicine series with Dr Glenn Gardener looks to the next frontier of complicated pregnancy treatments.

The Director of the Mater Centre for Maternal Fetal Medicine delves into emerging treatments for pregnant women with Rhesus disease, and the role of advanced technologies in driving non-invasive procedures in the future.

To find out more about Mater's specialists and services, visit mater.org.au

GP Education activity log:

• Podcast title - sMater: In-utero treatments
• Provider - Mater Misericordiae Ltd Date published - March 7, 2025
• Certificate of completion - click here

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00:00 - Introduction

01:30 - Rhesus disease

11:05 - Questions from GPs

14:15 - The Check Up

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#pregnancyhealth #healtheducation #smater #mater

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of sMater. A podcast by clinicians for clinicians brought to you by Mater, an Australian leader in healthcare for more than a century. My name is Jillian Whiting and we're coming to you from Meanjin the land on which this podcast is being recorded.

In this final episode of our three-part miniseries we're again talking with Dr Glenn Gardner a Maternal Fetal Medicine specialist and director of the Mater Center for Maternal Fetal Medicine at Mater Mothers' Hospitals. We've spoken about TTTS and Spina Bifida previously and in this episode we're finding out what else is happening in the Maternal Fetal Medicine area.

We are Mater. We are Mater. We are Mater. This is sMater.

Hi Glenn, welcome back to sMater. Thank you very much for having me again. Pregnant women with complications today have so many more treatment options compared to decades ago is it improved technology or how much does technology driving those advances? I think technology is a large part of the reason why we are where we at with these advances but it actually is people working with the technology. Technology alone isn't the answer it's actually, you know, a lot of work of many people over many years that's building on information and and then the technology has has just made it happen sooner I think.

We've talked about in previous episodes TTTS and Spina Bifida and that incredible inutero surgery that you've been doing. What else I guess is the question? What else are you doing in this area?

Yeah I'd be nice to share with the audience some new developments around Rhesus disease and we call it isoimmunization or alloimmunization in pregnancy and I'll just briefly describe what that is. So if a pregnant woman's blood group isn't of a negative type and her baby is positive she can develop anti bodes that cross the placenta and cause anemia in the baby and that anemia can be life-threatening or it can cause after the baby's born severe jaundice and over the years people and the audience might think oh yeah you know we've known about this for many many years and it's old hat now actually this space has been still moving with some new advances which I will share but actually want to go back in time because a lot of people don't recognize how the advances in solving the problem of Rhesus disease in pregnancy was largely driven by you know a little corner of the world Australia and New Zealand and people that did work and so when it was first discovered kind of in the 1930s and 40s there was a chap John Gorman who ended up working in the states an Australian doctor and he did some studies where he solved the fact that if you give someone else's antibodies to a pregnant woman she will not develop the disease it'll protect her and um and so that had has led to our common day use of anti-d injections regularly in pregnancy for women who were Rhesus negative so that has literally in our country obliterated the disease and through that you know that discovery I'll also share how it was done.

So prisoners were asked if they wanted to participate if they were negative blood group they were injected with positive blood and that's how he demonstrated it's not harmful to do that to someone like a male prisoner who is not going to ever carry. Consenting I'm sure? Yes consenting always consenting. Consenting prisoners and male prisoners and that's how he demonstrated that and so where is that led to now and and well that has led to really the largely the the eradication of it but it's never going to you're never going to solve it completely and not and and so cases of Rhesus disease will still come to me for treatment and sometimes that treatment involves having to transfuse the fetus in the womb in the uterus and we do that usually as an ultrasound guided needle into the cord or into the baby's vessel in the liver and then we have to care carefully calculate how anemic is the baby, how much blood can we give and usually we have to do it a few times during the pregnancy until the baby's mature enough to be born.

How many of those would you see? How common? We do about 14 of those a year and in fact the first person to do that in the world was a New Zealander Sir William Liley and just as another little fun fact his daughter is one of our neonatologists Helen Liley. One of our senior neonatologist so his name is synonymous with also an amazing kind of discovery that you can transfuse a fetus in-utero and you know this is before Europe before the States you know again an Australians solving this. In Australia we were self-sufficient in anti-d which is the medication to prevent the disease. In 1967 we were the first country in the world we had a government supported program to provide this medication to women who were pregnant across the country and that fact alone you know is amazing to think for our Health Care system and then you know along with the discoveries by Bill Liley of treating once you've got the disease you can no longer prevent it you'll have it in every subsequent pregnancy and that's where the transfusions come into play. Now further to that more recently molecular genetics has led us to be able to test the baby's blood group just by testing a sample of the mother's blood. 
Wonderful and when would you do that at what stage do you do that?

You can do that at around 10 to 12 weeks gestation. Extraordinary. Yeah so DNA from the baby's placenta is in the mother's blood and we can actually separate that DNA and type the baby's blood group so if the baby is the same blood group as the mother that baby will not be at risk and the mother doesn't need to have those anti-d injections if the baby is positive those anti-d injections are necessary so we can reduce the use of anti-d by nearly 40% by knowing the baby's blood group very early in the pregnancy. I should add that the that the medication the anti-d comes from donors right a dedicated pool of donors not just any donor, the Red Cross have worked for many years to have a very dedicated pool of altruistic donors that don't get paid for this they line up every fortnight giving their blood and sometimes they actually have to get spiked with positive blood so the antibody levels go up so that that process is a concern for us if we're giving it to women who don't need it so this new technology means that we will be able to reduce the use of that precious product by some 40% and the Red Cross is working towards making that available for everyone certainly in Queensland and hopefully in Australia.

So the technology to do that test we developed between a collaboration between the Red Cross and then I just want to share with you one other new study that we're doing at the moment and that is giving a medication to women who have who are at risk of severe Rhesus disease and that blocks the antibody crossing the placenta. It's an early it's a phase three trial which means it's placebo controlled so I can't tell you the results or whether we will be using it in the future but certainly it's very exciting because this this is this is a completely new approach and it may mean that down the track any risks associated with transfusion are gone because we all we need to do is give a medication instead.

What are the risks with the transfusion? Every time we do a transfusion there's a 1 to 2% risk of harm to the baby and that might be early birth before the baby could even survive ruptured membranes so serious consequences. We only transfuse if we think if we don't transfuse the baby might die and so that risk is has to be balanced against why we're doing it but yeah serious consequences.

Should there be a, you know, a complication of the procedure, can you step us through the procedure? How long does it take what does it look like? I'm actually doing the procedure this afternoon so I can tell you exactly what I'll be doing. What are your plans this afternoon then? Thank you so this afternoon we'll actually do the procedure in Maternal Fetal Medicine one of our fetal therapy rooms. We don't have to go to the operating theater we usually give the mother some mild sedation because it's quite anxiety provoking to observe the whole thing and we usually just do it under local anesthetic ultrasound guided. We have very good ultrasound equipment as you'd imagine we would need and we introduced the needle into the umbilical cord of the fetus. Now depending upon the gestation that can be straightforward or sometimes it can be really tricky. If it's an early gestation, it's tiny and the target is tiny we take a sample and we have someone from the blood bank who can test that in our in the room on the spot and within 30 seconds tell us how anemic the baby is. We have blood bank provide us with a sample of blood that we can have ready that we can transfuse and then I would test again before I remove the needle to make sure that I've returned the baby's blood count to normal.

So you said this can happen a number of times through their pregnancy, earliest and latest? So usually the earliest is around 18 weeks which is what I'm doing today and that's not it's quite much more difficult because when the cord is bigger later it is more it is easier and the latest we would do it is 34 weeks so quite a broad range and because the disease is still ongoing you have to keep giving the baby blood and to avoid prematurity you really want to then deliver after 34 weeks sometime if you can.

And what would you like GPs to know about the care and the support of that woman through that time and her pregnancy? So how we pick this up in the first place is all pregnant women in every pregnancy should have a blood group and an antibody screen done and you know I think you know we rely upon the GPs to do that and in general they without fail they do that and it's just to impress upon them the importance of that test because if antibodies are found and it doesn't isn't always common antibodies sometimes it's actually an unusual antibody that can also cause anemia so if they find anything any antibodies then they would refer the patient to us and then we would decide the ongoing care plan for that pregnancy and a bit like any of our fetal therapy patients maintaining contact with the GP the person that has known them longer than us and knows how you know their social situation and can provide that support in the community is crucial right up until they turn up with their baby as their as the GPs new patient.

Well on that - so much interest in the work that you're doing so we have some questions specifically from GPS for you. The first one is how do we manage uncertainty in a pregnancy for example when a diagnosis or a prognosis is uncertain how do we help patients cope with this? Yeah that's a really good question but a difficult one because I think the way to manage uncertainty is with honesty and I think we have to be honest that uncertainty is part of kind of what we're dealing with we don't always have the answer straight up but the uncertainty has to be met with a desire to find answers and if a patient knows that you're on their side and that you are going to leave no stone unturned to get answers then I think that's the co that's how you cope and just to kind of throw your hands in the air and say well we don't know I just think it's not good enough and so information support around what can we do how can we get more better information how can we find out what's going on is how I would suggest know you're in the corner in their corner and doing everything you possibly can another great question from um a GP who do I contact if I find an abnormality MFM available outside of office hours yeah we we're a bit unique here we're one of the few sites that has a 24-hour service um on every day of the year um and so I would do a one in four like all weekend overnight with my Maternal Fetal Medicine colleagues and in general it's for emergencies and it's not usually we wouldn't normally have people ring ringing us up saying oh someone's had a scan today you know that would normally be the next day and we always are available within our service to be contacted in the daytime but if someone is in a difficult situation they would normally be sent to the hospital and  the first team that are on at night seeing the patient would then contact us.

It it's great you're so excited about you know the future and what you've been talking about in the surgery and how Australia is is doing so well locally what do you think the next frontier of Maternal Fetal Medicine is? Yeah I think we're going to move away from kind of in more invasive to less invasive perhaps a more more more of approach to kind of a medical a bit like using medication to manage Rhesus disease rather than transfusions so I think there will be a move away from kind of that kind of invasiveness which is great for patients and less risk I think the molecular genetics will help us understand why things happen in the first place and then you know really if we look far into the future we're really looking at things like you know gene therapy modifying disease very early in pregnancy so that the the developing fetus might actually not have a condition that it was going to have. Finally three questions from me finding out a little bit more about you as a medical professional and as a person what was your first pet?

It was a mouse actually it was a little white mouse was my first pet yeah. What was its name? Mousy.

Don't know but I do remember she had babies and that was fascinating. Wow there you go inspired you from that point. What's the biggest misconception about your job? That we do Spina Bifida surgery every day of the week or  you know commonly I think there's a lot of our job that probably people don't appreciate is you know people coming with a risk but actually their baby's healthy and that and that's a nice part of our job to be able to give patients good news it's not all it's not all patients coming with difficult news. And finally who do you admire? I admire I guess the team mostly that I work with because everyone just pulls together to make things happen and they all have a focus of the patient and I think that just means you know as we go forward if everyone's it doesn't matter you know if we're doing our best and we don't always have you know a fantastic outcome everyone will feel that you know we were in it together and I think that team approach means that we can go forward we do you know I don't want to sound too negative we have a lot of lot of wins most of the time but in our line of work we we don't save every baby we don't always have a you know great outcome and that can be heavy if you were handling that by yourself but the team you know focuses on the fact that generally working together we we're doing the best we can. Glenn it's so great chatting to you thank you for giving up your time and talking with us here on sMater. It's been a pleasure thanks for having me and that wraps up our three-part series with Dr Gardner. For our listeners at home or in the car or having a well-deserved break between patients thanks for tuning in. See you next time on sMater.