Care Before Birth

Cassie Kroll was surprised and overjoyed to find out she was pregnant with her third child. She wondered how her husband and two daughters would react, what color she would paint the nursery, and she thought about baby names. Kroll was filled with excitement. But paired with that excitement was a deeply held fear.

During her second pregnancy, Kroll and her baby were diagnosed with fetal anemia — a condition that occurs when a mother and baby have incompatible blood types. When a baby has fetal anemia, the mother’s immune system reacts to her baby’s blood as a foreign substance and creates antibodies to attack the fetal red blood cells. Without treatment, fetal anemia can lead to fetal heart failure and death.

Upon finding out she was pregnant a third time, while her husband was stationed at Fort Campbell in Clarksville, Tennessee, Kroll immediately sought care at Monroe Carell Jr. Children’s Hospital at Vanderbilt, which offers specialized comprehensive maternal fetal care.

“We knew about the fetal anemia this time around; we knew it would be a problem; and we knew the condition gets worse with each pregnancy. As soon as we found out I was pregnant with Emmett, we didn’t wait around — we went straight to Vanderbilt,” Kroll said.

There, Kroll met Lisa Zuckerwise, MD, assistant professor of Obstetrics and Gynecology at Vanderbilt University Medical Center and associate program director of the Maternal Fetal Medicine fellowship at Children’s Hospital, and Matthew Grace, MD, assistant professor of Obstetrics and Gynecology, who were her physicians throughout the pregnancy.

“Dr. Grace and Dr. Zuckerwise truly cared. Anytime I mentioned that something didn’t seem right or that I was worried about Emmett, they heard me out and got me in to see someone immediately. They were reassuring, and they always told me that if something felt off, they would trust my instincts and bring me in,” Kroll said.

A hub of care for women and babies

For nearly 25 years, an experienced team of Vanderbilt experts in obstetrical and pediatric medical and surgical specialty care has helped expectant parents like the Krolls navigate the complex decision-making process for babies at risk for or born with birth defects or abnormalities.

Vanderbilt launched pioneering care and a hub of services to help women with complicated, high-risk pregnancies, and to provide the best possible outcomes for their babies. A major gift from the Junior League of Nashville in 2006 helped establish a fully coordinated center with an administrative staff to connect experts all over campus.

In September 2021, Children’s Hospital and VUMC experts opened The Reed Family Maternal Fetal Clinic, building and expanding upon that decades-long foundation to provide comprehensive maternal fetal care. The new clinic, located on the ninth floor of Children’s Hospital, is supported by a philanthropic gift from Brenda and Colin Reed and family in honor of the lifesaving fetal care for their twin granddaughters, Alice and Olivia, now 5.

The Reed Family Clinic is unique in its ability to harness the power of many specialties across VUMC and Children’s Hospital to provide compassionate, comprehensive care.

The maternal fetal team offers care to more than 2,500 expectant mothers and their babies from across the country every year, a number that is projected to grow in the coming years with the added space. Specialists will also expand the size and scope of care to diagnose and treat a range of conditions, including congenital heart defects, spina bifida and pulmonary malformations.

“Our patients have access to a very large team of maternal fetal medicine specialists, pediatric subspecialists, pediatric cardiologists and pediatric surgeons, and we also have access to ECMO (lung and heart support) technology,” said John Pietsch, MD, professor of Pediatric Surgery and Pediatrics, co-director of the Center for Advanced Maternal Fetal Care and founder of the VUMC ECMO program. “That is unique to Vanderbilt. We take care of sick babies and mothers — accommodating high-risk, complicated cases and involving a multidisciplinary team in the care of the baby and family before and after birth.”

There are several specialized clinics within Maternal Fetal Medicine that are equipped to handle complex and high-risk pregnancies — among them are a congenital cardiac clinic, an HIV clinic and a critical care clinic, which rely on surgeons, physicians, nurses and social workers to care for patients and their babies, says Kelly Bennett, MD, MS, director of the Division of Maternal Fetal Medicine and director of the Fetal Center at Vanderbilt.

The Fetal Cardiology Clinic is a particularly unique subset of Maternal Fetal Medicine. The clinic combines both the Fetal Center and the Pediatric Heart Institute to create a specialized health care plan for babies, which includes counseling, medical management and therapies, and delivery planning. Most babies with congenital heart disease are diagnosed before birth due to the overarching fetal echocardiogram program available through the Fetal Center.

“The patient’s interests are always first,” Bennett said. “Our patients are going through a stressful time in their lives, and we always want to take the most compassionate approach possible to care for them.”

The team — from the schedulers to nurses to doctors and every person in between — strives to provide individualized and personalized care for all members of a family, said maternal fetal medicine nurse, Sarah Kremer, RN.

“As nurses and patient care coordinators, we are given the opportunity to help develop and manage a plan of care that addresses both maternal and fetal diagnoses,” Kremer said. “Our patients’ medical histories are often very complex. When patients are diagnosed with a fetal condition, it increases the necessity for coordination of the remainder of their prenatal care, fetal surveillance, delivery planning and often surgical intervention. We pride ourselves on coordination of care for every patient experiencing a high-risk pregnancy that comes through our clinic.”

Every family that walks through the doors of The Reed Family Clinic has a plan created to fit their circumstances and needs.

“No one enters pregnancy expecting to need care at a fetal center like ours, so it is our priority to provide compassionate, informative and loving care of our families facing often difficult and scary diagnoses,” said Zuckerwise. “Cassie and Emmett’s story speaks to our commitment to not only hear, but to truly listen to our patients each time we see them, to tailor our care to their individual needs, and to remember that our fetal patients are also part of a family that benefits from our comprehensive care.”

A happy, healthy baby boy

Kroll was one of the highest-risk patients, requiring consistent monitoring to measure Emmett’s red blood cell count. If his numbers were too low, Kroll would undergo blood transfusions to get Emmett’s blood cell count back up.

“Since Emmett was too early for delivery at the time of diagnosis, the only way to keep him safe so that he could grow and develop was by using in utero transfusion,” said Zuckerwise. “During these procedures, we were able to give Emmett carefully selected, safe donor blood through his umbilical cord with the goal of restoring his blood cell count back to normal.”

Kroll and Emmett endured two blood transfusions before his birth. Before Kroll’s first transfusion, she was terrified that she would experience complications. By the time she was being rolled back to the operating room, she was having a full-blown panic attack and struggling to breathe. Grace stood by her side, calming her and addressing her specific concerns.

“I don’t know how he stayed so calm and reassuring,” Kroll said. “I’ll never forget that moment. I was panicking, and he knew exactly what to say to help.”

Following a second transfusion and signs that Emmett was in distress, Kroll’s maternal fetal team decided that it was time for him to be delivered at 32 weeks.

She worried that on top of a blood condition, Emmett would be born prematurely and face additional complications. She also had concerns remaining from her last pregnancy that were quickly addressed by the NICU team, who reassured her that they had Emmett’s bed ready as soon as he arrived.

Children’s Hospital’s level IV NICU, the highest level of NICU care, often works closely with Maternal Fetal Medicine to determine optimal timing and location of delivery for mothers and their babies. Neonatology clinicians see families in the clinic to provide counsel about what to anticipate for the care and needs of the baby and what to expect in the first few moments and days of their baby’s life. NICU clinicians recognize that maternal health is paramount to the continued health of babies, and as a result, NICU care is intertwined closely with maternal fetal care.

When it came time for Emmett’s birth, the team again jumped into action, not only caring for Kroll and Emmett before, during and after the birth, but also arranging with the Army for her husband, who was on rotation in Europe, to be flown back to Fort Campbell in time for Emmett’s birth.

“Being involved in the care of patients like Cassie and Emmett is my greatest privilege,” said Grace. “We had the opportunity to provide reassurance and comfort to Cassie during a time when she was most fearful. We then leveraged the expertise and experience of a multidisciplinary team that can only be found at a place like Vanderbilt to provide the best possible treatment and care.”

Emmett Matthew Lee Kroll was born on Oct. 17, 2020, at 3:37 a.m. and stayed in the NICU for 24 days. At 3 months old, after five additional blood transfusions, he was cleared from needing any more transfusions.

Emmett, now 16 months old, is a happy, healthy baby. He is named after Grace, whose first name is Matthew, and creatively named “Lee” after Zuckerwise, whose first name is Lisa. “We really wanted to honor them with his name because they were amazing throughout this whole thing. They became like family to us,” Kroll said.

The Krolls often send photos and videos of Emmett to the team to show his progress.

“Cassie and Emmett’s success could only be accomplished through collaboration of many teams including maternal fetal medicine physicians, nurses and sonographers, neonatology, blood bank and transfusion medicine, and obstetric anesthesia,” said Zuckerwise. “Seeing Emmett healthy and growing reminds us daily why we chose to work in maternal fetal medicine and specifically care for families facing difficult and often life-altering fetal diagnoses.”