Caring for moms in crisis

Macones’ vision inspires research to improve women’s health

George Macones, MD (left), and Molly Henson, a nurse in obstetrics and gynecology, review a patient’s sonogram in the Ob/Gyn Clinic at the Center for Advanced Medicine. “He has a terrific vision for our ob/gyn department,” says Jeff Peipert, MD, the Robert J. Terry Professor of Obstetrics, who trained Macones at Pennsylvania Hospital. “He simply wants us to be the best. He wants us to have the best residency training program, the best clinical research program, the best basic research program and to provide the best patient care.”

When George Macones, MD, was a resident at Pennsylvania Hospital, his 25-year-old patient died of a blood clot two days after delivering a healthy baby girl by cesarean section.

“She got sicker and sicker after delivery, and multiple people were trying to figure out why she wasn’t getting better,” says Macones, WUSTL’s Mitchell and Elaine Yanow Professor and head of the Department of Obstetrics and Gynecology. “I was in her room when she died.”

This patient’s death made Macones want to understand how to care for extremely sick pregnant women.

He now cares for women who have had previous complicated pregnancies, have lost a fetus during pregnancy or are carrying twins or triplets. He also sees patients with pre-existing medical conditions such as high blood pressure or lupus.

Additionally, Macones is internationally renowned for his research on the safety of vaginal birth after cesarean (VBAC) and has published new guidelines on monitoring fetuses during labor.

His clinical and research skills are just two of the attributes faculty in his department mention when they’re describing Macones, who joined Washington University from the University of Pennsylvania in 2005. They also herald his leadership, citing his foresight, willingness to make tough decisions and zeal for administrative duties.

“He has a terrific vision for our ob/gyn department,” says Jeff Peipert, MD, the Robert J. Terry Professor of Obstetrics, who trained Macones at Pennsylvania Hospital. “He simply wants us to be the best. He wants us to have the best residency training program, the best clinical research program, the best basic research program and to provide the best patient care. I can’t believe he was my junior resident!”

David Mutch, MD, the Ira C. and Judith Gall Professor of Obstetrics and Gynecology, says that Macones is thoughtful, nonjudgmental and sees the good in everyone. “And he is keenly committed to the academic mission of patient care, teaching and research,” Mutch says.

The son of a judge and a nurse, Macones grew up in Philadelphia. He wasn’t interested in science until high school, but his mother encouraged him to pursue medicine as a career.

He had no interest in obstetrics and gynecology until his third-year clinical rotation in the specialty during medical school at Jefferson Medical College in Philadelphia.

“I then knew there was nothing else for me,” says Macones, who also serves as chief of obstetrics and gynecology at Barnes-Jewish Hospital. “I fell in love with the labor floor and thought pregnancy was very interesting.”

After earning his medical degree in 1988, Macones completed a fellowship in maternal-fetal medicine at Jefferson Medical College in 1994 and earned a master of science degree in clinical epidemiology from the University of Pennsylvania in 1996.

New generation
Macones was in the first generation of maternal/fetal specialists to conduct clinical research on obstetrical practices that had been in use for decades. These practices range from fetal monitoring to labor induction to methods to prevent preterm birth.

Allowing a woman to try to give birth vaginally after cesarean, commonly called VBAC, gained widespread acceptance in the 1980s. But according to Macones, a mix of concerns about the possibility of the previous uterine incision breaking open, patient preferences and fear of liability, among other factors, has caused a shift. Currently, more and more hospitals do not allow women to try to give birth vaginally after a previous C-section.

“It’s a complex and concerning trend,” he says. “Research clearly shows that a woman’s health risk increases progressively with each repeat cesarean delivery. The effect on maternal health can be profound.”

Macones conducted one of two large observational studies in the United States in the past decade that have looked at the efficacy and safety of allowing a women to try to give birth vaginally after a prior C-section. In the study Macones led, which reviewed the records of approximately 25,000 women, the rates of the previous uterine incision breaking open were less than 1 percent.

“The rates are quite low and are comparable to, if not lower than, the complication rates of most other obstetrical procedures we perform on a daily basis,” Macones says. “It’s important to share this data with patients.”

This year, he served on an expert panel convened by the National Institutes of Health that affirmed that allowing women to try to give birth vaginally after a prior C-section is a reasonable option. The panel also recommended that current VBAC guidelines be reconsidered and more research conducted.

Helping drive change
In the early 1970s, electronic fetal monitoring during labor and delivery was introduced to keep an eye on the fetus and intervene surgically if necessary. The monitors continually measure the fetal heart rate and produce tracings on a screen and paper that can let a doctor know if a baby is doing poorly during labor.

Today, more than 85 percent of the 4 million babies born alive in the United States annually are monitored electronically, but there is ongoing controversy about whether the practice does more harm than good.

“The technology got rolled out before we knew if it worked or not,” Macones says.

Macones published new guidelines in 2009 to provide more consistency on how doctors should decide when to intervene and when to let the mother deliver naturally.

Previous guidelines divided readings into two categories — reassuring and nonreassuring. Because of the threat of liability, many babies with nonreassuring readings who might have been OK after a vaginal delivery are being delivered surgically or with forceps, according to Macones.

Courtesy photo

The Macones family: (From right) George Macones, MD, and sons Cameron and Colin visit the Jefferson National Expansion Memorial and the Gateway Arch in St. Louis. Daughter Caroline is not pictured.

The new guidelines divide monitor readings into three new categories and recommend more specific actions. In particular, physicians will closely monitor the baby’s heart rate, and if it becomes abnormal, they can look at other factors, such as the mother’s blood pressure and heart rate and how fast labor is progressing. A doctor might give the mother oxygen or treat her low blood pressure. If these efforts do not improve the baby’s heart rate, the new guidelines call for immediate delivery.

“Our hope is that these new guidelines will help all health-care providers ‘speak the same language’ and also move forward a research agenda,” Macones says.

Macones’ clinical research also has earned him the respect of peers at other academic medical centers.

Haywood Brown, MD, the Roy T. Parker Professor and chair of the Department of Obsetrics and Gynecology at Duke University Medical Center, calls Macones a respected national leader in the field of obstetrics and gynecology.

“He is an outstanding clinician, researcher, educator and mentor and exemplifies the definition of an academic physician,” he says.

At the School of Medicine, Kelle Moley, MD, the James P. Crane Professor of Obstetrics and Gynecology, says Macones has taken the department to a new level in the past five years. “There are so many good things I could say about George,” she says. “He brought very strong faculty with him and recruited the best and brightest residents, in addition to taking an active role in the development of junior faculty. He’s a role model for all of us.”

Facts about George Macones, MD
Birthplace: Philadelphia
Education: BA in biology, University of Pennsylvania, 1984; MD, Jefferson Medical College, 1988; MSCE, University of Pennsylvania, 1996.
Family: Daughter Caroline, 18, psychology student at the University of Utah; son Colin, 14, student at Mary Institute and Saint Louis Country Day School; son Cameron, 11, student at Rohan Woods School.
Supports opera: Some of his favorites are Rusalka by Dvorak, La Sonnambula by Bellini and Semiramide by Rossini.
Enjoys hitting the links: “I’m an avid and perhaps overly competitive golfer.”
Camps throughout Missouri and Illinois: “It’s great one-on-one time with my boys. I actually never camped until my boys got into Boy Scouts.”