Uniquely Ulisse

Sara Colombo walked out of her ultrasound appointment with no hope after a Miami-based doctor gave a grim prognosis. In a few days, he said, Sara’s extremely anemic fetus would be stillborn, just shy of 20 weeks.

Two years later, Ulisse bounds across the Colombos’ house, chasing their cavalcade of dogs and impishly grinning when caught by his dad, Ugo.

“If not for Mayo Clinic, we wouldn’t have had a baby,” Sara says.

The man at the center of Sara’s care at Mayo Clinic, obstetrician and fetal surgeon Rodrigo Ruano, M.D., Ph.D., describes it another way.

“I call Ulisse a miracle baby,” Dr. Ruano says. “That’s the best definition.”

A Series of Fortunate Events

Sara was in shock following her ultrasound appointment that Friday in January 2017.

A decade after her first two children — Uberto and Stella — were born, she and Ugo were excited and surprised when Sara discovered she was pregnant again. Up to that point in her pregnancy, things had been pretty normal, and she and Ugo had been planning a trip to Paris. They were to depart the day after her checkup when their lives were thrown into tumult.

“Friday, I had zero hope and zero focus,” Sara says. “Ugo’s very methodical. In a crisis like that, he starts to research and ask questions.”

She and Ugo tried to decide what to do next while still taking their older children to their weekend activities.

Ugo first called a friend at the University of Miami’s Miller School of Medicine to discuss the situation and its urgency. Then, the Colombos decided to turn to Mayo Clinic.

An Italian-born real estate developer, Ugo had a long relationship as a patient at Mayo Clinic under physician Ian D. Hay, M.D., Ph.D., Dr. Richard F. Emslander Professor of Endocrinology and Nutrition Research, and knew the organization was an international destination for complex and serious patient care. That knowledge led the Colombos to quickly connect with Mayo Clinic to arrange an appointment.

No Time to Wait

As soon as they could, the Colombos flew to Rochester, Minnesota, where they met Dr. Ruano, the chair of the Division of Maternal and Fetal Medicine at Mayo Clinic.

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Extra Effort

“I believe in the teamwork, the technology, the innovation and Mayo’s primary value — the needs of the patient come first,” says Rodrigo Ruano, M.D., Ph.D., who learned firsthand of the clinic as a visiting resident at the Jacksonville, Florida, campus in 2000. “That was my personal philosophy. I need to do the best for every patient I see.”

Dr. Ruano is an international expert in complex fetal surgery techniques, including fetoscopic laser ablation for twin-to-twin transfusion syndrome, fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia, in utero repair of spina bifida, fetal cystoscopy for lower urinary tract obstruction, intrauterine fetal blood transfusion and in utero treatment of fetal tumors.

“We are here to give hope. We are here to give the babies a chance,” Dr. Ruano says. “I fight for those babies; I fight for those moms; I fight for those families.”

Though Dr. Ruano was a perfect fit for Mayo Clinic’s team-based approach and its efforts to establish a center of excellence for fetal surgery in the Midwest, getting him to Rochester, Minnesota, was unique.

As a Brazilian-born physician who was trained outside the United States, Dr. Ruano would have needed to pass the U.S. Medical Licensing Exam — a three-step examination for medical licensure that typically takes at least a year of study to pass.

Some states, such as Texas, where Dr. Ruano had previously practiced, adopted provisions that allowed skilled international physicians to practice at academic medical centers.

But Minnesota wasn’t one of them. In May 2016 Mayo Clinic appealed to change the law in Minnesota, opening the door for Mayo Clinic and the University of Minnesota to allow highly skilled physicians such as Dr. Ruano to practice.

“It meant a lot for Mayo Clinic to do this for me,” Dr. Ruano says. “When I joined Mayo, I decided to join because of opportunities that we have here of doing something different.”

Benefactor support such as that given by Ugo and Sara Colombo helps continue research into leading-edge surgical innovations and develop new techniques that are quickly deployed into practice.

“There are many opportunities nowadays to treat difficult diseases in utero,” Dr. Ruano says. “We have a vision to offer fetal interventions to as many patients as we can, and we hope Mayo Clinic becomes a destination medical practice for these types of procedures. We are progressing, we are moving so fast and we are going to do so much in the future.”

After a quick examination, Dr. Ruano acknowledged just how serious the situation was. The fetus had hydrops, a condition where fluid accumulates in places it shouldn’t. The cause became apparent too.

“I thought the baby would die,” Dr. Ruano says. “It was not moving a lot. It was hydropic. In the ultrasound, we discovered signs of fetal anemia. The baby wasn’t getting any blood. We did some lab tests. We determined the fetal red cells were being destroyed by Sara’s immune system. That’s very severe, very lethal.”

Thanks to Mayo Clinic’s on-site laboratory services, the initial appointment and associated lab work took only about an hour before Dr. Ruano and his team came up with a plan — they’d start special blood transfusions directly to the fetus in utero through the umbilical cord, which was a risky proposition at 19½ weeks because of how early it was in the pregnancy.

“Dr. Ruano was very clear. He never said this is going to work 100%,” Sara says. “But, we had gone from zero hope to, OK, maybe we can save the baby. So, obviously, we’re going to try to save the baby.”

It still seemed like a long shot.

Dr. Ruano, who specializes in complex fetal conditions, transfused blood to the umbilical cord. However, with the heart getting weaker, he had to inject medication to help the fetus’s heart and resuscitate it through what’s known as intrauterine cardiac compressions.

“He saved the baby,” Ugo says.

By the next day, the hydrops had resolved substantially. But Sara’s fetus continued to need transfusions every two weeks. The second and third transfusions were tolerated well, but Mayo Clinic’s multidisciplinary staff was ready if things went awry.

A Sudden Arrival

In March, the day of the fourth transfusion, neonatologist Christopher E. Colby, M.D., was on call and stopped by to counsel the family.

“I was paged to visit with the family by Dr. Ruano and his team,” Dr. Colby says. “The reason the discussion was important was that the pregnancy had progressed to a point that there was a meaningful chance of survival if the baby didn’t tolerate the transfusion and needed to be delivered. The family needed to understand the basics of newborn resuscitation at such an early gestational age.”

Dr. Colby discussed the case with the Colombos and took time to answer all their questions. He told them that he anticipated the procedure would go smoothly and that Dr. Ruano would continue taking care of them.

Later that day, Dr. Colby received another page.

“I got called over to the delivery room because they were having trouble keeping Ulisse’s heart rate in a normal range during the transfusion,” Dr. Colby says. “Dr. Ruano was doing everything he could to bring the heart rate back into a normal range, but it remained so dangerously low that they decided they were going to have to deliver.”

Sara underwent an emergency C-section. Ulisse wasn’t faring well out of the womb either.

“I remember almost every step of the resuscitation,” Dr. Colby says. “It took several minutes for his heart rate to recover into a normal range. By 15 minutes he had a breathing tube in and his heart rate was normal. I remember thinking, we have a good chance of this baby surviving.”

Surviving and Thriving

Ulisse Colombo was born March 20, 2017, 12 weeks early and 1,436 miles away from his future home. He went to the NICU at Mayo Clinic Hospital – Rochester, Saint Marys Campus.

While there have been great advancements in saving extremely premature babies, infants younger than 22 weeks aren’t developed enough to survive.

“Dr. Ruano took a 19-week fetus that was dying and stabilized him,” says neonatologist Douglas P. Derleth, M.D., the attending physician the first week of Ulisse’s life. “We went from previable at 19 weeks and very sick to still premature but viable at 28 weeks.”

The Colombos elected to have Ulisse transported by the Mayo Clinic neonatal transport team to Miami at 34 weeks to be closer to his family and finish his time in the hospital. Then, finally, he went home for good on June 28, 2017.

“The way I think about it, any one of these newborn risk factors creates challenges — severe anemia, cardiac arrest at birth or significant prematurity,” Dr. Colby says. “Ulisse had all three, and despite that combination of risk factors, he’s thriving.”

A Culture of Caring

Sara says subsequent visits to health care providers determined that Ulisse has no long-term cardiac issues. As Ulisse grew, the Colombos decided to help advance Mayo Clinic’s mission and the work of maternal fetal medicine.

“What Dr. Ruano wants to do with his research and his focus at Mayo Clinic is something that we believe should be supported,” Sara says. “We walked out of that NICU with a result that I know a lot of families I saw every day in there didn’t leave with. I know they didn’t. If maybe we could make a difference for some of those families and the families that pass through Mayo, it would mean so much. Mayo is serving the entire world really.”

Mayo Clinic honors the Colombos by recognizing them as Distinguished Benefactors.

For Ulisse, every day is a new experience.

“There’s absolutely no question in my mind that without Mayo Clinic there would be no Ulisse,” Sara says. “He just would not be here.”■

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