- Maternal and Fetal Medicine
Clinical Assistant Professor, Obstetrics & Gynecology - Maternal Fetal Medicine
Board Certification: American Board of Obstetrics and Gynecology, Maternal and Fetal Medicine (2019)
Board Certification, Maternal Fetal Medicine, American Board of Obstetrics and Gynecology (2019)
Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2015)
Fellowship: UCSD Maternal Fetal Medicine Fellowship (2017) CA
Residency: Cedars Sinai Medical Center Obstetrics and Gynecology Residency (2014) CA
Medical Education: University of California at Irvine School of Medicine Registrar (2010) CA
Postpartum Readmission for Hypertension After Discharge on Labetalol or Nifedipine.
Obstetrics and gynecology
To assess whether readmission for hypertension by 6 weeks postpartum differed between patients discharged on nifedipine or labetalol.This cohort study included patients with delivery admissions from 2006 to 2017 who were discharged from the hospital on nifedipine or labetalol and were included in a large, national adjudicated claims database. We identified patients' discharge medication based on filled outpatient prescriptions. We compared rates of hospital readmission for hypertension between patients discharged postpartum on labetalol alone, nifedipine alone, or combined nifedipine and labetalol. Patients with chronic hypertension without superimposed preeclampsia were excluded. Comparisons based on medication were performed using logistic regression models with adjustment for prespecified confounders. Comparisons were also stratified by hypertensive disorder of pregnancy severity.Among 1,582,335 patients overall, 14,112 (0.89%) were discharged postpartum on labetalol, 9,001 (0.57%) on nifedipine, and 1,364 (0.09%) on both medications. Postpartum readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine (641 patients vs 185 patients, 4.5% vs 2.1%, adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine for both mild (4.5% vs 2.7%, aOR 1.57, 95% CI 1.29-1.93) and severe hypertensive disorders of pregnancy (261 patients vs 72 patients, 5.7% vs 3.2%, aOR 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent on combined nifedipine and labetalol compared with nifedipine (3.1% vs 2.1%), but the odds were lower after confounder adjustment (aOR 0.80, 95% CI 0.64-0.99).Postpartum discharge on labetalol was associated with increased risk of readmission for hypertension compared with discharge on nifedipine.
View details for DOI 10.1097/AOG.0000000000004918
View details for PubMedID 36075068
Clinical and Hospital Factors Associated with Increased Cesarean Birth Rate Among People with Epilepsy
SPRINGER HEIDELBERG. 2022: 216
View details for Web of Science ID 000762765300443
Provider utilization of gestational diabetes screening methods - Have practices changed since the HAPO trial?
MOSBY-ELSEVIER. 2022: S483-S484
View details for Web of Science ID 000737459401108
To Eat or not to Eat? Provider Recommendations Surrounding Oral Intake Before the 50g OGTT
MOSBY-ELSEVIER. 2022: S350-S351
View details for Web of Science ID 000737459400522
Patient preferences, beliefs, and experiences regarding oral intake and the 1-hour oral glucose tolerance test
MOSBY-ELSEVIER. 2022: S325-S326
View details for Web of Science ID 000737459400479
Ketonuria is associated with a positive 1-hour oral glucose tolerance test
MOSBY-ELSEVIER. 2022: S574-S575
View details for Web of Science ID 000737459401259
Fasting vs fed: A randomized trial assessing oral intake prior to the glucose tolerance test
MOSBY-ELSEVIER. 2022: S189
View details for Web of Science ID 000737459400263
Association of Epilepsy and Severe Maternal Morbidity.
Obstetrics and gynecology
OBJECTIVE: To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy.METHODS: We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models.RESULTS: Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion.CONCLUSION: Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.
View details for DOI 10.1097/AOG.0000000000004562
View details for PubMedID 34619720
Clinical factors associated with spontaneous preterm birth in women with active post-traumatic stress disorder
MOSBY-ELSEVIER. 2021: S100
View details for Web of Science ID 000621547400147
Inflammatory bowel disease and the impact on rates of chorioamnionitis, sepsis, and severe maternal morbidity
MOSBY-ELSEVIER. 2021: S441–S442
View details for Web of Science ID 000621547401249
- Positive antenatal Edinburgh Depression Scale: examining behavioral and pharmacological therapy on maternal and neonatal outcomes JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 2020; 33 (2): 212–16
- Post-traumatic stress disorder in pregnancy: Does treatment impact the risk of preterm birth? MOSBY-ELSEVIER. 2020: S328
- Comparing insulin, metformin, and glyburide in treating diabetes in pregnancy and analyzing obstetric outcomes MOSBY-ELSEVIER. 2020: S481
Discovery and Verification of Extracellular miRNA Biomarkers for Non-invasive Prediction of Pre-eclampsia in Asymptomatic Women.
Cell reports. Medicine
2020; 1 (2)
Development of effective prevention and treatment strategies for pre-eclampsia is limited by the lack of accurate methods for identification of at-risk pregnancies. We performed small RNA sequencing (RNA-seq) of maternal serum extracellular RNAs (exRNAs) to discover and verify microRNAs (miRNAs) differentially expressed in patients who later developed pre-eclampsia. Sera collected from 73 pre-eclampsia cases and 139 controls between 17 and 28 weeks gestational age (GA), divided into separate discovery and verification cohorts, are analyzed by small RNA-seq. Discovery and verification of univariate and bivariate miRNA biomarkers reveal that bivariate biomarkers verify at a markedly higher rate than univariate biomarkers. The majority of verified biomarkers contain miR-155-5p, which has been reported to mediate the pre-eclampsia-associated repression of endothelial nitric oxide synthase (eNOS) by tumor necrosis factor alpha (TNF-α). Deconvolution analysis reveals that several verified miRNA biomarkers come from the placenta and are likely carried by placenta-specific extracellular vesicles.
View details for DOI 10.1016/j.xcrm.2020.100013
View details for PubMedID 32864636
View details for PubMedCentralID PMC7455024
Ultrasound Measurements of Frontal Horns and the Cavum Septi Pellucidi in Healthy Fetuses in the Second and Third Trimesters of Pregnancy.
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
OBJECTIVES: To assess the visualization rate and size of the frontal horns (FHs) and cavum septi pellucidi (CSP) in healthy fetuses throughout pregnancy.METHODS: After Institutional Review Board approval, 522 consecutive uncomplicated singleton pregnancies between 15 and 39 gestational weeks were enrolled in the study. Ultrasound measurements of the anterior horn width (AHW), center from the horn distance (CFHD), distance from the FHs to the CSP, and CSP width were retrospectively performed using axial transventricular or transcerebellar planes. Available maternal body mass indices were recorded.RESULTS: At least 1 FH was seen in 78% of the cases. The mean AHW decreased over the second trimester and plateaued in the third trimester. The CFHD plateaued in the second trimester and increased in the third trimester. Downside FHs were generally larger than upside FHs. More FHs were measured in transventricular (69%) than transcerebellar (31%) planes. Frontal horns were seen with high, low, and no confidence in 57%, 21%, and 22% of cases, respectively. No-confidence rates were 17% in the second trimester and 42% in the third trimester. The CSP was not visualized in 4% of cases; 15 of 19 cases of a nonvisualized CSP were scanned between 18 and 37 weeks. Mean body mass indices ± SDs were 27.6±6.7 kg/m2 for the patients in cases of a visualized CSP and 32.4±9.1 kg/m2 for the patients in cases of a nonvisualized CSP.CONCLUSIONS: Normative data for the fetal FH and CSP width were established. Frontal horns are more frequently seen on transventricular views and are difficult to confidently assess in the late third trimester. This study challenges previously reported data that the CSP is seen in 100% of cases from 18 to 37 weeks.
View details for DOI 10.1002/jum.15086
View details for PubMedID 31281992
- Recognizing maternal mental health disorders: beyond postpartum depression CURRENT OPINION IN OBSTETRICS & GYNECOLOGY 2019; 31 (2): 116–19
Recognizing maternal mental health disorders: beyond postpartum depression.
Current opinion in obstetrics & gynecology
PURPOSE OF REVIEW: Maternal mental health disorders, including anxiety and depression, are one of the most common obstetric complications, presenting in pregnancy and postpartum.RECENT FINDINGS: Maternal mental health disorders are associated with adverse maternal and neonatal outcomes. Screening women in pregnancy and postpartum for mental health disorders is key to early identification and treatment of anxiety and depression in the perinatal population. Although universal screening is now recommended by numerous professional organizations, rates of screening are low and often not performed with a validated screening instrument. Although clinical assessment is important, it is insufficient to identify maternal mental health disorders. As symptoms may change throughout pregnancy, screening for anxiety and depression should be done at multiple time points in pregnancy, including intake and postpartum. In addition, it is important to complete a mental health history on intake to identify women who are either at risk for, or experiencing, anxiety and depression. All screening programmes must be accompanied by a protocol to respond to a positive screen to ensure appropriate follow-up and treatment.SUMMARY: Identification and treatment of maternal mental health disorders has important implications for maternal and child health. Obstetric providers should screen all women using a validated screening instrument and have systems in place to ensure timely diagnosis and treatment.
View details for PubMedID 30694850
Discovery and verification of maternal serum miRNA biomarkers predictive of preeclampsia
MOSBY-ELSEVIER. 2019: S344
View details for Web of Science ID 000454249401298
Obstetric outcomes for women receiving newer generation antiepileptic drugs: retrospective cohort study using claims database
MOSBY-ELSEVIER. 2019: S344–S345
View details for Web of Science ID 000454249401299
- Outcomes of women with primary and secondary pulmonary hypertension during pregnancy MOSBY-ELSEVIER. 2019: S405
Positive antenatal Edinburgh Depression Scale: examining behavioral and pharmacological therapy on maternal and neonatal outcomes.
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians
OBJECTIVE: We hypothesized that women with a positive antenatal Edinburgh Depression Screen (EPDS) (≥10), undergoing behavioral or pharmacologic therapy have improved maternal and neonatal outcomes.STUDY DESIGN: This is a retrospective study of singleton pregnancies at UC, San Diego from 2010 to 2014. Patients with an antenatal EPDS were subdivided based on their intervention: negative score, positive score no treatment, behavioral therapy only, and pharmacologic therapy. The primary outcome was rate of preterm birth with secondary outcomes of maternal and neonatal outcomes.RESULTS: Patients with a positive EPDS had a higher rate of preterm delivery, small-for-gestational age, NICU admission and Apgar score <7. Rates of adverse outcomes were highest among women receiving pharmacologic therapy. Rates of adverse outcomes women were not increased in the behavioral therapy group compared to the negative EPDS group. When adjusting for confounding variables, patient with a positive EPDS were more likely deliver preterm with an adjusted odds ratio of 1.71. Among varying treatment modalities, the odds ratio for preterm delivery was not statistically significant.CONCLUSION: Adverse pregnancy outcomes were highest among those requiring pharmacotherapy. Behavioral therapy had a positive effect on outcomes. Intervention to reduce these adverse outcomes in these patients needs further study.
View details for PubMedID 30033785
- Continuous Glucose Monitoring in Pregnancies Complicated by Type 1 Diabetes Mellitus LIPPINCOTT WILLIAMS & WILKINS. 2018: 125S
Maternal extracellular miRNAs as biomarkers for placental dysfunction between 17-28 weeks gestation
MOSBY-ELSEVIER. 2018: S197
View details for Web of Science ID 000422946900313
Anti-coagulation complications in pregnancies with severe pulmonary arterial hypertension.
journal of maternal-fetal & neonatal medicine
Epoprostenol, a potent vasodilator, is the treatment of choice for severe pulmonary arterial hypertension (PAH) in pregnancy. However, its inhibition of platelet aggregation increases the risk of coagulation complications with conjunctive use of anti-coagulants for thromboprophylaxis.Case 1 demonstrates a pregnancy complicated by thrombocytopenia. Case 2 describes a pregnancy with newly diagnosed PAH at 35 weeks who delivered by repeat cesarean delivery complicated by a wound hematoma. Case 3 describes a patient who delivered at 32 weeks. She required extracorporeal membrane oxygenation and a heart-lung transplant. Her care was further complicated by severe thrombocytopenia with postpartum hemorrhage refractory to usual conservative measures.This case series describes three patients with severe PAH in pregnancy and the range of different complications that arose from anticoagulation in the setting of epoprostenol.
View details for DOI 10.1080/14767058.2017.1312329
View details for PubMedID 28353362
Pre-gestational versus gestational diabetes: A population based study on clinical and demographic differences
JOURNAL OF DIABETES AND ITS COMPLICATIONS
2014; 28 (1): 29-34
To assess the clinical and demographic differences in patients with pre-gestational diabetes mellitus (PGDM) compared to those with gestational diabetes (GDM).Using the 2001-2007 California Health Discharge Database, we identified 22,331 cases of PGDM and 147,097 cases of GDM via ICD-9-CM codes after excluding cases which were missing race or age data or with extremes of age. Data analyzed included demographics, pre-existing medical conditions, antepartum complications, and intrapartum complications. Logistic regression was used to adjust for potential confounders.Both PGDM and GDM incidences increased during the study period. Advancing age was associated with increased prevalence of both diseases. Although Asians were found to have the highest prevalence of GDM, they, along with Caucasians, were found have the lowest prevalence of PGDM. Conditions with increased frequency in PGDM versus GDM included chronic hypertension, renal disease, thyroid dysfunction, fetal CNS malformation, fetal demise, pyelonephritis, and eclampsia. Subjects with PGDM were more likely than those with GDM to have a shoulder dystocia, failed induction of labor, or undergo cesarean delivery.We have demonstrated clinical morbidities and demographic factors which differ in patients with PGDM compared to patients with GDM. Our findings suggest PGDM to be associated with significantly higher morbidity when compared to GDM. Our findings also suggest that races with the highest tendency for GDM during pregnancy may not necessarily have the highest tendency for PGDM outside of pregnancy.
View details for DOI 10.1016/j.jdiacomp.2013.08.009
View details for Web of Science ID 000329592100008
View details for PubMedID 24094665
View details for PubMedCentralID PMC3887473
Contemporary 2-year outcomes of complex gastroschisis
JOURNAL OF PEDIATRIC SURGERY
2012; 47 (8): 1521-1528
Outcomes of gastroschisis are influenced by associated intestinal complications. We present a detailed analysis of complex gastroschisis.A retrospective study of all patients with gastroschisis treated at 2 university neonatal intensive care units between January 1, 2001, and March 31, 2007, was performed.Of 83 patients, 19 (23%) had complex gastroschisis, including atresias (68%), gangrene (37%), closing gastroschisis (32%), perforation (21%), strictures (21%), and volvulus (11%). Prenatal ultrasound did not predict complications. Fifty-three percent underwent primary closure. Duration of mechanical ventilation and total parenteral nutrition (TPN) was 14.4 ± 1.9 days and 90.7 ± 9.0 days, respectively. Enteral feeds started at 35.9 ± 4.6 days. Hospital stay was 104.4 ± 9.6 days. Patients underwent a median of 3 abdominal procedures (range, 2-5) before discharge. Ninety-five percent survived to discharge; 33% and 67% were discharged on TPN and gastrostomy feeds, respectively. Two-year survival was 89%, with 82% on full oral feeding, 12% on a combination of oral and gastrostomy feeding, and 1 patient (who received a liver/bowel transplant) on a combination of enteral and parenteral nutrition.Complex gastroschisis continues to produce significant morbidity. However, most of the patients are TPN free by 2 years of age.
View details for DOI 10.1016/j.jpedsurg.2011.12.023
View details for Web of Science ID 000308000100017
View details for PubMedID 22901911
Gastroschisis: a multi-centre comparison of management and outcome.
African journal of paediatric surgery : AJPS
2012; 9 (1): 17-21
Anecdotal evidence and a handful of literature reports suggest that the outcome for infants born with gastroschisis in many African countries is poor when compared to Western nations. We wished to evaluate current management strategies and outcomes in African and Western units that treat infants with gastroschisis.We conducted a retrospective review of case-notes for infants with gastroschisis who presented to a hospital between 1 January 2004 and 31 December 2007. There were five participating centres, divided for analysis into an African cohort (three centres) and a Western cohort (two centres).Fewer infants presented to a hospital with gastroschisis in the African cohort when compared to the Western cohort, particularly when the size of catchment area of each hospital was taken into account. The physiological state of the infant on presentation and management strategy varied widely between centres. Primary closure, preformed silo and surgical silo with delayed closure were all utilised in the African cohort. Use of the preformed silo and delayed abdominal wall closure was the strategy of choice in the Western cohort. The 30-day mortality was 23% and 1% respectively. This primary outcome measure varied considerably in the African cohort but was the same in the two Western units.Gastroschisis in the African cohort was characterised by fewer infants presenting to a hospital and a more variable outcome when compared to the Western cohort. A detailed epidemiological study to determine the incidence of gastroschisis in African countries may provide valuable information. In addition, interventions such as prompt resuscitation, safe neonatal transfer, the use of the preformed silo and parenteral nutrition could improve outcomes in infants with gastroschisis.
View details for DOI 10.4103/0189-6725.93296
View details for PubMedID 22382099
The controlled release of drugs from emulsified, sol gel processed silica microspheres
2009; 30 (5): 850-858
Controlled release silica sol gels are room temperature processed, porous, resorbable materials with generally good compatibility. Many molecules including drugs, proteins and growth factors can be released from sol gels and the quantity and duration of the release can vary widely. Processing parameters render these release properties exquisitely versatile. The synthesis of controlled release sol gels typically includes acid catalyzed hydrolysis to form a sol with the molecules included. This is then followed by casting, aging and drying. Additional steps such as grinding and sieving are required to produce sol gel granules of a desirable size. In this study, we focus on the synthesis of sol gel microspheres by using a novel process with only two steps. The novelty is related to acid-base catalysis of the sol prior to emulsification. Sol gel microspheres containing either vancomycin (antibiotic) or bupivacaine (analgesic) were successfully synthesized using this method. Both drugs showed controlled, load dependent and time dependent release from the microspheres. The in vitro release properties of sol gel microspheres were remarkably different from those of sol gel granules produced by grinding and sieving. In contrast to a fast, short-term release from granules, the release from microspheres was slower and of longer duration. In addition, the degradation rate of microspheres was significantly slower than that of the granules. Using various mathematical models, the data reveal that the release from sol gel powder is governed by two distinct phases of release. In addition, the release from emulsified microspheres is delayed, a finding that can be attributed to differences in surface properties of the particles produced by emulsification and those produced by casting and grinding. The presented results represent an excellent data set for designing and implementing preclinical studies.
View details for DOI 10.1016/j.biomaterials.2008.09.066
View details for Web of Science ID 000262552600020
View details for PubMedID 19010531
Closed loop foregut obstruction in a premature neonate
JOURNAL OF PEDIATRIC SURGERY
2008; 43 (7)
Multiple foregut atresias are exceedingly rare. We present a unique case of combined pyloric and duodenal atresia in a premature neonate. The anomaly appeared to evolve into a closed loop foregut obstruction in the postnatal period. Foregut continuity was established with a gastroduodenostomy, duodenoduodenostomy, and duodenal tapering. The child survived and continued to thrive at 2 years of age.
View details for DOI 10.1016/j.jpedsurg.2008.02.054
View details for Web of Science ID 000258333300041
View details for PubMedID 18639667
Comparison of pulse wave analysis between persons with white coat hypertension and normotensive persons.
Journal of clinical hypertension
2007; 9 (7): 513-517
White coat hypertension (WCH) is considered by some but not all investigators to be a benign condition without increased cardiovascular risk. Pulse wave analysis is a noninvasive method to measure how the reflected pressure wave interacts with central aortic blood pressure (BP) and to assess how it is related to vascular stiffness. The purpose of the study was to compare central aortic BP in normotensive and WCH participants. WCH participants were identified after ambulatory BP monitoring. Normotensive participants served as controls. Using radial artery applanation tonometry, aortic pulse wave analysis was performed. Augmentation index (AI), AI75, and differences in systolic BP between central aortic and peripheral vasculatures were calculated. Results show a difference in AI, AI75, (AI standardized to a heart rate of 75 beats per minute), and central aortic systolic pressures between WCH and normotensive participants. The WCH group had significantly higher systolic BP and pulse pressure; however, these were still within the normal range. In summary, WCH participants had increased central aortic pressures compared with normotensives, supporting the potential for increased cardiovascular risk in WCH.
View details for PubMedID 17617760
- Emulsified sol-gel microspheres for controlled drug delivery TRANS TECH PUBLICATIONS LTD. 2007: 1025-+