- Maternal and Fetal Medicine
- Preterm Birth
- Prenatal Diagnosis
Medical Director, Sequoia Perinatal Diagnostic Center in Redwood City (2013 - Present)
Medical Director, Perinatal Diagnostic Center-Salinas (2006 - 2012)
Honors & Awards
Boggs Research Award, Philadelphia Perinatal Society (2006)
Board Certification: Maternal and Fetal Medicine, American Board of Obstetrics and Gynecology (2008)
Fellowship:Thomas Jefferson Univ Hospital (2006) PA
Board Certification: Obstetrics and Gynecology, American Board of Obstetrics and Gynecology (1985)
Residency:New York Hospital/Cornell Medical Center (1983) NY
Internship:UCLA Health Sciences (1980) CA
Medical Education:Albert Einstein College of Medicine Office of the Registrar (1979) NY
Board Certification, ABOG, Maternal Fetal Medicine (2008)
BS/AA, Yeshiva University, PreMed Biology (1975)
MD, Albert Einstein, Medical School (1979)
MD, UCLA, Internship OB/GYN (1980)
MD, Cornell, Residency OB/GYN (1983)
MD, Thomas Jefferson University, Maternal Fetal Medicne (2006)
MSCP, Thomas Jefferson Universtiy, Human Investigation (2007)
Current Research and Scholarly Interests
Progesterone for Maintenance Tocolysis: A Randomized Placebo Controlled Trial
Preterm delivery is the most common cause of infant morbidity and mortality in the United States. Some women have episodes of preterm labor during their pregnancy which can be temporarily stopped. These women, however, are at high risk for delivering before term. At this time, we do not have sufficient evidence to use any medication to help prevent these women from delivering early. Recently, preliminary studies have shown that progesterone may help prevent some women at high risk for preterm delivery from delivering early. Our study will investigate whether progesterone can help this specific group of women, women with arrested preterm labor, deliver healthy infants at term.
Stanford is currently not accepting patients for this trial.
Independent Studies (5)
- Directed Reading in Obstetrics and Gynecology
OBGYN 299 (Win, Spr, Sum)
- Early Clinical Experience in Obstetrics and Gynecology
OBGYN 280 (Win, Spr, Sum)
- Graduate Research in Reproductive Biology
OBGYN 399 (Win, Spr, Sum)
- Medical Scholars Research
OBGYN 370 (Win, Spr, Sum)
- Undergraduate Research in Reproductive Biology
OBGYN 199 (Win, Spr, Sum)
- Directed Reading in Obstetrics and Gynecology
Cervical length screening for prevention of preterm birth in singleton pregnancy with threatened preterm labor: systematic review and meta-analysis of randomized controlled trials using individual patient-level data.
Ultrasound in obstetrics & gynecology
2017; 49 (3): 322-329
Cervical length screening by transvaginal sonography (TVS) has been shown to be a good predictive test for spontaneous preterm birth (PTB) in symptomatic singleton pregnancy with threatened preterm labor (PTL). The aim of this review and meta-analysis of individual participant data was to evaluate the effect of knowledge of the TVS cervical length (CL) in preventing PTB in singleton pregnancies presenting with threatened PTL.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and the Cochrane Complementary Medicine Field's Trials Register (May 2016) and reference lists of retrieved studies. Selection criteria included randomized controlled trials of singleton gestations with threatened PTL randomized to management based mainly on CL screening (intervention group), or CL screening with no knowledge of results or no CL screening (control group). Participants included women with singleton gestations at 23 + 0 to 36 + 6 weeks with threatened PTL. We contacted corresponding authors of included trials to request access to the data and perform a meta-analysis of individual participant data. Data provided by the investigators were merged into a master database constructed specifically for the review. The primary outcome was PTB < 37 weeks. Summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% CI.Three trials including a total of 287 singleton gestations with threatened PTL between 24 + 0 and 35 + 6 weeks were included in the meta-analysis, of which 145 were randomized to CL screening with knowledge of results and 142 to no knowledge of CL. Compared with the control group, women who were randomized to the known CL group had a significantly lower rate of PTB < 37 weeks (22.1% vs 34.5%; RR, 0.64 (95% CI, 0.44-0.94); three trials; 287 participants) and a later gestational age at delivery (MD, 0.64 (95% CI, 0.03-1.25) weeks; MD, 4.48 (95% CI, 1.18-8.98) days; three trials; 287 participants). All other outcomes for which there were available data were similar in the two groups.There is a significant association between knowledge of TVS CL and lower incidence of PTB and later gestational age at delivery in symptomatic singleton gestations with threatened PTL. Given that in the meta-analysis we found a significant 36% reduction in the primary outcome, but other outcomes were mostly statistically similar, further study needs to be undertaken to understand better whether the predictive characteristics of CL screening by TVS can be translated into better clinical management and therefore better outcomes and under what circumstances. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. CRIBADO MEDIANTE LA LONGITUD CERVICAL PARA LA PREVENCIÓN DEL PARTO PRETÉRMINO EN EMBARAZOS CON FETO ÚNICO Y RIESGO DE PARTO PREMATURO: REVISIÓN SISTEMÁTICA Y METAANÁLISIS DE ENSAYOS CONTROLADOS ALEATORIZADOS HACIENDO USO DE LOS DATOS INDIVIDUALES DE LAS PACIENTES: RESUMEN OBJETIVO: El cribado mediante la longitud cervical obtenida con ecografía transvaginal (ETV) ha demostrado ser una buena prueba para la predicción del parto pretérmino espontáneo (PPTE) en embarazos con feto único sintomáticos debido a la amenaza de parto pretérmino (PPT). El objetivo de esta revisión y metaanálisis de los datos de participantes individuales fue evaluar el efecto de medir la longitud cervical (LC) mediante ETV con el fin de prevenir el parto prematuro en embarazos únicos con amenaza de PPT. MÉTODOS: Se realizaron búsquedas en los ficheros de ensayos de Cochrane Pregnancy and Childbirth Group y Complementary Medicine Field (mayo de 2016), y en las listas de referencias de los estudios encontrados. Los criterios de selección incluyeron ensayos controlados aleatorizados de embarazos con feto único y riesgo de PPT con aleatorización de la paciente basada principalmente en el cribado mediante la LC (grupo de intervención), el cribado mediante la LC sin conocimiento de los resultados, o sin cribado de LC (grupo de control). Las participantes fueron mujeres embarazadas con feto único desde las 23 + 0 hasta las 36 + 6 semanas y con riesgo de PPT. Se estableció contacto con los autores de los ensayos incluidos para solicitar el acceso a los datos y llevar a cabo un metaanálisis de los datos de las participantes individualmente. Los datos proporcionados por los investigadores se agregaron a una base de datos maestra creada específicamente para esta revisión. El resultado primario fue el PPTE < 37 semanas. Las medidas resumen se reportaron como riesgo relativo (RR) o como diferencia de medias (DM) con IC del 95%.En el metaanálisis se incluyeron tres ensayos con un total de 287 embarazos con feto único y riesgo de PPT entre 24 + 0 y 35 + 6 semanas, de los cuales 145 fueron asignados al azar a un cribado mediante la LC con conocimiento de los resultados y 142 a aquellos para los que se desconocía la LC. En comparación con el grupo control, las mujeres que fueron asignadas aleatoriamente al grupo en el que se conocía la LC tuvieron una tasa de parto prematuro a < 37 semanas significativamente menor (22,1% vs. 34,5%; RR 0,64 (IC 95%, 0,44-0,94); 3 ensayos; 287 participantes ) y una edad gestacional al momento del parto más tardía (DM 0,64 (IC 95%, 0.03-1.25) semanas; DM 4,48 (IC 95%, 1,18-8,98) días; 3 ensayos; 287 participantes). El resto de los resultados para los cuales había datos disponibles fueron similares en ambos grupos.Existe una asociación significativa entre el conocimiento de la LC obtenida mediante ETV y una menor incidencia de PPTE y edad gestacional más tardía en el momento del parto en embarazos con feto único sintomáticos debido al riesgo de parto pretérmino (PPT). Teniendo en cuenta que en el metaanálisis se encontró una reducción significativa del 36% en el resultado primario, pero que los otros resultados fueron estadísticamente similares en su mayoría, serán necesarios más estudios para entender mejor si las propiedades predictivas del cribado mediante la LC obtenida con ETV se pueden traducir en una mejor atención clínica y por lo tanto mejores resultados dependiendo de las circunstancias. :META: : ,(preterm labor,PTL),(transvaginal sonography,TVS)(spontaneous preterm birth,PTB)。metaPTL,TVS(cervical length,CL)PTB。 : CochraneCochrane(20165)。PTL,CL()CLCL()。23 + 036+6PTL。,,meta。。37PTB。(relative risk,RR)95%CI(mean difference,MD)。 : meta3,28724 + 035+6PTL,145CL,142CL。,CL37PTB[22.1%34.5%;RR,0.64(95% CI,0.44 ~ 0.94);3;287],[MD,0.64(95% CI,0.03 ~ 1.25);MD,4.48(95% CI,1.18 ~ 8.98);3;287]。2,。 : PTL,TVS CLPTB。meta36%,,,TVSCL,。.
View details for DOI 10.1002/uog.17388
View details for PubMedID 27997053
Fetofetal Transfusion Syndrome in Monochorionic-Triamniotic Triplets Treated with Fetoscopic Laser Ablation: Report of Two Cases and A Systematic Review.
2015; 5 (2): e153-60
Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.
View details for DOI 10.1055/s-0035-1552931
View details for PubMedID 26495175
Maternal-fetal medicine fellowship 3- and 4-dimensional ultrasound experience: room for improvement.
Journal of ultrasound in medicine
2013; 32 (6): 949-953
The purpose of this study was to assess maternal-fetal medicine (MFM) fellowship 3- and 4-dimensional (3D/4D) ultrasound experience and training.A 53-item prenatal diagnosis survey was emailed to 458 associate members of the Society for Maternal-Fetal Medicine. Associate members include both MFM fellows and recent graduates who are not yet board certified in MFM.A total of 148 associate members completed the survey (32% response rate); 92% were at least in their second year of a fellowship, and 48.1% had completed a fellowship. About half (50.8%) were capable of performing 3D/4D ultrasound examinations ("performers"), whereas 49.2% were not ("nonperformers"). Among performers, about 80% were capable of only basic image acquisition. Overall, 39.5% of respondents received no official 3D/4D ultrasound training, and 55.5% stated that fewer than 1 in 5 of their MFM faculty routinely performed 3D/4D ultrasound examinations. Compared with performers, nonperformers had less formal 3D/4D ultrasound training (53% versus 26%; P = .018) and fewer MFM faculty who performed 3D/4D ultrasound examinations (43% versus 68%; P = .005), and fewer nonperformers were taught by ultrasound mentors (25% versus 47.8%; P = .011).Most fellows are not trained in 3D/4D ultrasound. Greater emphasis on ultrasound mentorship and formalized ultrasound training by MFM faculty during fellowships is needed.
View details for DOI 10.7863/ultra.32.6.949
View details for PubMedID 23716515
Maternal-fetal medicine fellowship obstetrical ultrasound experience: results from a fellowship survey
2013; 33 (2): 158-161
To assess maternal-fetal medicine (MFM) fellowship obstetrical ultrasound training, scope of practice and research.A 52-item prenatal diagnosis survey was e-mailed to 458 associate members of the Society for Maternal-Fetal Medicine on two separate occasions. Associate members include both MFM fellows and recent graduates who are not yet board certified in MFM.A total of 148 associate members completed the survey (32% response rate), 92% of whom were at least in their second year of fellowship. A total of 58% of fellows spend at least 20% of their fellowship time performing prenatal ultrasounds, and most begin their ultrasound training in their first year. Most fellows describe being comfortable performing routine fetal anatomy surveys, growth ultrasounds and umbilical artery Doppler measurements, but only 48% are nuchal translucency (NT) certified, most through Nuchal Translucency Quality Review. A total of 7% of fellows do not receive structured training in 2D ultrasound, 39% receive no structured training in 3D/4D ultrasound, and 28% receive no structured training in fetal echocardiography. Only 38% can identify an ultrasound mentor during fellowship.Most fellows are trained in ultrasound during their first year of fellowship and feel comfortable performing routine exams. However, ultrasound mentorship, structured training and research in prenatal ultrasound are limited in some programs.
View details for DOI 10.1002/pd.4029
View details for Web of Science ID 000314493500010
View details for PubMedID 23229275
Prevention of Preterm Birth Based on Short Cervix: Symptomatic Women With Preterm Labor or Premature Prelabor Rupture of Membranes
SEMINARS IN PERINATOLOGY
2009; 33 (5): 343-351
The diagnosis of preterm labor (PTL) is challenging, especially in women whose cervical dilatation is <2 cm and who are <80% effaced. In symptomatic women, with threatened PTL in both singletons and twins, transvaginal ultrasound cervical length (CL) identifies a high-risk group that is more likely to be in true PTL, more likely to deliver sooner, and more likely to deliver preterm. The addition of fetal fibronectin improves the predictive accuracy in women whose CL is <30 mm but >15 mm. Transvaginal ultrasound CL can also be performed in the presence of ruptured membranes and predicts latency. Although additional data are needed, the evidence so far suggests that the use of transvaginal ultrasound CL and fetal fibronectin can be used to better identify and manage women with PTL likely to have an imminent preterm delivery, and to avoid interventions in women who would not.
View details for DOI 10.1053/j.semperi.2009.06.009
View details for Web of Science ID 000270760200009
View details for PubMedID 19796733
Does knowledge of cervical length and fetal fibronectin affect management of women with threatened preterm labor? A randomized trial
27th Annual Meeting of the Society-of-Maternal-Fetal-Medicine
The purpose of this study was to estimate the effect of sonographic cervical length (CL) and fetal fibronectin (FFN) on length of evaluation and outcomes in women with preterm labor (PTL).Women with threatened PTL were randomized to either a knowledge group (results of CL and FFN available and used according to study protocol), or a standard group (blinded to CL and FFN). Primary outcome was length of evaluation in triage.One hundred women were randomized. There was no significant difference between groups in length of evaluation, but in women with CL > or = 30 mm, the mean time for evaluation was significantly shorter in the knowledge group (1:58 h +/- 0:50 vs 2:53 h +/- 0:50, P = .004). Incidence of spontaneous preterm birth (SPTB) in the knowledge group was significantly reduced (13.0 vs 36.2%, P = .01).The knowledge of CL and FFN was associated with reduction in length of evaluation in women with CL > or = 30 mm and in incidence of SPTB in all women with PTL.
View details for DOI 10.1016/j.ajog.2007.07.017
View details for Web of Science ID 000250097300037
View details for PubMedID 17904989
Gestational age at cervical length measurement and incidence of preterm birth
OBSTETRICS AND GYNECOLOGY
2007; 110 (2): 311-317
To estimate the risk of spontaneous preterm birth based on transvaginal ultrasound cervical length and gestational age at which cervical length was measured.Women at high risk for spontaneous preterm birth and with transvaginal ultrasound cervical length measurements between weeks 12 and 32 were identified at one institution between July 1995 and June 2005. Inclusion criteria for women at high risk for spontaneous preterm birth were prior spontaneous preterm birth at 14 to 35 weeks, cone biopsy, müllerian anomaly, or two or more dilation and evacuations. Women with multiple gestations, cerclage, indicated preterm birth, or fetal anomalies were excluded. Logistic regression was used to estimate the spontaneous preterm birth risk before 35, 32, and 28 weeks.Seven hundred five women received 2,601 transvaginal ultrasound measurements for cervical length. The incidences of spontaneous preterm birth before 35, 32, and 28 weeks were 17.7, 10.6, and 6.7%, respectively. The risk of spontaneous preterm birth before 35 weeks decreased by approximately 6% for each additional millimeter of cervical length (odds ratio 0.94, 95% confidence interval, 0.92-0.95, P=.001) and by approximately 5% for each additional week of pregnancy at which the cervical length was measured (odds ratio 0.95, 95% confidence interval 0.92-0.98, P=.004). Similar results were obtained for spontaneous preterm birth before 32 and 28 weeks.Gestational age at which transvaginal ultrasound cervical length is measured significantly affects the calculation of risk of spontaneous preterm birth. The spontaneous preterm birth risk increases as the length of the cervix declines and as the gestational age decreases. These spontaneous preterm birth risks are important for counseling and management for women with various degrees of short cervical length at different gestational ages.II.
View details for Web of Science ID 000248290500013
View details for PubMedID 17666605
Very-low-birthweight neonates: Do outcomes differ in multiple compared with singleton gestations?
AMERICAN JOURNAL OF PERINATOLOGY
2007; 24 (6): 373-376
The purpose of this study is to determine if outcomes for very-low-birthweight (VLBW) neonates differ in multiple versus singleton gestations. This is a retrospective cohort study of neonates weighing less than 1500 g admitted to a neonatal intensive care unit from 1993 to 2004. Outcome variables were necrotizing enterocolitis, death, and/or severe intraventricular hemorrhage (IVH). Statistical analysis included univariate and multivariate analysis. During the study period, 1769 VLBW infants including 465 multiples and 1304 singletons were identified. Gestational age and birthweight were similar; conversely white race (68% multiples versus 43% singletons), maternal age (28.7 +/- 5.7 versus 26.1 +/- 6.5 years), born at facility (95% versus 86%), antenatal steroids (74% versus 58%), preeclampsia (14% versus 24%), and preterm labor (74% versus 62%) were significantly different. Correcting for these, VLBW multiples had a higher odds ratio (OR) of death and/or severe IVH, OR 1.4 (1.03-1.95). In our population, VLBW multiple gestations were at elevated odds for death and/or severe IVH compared with VLBW singletons.
View details for DOI 10.1055/s-2007-981852
View details for Web of Science ID 000247731500007
View details for PubMedID 17566946
- Diagnosis of gestational diabetes mellitus, Is it time for a new critical value? J Repro Med 2007; 52: 463-466
Is there any evidence for noncoached pushing in women with epidurals?
American journal of obstetrics and gynecology
2006; 195 (6): e5-?
View details for PubMedID 16584703
Impact of the recent randomized trials on the use of progesterone to prevent preterm birth: A 2005 follow-up survey
26th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2006: 1174–79
The purpose of this study was to determine whether current attitudes regarding the use of progesterone to prevent preterm birth have changed since our last survey in 2003.We mailed a 20 question survey to 1264 board certified Maternal-Fetal Medicine specialists in the United States between February and March of 2005 asking about their use and attitudes regarding progesterone to prevent preterm birth.Five hundred and seventy-two surveys were returned (response rate of 45%). In 2005, 67% of respondents used progesterone to prevent SPTB, compared to 38% in 2003 (P < .001). Among users, 38% recommended progesterone for indications other than previous SPTB. Users were more concerned about lack of insurance coverage compared to nonusers but nonusers were more concerned about safety, efficacy, need for more data, and long-term neonatal effects.Although the use of progesterone to prevent PTB has increased significantly since our last survey, there remain a substantial number of nonusers. Among users, many are using it for indications not yet proven in clinical trials. Current nonusers have higher levels of concerns compared to nonusers in the first survey and their major concern is the need for more data.
View details for DOI 10.1016/j.ajog.2006.06.034
View details for Web of Science ID 000241123500046
View details for PubMedID 17000251
- Massive fetal ileal duplication requiring antenatal intervention JOURNAL OF ULTRASOUND IN MEDICINE 2006; 25 (6): 785-790
Progesterone for preventing premature birth - Practice patterns of board-certified maternal-fetal medicine specialists in the United States
JOURNAL OF REPRODUCTIVE MEDICINE
2006; 51 (5): 411-415
To determine the current prescription of progesterone to prevent preterm birth (PTB) among board-certified maternal-fetal medicine (MFM) specialists in the United States.A survey of the board-certified MFM specialists in the United States examining their prescription of and attitudes regarding progesterone to prevent PTB 6 months following publication of a National Institute for Child Health and Human Development trial.Of 1,264 questionnaires sent, 526 were returned (response rate, 42%). After exclusions, 522 surveys remained. One hundred ninety-eight (38%) respondents prescribed progesterone, and 324 (62%) did not. Most nonprescribers were awaiting more data and were more concerned than prescribers about long-term effects (p < 0.0001). Twenty percent of prescribers prescribed progesterone for women with current signs or symptoms of preterm labor.As a result of recent evidence, over one third of MFM specialists surveyed have begun prescribing progesterone to prevent PTB. Of these specialists, 20% are using it for indications other than a prior PTB.
View details for Web of Science ID 000237788700008
View details for PubMedID 16779989
Cervical sonography in women with symptoms of preterm labor
OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA
2005; 32 (3): 383-?
In the last few years, ultrasound of the cervix during pregnancy has been the focus of much research. Significant advances have been made in its technique and in understanding the proper role of this procedure in several clinical settings. This article reviews the evidence for the clinical role of transvaginal cervical assessment in women with symptoms of preterm labor.
View details for DOI 10.1016/j.jogc.2005.04.007
View details for Web of Science ID 000232184600004
View details for PubMedID 16125039
Abnormalities of the first and second stages of labor
OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA
2005; 32 (2): 201-?
Abnormalities of the first and second stages of labor refer for the most part to abnormal progression of labor. This article discusses the risk factors, diagnoses, management options, and outcomes of the various categories of labor abnormalities, and provides an evidence-based approach where one exists. The article concentrates on the term, healthy woman carrying a singleton, vertex, normally grown fetus with no anomalies.
View details for DOI 10.1016/j.ogc.2005.01.007
View details for Web of Science ID 000229870600005
View details for PubMedID 15899355