Amy Judy, MD MPH

All Publications

• Lessons learned in maternal cardiopulmonary arrest simulation: where should educational efforts be concentrated? Minor, K. C., Trepman, P., Miller, H. E., Judy, A., Arafeh, J., Jayaraman, T., Druzin, M. L., Harney, K. MOSBY-ELSEVIER. 2022: S718

  View details for Web of Science ID 000737459401488

• To pull or not to pull: clinical factors associated with failed operative vaginal delivery Panelli, D. M., Leonard, S. A., Joudi, N., Girsen, A., Judy, A., Bianco, K., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2021: S101

  View details for Web of Science ID 000621547400148

• Severe maternal and neonatal morbidity after attempted operative vaginal delivery. American journal of obstetrics & gynecology MFM Panelli, D. M., Leonard, S. A., Joudi, N. n., Girsen, A. I., Judy, A. E., El-Sayed, Y. Y., Gilbert, W. M., Lyell, D. J. 2021: 100339

  Abstract

  Operative vaginal delivery (OVD) is a critical tool in reducing primary cesarean birth, but declining OVD rates and concerns about provider skill necessitate a clear understanding of risks. These risks are ambiguous because most studies compare outcomes with OVD to spontaneous vaginal delivery, rather than to second stage cesarean which is usually the realistic alternative.Our objective was to compare severe maternal and neonatal morbidity by mode of delivery among patients with a prolonged second stage of labor who had a successful OVD, a cesarean birth after failed OVD, or a cesarean birth without an OVD attempt.We used a population-based database to evaluate nulliparous, term, singleton, vertex livebirths in California between 2007 and 2012 among patients with a prolonged second stage of labor. Birth certificate and ICD-9-CM coded diagnoses and procedures were used for ascertainment of exposure, outcome, and demographics. Exposure was mode of delivery among patients who had any OVD attempt versus cesarean without OVD attempt. The outcomes were severe maternal morbidity (SMM) and severe unexpected newborn morbidity (UNM), defined using established indices. Anticipating that the code for prolonged second stage of labor would represent only a fraction of true OVD candidates, a secondary analysis was conducted removing this restriction in order to explore granular outcomes in a larger cohort with unsuccessful labor. Multivariable logistic regression was used to compare outcomes by mode of delivery adjusted for measured confounders. Sensitivity analyses were done excluding patients with combined vacuum-forceps and birthweight >4000g.9,239 prolonged second stage births were included; 6,851 (74.1%) were successful OVDs, 301 (3.3%) were failed OVDs, and 2,087 (22.6%) were cesareans without OVD attempts. Of successful OVDs, 6,195 (90.4%) were vacuums and 656 (10.6%) were forceps. Of failed OVDs where OVD type was specified, 83 (47.4%) were vacuums, 38 (21.7%) were forceps, and 54 (30.9%) were combined vacuum-forceps. Of note, all 54 combined vacuum-forceps OVD attempts that we identified failed. Patients with failed OVD differed from those with successful OVD, with higher rates of comorbidities, use of combined OVD, and birthweight >4000 g. Successful OVD was associated with reduced SMM (aOR 0.55, 95% CI 0.39-0.78) without a difference in severe UNM (aOR 0.99, 95% CI 0.78-1.26). In contrast, failed OVD was associated with increased SMM (aOR 2.14, 95% CI 1.20-3.82) and severe UNM (aOR 1.78, 95% CI 1.09-2.86). Findings were similar in secondary analysis of 260,585 patients with unsuccessful labor.In this large cohort of nulliparous, term, singleton, vertex births, successful OVD was associated with a 45% reduction in SMM without differences in severe UNM when compared to cesarean birth after prolonged second stage of labor. OVD failed infrequently, but when it did it was associated with a 214% increase in SMM and a 78% increase in severe UNM; combined OVDs were major contributors to this, since all combined OVDs failed. Optimization of OVD success rates through means such as improved patient selection, enhanced provider skill, and dissuasion against combined OVD could reduce maternal and neonatal complications.

  View details for DOI 10.1016/j.ajogmf.2021.100339

  View details for PubMedID 33631384

• Ampicillin Pharmacokinetics in Peripartum and Laboring Women. American journal of perinatology Judy, A. E., Frymoyer, A., Ansari, J., Drover, D. R., Carvalho, B. 2021

  Abstract

  Ampicillin is used for multiple peripartum indications including prevention of neonatal group beta streptococcus (GBS) and treatment of chorioamnionitis. Despite its widespread use in obstetrics, existing pharmacokinetic data for ampicillin do not address contemporary indications or dosing paradigms for this population. We sought to characterize the pharmacokinetic profile of ampicillin administered to laboring women.Using whole blood dried blood spot sampling technique, maternal blood samples were collected at specified times from 31 women receiving IV ampicillin for peripartum indications. Women received either a 2-g loading dose with 1-g administered every 4 h (GBS), or 2-g every 6 h (chorioamnionitis). Pharmacokinetics were analyzed via a population approach with non-linear mixed-effect modeling.The data were best described by a two-compartment model with first-order elimination, with the following whole blood parameters: central volume of distribution (V1) 75.2 L (95% CI 56.3-93.6), clearance (CL) 82.4 L/h (95% CI 59.7-95.7), inter-compartmental clearance (Q) 20.9 L/h (95% CI 16.2-38.2), and peripheral volume of distribution (V2) 61.1 L (95% CI 26.1-310.5). Inter-patient variation in CL and V1 was large (42.0% and 56.7% respectively). Simulations of standard dosing strategies demonstrated over 98% of women are predicted to achieve an estimated free plasma concentration above MIC 0.5 mcg/mL for more than 50% of the dosing interval.Although large variation in the pharmacokinetics of ampicillin in pregnant women exists, as predicted by our model, current standard dosing strategies achieve adequate exposure for GBS in nearly all patients.

  View details for DOI 10.1055/a-1674-6394

  View details for PubMedID 34670320

• Postpartum Depression Among Women with Cardiac Disease: Considerations During the Delivery Admission Panelli, D., Sherwin, E. B., Lee, C. J., Suharwardy, S., Miller, H. E., Tolani, A. T., Girsen, A. I., Leonard, S. A., Warshawsky, S., Judy, A., Khandel-Wal, A., Bianco, Y. K. SPRINGER HEIDELBERG. 2020: 246A

  View details for Web of Science ID 000525432601113

• Acceptability of postnatal mood management through a smartphone-based automated conversational agent Ramachandran, M., Suharwardy, S., Leonard, S. A., Gunaseelan, A., Robinson, A., Darcy, A., Lyell, D. J., Judy, A. MOSBY-ELSEVIER. 2020: S62

  View details for DOI 10.1016/j.ajog.2019.11.090

  View details for Web of Science ID 000504997300075

• Sustaining the practice of operative vaginal delivery: Maternal and neonatal outcomes among a contemporary cohort Panelli, D. M., Leonard, S. A., Judy, A., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2020: S568

  View details for DOI 10.1016/j.ajog.2019.11.929

  View details for Web of Science ID 000504997301240

• Operative vaginal delivery in the modern obstetric era: How does it compare to the alternative? Panelli, D. M., Leonard, S. A., Judy, A., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2020: S327–S328

  View details for DOI 10.1016/j.ajog.2019.11.519

  View details for Web of Science ID 000504997300502

• Effect of an automated conversational agent on postpartum mental health: A randomized, controlled trial Suharwardy, S., Ramachandran, M., Leonard, S. A., Gunaseelan, A., Robinson, A., Darcy, A., Lyell, D. J., Judy, A. MOSBY-ELSEVIER. 2020: S91

  View details for DOI 10.1016/j.ajog.2019.11.132

  View details for Web of Science ID 000504997300116

• Differential Dynamics of the Maternal Immune System in Healthy Pregnancy and Preeclampsia. Frontiers in immunology Han, X., Ghaemi, M. S., Ando, K., Peterson, L. S., Ganio, E. A., Tsai, A. S., Gaudilliere, D. K., Stelzer, I. A., Einhaus, J., Bertrand, B., Stanley, N., Culos, A., Tanada, A., Hedou, J., Tsai, E. S., Fallahzadeh, R., Wong, R. J., Judy, A. E., Winn, V. D., Druzin, M. L., Blumenfeld, Y. J., Hlatky, M. A., Quaintance, C. C., Gibbs, R. S., Carvalho, B., Shaw, G. M., Stevenson, D. K., Angst, M. S., Aghaeepour, N., Gaudilliere, B. 2019; 10: 1305

  Abstract

  Preeclampsia is one of the most severe pregnancy complications and a leading cause of maternal death. However, early diagnosis of preeclampsia remains a clinical challenge. Alterations in the normal immune adaptations necessary for the maintenance of a healthy pregnancy are central features of preeclampsia. However, prior analyses primarily focused on the static assessment of select immune cell subsets have provided limited information for the prediction of preeclampsia. Here, we used a high-dimensional mass cytometry immunoassay to characterize the dynamic changes of over 370 immune cell features (including cell distribution and functional responses) in maternal blood during healthy and preeclamptic pregnancies. We found a set of eight cell-specific immune features that accurately identified patients well before the clinical diagnosis of preeclampsia (median area under the curve (AUC) 0.91, interquartile range [0.82-0.92]). Several features recapitulated previously known immune dysfunctions in preeclampsia, such as elevated pro-inflammatory innate immune responses early in pregnancy and impaired regulatory T (Treg) cell signaling. The analysis revealed additional novel immune responses that were strongly associated with, and preceded the onset of preeclampsia, notably abnormal STAT5ab signaling dynamics in CD4+T cell subsets (AUC 0.92, p = 8.0E-5). These results provide a global readout of the dynamics of the maternal immune system early in pregnancy and lay the groundwork for identifying clinically-relevant immune dysfunctions for the prediction and prevention of preeclampsia.

  View details for DOI 10.3389/fimmu.2019.01305

  View details for PubMedID 31263463

  View details for PubMedCentralID PMC6584811

• Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 133 (6): 1151–59

  Abstract

  OBJECTIVE: To describe the clinical characteristics of stroke and opportunities to improve care in a cohort of preeclampsia-related maternal mortalities in California.METHODS: The California Pregnancy-Associated Mortality Review retrospectively examined a cohort of preeclampsia pregnancy-related deaths in California from 2002 to 2007. Stroke cases were identified among preeclampsia deaths, and case summaries were reviewed with attention to clinical variables, particularly hypertension. Health care provider- and patient-related contributing factors were also examined.RESULTS: Among 54 preeclampsia pregnancy-related deaths that occurred in California from 2002 to 2007, 33 were attributed to stroke. Systolic blood pressure exceeded 160 mm Hg in 96% of cases, and diastolic blood pressure was 110 or higher in 65% of cases. Hemolysis, elevated liver enzymes, and low platelet count syndrome was present in 38% (9/24) of cases with available laboratory data; eclampsia occurred in 36% of cases. Headache was the most frequent symptom (87%) preceding stroke. Elevated liver transaminases were the most common laboratory abnormality (71%). Only 48% of women received antihypertensive treatment. A good-to-strong chance to alter outcome was identified in stroke cases 66% (21/32), with delayed response to clinical warning signs in 91% (30/33) of cases and ineffective treatment in 76% (25/33) cases being the most common areas for improvement.CONCLUSION: Stroke is the major cause of maternal mortality associated with preeclampsia or eclampsia. All but one patient in this series of strokes demonstrated severe elevation of systolic blood pressure, whereas other variables were less consistently observed. Antihypertensive treatment was not implemented in the majority of cases. Opportunities for care improvement exist and may significantly affect maternal mortality.

  View details for DOI 10.1097/AOG.0000000000003290

  View details for PubMedID 31135728

• In Reply. Obstetrics and gynecology Judy, A. E., McCain, C. L., Lawton, E. S., Morton, C. H., Main, E. K., Druzin, M. L. 2019; 134 (4): 880–81

  View details for DOI 10.1097/AOG.0000000000003494

  View details for PubMedID 31568351

• Development of the TeamOBS-PPH - targeting clinical performance in postpartum hemorrhage ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA Brogaard, L., Hvidman, L., Hinshaw, K., Kierkegaard, O., Manser, T., Musaeus, P., Arafeh, J., Daniels, K. I., Judy, A. E., Uldbjerg, N. 2018; 97 (6): 677–87

  Abstract

  This study aimed to develop a valid and reliable TeamOBS-PPH tool for assessing clinical performance in the management of postpartum hemorrhage (PPH). The tool was evaluated using video-recordings of teams managing PPH in both real-life and simulated settings.A Delphi panel consisting of 12 obstetricians from the UK, Norway, Sweden, Iceland, and Denmark achieved consensus on (i) the elements to include in the assessment tool, (ii) the weighting of each element, and (iii) the final tool. The validity and reliability were evaluated according to Cook and Beckman. (Level 1) Four raters scored four video-recordings of in situ simulations of PPH. (Level 2) Two raters scored 85 video-recordings of real-life teams managing patients with PPH ≥1000 mL in two Danish hospitals. (Level 3) Two raters scored 15 video-recordings of in situ simulations of PPH from a US hospital.The tool was designed with scores from 0 to 100. (Level 1) Teams of novices had a median score of 54 (95% CI 48-60), whereas experienced teams had a median score of 75 (95% CI 71-79; p < 0.001). (Level 2) The intra-rater [intra-class correlation (ICC) = 0.96] and inter-rater (ICC = 0.83) agreements for real-life PPH were strong. The tool was applicable in all cases: atony, retained placenta, and lacerations. (Level 3) The tool was easily adapted to in situ simulation settings in the USA (ICC = 0.86).The TeamOBS-PPH tool appears to be valid and reliable for assessing clinical performance in real-life and simulated settings. The tool will be shared as the free TeamOBS App.

  View details for PubMedID 29485679

• Effectiveness of intramuscular progesterone for the prevention of preterm birth in twin pregnancies based on body mass index Do, S., Yeaton-Massey, A., Judy, A. E., O'Malley, K., Moore, G. S. MOSBY-ELSEVIER. 2016: S333–S334

  View details for DOI 10.1016/j.ajog.2015.10.671

  View details for Web of Science ID 000367092800619

• Effect of 17-alpha hydroxyprogesterone caproate on labor at preterm gestations Judy, A. E., El-Sayed, Y. Y., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2016: S294

  View details for DOI 10.1016/j.ajog.2015.10.590

  View details for Web of Science ID 000367092800540

• Effect of 17-alpha hydroxyprogesterone caproate on labor at term Judy, A. E., El-Sayed, Y. Y., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2016: S444

  View details for DOI 10.1016/j.ajog.2015.10.902

  View details for Web of Science ID 000367092800841

• Does obesity alter the effect of 17 Alpha-Hydroxyprogesterone in singleton pregnancies? Do, S., Judy, A. E., O'Malley, K., Yeaton-Massey, A., Moore, G. S. MOSBY-ELSEVIER. 2016: S219

  View details for DOI 10.1016/j.ajog.2015.10.439

  View details for Web of Science ID 000367092800392

• Does the rate of preterm delivery in twin pregnancies differ by body mass index in women exposed to 17 alpha-hydroxyprogesterone? Do, S., O'Malley, K., Yeaton-Massey, A., Judy, A. E., Moore, G. S. MOSBY-ELSEVIER. 2016: S288

  View details for DOI 10.1016/j.ajog.2015.10.578

  View details for Web of Science ID 000367092800528

• Disseminated Intravascular Coagulation Complicating the Conservative Management of Placenta Percreta OBSTETRICS AND GYNECOLOGY Judy, A. E., Lyell, D. J., Druzin, M. L., Dorigo, O. 2015; 126 (5): 1016-1018

  Abstract

  Retention of the placenta is an option in the management of placenta percreta; however, it may be associated with significant morbidity.We present a case of conservative management of placenta percreta. Disseminated intravascular coagulation (DIC) developed 49 days after delivery. An urgent hysterectomy was performed, followed by rapid normalization of coagulation parameters.Disseminated intravascular coagulation may complicate the conservative management of placenta percreta and can manifest weeks after delivery in the absence of antecedent hemorrhage or infection. The time course and presentation of this case are similar to the development of DIC after prolonged retention of a fetal demise with a probable shared pathophysiology. Close follow-up may facilitate prompt diagnosis of DIC, thereby minimizing associated morbidity.

  View details for DOI 10.1097/AOG.0000000000000960

  View details for Web of Science ID 000363974000016

  View details for PubMedID 26132459

• Cesarean Sections Increase the Risk of Sepsis in Neonates With Gastroschisis. Desai, A. K., Mansour, T., Billings, T. L., Merritt, T. A., Girsen, A., Judy, A., Davis, A. S., Hintz, S., Blumenfeld, Y., Oshiro, B. T. SAGE PUBLICATIONS INC. 2015: 339A

  View details for Web of Science ID 000351407202491

• TDaP vaccination safety in pregnancy: a comparison of neonatal and obstetric outcomes among women receiving antepartum and postpartum vaccination Judy, A., Singh, A., Lee, H., Gaskari, S., Brodzinsky, L., Vik, J., Druzin, M., El-Sayed, Y., Aziz, N. MOSBY-ELSEVIER. 2015: S300–S301

  View details for DOI 10.1016/j.ajog.2014.10.810

  View details for Web of Science ID 000361140900599

• Maternal characteristics and neonatal outcomes in women with eclampsia versus severe preeclampsia Judy, A., Chao, L., Girsen, A., O'Malley, K., Lyell, D., Blumenfeld, Y., Butwick, A., El-Sayed, Y. MOSBY-ELSEVIER. 2014: S188–S189

  View details for DOI 10.1016/j.ajog.2013.10.404

  View details for Web of Science ID 000330322600372

• Fetal adrenal gland size and risk of preterm birth Langen, E., Judy, A., Norton, M. MOSBY-ELSEVIER. 2014: S398-S399

  View details for DOI 10.1016/j.ajog.2013.10.852

  View details for Web of Science ID 000330322600817