- Obstetrics and Gynecology
- Maternal-Fetal Medicine
- Maternal morbidity
- Perinatal mental health
Member, Cardiovascular Institute
Director of Research, Maternal-Fetal Medicine Fellowship (2022 - Present)
Honors & Awards
Women's Reproductive Health Research Scholar (WRHR K12), Department of Obstetrics and Gynecology, Stanford, NIH/NICHD (2021)
Loan Repayment Program Award, NIH/NICHD (2021)
Instructor K Award Support Grant, Stanford Maternal Child Health Research Institute (2021)
Masters Tuition Program Award, Stanford Maternal Child Health Research Institute (2021)
Fellow's Teaching Award, Obstetrics and Gynecology Residency Program, Stanford University (2021)
Society for Maternal-Fetal Medicine Resident Award, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School (2017)
Departmental Award, Obstetrics and Gynecology, UCSD School of Medicine (2014)
Robert Sinsheimer Award in Molecular and Cellular Biology, University of California, Santa Barbara (2009)
Colville Dearborn Award for Highest Academic Achievement in College of Science and Mathematics, University of California, Santa Barbara (2009)
Boards, Advisory Committees, Professional Organizations
Communications Committee Member, Society for Maternal Fetal Medicine (2023 - Present)
Research Committee Member, Society for Maternal Fetal Medicine (2021 - Present)
Co-Lead, Stanford Reproductive Neurology Quality Improvement Committee (2022 - Present)
MS, Stanford University, Epidemiology and Clinical Research (2023)
Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2019)
Fellowship, Stanford University, Maternal-Fetal Medicine (2021)
Residency, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Obstetrics and Gynecology (2018)
MD, University of California, San Diego School of Medicine (2014)
BS, University of California, Santa Barbara, Biochemistry and Molecular Biology (2009)
Physical Fitness in Relationship to Depression and Post-Traumatic Stress Disorder During Pregnancy Among U.S. Army Soldiers.
Journal of women's health (2002)
Background: Depression and post-traumatic stress disorder (PTSD) are prevalent in pregnancy, especially among military members. These conditions can lead to adverse birth outcomes, yet, there's a paucity of evidence for prevention strategies. Optimizing physical fitness is one understudied potential intervention. We explored associations between prepregnancy physical fitness and antenatal depression and PTSD in soldiers. Materials and Methods: This was a retrospective cohort study of active-duty U.S. Army soldiers with live births between 2011 and 2014, identified with diagnosis codes from inpatient and outpatient care. The exposure was each individual's mean Army physical fitness score from 10 to 24 months before childbirth. The primary outcome was a composite of active depression or PTSD during pregnancy, defined using the presence of a code within 10 months before childbirth. Demographic variables were compared across four quartiles of fitness scores. Multivariable logistic regression models were conducted adjusting for potential confounders selected a priori. A stratified analysis was conducted for depression and PTSD separately. Results: Among 4,583 eligible live births, 352 (7.7%) had active depression or PTSD during pregnancy. Soldiers with the highest fitness scores (Quartile 4) were less likely to have active depression or PTSD in pregnancy (Quartile 4 vs. Quartile 1 adjusted odds ratio 0.55, 95% confidence interval 0.39-0.79). Findings were similar in stratified analyses. Conclusion: In this cohort, the odds of active depression or PTSD during pregnancy were significantly reduced among soldiers with higher prepregnancy fitness scores. Optimizing physical fitness may be a useful tool to reduce mental health burden on pregnancy.
View details for DOI 10.1089/jwh.2022.0538
View details for PubMedID 37196157
Clinical and Physician Factors Associated With Failed Operative Vaginal Delivery.
Obstetrics and gynecology
To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births.This was a retrospective cohort study of individuals with NTSV live births with an attempted operative vaginal delivery by a physician between 2016 and 2020 in California. The primary outcome was cesarean birth after failed operative vaginal delivery, identified using linked diagnosis codes, birth certificates, and physician licensing board data stratified by device type (vacuum or forceps). Clinical and physician-level exposures were selected a priori, defined using validated indices, and compared between successful and failed operative vaginal delivery attempts. Physician experience with operative vaginal delivery was estimated by calculating the number of operative vaginal delivery attempts made per physician during the study period. Multivariable mixed effects Poisson regression models with robust standard errors were used to estimate risk ratios of failed operative vaginal delivery for each exposure, adjusted for potential confounders.Of 47,973 eligible operative vaginal delivery attempts, 93.2% used vacuum and 6.8% used forceps. Of all operative vaginal delivery attempts, 1,820 (3.8%) failed; the success rate was 97.3% for vacuum attempts and 82.4% for forceps attempts. Failed operative vaginal deliveries were more likely with older patient age, higher body mass index, obstructed labor, and neonatal birth weight more than 4,000 g. Between 2016 and 2020, physicians who attempted more operative vaginal deliveries were less likely to fail. When vacuum attempts were successful, physicians who conducted them had a median of 45 vacuum attempts during the study period, compared with 27 attempts when vacuum attempts were unsuccessful (adjusted risk ratio [aRR] 0.95, 95% CI 0.93-0.96). When forceps attempts were successful, physicians who conducted them had a median of 19 forceps attempts, compared with 11 attempts when forceps attempts were unsuccessful (aRR 0.76, 95% CI 0.64-0.91).In this large, contemporary cohort with NTSV births, several clinical factors were associated with operative vaginal delivery failure. Physician experience was associated with operative vaginal delivery success, more notably for forceps attempts. These results may provide guidance for physician training in maintenance of operative vaginal delivery skills.
View details for DOI 10.1097/AOG.0000000000005181
View details for PubMedID 37141591
Associations between pregnancy glucose measurements and risk of preterm birth: a retrospective cohort study of commercially insured women in the United States from 2003-2021.
Annals of epidemiology
To investigate associations between glucose measurements during pregnancy and risk of preterm birth (PTB).Retrospective cohort study of commercially insured women with singleton live births in the United States from 2003-2021 using longitudinal medical claims, socioeconomic data, and eight glucose results from different types of fasting and post-load tests performed between 24-28 weeks of gestation for gestational diabetes screening. Risk ratios of PTB (<37 weeks) were estimated via Poisson regression for z-standardized glucose measures. Non-linear relationships for continuous glucose measures were examined via generalized additive models.Elevations in all eight glucose measures were associated with increased risk (adjusted risk ratio point estimates: 1.05-1.19) of PTB for 196,377 women with non-fasting 50-gram glucose challenge test (one glucose result), 31,522 women with complete 100-gram, 3-hour fasting oral glucose tolerance test (OGTT) results (four glucose results), and 10,978 women with complete 75-gram, 2-hour fasting OGTT results (three glucose results). Associations were consistent after adjusting for and stratifying by sociodemographic and clinical factors. Substantial non-linear relationships (U-, J-, and S-shaped) were observed between several glucose measurements and PTB.Elevations in various glucose measures were linearly and non-linearly associated with increased risk of PTB, even before diagnostic thresholds for gestational diabetes.
View details for DOI 10.1016/j.annepidem.2023.03.002
View details for PubMedID 36905977
An Exploratory Analysis of Factors Associated With Spontaneous Preterm Birth Among Pregnant Veterans With Post-Traumatic Stress Disorder
WOMENS HEALTH ISSUES
2023; 33 (2): 191-198
View details for DOI 10.1016/j.whi.2022.09.005
View details for Web of Science ID 000990469400001
Quasi-experimental study designs can inform pandemic effects on nutrition and weight gain in pregnancy.
The American journal of clinical nutrition
2023; 117 (2): 216-217
View details for DOI 10.1016/j.ajcnut.2022.09.004
View details for PubMedID 36863821
Increased rates of postpartum emergency department visits and inpatient readmissions in people with epilepsy
MOSBY-ELSEVIER. 2023: S163
View details for Web of Science ID 000909337400235
Maternal congenital heart disease and effects on neonatal outcomes: the other side of the dyad
MOSBY-ELSEVIER. 2023: S554-S555
View details for Web of Science ID 000909337401413
Impact of psychiatric conditions on the risk of severe maternal morbidity in veterans
MOSBY-ELSEVIER. 2023: S457-S458
View details for Web of Science ID 000909337401261
Associations between physical fitness, depression, and PTSD during pregnancy among US Army soldiers
MOSBY-ELSEVIER. 2023: S121
View details for Web of Science ID 000909337400167
Antenatal wildfire smoke exposure and hypertensive disorders of pregnancy
MOSBY-ELSEVIER. 2023: S59-S60
View details for Web of Science ID 000909337400072
Severe maternal morbidity among people with cardiac disease: getting to the heart of the problem
MOSBY-ELSEVIER. 2023: S163-S164
View details for Web of Science ID 000909337400236
Increased primary cesarean delivery rate among people with epilepsy: Risks, drivers and future directions
MOSBY-ELSEVIER. 2023: S162-S163
View details for Web of Science ID 000909337400234
Shorter maternal leukocyte telomere length following cesarean birth: Implications for future research
MOSBY-ELSEVIER. 2023: S456-S457
View details for Web of Science ID 000909337401260
Contemporary management of epilepsy in pregnancy.
Current opinion in obstetrics & gynecology
The number of reproductive aged people with epilepsy in the United States is increasing, making epilepsy during pregnancy more prevalent. Simultaneously, more people are using newer generations of antiseizure medications before, during and after pregnancy. Here, we review current evidence on contemporary management and outcomes of pregnancies among people with epilepsy.This review evaluates recent literature to summarize current practices in preconception counselling, contraception, antiseizure medications before, during and after pregnancy, and peri-partum and postpartum risks in people with epilepsy.With the introduction of newer generation antiseizure medications being used during pregnancy, current literature shows that there may be decreased risk in adverse foetal and maternal outcomes. In the peri-partum and postpartum period, recent literature shows that people with epilepsy have an increased risk of severe maternal morbidity and hospital readmission. Given this, as well as considerations for dosing of antiseizure medications, close surveillance of people with epilepsy during pregnancy is warranted.
View details for DOI 10.1097/GCO.0000000000000844
View details for PubMedID 36912246
An exploratory analysis of leukocyte telomere length among pregnant and non-pregnant people.
Brain, behavior, & immunity - health
2022; 25: 100506
Background: Leukocyte telomere length (LTL) is a biomarker that is affected by older age, psychosocial stress, and medical comorbidities. Despite the relevance of these factors to obstetric practice, little is known about LTL in pregnancy. Our study explored longitudinal LTL dynamics in pregnant and non-pregnant people.Objective: This pilot study compares changes in LTL between pregnant and non-pregnant people over time, explores potential correlations between LTL and mental health measures, and investigates associations between short first-trimester LTL and adverse pregnancy outcomes.Study design: This was a prospective pilot cohort study of nulliparous pregnant and non-pregnant people between ages 18 and 50 who presented for care at a single institution from January to November 2020. Pregnant people were enrolled between 10 and 14 weeks gestation. Participants had two blood samples drawn for LTL; the first on the day of enrollment and the second on postpartum day 1 (pregnant cohort) or 7 months later (non-pregnant cohort). LTL was measured using quantitative PCR. The primary outcome was the difference between pregnant and non-pregnant people in LTL change between the two timepoints (basepair difference per 30-day period). Secondary outcomes included differences in responses to the Patient Health Questionnaire-9 (PHQ-9) and a survey about stress related to COVID-19. Differences in LTL were tested using t-tests and linear regression models, both crude and adjusted for age. A subgroup analysis was conducted within the pregnant cohort to examine whether shorter first-trimester LTL was associated with adverse pregnancy outcomes. We conducted t-tests to compare LTL between people with and without each categorical outcome and computed Pearson correlation coefficients between LTL and continuous outcomes such as gestational age at delivery.Results: 46 pregnant and 30 non-pregnant people were enrolled; 44 pregnant and 18 non-pregnant people completed all LTL assessments. There were no between-group differences in LTL change (-4.2±22.2 bp per 30 days pregnant versus -6.4±11.2 bp per 30 days non-pregnant, adjusted beta 2.1, 95% CI -9.0-13.2, p=0.60). The prevalence of depression and pandemic-related stress were both low overall. The two groups did not differ in PHQ-9 scores, and no correlations were significant between LTL and PHQ-9 scores. Among the 44 pregnant people, shorter first-trimester LTL was significantly correlated with earlier gestational age at delivery (r=0.35, p=0.02).Conclusion: In this exploratory pilot cohort of reproductive-aged people with low levels of psychological stress, we described baseline changes in LTL over time in pregnant and non-pregnant participants. We found a correlation between shorter first-trimester LTL and earlier gestational age at delivery, which warrants further investigation in a larger cohort.
View details for DOI 10.1016/j.bbih.2022.100506
View details for PubMedID 36110146
Addressing postpartum contraception practices utilizing a multidisciplinary Pregnancy Heart Team approach.
AJOG global reports
2022; 2 (4): 100100
BACKGROUND: Cardiovascular disease has emerged as the leading cause of maternal morbidity and mortality, making planned pregnancy, and thereby reliable contraception among people with cardiovascular disease, vital.OBJECTIVE: This study aimed to compare postpartum contraceptive practices among people with cardiovascular disease (cardiac cohort) cared for by a Pregnancy Heart Team to people with other chronic comorbidities (high-risk cohort), and people without comorbidities (low-risk cohort). We hypothesized that the Pregnancy Heart Team influenced baseline contraception counseling and practices among those with cardiovascular disease.STUDY DESIGN: This was a retrospective cohort study comparing postpartum contraceptive practices between a cardiac cohort who received care by a multidisciplinary team between 2012 and 2020 and high-risk and low-risk cohorts delivering at a single academic center between 2016 and 2019. We investigated presence of a contraceptive plan (at birthing admission, discharge, and postpartum visit) and uptake of reliable contraception by 8 weeks postpartum.RESULTS: We included 1464 people: 189 with cardiovascular disease, 197 with other chronic comorbidities, and 1078 low-risk people. At birth hospitalization admission, reliable contraception was planned among 42% of the cardiac cohort, 40% of the high-risk cohort, and 31% of the low-risk cohort, with similar distributions at the time of discharge and at 8 weeks postpartum.Compared with the cardiac cohort, by 8 weeks postpartum,the high-risk cohort had similar odds of using highly reliable forms of contraception (39% vs 36%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.21) and similar odds of having a plan to use the most reliable forms of contraception (intrauterine device, implant, bilateral tubal ligation) at the time of birthing admission (42% vs 40%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.22), discharge (47% vs 45%; adjusted odds ratio, 0.95; 95% confidence interval, 0.61-1.48), and postpartum visit (35% vs 29%; adjusted odds ratio, 0.76; 95% confidence interval, 0.49-1.17).The low-risk cohort had lower odds of using a reliable form of contraception (39% vs 27%; adjusted odds ratio, 0.53; 95% confidence interval, 0.37-0.75) and was less likely to have a plan for reliable contraception at the time of birthing admission (42% vs 31%; adjusted odds ratio, 0.54; 95% confidence interval, 0.38-0.76), discharge (47% vs 33%; adjusted odds ratio, 0.58; 95% confidence interval, 0.4-0.82), and postpartum visit (35% vs 21%; adjusted odds ratio, 0.50; 95% confidence interval, 0.35-0.71).CONCLUSION: People with cardiovascular disease cared for by a Pregnancy Heart Team had higher odds of reliable postpartum contraception planning and uptake compared with a low-risk cohort and similar odds compared with a high-risk cohort. Pregnancy could serve as a critical period for contraception counseling and family planning among people with cardiovascular disease. A multidisciplinary team should be used to address postpartum contraception as a modifiable risk factor to reduce maternal morbidity and mortality among those with cardiovascular disease.
View details for DOI 10.1016/j.xagr.2022.100100
View details for PubMedID 36536840
Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth.
Epidemiology (Cambridge, Mass.)
The International Classification of Diseases Clinical Modification 10th Revision (ICD-CM-10) introduced diagnosis codes for week of gestation. Our objective was to assess the validity of these codes among live births, which could have major utility in perinatal research and quality improvement.We used linked birth certificate and patient discharge data from births in California during 2016-2019 (N = 1,843,992). We identified gestational age using Z3A.xx ICD-10-CM diagnosis codes in birthing patient discharge data and compared it with the gold standard of obstetric estimate, as recorded on the birth certificate. We further assessed sensitivity and specificity of gestational age categories (≥37 weeks, <37 weeks, <32 weeks, <28 weeks), given these categories are frequently of interest, and evaluated differences in validity of preterm birth (<37 weeks' gestation) by patient characteristics.1,770,103 patients had a gestational age recorded in patient discharge and birth certificate data. When comparing gestational age in patient discharge data with birth certificate data, the concordance correlation coefficient was 0.96 (95% CI: 0.96, 0.96) and the mean difference between the two measurements was 0.047 (95% CI: 0.046, 0.047) weeks. 95% of the differences between the two measurements were between -1.00 week and +1.09 weeks. Sensitivity and specificity were 0.94 to 1.00 for all gestational age categories and were 0.94 to 1.00 for preterm birth across sociodemographic groups.We found week-specific gestational age at delivery ICD-10-CM diagnosis codes in patient discharge data to have high validity when compared with the best obstetric estimate on the birth certificate.
View details for DOI 10.1097/EDE.0000000000001557
View details for PubMedID 36166206
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
Leukocyte telomere dynamics across gestation in uncomplicated pregnancies and associations with stress.
BMC pregnancy and childbirth
2022; 22 (1): 381
Short leukocyte telomere length is a biomarker associated with stress and morbidity in non-pregnant adults. Little is known, however, about maternal telomere dynamics in pregnancy. To address this, we examined changes in maternal leukocyte telomere length (LTL) during uncomplicated pregnancies and explored correlations with perceived stress.In this pilot study, maternal LTL was measured in blood collected from nulliparas who delivered live, term, singleton infants between 2012 and 2018 at a single institution. Participants were excluded if they had diabetes or hypertensive disease. Samples were collected over the course of pregnancy and divided into three time periods: < 200/7 weeks (Timepoint 1); 201/7 to 366/7 weeks (Timepoint 2); and 370/7 to 9-weeks postpartum (Timepoint 3). All participants also completed a survey assessing a multivariate profile of perceived stress at the time of enrollment in the first trimester. LTL was measured using quantitative polymerase chain reaction (PCR). Wilcoxon signed-rank tests were used to compare LTL differences within participants across all timepoint intervals. To determine whether mode of delivery affected LTL, we compared postpartum Timepoint 3 LTLs between participants who had vaginal versus cesarean birth. Secondarily, we evaluated the association of the assessed multivariate stress profile and LTL using machine learning analysis.A total of 115 samples from 46 patients were analyzed. LTL (mean ± SD), expressed as telomere to single copy gene (T/S) ratios, were: 1.15 ± 0.26, 1.13 ± 0.23, and 1.07 ± 0.21 for Timepoints 1, 2, and 3, respectively. There were no significant differences in LTL between Timepoints 1 and 2 (LTL T/S change - 0.03 ± 0.26, p = 0.39); 2 and 3 (- 0.07 ± 0.29, p = 0.38) or Timepoints 1 and 3 (- 0.07 ± 0.21, p = 0.06). Participants who underwent cesareans had significantly shorter postpartum LTLs than those who delivered vaginally (T/S ratio: 0.94 ± 0.12 cesarean versus 1.12 ± 0.21 vaginal, p = 0.01). In secondary analysis, poor sleep quality was the main stress construct associated with shorter Timepoint 1 LTLs (p = 0.02) and shorter mean LTLs (p = 0.03).In this cohort of healthy pregnancies, maternal LTLs did not significantly change across gestation and postpartum LTLs were shorter after cesarean than after vaginal birth. Significant associations between sleep quality and short LTLs warrant further investigation.
View details for DOI 10.1186/s12884-022-04693-0
View details for PubMedID 35501726
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
Cellular Aging and Stress in Pregnant and Non-Pregnant People During the COVID-19 Pandemic
SPRINGER HEIDELBERG. 2022: 191
View details for Web of Science ID 000762765300376
Leukocyte Telomere Length in the First Trimester of Pregnancy and its Association with Perinatal Outcomes
SPRINGER HEIDELBERG. 2022: 155
View details for Web of Science ID 000762765300282
The Loop Electrosurgical Excision Procedure and Cone Conundrum: The Role of Cumulative Excised Depth in Predicting Preterm Birth
2022; 12 (01): E41-E48
Objective The objective was to determine factors associated with spontaneous preterm birth at less than 37 weeks in a cohort of patients who underwent a loop electrosurgical excision procedure (LEEP) or cone prior to pregnancy. Study Design This was a nested case-control study within a cohort of patients who underwent at least one LEEP or cone and had care for the next singleton pregnancy at either of two institutions between 1994 and 2014. Cases had spontaneous preterm birth at less than 37 weeks. Exposures included potential risk factors for preterm birth such as cumulative depth of excised cervix and time since excision. Reverse stepwise selection was used to identify the covariates for multivariable logistic regression. Results A total of 134 patients were included. Eighteen (13%) had a spontaneous preterm birth at less than 37 weeks. Median second-trimester cervical lengths were similar between those who delivered preterm and term (3.9-cm preterm and 3.6-cm term, p = 0.69). Patients who delivered preterm had a significantly greater median total excised depth of cervix (1.2 vs. 0.8 cm, p = 0.04). After adjustment for confounders, total excised depth remained significantly associated with preterm birth (adjusted odds ratio [aOR] = 2.2, 95% confidence interval [CI]: 1.3-3.8). Conclusion Total excised depth should be considered in addition to cervical length screening when managing subsequent pregnancies. Key Points A history of a LEEP or cone excision has been associated with spontaneous preterm birth.A two-fold increase in spontaneous preterm birth was seen per cumulative centimeter excised.There was no difference in second-trimester cervical length between the term and preterm groups.
View details for DOI 10.1055/s-0041-1742271
View details for Web of Science ID 000751029800006
View details for PubMedID 35141035
View details for PubMedCentralID PMC8816626
Clinical factors associated with a positive postpartum depression screen in people with cardiac disease during pregnancy.
Current research in psychiatry
2022; 2 (2): 25-29
Background: While people with cardiac disease are known to be at increased lifetime risk of depression, little is known about postpartum depression rates in this population. Describing rates of positive postpartum depression screens and identifying risk factors that are unique to cardiac patients may help inform risk reduction strategies.Methods: This retrospective cohort study included pregnant patients with congenital and/or acquired cardiac disease who delivered at a single institution between 2014 and 2020. The primary outcome was a positive postpartum depression screen, defined as Edinburgh Postpartum Depression Score (EPDS) ≥10. Potential exposures were selected a priori and compared between patients with and without a positive postpartum depression screen using Wilcoxon rank-sum and Fisher's exact tests. Secondary outcomes were responses to a longitudinal follow-up survey sent to English-speaking patients evaluating cardiac status, mental health, and infant development.Results: Of 126 eligible cardiac patients, 23 (18.3%) had a positive postpartum depression screen. Patients with a positive postpartum depression screen were more likely to have had antepartum anticoagulation with heparin or enoxaparin (56.5% versus 26.2%, p=0.007), blood transfusion during delivery (8.7% versus 0%, p=0.032), and maternal-infant separation postpartum (52.2% versus 28.2%, p=0.047) compared to patients with a negative screen. Among 29 patients with a positive screen who responded to the follow up survey, 50% reported being formally diagnosed with anxiety or depression and 33.3% reported child development problems.Conclusions: Our results highlight the importance of screening for postpartum depression in patients with cardiac disease, especially those requiring antepartum anticoagulation or maternal-infant separation postpartum.
View details for DOI 10.46439/Psychiatry.2.027
View details for PubMedID 36570491
Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth
MOSBY-ELSEVIER. 2022: S429
View details for Web of Science ID 000737459401022
Cellular aging and pregnancy complications: Examining maternal leukocyte telomere length in two diverse cohorts.
MOSBY-ELSEVIER. 2022: S646
View details for Web of Science ID 000737459401371
Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease
View details for DOI 10.1007/s43032-022-00978-z
Cellular aging and telomere dynamics in pregnancy.
Current opinion in obstetrics & gynecology
PURPOSE OF REVIEW: Telomere biology is an emerging area of scientific interest. Telomeres are deoxynucleic acid caps at the ends of chromosomes that naturally shorten over one's lifespan; because of this, short telomeres have been studied as a marker of cellular aging. Given the association between short telomeres and genetic and environmental factors, their role in pregnancy has become an intriguing area of research.RECENT FINDINGS: This review describes recent data on telomeres in pregnancy. Specifically, we discuss the association between short maternal leukocyte telomeres and poor nutritional status, between short neonatal telomeres and greater maternal psychosocial stress, and between shorter fetal amniotic membrane telomeres and the spontaneous onset of parturition. We also review recent studies suggesting that events during pregnancy can impact telomeres in the offspring years into the future.SUMMARY: Telomere length varies in maternal, placental, and neonatal cells, but within each of these compartments telomeres may play their own distinct role during pregnancy. Whether telomeres are reflective of the cumulative impact of stressors, or part of an as-yet unknown fetal programming mechanism is an area of interest. With future research, we may work toward a better understanding of gestational biology which could have far reaching intergenerational impacts.
View details for DOI 10.1097/GCO.0000000000000765
View details for PubMedID 34845136
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
Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans' Re-Engagement in VA Primary Care after Pregnancy.
Women's health issues : official publication of the Jacobs Institute of Women's Health
INTRODUCTION: Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition.METHODS: We conducted a complete case analysis of the 2005-2014 national VA birth cohort (n=18,414), and subcohorts of veterans with GDM (n=1,253), and hypertensive disorders of pregnancy (HDP; n=2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor.RESULTS: In the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81-0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61-0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55-0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity.CONCLUSIONS: One-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations like VA maternity care coordinators to address such gaps merits attention.
View details for DOI 10.1016/j.whi.2021.06.003
View details for PubMedID 34229932
Long Term Patient Follow-Up of Cardiac Disease in Pregnancy: Multidisciplinary Teams Tether At-Risk Patients to the System.
SPRINGER HEIDELBERG. 2021: 268A-269A
View details for Web of Science ID 000675441000564
To pull or not to pull: clinical factors associated with failed operative vaginal delivery
MOSBY-ELSEVIER. 2021: S101
View details for Web of Science ID 000621547400148
Vaginal breech delivery: maternal and neonatal outcomes
MOSBY-ELSEVIER. 2021: S211
View details for Web of Science ID 000621547400320
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
Severe maternal and neonatal morbidity after attempted operative vaginal delivery.
American journal of obstetrics & gynecology MFM
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
Cellular Aging in Pregnancy: Telomere Dynamics Across Gestation.
SPRINGER HEIDELBERG. 2020: 127A–128A
View details for Web of Science ID 000525432600181
Postpartum Depression Among Women with Cardiac Disease: Considerations During the Delivery Admission
SPRINGER HEIDELBERG. 2020: 246A
View details for Web of Science ID 000525432601113
Perinatal Outcomes in Women With Cardiac Arrhythmia.
SPRINGER HEIDELBERG. 2020: 161A
View details for Web of Science ID 000525432600268
Post-traumatic stress disorder in pregnancy: Does treatment impact the risk of preterm birth?
MOSBY-ELSEVIER. 2020: S328
View details for DOI 10.1016/j.ajog.2019.11.520
View details for Web of Science ID 000504997300503
The LEEP and cone conundrum: The role of cumulative excised depth in predicting preterm birth
MOSBY-ELSEVIER. 2020: S10
View details for DOI 10.1016/j.ajog.2019.11.026
View details for Web of Science ID 000504997300011
Contraception uptake among women with cardiovascular disease: The impact of a multidisciplinary team care approach
MOSBY-ELSEVIER. 2020: S707–S708
View details for DOI 10.1016/j.ajog.2019.11.1161
View details for Web of Science ID 000504997301467
Comparing insulin, metformin, and glyburide in treating diabetes in pregnancy and analyzing obstetric outcomes
MOSBY-ELSEVIER. 2020: S481
View details for DOI 10.1016/j.ajog.2019.11.773
View details for Web of Science ID 000504997301086
Sustaining the practice of operative vaginal delivery: Maternal and neonatal outcomes among a contemporary cohort
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?
MOSBY-ELSEVIER. 2020: S327–S328
View details for DOI 10.1016/j.ajog.2019.11.519
View details for Web of Science ID 000504997300502
Contraceptive utilization and counseling among breast cancer survivors
JOURNAL OF CANCER SURVIVORSHIP
2019; 13 (3): 438–46
View details for DOI 10.1007/s11764-019-00765-x
View details for Web of Science ID 000470260400010
Maternal Outcomes in Planned and Unplanned Pregnancies in Women with Cardiac Disease.
SAGE PUBLICATIONS INC. 2019: 323A
View details for Web of Science ID 000459610400771
Using Cervical Dilation to Predict Labor Onset: A Tool for Elective Labor Induction Counseling.
American journal of perinatology
To evaluate whether cervical dilation predicts the timing and likelihood of spontaneous labor at term. This was a retrospective cohort of nulliparous women with singleton pregnancies who delivered at term from 2013 to 2015. Outpatient cervical examinations performed after 37 weeks and prior to labor onset were collected. Survival analysis was used to analyze time to spontaneous labor with cervical dilation as the primary predictor, modeled as continuous and categorical variables (<1 cm, 1 cm, >1 cm). Our cohort included 726 women; 407 (56%) spontaneously labored, 263 (36%) were induced, and 56 (8%) had an unlabored cesarean delivery. Women with >1-cm dilation were three times more likely to spontaneously labor (adjusted hazard ratio [aHR]: 3.1; 95% confidence interval [CI]: 2.4-4) than those with <1-cm dilation. At 39 weeks, 60% of women with >1-cm dilation went into spontaneous labor as compared with only 28% of those with <1-cm dilation (aHR: 2.9; 95% CI: 2-4.4). In our cohort of nulliparous women at term, those with cervical dilation > 1 cm were significantly more likely to go into labor in the following week. This information can aid in counseling about elective induction of labor.
View details for DOI 10.1055/s-0039-1677866
View details for PubMedID 30695793
Contraceptive utilization and counseling among breast cancer survivors.
Journal of cancer survivorship : research and practice
To explore contraceptive counseling and utilization among breast cancer survivors.We enrolled reproductive-aged women with a history of breast cancer for a cross-sectional study. Participants were recruited via the Athena Breast Health Network and via the Young Survival Coalition's social media postings. Descriptive statistics were calculated to understand utilization of and feelings about contraceptive methods before, during, and after breast cancer treatment.Data presented here are from an online survey of 150 breast cancer survivors who completed the survey. Seventy-one percent (n = 105) of respondents reported being sexually active and not pregnant during their primary cancer treatment (surgery, chemotherapy, and/or radiation). Of these, 90% (n = 94) reported using any form of contraceptive, and the most common method was condoms (n = 55, 52%). Respondents reported that safety concerns had the biggest influence on their contraception method choice. Sixty-one percent (n = 92) reported receiving contraceptive counseling by their oncologist either before or after treatment; however, 49% (n = 45) of those did not receive a specific recommendation for a contraceptive method. Of respondents who reported receiving contraceptive counseling from their gynecologist, 44% (n = 35) reported that their gynecologist specifically recommended a copper intrauterine device (IUD). The majority of respondents (n = 76, 52%) wanted their oncologist to discuss contraceptive options with them and preferred to receive this counseling at the time of diagnosis (n = 81, 57%).Breast cancer survivors in this study remained sexually active across the cancer care continuum and predominantly used condoms as their contraceptive method during treatment. Breast cancer patients would prefer contraceptive counseling from their oncologist at the time of their cancer diagnosis.Education efforts in the future should focus on initiatives to improve comprehensive contraceptive counseling at the time of diagnosis by an oncologist.
View details for PubMedID 31065953
Readmission following discharge on labetalol or nifedipine for management of hypertensive disorders of pregnancy
MOSBY-ELSEVIER. 2019: S341
View details for DOI 10.1016/j.ajog.2018.11.530
View details for Web of Science ID 000454249401294
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
Obstetrics and gynecology
2018; 132 (1): 216
View details for DOI 10.1097/AOG.0000000000002716
View details for PubMedID 29939918
Evaluation of a Quality Improvement Intervention to Increase Vaginal Birth for Twins.
Obstetrics and gynecology
2018; 132 (1): 85-93
To evaluate whether there was an association between the systematic promotion of twin vaginal delivery and an increase in the rates of twin vaginal birth.We conducted a retrospective cohort study. We implemented a quality improvement initiative promoting twin vaginal delivery at an academic tertiary care center in 2013. The program included a needs assessment, simulation of vaginal twin delivery, online educational material, and the expansion of a dedicated twin clinic. We analyzed rates of twin vaginal birth in pregnancies at or beyond 24 weeks of gestation without a contraindication to labor, prior uterine surgery, or a demise or lethal anomaly of either twin. Using linear regression, we calculated annual adjusted rates of twin vaginal birth from 2010 to 2015 and in the 3 years before and after our intervention. We performed an interrupted time-series analysis estimating rates of change before and after the intervention to account for the influence of secular trend.Of 1,574 patients delivering twins, 897 (57%) were included, with 479 in the 3 years before and 418 in the 3 years after the intervention. Adjusted rates of vaginal delivery increased from 32.1% (n=153) to 44.2% (n=185) before and after the intervention (P<.01), with a decrease in elective cesarean delivery from 54.6% (n=479) to 44.3% (n=185) (P<.01). Rates of breech extraction increased after the intervention (5.7% vs 9.3%, P=.04). However, there was no difference in the rate of change in twin vaginal birth in the time period before (1.35% annual increase, P=.76) or after (5.8% annual increase, P=.40) the intervention.Although we observed an increased rate of twin vaginal birth in the time period after our intervention, because the rates of increase before and after the intervention were not statistically different, the increase is not attributable to our intervention and is more properly attributed to secular trend.
View details for DOI 10.1097/AOG.0000000000002680
View details for PubMedID 29889747
Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin.
Obstetrics and gynecology
2017; 130 (5): 1104-1111
To identify clinical factors associated with a change from vertex to nonvertex presentation in the second twin after vaginal birth of the first.We assembled a retrospective cohort of women with viable vertex-vertex twin pregnancies who delivered the presenting twin vaginally. Women whose second twin changed from vertex to nonvertex after vaginal birth of the first were classified as experiencing an intrapartum change in presentation. Characteristics associated with intrapartum presentation change in a univariate analysis with a P value ≤.10 were then evaluated in a multivariate logistic regression model.Four-hundred fifty women met inclusion criteria, of whom 55 (12%) had intrapartum presentation change of the second twin. Women experiencing intrapartum presentation change were more likely to be multiparous (69% compared with 47%, P<.01) and to have had a change in the presentation of the second twin between the most recent antepartum ultrasonogram and the ultrasonogram done on admission to labor and delivery (11% compared with 4%, P=.04). In an adjusted analysis, multiparity and gestational age less than 34 weeks were significantly associated with presentation change (adjusted odds ratio [OR] 2.9, 95% CI 1.5-5.6 and adjusted OR 2.6, 95% CI 1.1-5.9, respectively). Women with intrapartum presentation change were more likely to undergo cesarean delivery for their second twin (44% compared with 7%, P<.01) with an adjusted OR of 10.50 (95% CI 5.20-21.20) compared with those with stable intrapartum presentation. Twenty of the 24 (83%) cesarean deliveries performed in the intrapartum presentation change group were done for issues related to malpresentation.Multiparity and gestational age less than 34 weeks are associated with intrapartum presentation change of the second twin.
View details for DOI 10.1097/AOG.0000000000002329
View details for PubMedID 29016498
Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review.
Fertility research and practice
2015; 1: 15
Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.
View details for DOI 10.1186/s40738-015-0008-z
View details for PubMedID 28620520
View details for PubMedCentralID PMC5424401