- Obstetrics and Gynecology
- Maternal-Fetal Medicine
- Maternal morbidity
- Perinatal mental health
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)
Colville Dearborn Award, University of California, Santa Barbara (2009)
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)
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
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
- The LEEP and cone conundrum: The role of cumulative excised depth in predicting preterm birth MOSBY-ELSEVIER. 2020: S10
- Contraception uptake among women with cardiovascular disease: The impact of a multidisciplinary team care approach MOSBY-ELSEVIER. 2020: S707–S708
- Comparing insulin, metformin, and glyburide in treating diabetes in pregnancy and analyzing obstetric outcomes MOSBY-ELSEVIER. 2020: S481
- Sustaining the practice of operative vaginal delivery: Maternal and neonatal outcomes among a contemporary cohort MOSBY-ELSEVIER. 2020: S568
- Operative vaginal delivery in the modern obstetric era: How does it compare to the alternative? MOSBY-ELSEVIER. 2020: S327–S328
- Contraceptive utilization and counseling among breast cancer survivors JOURNAL OF CANCER SURVIVORSHIP 2019; 13 (3): 438–46
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 PubMedID 30695793
- Readmission following discharge on labetalol or nifedipine for management of hypertensive disorders of pregnancy MOSBY-ELSEVIER. 2019: S341
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
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
Obstetrics and gynecology
2018; 132 (1): 216
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 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): 1104–11
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 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 PubMedID 28620520
View details for PubMedCentralID PMC5424401