- Maternal - Fetal Medicine
- Obstetrics and Gynecology
Associate Fellowship Program Director, Division of Maternal-Fetal Medicine (2006 - 2011)
Dean's Task Force on Clinical Excellence, Stanford Medical School (2007 - 2009)
Quality Assurance Committee, Department of Obstetrics and Gynecology (2007 - 2014)
Director, Program in Placental Disorders, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (2010 - Present)
Credentials Committee, Lucile Packard Children's Hospital (2011 - Present)
Fellowship Program Director, Maternal-Fetal Medicine (2011 - Present)
Dean's Billet Cap Committee, Stanford Medical School (2012 - 2013)
Alternate Principal Investigator, Eunice Kennedy Shriver N.I.C.H.D. Maternal-Fetal Medicine Units Network, Washington DC (2013 - Present)
Honors & Awards
Harvard Medical Student Teaching Award, Harvard Medical School (1999)
Stanford University Residents Outstanding Fellow Award, Stanford University, Department of Obstetrics & Gynecology (2001)
Residents Obstetrics Teaching Award, Stanford University, Department of Obstetrics & Gynecology (2004)
Roy M. Pitkin Research Award, American College of Obstetricians and Gynecologists (2009)
Resident's Obstetrics Teaching Award, Stanford University Department of Obstetrics & Gynecology (2012)
Fellowship:Stanford University Medical Center (2003)
Medical Education:George Washington University (1996) DC
B.A.S., Stanford University, Biology and History (1990)
Residency:Brigham and Women's Hospital Harvard Medical School (2000) MA
Fellowship, Stanford School of Medicine, Maternal- Fetal Medicine (2003)
Board Certification: Obstetrics and Gynecology, American Board of Obstetrics and Gynecology (2004)
Board Certification: Maternal and Fetal Medicine, American Board of Obstetrics and Gynecology (2007)
Current Research and Scholarly Interests
Preterm labor prevention and management, preeclampsia prevention and treatment, short and long-term impact of surgical techniques at cesarean, depression during pregnancy, fetal heart rate monitoring and long-term neurologic outcome, randomized clinical trials.
Independent Studies (5)
- Directed Reading in Obstetrics and Gynecology
OBGYN 299 (Aut, Win, Spr, Sum)
- Early Clinical Experience in Obstetrics and Gynecology
OBGYN 280 (Aut, Win, Spr, Sum)
- Graduate Research in Reproductive Biology
OBGYN 399 (Aut, Win, Spr, Sum)
- Medical Scholars Research
OBGYN 370 (Aut, Win, Spr, Sum)
- Undergraduate Research in Reproductive Biology
OBGYN 199 (Aut, Win, Spr, Sum)
- Directed Reading in Obstetrics and Gynecology
Magnesium sulfate exposure and neonatal intensive care unit admission at term.
Journal of perinatology
2015; 35 (3): 181-185
Objective:The aim of this study was to investigate the effect of maternal magnesium sulfate (MgSO4) exposure for eclampsia prophylaxis on neonatal intensive care unit (NICU) admission rates for term newborns.Study Design:A secondary analysis of the Maternal-Fetal Medicine Unit Network Cesarean Registry, including primary and repeat cesarean deliveries, and failed and successful trials of labor after cesarean was conducted. Singleton pregnancies among women with preeclampsia and >37 weeks of gestation were included. Pregnancies with uterine rupture, chorioamnionitis and congenital malformations were excluded. Logistic regression analysis was used to determine associations between MgSO4 exposure and NICU admission. P<0.05 was considered statistically significant.Result:Two thousand one hundred and sixty-six term pregnancies of women with preeclampsia were included, of whom 1747 (81%) received MgSO4 for eclampsia prophylaxis and 419 (19%) did not. NICU admission rates were higher among newborns exposed to MgSO4 vs unexposed (22% vs 12%, P<0.001). After controlling for neonatal birth weight, gestational age and maternal demographic and obstetric factors, NICU admission remained significantly associated with antenatal MgSO4 exposure (adjusted odds ratio 1.9, 95% confidence interval 1.3 to 2.6, P<0.001). Newborns exposed to MgSO4 were more likely to have Apgar scores <7 at 1 and 5 min (15% vs 11% unexposed, P=0.01 and 3% vs 0.7% unexposed, P=0.008). There were no significant differences in NICU length of stay (median 5 (range 2 to 91) vs 6 (3 to 15), P=0.5).Conclusion:Antenatal maternal MgSO4 treatment was associated with increased NICU admission rates among exposed term newborns of mothers with preeclampsia. This study highlights the need for studies of maternal MgSO4 administration protocols that optimize maternal and fetal benefits and minimize risks.Journal of Perinatology advance online publication, 16 October 2014; doi:10.1038/jp.2014.184.
View details for DOI 10.1038/jp.2014.184
View details for PubMedID 25321647
- In reply. Obstetrics and gynecology 2015; 125 (3): 740-?
Risk factors for classical hysterotomy in twin pregnancies.
Obstetrics and gynecology
2015; 125 (3): 643-648
To describe the rate of classical hysterotomy in twin pregnancies across gestational age and examine risk factors that increase its occurrence.This is a secondary analysis of the Cesarean Registry, a cohort study of women who underwent a cesarean delivery or a trial of labor after cesarean delivery at 19 academic centers between 1999 and 2002. Our study included all women with twin pregnancies and a recorded hysterotomy type who underwent cesarean delivery between 23 0/7 and 41 6/7 weeks of gestation. Primary exposures were gestational age at delivery and combined birth weight of twin A and twin B. Multivariate logistic regression was used to study factors thought to influence hysterotomy type including maternal age, body mass index (BMI) at delivery, obesity (BMI 30 or higher), nulliparity, labor, prior cesarean delivery, emergent delivery, and fetal presentation at delivery.Of 1,820 women meeting inclusion criteria, 125 (7%) underwent a classical hysterotomy. The risk of classical hysterotomy was greatest at 25 weeks of gestation (41%) and declined thereafter. The adjusted odds ratio (OR) for cesarean delivery declined as gestation age advanced (OR 0.87, 95% confidence interval 0.78-0.98). African American race and emergent delivery were associated risk factors for classical hysterotomy at 32 weeks of gestation or greater.Among women with twin pregnancies who deliver by cesarean, the incidence of classical hysterotomy is inversely related to gestational age but does not exceed 50% at any week; African American race and emergent delivery are associated risk factors at 32 weeks of gestation or greater.: II.
View details for DOI 10.1097/AOG.0000000000000693
View details for PubMedID 25730228
Feasibility of neonatal pulse wave velocity and association with maternal hemoglobin a1c.
2015; 107 (1): 20-26
Use of non-invasive peripheral arterial tonometry to assess arterial stiffness has not been studied in neonates. Perinatal factors impact childhood vascular health, but the effect in neonates remains to be examined.To examine the feasibility of pulse wave velocity (PWV) among healthy term neonates, and to evaluate the effects of perinatal factors on neonatal PWV.Pregnant women with singleton gestation presenting for routine care were enrolled. Postnatally, PWV measurements of their neonates were obtained using an arterial tonometer. A variability index was calculated for each PWV measurement. Intra- and inter-observer reproducibility were illustrated with Bland-Altman plots. Medical records were reviewed. Relationships between neonatal PWV and perinatal factors were examined.PWV measurements were attempted in 76 neonates and successfully obtained in 67 (88%). Using PWV measurements with a variability index ≤0.25 (48 neonates), the intra-class coefficient was 0.69. The mean differences (limits of agreement) for intra- and inter-rater reproducibility were 0.02 (-3.64 to 3.60) and 0.34 (-2.23 to 2.39), respectively. Median neonatal PWV was 2.80 m/s (range 0.60-8.40). Neonates of mothers with HgbA1c ≥6% had significantly higher PWV than neonates of mothers with HgbA1c <6% (4.12 m/s, 95% CI 3.22-5.02, vs. 2.78 m/s, 95% CI 2.28-3.28, p = 0.02).Neonatal PWV using peripheral arterial tonometry is feasible and reproducible when using measurements with a variability index ≤0.25. Neonates of mothers with increased HgbA1c had higher PWV, suggesting an effect of maternal hyperglycemia on neonatal vasculature. The long-term implications of this finding warrant further investigation. © 2014 S. Karger AG, Basel.
View details for DOI 10.1159/000366467
View details for PubMedID 25301402
- Mini commentary author's reply. bjog-an international journal of obstetrics and gynaecology 2015; 122 (1): 143-144
- Feasibility of Neonatal Pulse Wave Velocity and Association with Maternal Hemoglobin A(1c) NEONATOLOGY 2015; 107 (1): 20-26
- Body Mass Index and Operative Times at Cesarean Delivery OBSTETRICS AND GYNECOLOGY 2014; 124 (4): 684-689
Anticoagulant prescribing practices and anesthetic interventions among anticoagulated pregnant patients: a retrospective study.
International journal of obstetric anesthesia
2014; 23 (3): 238-245
The peripartum management of anticoagulated patients poses important challenges for obstetric anesthesiologists, especially when deciding to perform neuraxial block. However, there is limited evidence evaluating anticoagulant prescribing practices and neuraxial block utilization in this setting. Our objective was to examine peripartum anticoagulant prescribing and anesthetic practices in a cohort of anticoagulated patients receiving subcutaneous enoxaparin, and subcutaneous or intravenous unfractionated heparin.We performed a retrospective study of anticoagulant prescribing patterns and anesthetic interventions among patients receiving enoxaparin and/or unfractionated heparin who delivered at a USA obstetric center over a seven-year period.We identified 101 patients who received enoxaparin and/or unfractionated heparin before delivery. Thirty-nine (38.6%) patients received enoxaparin only, 41 (40.6%) patients received enoxaparin bridged to subcutaneous unfractionated heparin, 11 (10.9%) patients received enoxaparin and were converted to intravenous unfractionated heparin and 10 (9.9%) patients received only subcutaneous unfractionated heparin. The overall rate of neuraxial block utilization was 80.2%. The median [IQR] time-period between the last dose of enoxaparin and neuraxial block was significantly shorter for patients who received only enoxaparin vs. enoxaparin with subcutaneous unfractionated heparin (54h [12-192h] (n=26) vs. 216h [39-504h] (n=23), P=0.04). Among patients who received only subcutaneous unfractionated heparin, the time period between unfractionated heparin and neuraxial block was 24h [19-51h].In this study, the neuraxial block rate was high among patients receiving enoxaparin and/or subcutaneous unfractionated heparin with patients undergoing relatively long periods off anticoagulation. Careful multidisciplinary planning is recommended for the peripartum management of anticoagulated pregnant patients.
View details for DOI 10.1016/j.ijoa.2014.03.007
View details for PubMedID 24910353
Combined elevated midpregnancy tumor necrosis factor alpha and hyperlipidemia in pregnancies resulting in early preterm birth.
American journal of obstetrics and gynecology
2014; 211 (2): 141 e1-9
The objective of the study was to determine whether pregnancies resulting in early preterm birth (PTB) (<30 weeks) were more likely than term pregnancies to have elevated midtrimester serum tumor necrosis factor alpha (TNF-α) levels combined with lipid patterns suggestive of hyperlipidemia.In 2 nested case-control samples drawn from California and Iowa cohorts, we examined the frequency of elevated midpregnancy serum TNF-α levels (in the fourth quartile [4Q]) and lipid patterns suggestive of hyperlipidemia (eg, total cholesterol, low-density-lipoproteins, or triglycerides in the 4Q, high-density lipoproteins in the first quartile) (considered independently and by co-occurrence) in pregnancies resulting in early PTB compared with those resulting in term birth (n = 108 in California and n = 734 in Iowa). Odds ratios (ORs) and 95% confidence intervals (CIs) estimated in logistic regression models were used for comparisons.Early preterm pregnancies were 2-4 times more likely than term pregnancies to have a TNF-α level in the 4Q co-occurring with indicators of hyperlipidemia (37.5% vs 13.9% in the California sample (adjusted OR, 4.0; 95% CI, 1.1-16.3) and 26.3% vs 14.9% in the Iowa sample (adjusted OR, 2.7; 95% CI, 1.1-6.3). No differences between early preterm and term pregnancies were observed when TNF-α or target lipid abnormalities occurred in isolation. Observed differences were not explicable to any maternal or infant characteristics.Pregnancies resulting in early PTB were more likely than term pregnancies to have elevated midpregnancy TNF-α levels in combination with lipid patterns suggestive of hyperlipidemia.
View details for DOI 10.1016/j.ajog.2014.02.019
View details for PubMedID 24831886
Association between maternal characteristics, abnormal serum aneuploidy analytes, and placental abruption.
American journal of obstetrics and gynecology
2014; 211 (2): 144 e1-9
The objective of the study was to examine the association between placental abruption, maternal characteristics, and routine first- and second-trimester aneuploidy screening analytes.The study consisted of an analysis of 1017 women with and 136,898 women without placental abruption who had first- and second-trimester prenatal screening results, linked birth certificate, and hospital discharge records for a live-born singleton. Maternal characteristics and first- and second-trimester aneuploidy screening analytes were analyzed using logistic binomial regression.Placental abruption was more frequent among women of Asian race, age older than 34 years, women with chronic and pregnancy-associated hypertension, preeclampsia, preexisting diabetes, previous preterm birth, and interpregnancy interval less than 6 months. First-trimester pregnancy-associated plasma protein-A of the fifth percentile or less, second-trimester alpha fetoprotein of the 95th percentile or greater, unconjugated estriol of the fifth percentile or less, and dimeric inhibin-A of the 95th percentile or greater were associated with placental abruption as well. When logistic models were stratified by the presence or absence of hypertensive disease, only maternal age older than 34 years (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.0-2.0), pregnancy-associated plasma protein-A of the 95th percentile or less (OR, 1.9; 95% CI, 1.2-3.1), and alpha fetoprotein of the 95th percentile or greater (OR, 2.3; 95% CI, 1.4-3.8) remained statistically significantly associated for abruption.In this large, population-based cohort study, abnormal maternal aneuploidy serum analyte levels were associated with placental abruption, regardless of the presence of hypertensive disease.
View details for DOI 10.1016/j.ajog.2014.03.027
View details for PubMedID 24631707
Maternal prepregnancy body mass index and risk of spontaneous preterm birth.
Paediatric and perinatal epidemiology
2014; 28 (4): 302-311
Findings from studies examining risk of preterm birth associated with elevated prepregnancy body mass index (BMI) have been inconsistent.Within a large population-based cohort, we explored associations between prepregnancy BMI and spontaneous preterm birth across a spectrum of BMI, gestational age, and racial/ethnic categories. We analysed data for 989 687 singleton births in California, 2007-09. Preterm birth was grouped as 20-23, 24-27, 28-31, or 32-36 weeks gestation (compared with 37-41 weeks). BMI was categorised as <18.5 (underweight); 18.5-24.9 (normal); 25.0-29.9 (overweight); 30.0-34.9 (obese I); 35.0-39.9 (obese II); and ≥40.0 (obese III). We assessed associations between BMI and spontaneous preterm birth of varying severity among non-Hispanic White, Hispanic, and non-Hispanic Black women.Analyses of mothers without hypertension and diabetes, adjusted for age, education, height, and prenatal care initiation, showed obesity categories I-III to be associated with increased risk of spontaneous preterm birth at 20-23 and 24-27 weeks among those of parity 1 in each race/ethnic group. Relative risks for obese III and preterm birth at 20-23 weeks were 6.29 [95% confidence interval (CI) 3.06, 12.9], 4.34 [95% CI 2.30, 8.16], and 4.45 [95% CI 2.53, 7.82] for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, respectively. A similar, but lower risk, pattern was observed for women of parity ≥2 and preterm birth at 20-23 weeks. Underweight was associated with modest risks for preterm birth at ≥24 weeks among women in each racial/ethnic group regardless of parity.The association between women's prepregnancy BMI and risk of spontaneous preterm birth is complex and is influenced by race/ethnicity, gestational age, and parity.
View details for DOI 10.1111/ppe.12125
View details for PubMedID 24810721
Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation.
2014; 54 (6): 1530-1536
Women with placenta increta (PI) and placenta percreta (PP) are at high risk of obstetric hemorrhage; however, the severity of hemorrhage and perioperative morbidity may differ according to the degree of placental invasion. We sought to compare blood component usage and perioperative morbidity between women with PI versus PP undergoing cesarean hysterectomy (CH).We identified 77 women who underwent CH for PI or PP from the NICHD MFMU Network Cesarean Registry, which sourced data from 19 centers from 1999 to 2002. We examined demographic, obstetric, and surgical data and rates of transfusion and perioperative morbidity. We performed statistical tests for between-group analyses; p values less than 0.05 were significant.Rates of intraoperative or postoperative red blood cell (RBC) transfusion were similar between groups (PI 84% vs. PP 88%; p = 0.7). We observed no between-group differences in rates of fresh-frozen plasma (FFP) transfusion (intraoperative FFP-PI 30% vs. PP 41%; p = 0.3; postoperative FFP-PI 28% vs. PP 18%; p = 0.4) or platelet (PLT) transfusion (intraoperative PLTs-PI 14% vs. PP 29%; p = 0.2; postoperative PLTs-PI 9% vs. PP 9%; p = 1.0). Among the morbidities, a higher proportion of PP women underwent cystotomy (PI 14% vs. PP 38%; p = 0.02) and postoperative mechanical ventilation (PI 14% vs. PP 35%; p = 0.03).Rates of intraoperative RBC, FFP, and PLT transfusion are similar for PI and PP women, and perioperative outcomes are worse for PP women. We suggest the same mobilization transfusion medicine support for both groups, including blood ordering (type and cross-match for CH) and availability of emergency blood protocols including fibrinogen-containing preparations.
View details for DOI 10.1111/trf.12483
View details for PubMedID 24188691
- Integrating multiple 'omics' analyses identifies serological protein biomarkers for preeclampsia BMC MEDICINE 2013; 11
Risk factors for classical hysterotomy by gestational age.
Obstetrics and gynecology
2013; 122 (4): 845-850
To examine the likelihood of classical hysterotomy across preterm gestational ages and to identify factors that increase its occurrence.This is a secondary analysis of a prospective observational cohort collected by the Maternal-Fetal Medicine Network of all women with singleton gestations who underwent a cesarean delivery with a known hysterotomy. Comparisons were made based on gestational age. Factors thought to influence hysterotomy type were studied, including maternal age, body mass index, parity, birth weight, small for gestational age (SGA) status, fetal presentation, labor preceding delivery, and emergent delivery.Approximately 36,000 women were eligible for analysis, of whom 34,454 (95.7%) underwent low transverse hysterotomy and 1,562 (4.3%) underwent classical hysterotomy. The median gestational age of women undergoing a classical hysterotomy was 32 weeks and the incidence peaked between 24 0/7 weeks and 25 6/7 weeks (53.2%), declining with each additional week of gestation thereafter (P for trend <.001). In multivariable regression, the likelihood of classical hysterotomy was increased with SGA (n=258; odds ratio [OR] 2.71; confidence interval [CI] 1.78-4.13), birth weight 1,000 g or less (n=467; OR 1.51; CI 1.03-2.24), and noncephalic presentation (n=783; OR 2.03; CI 1.52-2.72). The likelihood of classical hysterotomy was decreased between 23 0/7 and 27 6/7 weeks of gestation and after 32 weeks of gestation when labor preceded delivery, and increased between 28 0/7 and 31 6/7 weeks of gestation and after 32 weeks of gestation by multiparity and previous cesarean delivery. Emergent delivery did not predict classical hysterotomy.Fifty percent of women at 23-26 weeks of gestation who undergo cesarean delivery have a classical hysterotomy, and the risk declines steadily thereafter. This likelihood is increased by fetal factors, especially SGA and noncephalic presentation.: II.
View details for DOI 10.1097/AOG.0b013e3182a39731
View details for PubMedID 24084543
Effect of magnesium sulfate exposure on term neonates
JOURNAL OF PERINATOLOGY
2013; 33 (3): 188-193
To compare neonatal intensive care unit and special care unit (NICU) admission rates between term neonates exposed to antenatal magnesium sulfate (MS) and those unexposed.We performed a retrospective cohort study of all singleton neonates ≥37 weeks born to women with pre-eclampsia from August 2006 to July 2008. Cases were defined by antenatal exposure to MS and controls by absence of MS exposure. The primary outcome was NICU admission. Data were analyzed via univariable and multivariable regression analyses.In all, 28 (14.7%) out of 190 MS-exposed neonates ≥37 weeks were admitted to the NICU, compared with 4 (5.4%) of 74 non-exposed neonates (P=0.04). This association persisted after controlling for potential confounding variables including severe pre-eclampsia and cesarean delivery (AOR 3.69, 1.13 to 11.99). NICU admission was associated in a dose-dependent relationship with total hours and mean dose of MS exposure. Number needed to harm with MS was 11 per NICU admission. Among neonates admitted to the NICU, MS-exposed were more likely to require fluid and nutritional support than unexposed neonates (60.7 vs 0%, P=0.04), and trended toward more frequent requirement for respiratory support and greater length of stay.In term neonates, MS exposure may be associated independently with NICU admission in a dose-dependent relationship. Requirements for fluid and nutritional support are common in this group, likely due to feeding difficulties in exposed neonates. Assessment of acute care needs among all neonates exposed to MS for maternal eclampsia prophylaxis should be considered.
View details for DOI 10.1038/jp.2012.95
View details for Web of Science ID 000315664700005
View details for PubMedID 22836873
Integrating multiple 'omics' analyses identifies serological protein biomarkers for preeclampsia.
2013; 11: 236-?
Preeclampsia (PE) is a pregnancy-related vascular disorder which is the leading cause of maternal morbidity and mortality. We sought to identify novel serological protein markers to diagnose PE with a multi-'omics' based discovery approach.Seven previous placental expression studies were combined for a multiplex analysis, and in parallel, two-dimensional gel electrophoresis was performed to compare serum proteomes in PE and control subjects. The combined biomarker candidates were validated with available ELISA assays using gestational age-matched PE (n=32) and control (n=32) samples. With the validated biomarkers, a genetic algorithm was then used to construct and optimize biomarker panels in PE assessment.In addition to the previously identified biomarkers, the angiogenic and antiangiogenic factors (soluble fms-like tyrosine kinase (sFlt-1) and placental growth factor (PIGF)), we found 3 up-regulated and 6 down-regulated biomakers in PE sera. Two optimal biomarker panels were developed for early and late onset PE assessment, respectively.Both early and late onset PE diagnostic panels, constructed with our PE biomarkers, were superior over sFlt-1/PIGF ratio in PE discrimination. The functional significance of these PE biomarkers and their associated pathways were analyzed which may provide new insights into the pathogenesis of PE.
View details for DOI 10.1186/1741-7015-11-236
View details for PubMedID 24195779
View details for PubMedCentralID PMC4226208
Antenatal identification of major depressive disorder: a cohort study
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2012; 207 (6)
The purpose of this study was to estimate the frequency of identification of major depressive disorder by providers during prenatal care.A cohort of pregnant women who were participating in a randomized controlled trial and who had received a diagnosis of major depressive disorder was examined. Women were included in the current study if prenatal clinic records were available and legible.Clinical depression was noted in 56% of prenatal charts and on 24% of problem lists. Physicians and certified nurse midwives noted depression equally (P = .935); physicians more frequently noted mental health referral (23% vs 0%; P = .01), and midwives more frequently included depression on the problem list (P = .01). Recent medication use, which was stopped before conception or study participation, predicted notation of depression in the chart (P = .001).Depression frequently is missed during pregnancy and, when identified, is underacknowledged as a problem. Women who have not recently used antidepressant medication are more likely to be missed. Better screening and acknowledgment are needed.
View details for DOI 10.1016/j.ajog.2012.09.030
View details for Web of Science ID 000311483300030
View details for PubMedID 23099192
Interpregnancy Interval and Obstetrical Complications
OBSTETRICAL & GYNECOLOGICAL SURVEY
2012; 67 (9): 584-596
Obstetricians are often presented with questions regarding the optimal interpregnancy interval (IPI). Short IPI has been associated with adverse perinatal and maternal outcomes, ranging from preterm birth and low birth weight to neonatal and maternal morbidity and mortality. Long IPI has in turn been associated with increased risk for preeclampsia and labor dystocia. In this review, we discuss the data regarding these associations along with recent studies revealing associations of short IPI with birth defects, schizophrenia, and autism. The optimal IPI may vary for different subgroups. We discuss the consequences of short IPI in women with a prior cesarean section, in particular the increased risk for uterine rupture and the considerations regarding a trial of labor in this subgroup. We review studies examining the interaction between short IPI and advanced maternal age and discuss the risk-benefit assessment for these women. Finally, we turn our attention to women after a stillbirth or an abortion, who often desire to conceive again with minimal delay. We discuss studies speaking in favor of a shorter IPI in this group. The accumulated data allow for the reevaluation of current IPI recommendations and management guidelines for women in general and among subpopulations with special circumstances. In particular, we suggest lowering the current minimal IPI recommendation to only 18 months (vs 24 months according to the latest World Health Organization recommendations), with even shorter recommended minimal IPI for women of advanced age and those who conceive after a spontaneous or induced abortion.
View details for DOI 10.1097/OGX.0b013e31826b2c3e
View details for Web of Science ID 000310568300018
View details for PubMedID 22990461
Rectus muscle and visceral peritoneum closure at cesarean delivery and intraabdominal adhesions
78th Annual Meeting of the Pacific-Coast-Obstetrical-and-Gynecological-Society
The purpose of this study was to evaluate the effect of the rectus muscle and visceral peritoneum closure at cesarean delivery on adhesions.We performed a secondary analysis of a prospective cohort study of women who underwent first repeat cesarean delivery. Surgeons scored the severity and location of adhesions. Records were abstracted to assess previous surgical techniques.The original cohort included 173 patients. Rectus muscle closure was associated with fewer combined filmy and dense adhesions overall (27.5% vs 46%; P = .04) and fewer dense adhesions overall (17.5% vs 46%; P = .001; adjusted odds ratio, [aOR], 0.24; 95% confidence interval [CI], 0.09-0.65), particularly from fascia to omentum (aOR, 0.08; 95% CI, 0.007-0.82). Visceral peritoneum closure was associated with increased dense fascia-to-omentum adhesions (aOR, 15.78; 95% CI, 1.81-137.24).Closure of the rectus muscles at cesarean delivery may reduce adhesions, and visceral peritoneum closure may increase them. Surgical techniques at cesarean delivery should be assessed independently, because they may have opposite effects on adhesion formation.
View details for DOI 10.1016/j.ajog.2012.02.033
View details for Web of Science ID 000304442900029
View details for PubMedID 22463952
Adhesions and perioperative complications of repeat cesarean delivery
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2011; 205 (6): S11-S18
The unprecedented high rate of cesarean delivery and the declining rate of vaginal birth after cesarean delivery make necessary awareness of the potential complications that are associated with repeat cesarean delivery. This article reviews the epidemiologic features of cesarean delivery and the perioperative risks that are associated with repeat cesarean delivery. These risks include increased adhesions, infections and wound complications, bleeding, bowel injury and obstruction, hysterectomy, operative time, hospital stay, and delays in delivery.
View details for DOI 10.1016/j.ajog.2011.09.029
View details for Web of Science ID 000297333900003
View details for PubMedID 22114993
Do adhesions at repeat cesarean delay delivery of the newborn?
31st Annual Scientific Meeting of the Society-of-Maternal-Fetal-Medicine (SMFM)
We sought to assess whether the presence and severity of adhesions at first repeat cesarean delivery are associated with delayed delivery of the newborn.We conducted secondary analysis of a prospective cohort of women undergoing first repeat cesarean. Severity and location of adhesions were reported by surgeons immediately postoperatively. We compared adhesion density scores with delivery data.Of 145 women analyzed, 92 (63.5%) had adhesions and 53 (36.5%) did not. Mean incision to delivery time in women with adhesion scores >3 was 19.8 minutes, compared to 15.6 minutes with scores ≤ 3 (P = .04). More women with adhesion scores >3 remained undelivered at 30 minutes after incision compared to scores ≤ 3 (17.9% vs 5.1%; odds ratio, 7.6; 95% confidence interval, 1.6-34.5), after controlling for potential confounders.Among women undergoing first repeat cesarean, severity of adhesions may delay delivery of the newborn. Study of techniques to reduce adhesions may be warranted to prevent delayed delivery at repeat cesarean.
View details for DOI 10.1016/j.ajog.2011.06.088
View details for Web of Science ID 000296084600050
View details for PubMedID 21864825
Neonatal medical admission in a term and late-preterm cohort exposed to magnesium sulfate
31st Annual Western Conference on Perinatal Research
The purpose of this study was to estimate neonatal intensive care unit and special care unit (NICU) admission rates and care needs among term and late-preterm neonates who are exposed to antenatal magnesium sulfate.We conducted a retrospective cohort study of all singleton neonates of ≥35 weeks' gestation who were exposed immediately antenatally to magnesium sulfate for maternal eclampsia prophylaxis (August 2006 through July 2008).Fifty-one of 242 neonates (21.1%) who, at ≥35 weeks' gestation, had been exposed to antenatal magnesium sulfate were admitted to the NICU. NICU admission was associated in a dose-dependent fashion with total hours and mean dose of magnesium: >12 hours exposure, odds ratio, 2.81 (95% confidence interval, 1.31-6.03); >30 g exposure, odds ratio, 2.59 (95% confidence interval, 1.22-5.51). Infants in NICU who were diagnosed with hypermagnesemia required fluid or nutritional support more frequently (91.3% vs 39.3%; P < .001) than those without hypermagnesemia.Antenatal magnesium sulfate exposure is associated with NICU admission among term and late-preterm neonates in a dose-dependent fashion. Fluid and nutritional assistance commonly are needed in this cohort.
View details for DOI 10.1016/j.ajog.2011.01.046
View details for Web of Science ID 000291477300029
View details for PubMedID 21376302
- The Residency Certificate: The Rite of Passage OBSTETRICS AND GYNECOLOGY 2011; 117 (1): 174-174
Oral Misoprostol and Vaginal Isosorbide Mononitrate for Labor Induction A Randomized Controlled Trial
29th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
LIPPINCOTT WILLIAMS & WILKINS. 2010: 121–26
To estimate whether vaginal isosorbide mononitrate, added to oral misoprostol for cervical ripening and labor induction, shortens time to vaginal delivery.A prospective, randomized trial was conducted. Women scheduled for labor induction between 32 and 42 weeks and with unfavorable cervices (modified Bishop score 6 or lower) were randomized to receive oral misoprostol every 4 hours, up to four doses, with or without isosorbide mononitrate every 6 hours, up to two doses. A strict protocol was used, including timing of oxytocin use and amniotomy. Side effects were assessed 6 hours after study initiation. One hundred forty-two patients were required to detect a change in time to vaginal delivery of 4 hours (alpha=.05 and beta=.20). Data were analyzed by intent to treat. Student's t, chi square, Fisher's exact, and Mann-Whitney tests were used where appropriate with P< or =.05 deemed significant.One hundred fifty-six women were randomized; three were excluded after randomization. Seventy-eight women received misoprostol, and 78 received misoprostol with isosorbide mononitrate. Demographic characteristics were similar between groups. The time to vaginal delivery was not reduced when isosorbide mononitrate was added to misoprostol. Cesarean delivery rates and contraction and fetal heart rate abnormalities were similar between groups. Side effects were also similar between groups, except that women given isosorbide mononitrate experienced headaches more often. Neonatal outcomes were similar between groups.The addition of vaginal isosorbide mononitrate to oral misoprostol for cervical ripening and labor induction did not reduce time to vaginal delivery and was associated with a greater incidence of headache.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00374621.I.
View details for Web of Science ID 000278998600019
View details for PubMedID 20567177
Single- versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions
BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY
2010; 117 (6): 690-694
To determine the association between single-layer (one running suture) and double-layer (second layer or imbricating suture) hysterotomy closure at primary caesarean delivery and subsequent adhesion formation.A secondary analysis from a prospective cohort study of women undergoing first repeat caesarean section.Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.One hundred and twenty-seven pregnant women undergoing first repeat caesarean section.Patient records were reviewed to identify whether primary caesarean hysterotomies were closed with a single or double layer. Data were analysed by Fisher's exact tests and multivariable logistic regression.Prevalence rate of pelvic and abdominal adhesions.Of the 127 women, primary hysterotomy closure was single layer in 56 and double layer in 71. Single-layer hysterotomy closure was associated with bladder adhesions at the time of repeat caesarean (24% versus 7%, P = 0.01). Single-layer closure was associated in this study with a seven-fold increase in the odds of developing bladder adhesions (odds ratio, 6.96; 95% confidence interval, 1.72-28.1), regardless of other surgical techniques, previous labour, infection and age over 35 years. There was no association between single-layer closure and other pelvic or abdominal adhesions.Primary single-layer hysterotomy closure may be associated with more frequent bladder adhesions during repeat caesarean deliveries. The severity and clinical implications of these adhesions should be assessed in large prospective trials.
View details for DOI 10.1111/j.1471-0528.2010.02529.x
View details for Web of Science ID 000276509100007
View details for PubMedID 20236104
TITLE: SLEEPLESSNESS DURING PREGNANCY: ESTIMATING THE PREVALENCE OF INSOMNIA
SPRINGER. 2010: 35–35
View details for Web of Science ID 000275841700134
Acupuncture for Depression During Pregnancy A Randomized Controlled Trial
OBSTETRICS AND GYNECOLOGY
2010; 115 (3): 511-520
To estimate the efficacy of acupuncture for depression during pregnancy in a randomized controlled trial.A total of 150 pregnant women who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for major depressive disorder were randomized to receive either acupuncture specific for depression or one of two active controls: control acupuncture or massage. Treatments lasted 8 weeks (12 sessions). Junior acupuncturists, who were not told about treatment assignment, needled participants at points prescribed by senior acupuncturists. All treatments were standardized. The primary outcome was the Hamilton Rating Scale for Depression, administered by masked raters at baseline and after 4 and 8 weeks of treatment. Continuous data were analyzed using mixed effects models and by intent to treat.Fifty-two women were randomized to acupuncture specific for depression, 49 to control acupuncture, and 49 to massage. Women who received acupuncture specific for depression experienced a greater rate of decrease in symptom severity (P<.05) compared with the combined controls (Cohen's d=0.39, 95% confidence interval [CI] 0.01-0.77) or control acupuncture alone (P<.05; Cohen's d=0.46, 95% CI 0.01-0.92). They also had significantly greater response rate (63.0%) than the combined controls (44.3%; P<.05; number needed to treat, 5.3; 95% CI 2.8-75.0) and control acupuncture alone (37.5%; P<.05: number needed to treat, 3.9; 95% CI 2.2-19.8). Symptom reduction and response rates did not differ significantly between controls (control acupuncture, 37.5%; massage, 50.0%).The short acupuncture protocol demonstrated symptom reduction and a response rate comparable to those observed in standard depression treatments of similar length and could be a viable treatment option for depression during pregnancy.Clinicaltrials.gov, www.clinicaltrials.gov, NCT00186654.
View details for DOI 10.1097/AOG.0b013e3181cc0816
View details for Web of Science ID 000275132300006
View details for PubMedID 20177281
Daily Compared With 8-Hour Gentamicin for the Treatment of Intrapartum Chorioamnionitis A Randomized Controlled Trial
28th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
LIPPINCOTT WILLIAMS & WILKINS. 2010: 344–49
To assess whether daily gentamicin is as effective as 8-hour gentamicin for the treatment of intrapartum chorioamnionitis.Women with a clinical diagnosis of chorioamnionitis between 32 and 42 weeks of gestation were randomly assigned in labor to receive either daily gentamicin (5 mg/kg intravenously (IV), then 2 placebo doses IV after 8 and 16 hours) or 8-hour gentamicin (2 mg/kg IV, then 1.5 mg/kg IV after 8 and 16 hours). Both groups received ampicillin (2 grams IV every 6 hours for a total of four doses). Patients who underwent cesarean delivery also received clindamycin (900 mg IV every 8 hours, for a total of three doses). The primary outcome was treatment success, defined by resolution of chorioamnionitis after 16 hours of treatment without development of endometritis. One hundred twenty-six patients were required to have 95% confidence that daily gentamicin is at worst 15% inferior to 8-hour dosing with an alpha of .05 and a beta of 0.2.One hundred twenty-six women were enrolled, of whom 63 received daily gentamicin and 63 received 8-hour gentamicin. One patient was excluded from data analysis. Baseline maternal and obstetric characteristics were similar between groups except for longer mean duration of ruptured membranes in the 8-hour group (679+/-514 compared with 469+/-319 minutes; P =.03). Treatment success was equal between groups (94% daily gentamicin compared with 89% 8-hour gentamicin, P =.53). There were no differences in maternal or neonatal morbidities, including neonatal sepsis and newborn hearing screen.Daily and 8-hour gentamicin appear equally effective for the treatment of intrapartum chorioamnionitis.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00185991.I.
View details for Web of Science ID 000273872500020
View details for PubMedID 20093909
Acupuncture for depression during pregnancy
30th Annual Clinical Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2009: S19–S19
View details for Web of Science ID 000279559500035
Antenatal recognition of major depressive disorder
30th Annual Clinical Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2009: S55–S55
View details for Web of Science ID 000279559500106
- External cephalic version: a terrible opportunity to waste JOURNAL OF PERINATOLOGY 2009; 29 (2): 77-78
- 1. Blumenfeld Yair J and Lyell, Deirdre J. Prematurity prevention: the role of acute tocolysis. Curr Opin Obstet Gynecol. 2009; 21: 136-141
- RANDOMIZED CLINICAL TRIAL OF CERVICAL RIPENING AND LABOR INDUCTION USING ORAL MISOPROSTOL WITH OR WITHOUT INTRAVAGINAL ISOSORBIDE MONONITRATE 29th Annual Meeting of the Society-for-Maternal-Fetal-Medicine MOSBY-ELSEVIER. 2008: S53–S53
Maintenance Nifedipine Tocolysis Compared With Placebo A Randomized Controlled Trial
28th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
LIPPINCOTT WILLIAMS & WILKINS. 2008: 1221–26
To estimate whether maintenance nifedipine tocolysis after arrested preterm labor prolongs pregnancy and improves neonatal outcomes.A prospective, randomized double-blind, multicenter study was conducted. After successful tocolysis, patients were randomly assigned to receive 20 mg nifedipine or an identical-appearing placebo every 4-6 hours until 37 weeks of gestation. The primary outcome was attainment of 37 weeks of gestation. Patients were enrolled between 24 weeks and 34 weeks if they had six or fewer contractions per hour, intact membranes, and less than 4 cm cervical dilation. Exclusion criteria were placental abruption or previa, fetal anomaly incompatible with life, or maternal medical contraindication to tocolysis. Sixty-six patients were required for 80% power to detect a 50% reduction in birth before 37 weeks, with a two-tailed alpha of 0.05. Data were analyzed by intent to treat.Seventy-one patients were randomly assigned. Two patients were excluded after randomization and one was lost to follow-up. Thirty-five patients received placebo, and 33 received nifedipine. There were no maternal demographic differences between groups; the placebo group was significantly more dilated and effaced at study entry. There was no difference in attainment of 37 weeks (39% nifedipine compared with 37% placebo, P>.91), mean delay of delivery (33.5+/-19.9 days nifedipine compared with 32.6+/-21.4 days placebo, P=.81) or delay of delivery for greater than 48 hours or 1, 2, 3, or 4 weeks. Neonatal outcomes were similar between groups.When compared with placebo, maintenance nifedipine tocolysis did not confer a large reduction in preterm birth or improvement in neonatal outcomes.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00185952I.
View details for Web of Science ID 000261316200006
View details for PubMedID 19037029
Perinatal outcomes among Asian-white interracial couples
28th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
To investigate whether perinatal outcomes among interracial Asian-white couples are different than among Asian-Asian and white-white couples.This was a retrospective study of Asian, white, and Asian-white couples delivered at the Lucile Packard Children's Hospital from 2000-2005. Asian-white couples were subdivided into white-mother/Asian-father or Asian-mother/white-father. Perinatal outcomes included gestational diabetes, hypertensive disorders of pregnancy, preterm delivery, birth weight >4000 g and <2500 g, and cesarean delivery.In the study population of 868 Asian-white, 3226 Asian, and 5575 white couples there were significant outcome differences. Compared with white couples, Asian-white couples had an increased incidence of gestational diabetes (aOR 2.4 for white-mother/Asian-father and aOR 2.6 for Asian-mother/white-father), though not as high as Asian couples (aOR 4.7). Asian-white couples had larger babies (median 3360 g for Asian-mother/white-father and 3320 g for white-mother/Asian-father vs 3210 g for Asian, P < .001), but only Asian-mother/white-father couples had an increased rate of cesarean delivery (aOR 1.3-2.0).Significant differences in perinatal outcomes exist between Asian, white, and interracial Asian-white couples.
View details for DOI 10.1016/j.ajog.2008.06.065
View details for Web of Science ID 000260045700021
View details for PubMedID 18928981
- Uterine exteriorization compared with in situ repair at cesarean delivery: A randomized controlled trial OBSTETRICS AND GYNECOLOGY 2008; 112 (1): 183-183
Once daily vs. 8-hour gentamicin dosing for chorioamnionitis
28th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2007: S68–S68
View details for Web of Science ID 000251708500204
Cesarean delivery outcomes after a prolonged second stage of labor
27th Annual Meeting of the Society-of-Maternal-Fetal-Medicine
We hypothesized that prolonged second stage of labor increases the incidence of unintentional hysterotomy extensions at cesarean delivery.A retrospective cohort of term pregnant women who underwent primary cesarean delivery after failed second stage of labor at Stanford University was assessed for hysterotomy extensions and other maternal and neonatal morbidities. Groups included second stage length of 1-3 hours and >4 hours. Data were analyzed with the use of chi-square and Fisher's exact tests.Of the 239 women who were studied, the second stage of labor lasted 1-3 hours in 82 patients and >4 hours in 157 patients. Prolonged second stage of labor was associated with unintentional hysterotomy extensions (40% vs 26%; P = .03), particularly to the cervix (29% vs 5%; P = .005), and with surgery that lasted >90 minutes (9% vs 1%; P = .01). The incidence of hysterotomy extensions was associated positively with the length of the second stage. Other maternal and neonatal morbidities were similar between groups.Prolonged second stage of labor is associated with an increase in unintentional hysterotomy extensions at cesarean delivery and prolonged operative time. The future risk of hysterotomy extensions merits further investigation.
View details for DOI 10.1016/j.ajog.2007.07.005
View details for Web of Science ID 000249531300033
View details for PubMedID 17826431
Magnesium sulfate compared with nifedipine for acute tocolysis of preterm labor - A randomized controlled trial
26th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
LIPPINCOTT WILLIAMS & WILKINS. 2007: 61–67
To compare the efficacy and side effects of intravenous magnesium to oral nifedipine for acute tocolysis of preterm labor.A multicenter randomized trial was performed. Patients in active preterm labor who were at 24 to 33 weeks and 6 days of gestation were randomly assigned to receive magnesium sulfate or nifedipine. The primary outcome was arrest of preterm labor, defined as prevention of delivery for 48 hours with uterine quiescence.One hundred ninety-two patients were enrolled. More patients assigned to magnesium sulfate achieved the primary outcome (87% compared with 72%, P=.01). There were no differences in delivery within 48 hours (7.6% magnesium sulfate compared with 8.0% nifedipine, P=.92), gestational age at delivery (35.8 compared with 36.0 weeks, P=.61), birth before 37 and 32 weeks (57% compared with 57%, P=.97, and 11% compared with 8%, P=.39), and episodes of recurrent preterm labor. Mild and severe maternal adverse effects were significantly more frequent with magnesium sulfate. Birth weight, birth weight less than 2,500 g, and neonatal morbidities were similar between groups, but newborns in the magnesium sulfate group spent longer in the neonatal intensive care unit (8.8+/-17.7 compared with 4.2+/-8.2 days, P=.007).Patients who received magnesium sulfate achieved the primary outcome more frequently. However, delay of delivery, gestational age at delivery, and neonatal outcomes were similar between groups. Nifedipine was associated with fewer maternal adverse effects.
View details for Web of Science ID 000247572700011
View details for PubMedID 17601897
Presence of the sickle cell trait and preterm delivery in African-American women
OBSTETRICS AND GYNECOLOGY
2007; 109 (4): 870-874
To estimate the association between presence of the sickle cell trait and preterm delivery among African-American women.A retrospective cohort study was conducted to study all deliveries by African-American women at one institution between 1976 and 2001. The primary predictor of interest was the presence of the sickle cell trait, and the primary outcome was preterm delivery. Post hoc analyses were conducted to explore the relationship between presence of sickle cell trait and multiple gestations, an apparent modifier of the relationship between sickle cell trait and preterm delivery.Of the 5,028 African-American women eligible for inclusion, 6.5% carried the sickle cell trait. In adjusted analyses, the presence of sickle cell trait was associated with a lower risk of preterm delivery at less than 32 weeks (adjusted odds ratio 0.15, 95% confidence interval 0.05-0.49), and was found to be associated with an increased odds of multiple gestations (adjusted odds ratio 1.94, 95% confidence interval 1.22-2.09). A significant interaction exists between the presence of multiple gestation and sickle cell trait and the odds of preterm delivery, such that the protective effect of sickle cell trait on preterm delivery risk is greater among those with multiple gestations than those with singletons.Among African-American women, the presence of the sickle cell trait was associated with lower odds of early preterm delivery despite adjustment for potential confounders. An increased odds of multiple gestations was also noted among these women, possibly suggesting a persistence of selection for the hemoglobin S trait in nonmalarial settings.II.
View details for Web of Science ID 000248384500012
View details for PubMedID 17400848
Induction of labor and cesarean delivery by gestational age
26th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2006: 700–705
Studies of cesarean delivery (CD) rates among women undergoing induction of labor (IOL) often compare such women to women experiencing spontaneous labor at similar gestational ages. We sought to examine the association between IOL at various gestational ages and CD, accounting for the effect of increased gestational age among the comparison group who were managed expectantly.We conducted a retrospective cohort study of all term, singleton, cephalic presentation pregnancies delivered at our institution over 15 years excluding cesarean deliveries before labor. For each gestational age of induction, we created a comparison group of women who were undelivered at that gestational age, and who experienced labor at some future gestational age.In women undergoing IOL at 38 weeks gestation, the CD rate was 11.9% as compared to 13.3% (P = .42) of women beyond 38 weeks gestation. The CD rate for induction of labor compared to ongoing pregnancy was 14.3% versus 15.0% (P = .62) at 39 weeks, 20.4% versus 19.0% (P = .41) at 40 weeks, and 24.3% versus 26.0% (P = .39) at 41 weeks. When controlling for potential confounding, there was a higher rate of CD among women with expectant management beyond 38 weeks (adjusted odds ratio [AOR] 1.80; 95% CI 1.29-2.53), 39 weeks (1.39; 95% CI 1.08-1.80), and 40 weeks (AOR 1.27; 95% CI 1.00-1.62).Our findings suggest that IOL may not increase a woman's risk of CD when compared to expectant management. While this question has been addressed prospectively at 41 weeks gestation, it requires further examination at earlier gestations and among various subgroups.
View details for DOI 10.1016/j.ajog.2006.07.003
View details for Web of Science ID 000240473500007
View details for PubMedID 16949399
Ultrasound screening of fetuses at increased risk for Down syndrome: how many missed diagnoses?
2006; 26 (1): 22-27
To determine the number of Down syndrome (DS) fetuses identified, amniocenteses performed, and procedure-related losses incurred when second-trimester ultrasound is used to screen high-risk patients in order to determine who should undergo an amniocentesis.A decision analytic model was designed for women at increased risk for a DS fetus due to either advanced maternal age (AMA) or a positive expanded maternal serum alpha fetoprotein (MSAFP) screening test, also known as a triple screen (+triple) test. The model compared: (1) the current standard of offering all at-risk women amniocentesis to (2) a policy of performing amniocentesis only when sonographic markers of DS are seen on ultrasound. Baseline assumptions included a sensitivity of 60.6% for targeted ultrasound and a screen-positive rate of 16.2%.If targeted ultrasound is used to determine whether high-risk patients should undergo amniocentesis, 56% (3933/7025) of all DS fetuses are missed. The diagnosis of DS is missed most frequently among women at highest risk for DS (AMA and +triple). In this subgroup of patients, there are 3152 DS fetuses in the second trimester, of which 2815 (89%) are identified by triple screen test. When an ultrasound screen is added, only 1709 (54%) of DS fetuses will be identified.Substantially fewer DS fetuses will be detected when targeted ultrasound is used as a screen among already identified high-risk patients.
View details for DOI 10.1002/pd.1319
View details for Web of Science ID 000235173000006
View details for PubMedID 16378329
Percutaneous transluminal coronary angioplasty and stent placement in pregnancy
OBSTETRICS AND GYNECOLOGY
2005; 106 (5): 1162-1164
Myocardial infarction (MI) is uncommon during pregnancy. As the average maternal age increases and assisted reproductive technology allows for very advanced maternal ages, so too may the incidence of MI during pregnancy. Percutaneous transluminal coronary angioplasty (PTCA) with stent placement is an attractive option for treatment of MI in pregnancy when revascularization is required.We present a gravida with an ST elevation MI during the third trimester, who was treated with emergent PTCA, stent placement, and platelet inhibitors, and we discuss the patient's subsequent obstetric and anesthetic management.Percutaneous transluminal coronary angioplasty with stent placement may be used during the third trimester with successful outcome.
View details for Web of Science ID 000233018900008
View details for PubMedID 16260555
Peritoneal closure at primary cesarean delivery and adhesions
24th Annual Meeting of the Society-for-Maternal-Fetal-Medicine
LIPPINCOTT WILLIAMS & WILKINS. 2005: 275–80
To evaluate the effect of parietal peritoneal closure at cesarean delivery on adhesion formation.A prospective cohort study of women undergoing first repeat cesarean delivery was designed. All surgeons were asked immediately after surgery to score the severity and location of adhesions. Patient records were then abstracted to assess prior surgical technique, including parietal peritoneal closure, other attributes of first surgery, and patient characteristics. Exclusion criteria included adhesions, other surgery, or use of permanent suture at the first cesarean, unavailable first postoperative note and course, wound infection or breakdown following first surgery, intervening pelvic surgery, insulin-dependent diabetes mellitus, and steroid-dependent disease. The chi2 test and multivariable logistic regression were used for statistical comparison and analysis. A total of 128 patients was required to have 80% power to detect a 50% reduction in adhesions when the parietal peritoneum was left open.One hundred seventy-three patients were enrolled. Prior parietal peritoneal closure was associated with significantly fewer dense and filmy adhesions (52% versus 73%, P = .006) and significantly fewer dense adhesions (30% versus 45%, P = .043). When controlling for potential confounding variables, including prior infection, visceral peritoneal closure, rectus muscle closure, payor status, ethnicity, maternal age, gestational diabetes, and labor, parietal peritoneal closure at primary cesarean delivery was 5-fold protective against all adhesions (odds ratio 0.20, 95% confidence interval 0.08-0.49), and 3-fold protective against dense adhesions (odds ratio 0.32, 95% confidence interval 0.13-0.79). Omental-fascial adhesions were decreased most consistently.Parietal peritoneal closure at primary cesarean delivery was associated with significantly fewer dense and filmy adhesions. The practice of nonclosure of the parietal peritoneum at cesarean delivery should be questioned.
View details for Web of Science ID 000230717800010
View details for PubMedID 16055575
Randomized comparison of intravenous nitroglycerin and subcutaneous terbutaline for external cephalic version under tocolysis
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2004; 191 (6): 2051-2055
The purpose of this study was to compare the efficacy and safety of intravenous nitroglycerin with that of subcutaneous terbutaline as a tocolytic agent for external cephalic version at term.We performed a prospective randomized trial. Patients between 37 and 42 weeks of gestation were assigned randomly to receive either 200 microg of intravenous nitroglycerin therapy or 0.25 mg of subcutaneous terbutaline therapy for tocolysis during external cephalic version. The rate of successful external cephalic version and side effects were compared between groups.Of 59 randomly assigned patients, 30 patients received intravenous nitroglycerin, and 29 patients received subcutaneous terbutaline. The overall success rate of external cephalic version in the study was 39%. The rate of successful external cephalic version was significantly higher in the terbutaline group (55% vs 23%; P = .01). The incidence of palpitations was significantly higher in patients who received terbutaline therapy (17.2% vs 0%; P = .02), as was the mean maternal heart rate at multiple time periods.Compared with intravenous nitroglycerin, subcutaneous terbutaline was associated with a significantly higher rate of successful external cephalic version at term.
View details for DOI 10.1016/j.ajog.2004.04.040
View details for Web of Science ID 000225925800030
View details for PubMedID 15592291
Developmental response to hypoxia
2004; 18 (12): 1348-1365
Molecular mechanisms underlying fetal growth restriction due to placental insufficiency and in utero hypoxia are not well understood. In the current study, time-dependent (3 h-11 days) changes in fetal tissue gene expression in a rat model of in utero hypoxia compared with normoxic controls were investigated as an initial approach to understand molecular events underlying fetal development in response to hypoxia. Under hypoxic conditions, litter size was reduced and IGFBP-1 was up-regulated in maternal serum and in fetal liver and heart. Tissue-specific, distinct regulatory patterns of gene expression were observed under acute vs. chronic hypoxic conditions. Induction of glycolytic enzymes was an early event in response to hypoxia during organ development; consistently, tissue-specific induction of calcium homeostasis-related genes and suppression of growth-related genes were observed, suggesting mechanisms underlying hypoxia-related fetal growth restriction. Furthermore, induction of inflammation-related genes in placentas exposed to long-term hypoxia (11 days) suggests a mechanism for placental dysfunction and impaired pregnancy outcome accompanying in utero hypoxia.
View details for DOI 10.1096/fj.03-1377com
View details for Web of Science ID 000224243200054
View details for PubMedID 15333578
Postpartum uterine arteriovenous fistula
OBSTETRICS AND GYNECOLOGY
2004; 103 (5): 1076-1078
Uterine arteriovenous communications are uncommon lesions that may be associated with life-threatening postpartum and postinstrumentation hemorrhage.A primigravida presented with infected retained products of conception. Excessive hemorrhage of unclear etiology occurred at dilation and curettage. After a second episode of bleeding, the patient received a diagnosis of uterine arteriovenous fistula.Uterine arteriovenous communications should be included in the differential diagnosis in patients with excessive postpartum or postinstrumentation bleeding. Color and spectral flow Doppler can aid diagnosis and clinical management.
View details for DOI 10.1097/01.AOG.0000123241.44401.01
View details for Web of Science ID 000225470300017
View details for PubMedID 15121613
Neonatal chest wall rigidity following the use of remifentanil for cesarean delivery in a patient with autoimmune hepatitis and thrombocytopenia
INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA
2004; 13 (1): 53-56
Remifentanil is a useful adjunct in general anesthesia for high-risk obstetric patients. It provides effective blunting of the rapid hemodynamic changes that may be associated with airway manipulation and surgical stimulation. There have been no previous reports of opioid-related rigidity in the neonate delivered by a parturient receiving intraoperative remifentanil. We present a case of short-lived neonatal rigidity and respiratory depression following remifentanil administration during cesarean section to a parturient with autoimmune hepatitis complicated by cirrhosis, esophageal varices and thrombocytopenia.
View details for DOI 10.1016/j.ijoa.2003.09.001
View details for Web of Science ID 000188228500013
View details for PubMedID 15321443
Training and competency assessment in electronic fetal monitoring: A national survey
OBSTETRICS AND GYNECOLOGY
2003; 101 (6): 1243-1248
To investigate current patterns of training and competency assessment in electronic fetal monitoring (EFM) for obstetrics and gynecology residents and maternal-fetal medicine fellows.A questionnaire was mailed to the directors of all 254 accredited US residencies in obstetrics and gynecology and 61 accredited US fellowships in maternal-fetal medicine. Questions focused on the methods used for teaching and assessing competency in EFM.Two hundred thirty-nine programs (76%) responded to the survey. Clinical experience is used by 219 programs (92%) to teach EFM, both initially and on an ongoing basis. Significantly more residencies than fellowships use written materials and lectures to teach EFM. More than half of all programs require trainees to participate in some type of EFM training at least every 6 months; 23 programs (10%) have no requirement at all. Subjective evaluation is used by 174 programs (73%) to assess competency in EFM. Written or oral examinations, skills checklists, and logbooks are used exclusively by residencies as means of competency assessment. Two thirds of all programs assess EFM skills at least every 6 months; 40 programs (17%), the majority of which are fellowships, have no formal requirement.Most US training programs use supervised clinical experience as both their primary source of teaching EFM and their principal competency assessment tool. Residencies are more likely to have formal instruction and assessment than are fellowships. Few programs are using novel strategies (eg, computers or simulators) in their curriculum.
View details for DOI 10.1016/S0029-7844(03)00351-0
View details for Web of Science ID 000183293300018
View details for PubMedID 12798531
Prenatal screening, epidemiology, diagnosis, and management of preeclampsia
CLINICS IN LABORATORY MEDICINE
2003; 23 (2): 413-?
The cause of preeclampsia remains unknown. The disease manifests itself across a broad clinical spectrum from mild to severe, conferring vastly different morbidities and suggesting possibly different disease processes. Oxidative stress, endothelial dysfunction, maternal-fetal immune incompatibility, and abnormal placental implantation are among the suggested causes. The need for a marker or set of markers that allow for definitive diagnosis and assessment of future risk of preeclampsia is tremendous. Ultrasound techniques and several markers have been identified that are increased among patients with preeclampsia, but no test is highly sensitive. In the future, a combination of markers likely will be used to assess risk and, establish the diagnosis, and test treatment strategies. Such an approach would allow for more refined treatment studies of patients who are at highest risk for preeclampsia.
View details for DOI 10.1016/S0272-2712(03)00027-1
View details for Web of Science ID 000183712000010
View details for PubMedID 12848452
Evaluation of a novel electronic fetal monitor simulator
11th Annual Medicine Meets Virtual Reality Conference
I O S PRESS. 2003: 240–244
The purpose of this study was to evaluate the content validity and construct validity of a novel electronic fetal monitor (EFM) simulator. Fourteen residents in Gynecology and Obstetrics (OB/GYN) and 7 medical students in their OB/GYN clerkship interpreted 10 fetal heart rate (FHR) tracings and 4 clinical scenarios generated by the EFM simulator. Their responses were scored by experts in maternal-fetal medicine. Construct validity was determined by comparing subjects' scores to their level of experience. Subjects assessed content validity of the EFM simulator by rating the realism of its various elements on a 4-point Likert scale. Residents achieved statistically significant higher mean scores in the description of FHR tracings generated by the simulator than medical students and statistically significant higher mean scores in the correct interpretation of and interventions in 2 of 4 clinical scenarios. Two-thirds of the residents rated the simulator-generated FHR tracings and clinical scenarios as "real" or "very real." The EFM simulator exhibited both content and construct validity, supporting its use in an educational setting.
View details for Web of Science ID 000189484800048
View details for PubMedID 15455900
The impact of the use of the isolated echogenic intracardiac focus as a screen for Down syndrome in women under the age of 35 years
21st Annual Meeting of the Society-for-Maternal-Fetal-Medicine
MOSBY-ELSEVIER. 2001: 1021–27
The purpose of this study was to determine the public health impact of the routine offering of amniocentesis to women under the age of 35 years who have an isolated fetal echogenic intracardiac focus on second trimester ultrasound scan.A decision analytic model was designed that compared the accepted standard of second trimester triple marker screen for Down syndrome to a policy in which amniocentesis with an isolated echogenic intracardiac focus on ultrasound in addition to the triple marker screen is offered to all women in the United States who are <35 years of age. A sensitivity of 20%, an echogenic intracardiac focus screen positive rate of 5%, and a risk of Down syndrome of 1:1000 were assumed. A sensitivity analysis was performed that varied the screen positive rate, the sensitivity of echogenic intracardiac focus for Down syndrome, and the prescreen risk for Down syndrome in the population.With the baseline sensitivities, rates, and risks, the use of isolated echogenic intracardiac focus as a screen would result in an additional 118,146 amniocenteses performed annually to diagnose 244 fetuses with Down syndrome. These amniocenteses would result in 582 additional miscarriages. It would be necessary to perform 485 amniocenteses that would result in 2.4 procedure-related losses for each additional Down syndrome fetus that was identified.Although the echogenic intracardiac focus appears to be associated with a small increased risk of Down syndrome, its use as a screening tool in low-risk populations would lead to a large number of amniocenteses and miscarriages to identify a small number of Down syndrome fetuses.
View details for Web of Science ID 000172396100003
View details for PubMedID 11717625
New therapies for the pregnant patient with diabetes.
Diabetes technology & therapeutics
2001; 3 (4): 635-640
Gestational diabetes complicates 3-5% of pregnancies. Of diabetes seen during pregnancy, 10% is pregestational and the remaining 90% represents gestational diabetes. (1,2) Pregnancy in women with pregestational diabetes is especially high risk. Spontaneous abortion, preterm labor, congenital malformations, preeclampsia, macrosomia, birth injury, and cesarean section are all increased in these pregnancies. Deterioration of maternal health during pregnancy, especially in the setting of diabetes-induced end-organ disease, is a real concern. Vigilant surveillance and management of associated disorders such as retinopathy, nephropathy, and chronic hypertension are required. During the preinsulin era, maternal and perinatal mortality in pregnancies complicated by pregestational diabetes was approximately 50%. (1,2) Although modern obstetrical management and the appropriate use of insulin have dramatically improved maternal-fetal outcomes, pregnant patient with diabetes remains at increased risk for complications. There is no doubt that optimizing maternal glucose control is a key element in avoiding established perinatal risks. The most effective means to accomplish this control are topics of active research. Further, hormonal changes during pregnancy can make glycemic control difficult even for the most compliant and educated patient. This paper discusses several new approaches, either currently in practice or under consideration, to pregnancies complicated by diabetes, including oral hypoglycemic agents, lispro, the insulin pump, and transplantation.
View details for PubMedID 11911177
Videourodynamic diagnosis of occult genuine stress incontinence in patients with anterior vaginal wall relaxation
JOURNAL OF THE SOCIETY FOR GYNECOLOGIC INVESTIGATION
1998; 5 (6): 327-330
To (1) utilize videourodynamics, the gold standard, to assess the prevalence of occult genuine stress incontinence (GSI) among preoperative patients with symptomatic anterior vaginal wall relaxation and (2) identify urodynamic discriminators that might help predict occult GSI.In this prospective study, videourodynamic evaluation was performed on 48 consecutive patients presenting for preoperative urodynamic evaluation of anterior vaginal wall prolapse. Patients with occult GSI were identified by urodynamic testing with and without Gehrung pessary support of the bladder base during stress maneuvers. Variables from the history, physical examination, and videourodynamics were then analyzed.The overall incidence of occult GSI was 25% (22.7% in the pelvic organ prolapse [POP] group and 26.9% in the POP-UI group). Patients with occult GSI were not identifiable on history but did have a higher incidence of late first sensation, open bladder neck at rest, and hypermobility on imaging with videourodynamics.This study suggests that one quarter of women presenting with anterior wall relaxation with or without incontinence symptoms have occult GSI. Given this high prevalence, preoperative evaluation with urodynamics, possibly videourodynamics, utilizing bladder base support is justified if the data are substantiated in a larger, definitive study. Patients with a late first sensation, open bladder neck, and hypermobility may have a higher incidence of occult GSI.
View details for Web of Science ID 000076939400008
View details for PubMedID 9824814