Publications by authors named "Everett F Magann"

236 Publications

Is There a Difference in Sonographic Estimation of Amniotic Fluid Volume When Measuring With the Probe Perpendicular to the Floor Compared With Perpendicular to the Uterine Contour?

J Obstet Gynaecol Can 2019 Sep 23;41(9):1295-1301. Epub 2019 Mar 23.

Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR. Electronic address:

Objective: This study sought to determine whether there is a significant difference in amniotic fluid measurements when measuring perpendicular to the floor compared with perpendicular to the uterine contour using both amniotic fluid index and single deepest pocket.

Methods: This was a single-centre, prospective study of women with singleton gestation who were undergoing fetal ultrasound examination. A total of 240 women were enrolled, and single deepest pocket and amniotic fluid index were measured with both techniques. Correlation coefficient and intraclass correlation coefficient were used to assess the agreement between the values using the two methods of measurement (Canadian Task Force Classification II-2).

Results: A strong correlation was found between amniotic fluid index measurements (correlation coefficient 0.82; intraclass correlation coefficient 0.7). A strong correlation also was found between single deepest pocket measurements (correlation coefficient 0.7; intraclass correlation coefficient 0.6).

Conclusion: The measurement of amniotic fluid index and single deepest pocket can be performed either perpendicular to the floor or perpendicular to the uterine contour. There is no significant difference between these measurements and they correlate well.
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http://dx.doi.org/10.1016/j.jogc.2019.01.017DOI Listing
September 2019

Early development of the human placenta and pregnancy complications.

J Matern Fetal Neonatal Med 2020 Oct 27;33(20):3538-3545. Epub 2019 Feb 27.

Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA.

An adequately sized placenta at a suitable site with appropriate depth and centripetal progression of implantation are the major factors for optimal fetal development. The cytotrophoblasts surround the blastocyst fuses at the site of the uterine attachment. This forms a second layer of multinucleated syncytiotrophoblasts that constitutes the inner epithelial boundary of the chorionic villous against the intervillous space. In a normal pregnancy, extravillous cytotrophoblasts (EVT) invade and obstruct the spiral arteries and remodel them. Vacuoles in the syncytial cell layer fuse and develop the intervillous space. The inner cell mass (embryoblast) gives rise to the umbilical cord and the mesenchyme in the chorionic villi. Vasculogenesis starts with the formation of hemangioblastic cords in this mesenchyme. The trophoblastic cell columns anchor the placenta. A variety of molecular pathways participate in the placentation process. Placental morphogenesis occurs mainly through complex cellular interactions between the chorionic villous and the extravillous cytotrophoblasts. The formation of the normal structure of the chorionic villi, syncytiotrophoblast layer and vasculature is essential for placental function, hormone production, and regulation of fetal growth. At each stage of placental development, genetic variants, exposure to infection, poor vascular function, oxidative stress, or failure of normal development can all lead to abnormal formation resulting in the clinical complications of pregnancy such as fetal growth disorders, neonatal neurologic abnormalities, placental adhesions, and inflammatory problems as well as maternal disease such as preeclampsia.
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http://dx.doi.org/10.1080/14767058.2019.1578745DOI Listing
October 2020

The Role of Oxidative Stress, Adhesion Molecules and Antioxidants in Preeclampsia.

Curr Hypertens Rev 2019 ;15(2):105-112

Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi, MS, United States.

Oxidative stress is a consequence of reduction in the antioxidant capacity and excessive production of reactive oxygen and nitrogen species (ROS). Oxidative agents, which are overproduced due to ischemic-reperfusion injury in the placenta, may overwhelm the normal antioxidant activity. This imbalance is a key feature in the pathogenesis of preeclampsia. A decrease in glutathione peroxidase (GPX) activity is associated with the synthesis of vasoconstrictive eicosanoids such as F2-isoprostanes and thromboxane, which are known to be upregulated in preeclampsia. Biochemical markers of lipid peroxidation, such as malondialdehyde and F2-isoprostane in the placenta, are also increased. Adhesion molecules participate in the pathophysiology of preeclampsia by contributing to a reduced invasion by the trophoblast and increased vascular endothelial damage. Superoxide dismutase (SOD), catalase (CAT) and GPX play important roles counteracting oxidative stress. Other antioxidant factors participate in the etiology of preeclampsia. Levels of antioxidants such as Lycopene, Coenzyme 10, as well as some vitamins, are reduced in preeclamptic gestations.
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http://dx.doi.org/10.2174/1573402115666190119163942DOI Listing
May 2020

Bladder Stone in Pregnancy: A Case Report and Review of the Literature.

Am J Case Rep 2018 Dec 30;19:1546-1549. Epub 2018 Dec 30.

Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

BACKGROUND Bladder stones are rare in pregnancy, and can be associated with adverse outcomes such as recurrent urinary tract infection and obstruction of labor. Management of bladder stones discovered in pregnancy has traditionally been done via open techniques such as cystolithotomy or with percutaneous removal. Our objective was to present a case of bladder stone in pregnancy and review prior reports on bladder stones and management in pregnancy. CASE REPORT A 28-year-old gravida 4 para 3 at 10 weeks gestation presented with dysuria, bladder spasm, weak urinary stream, and positional voiding. On first trimester ultrasound, a bladder stone (sized 3.7 cm) was identified and was confirmed by x-ray (KUB). Urology was consulted and removed the stone via cystolitholapaxy with holmium laser. Her symptoms subsequently resolved, and she went on to have an uncomplicated term spontaneous vaginal delivery. The removal of the stone enabled her to have a subsequent vaginal delivery without the potential for obstruction of labor. CONCLUSIONS Based on our review of the literature and this case report, laser cystolitholapaxy is a safe alternative to open surgery for the management of bladder stones in pregnancy. When discovered at the time of delivery, vaginal delivery is feasible if the stone is small or can be displaced. If encountered at time of cesarean delivery, then cystotomy with stone removal is recommended provided inflammation is not present.
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http://dx.doi.org/10.12659/AJCR.912614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322064PMC
December 2018

Maternal/Perinatal Outcome in Women with Sickle Cell Disease: A Comparison of Two Time Periods.

South Med J 2018 12;111(12):742-745

From the Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, the Department of Obstetrics and Gynecology of the University of Mississippi Medical Center, Jackson, and Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City.

Objective: To compare pregnancy outcomes in women with sickle cell disease from recent deliveries with a similar group delivered earlier.

Methods: During a 12-year period (2005-2016), data from pregnant women with hemoglobin SS or SC were collected from three university medical centers and compared with earlier studies (1979-2003) involving similar patients. The primary endpoints were maternal complications during pregnancy and newborn outcomes.

Results: There were 278 patients in the control group (1979-2003) compared with 150 patients in the study group (2005-2016). Women in the study group were older ( < 0.0001) and of less parity ( =0.0001), and complications of preterm delivery, preeclampsia, and having a transfusion were similar between the two groups ( = 0.45, 0.95, and 0.49, respectively). Pain crises were more common in the study group ( = 0.02) as was cesarean section ( < 0.0001), but there was a reduction in pulmonary complications ( = 0.0002). Maternal mortality was uncommon (control group [N=4] vs study group [N=3], = 0.40). Newborn statistics revealed a similar gestational age at delivery (37 weeks), and the incidence of intrauterine growth restriction, as well as 5-minute Apgar score <7 did not differ by group ( = 0. 91, 0.85, and 0.16, respectively). Infants in the study group were heavier on average by approximately 220 g ( = 0.02), whereas the neonatal death rate was low (control group [N=1], study group [N=2] = 0.60).

Conclusions: Recent pregnancy outcome statistics in women with sickle cell disease have not changed through the years. Innovative strategies to improve maternal and newborn outcomes among such patients are needed.
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http://dx.doi.org/10.14423/SMJ.0000000000000900DOI Listing
December 2018

The Use of Electronic Cigarettes in Pregnancy: A Review of the Literature.

Obstet Gynecol Surv 2018 Sep;73(9):544-549

Associate Professor, Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR.

Importance: Electronic cigarette (e-cigarette) use in pregnancy has been steadily increasing and has been hyped as being a safe alternative to cigarette smoking during pregnancy. This review discloses what is currently known about e-cigarette use in pregnancy and the effects of its use on pregnancy outcomes.

Objective: To determine what is currently known about the prevalence of e-cigarette use in pregnancy and the effects of e-cigarette use on pregnancy and perinatal/neonatal outcomes.

Evidence Acquisition: A PubMed, CINAHL, and EMBASE search was undertaken using the search terms "pregnancy" OR "pregnancy complications" OR "pregnancy outcome" OR "newborn" OR "neonate" OR "birth" AND "electronic cigarettes" OR "e-cigarettes" OR "ecigarettes" OR "vaping" OR "vape." The search was limited to the English language and between 2007 and October 12, 2017.

Results: The search identified 91 articles, 40 of which are the basis for this review. The prevalence of e-cigarette use is 0.6% to 15%. The amount of nicotine consumed by e-cigarette users is comparable to that consumed by cigarette smokers. Most of the animal model studies suggest a potential danger to the developing fetus primarily because of the nicotine consumed and that consumption has multiple effects on the immune system, neural development, lung function, and cardiac function. There is a widespread flawed perception that e-cigarettes are safe to use during pregnancy.

Conclusions: The marketing of e-cigarette use as a safer alternative to cigarette smoking has led to an increasing use even in pregnancy. The nicotine consumed by e-cigarettes is similar to that consumed by cigarette smoking. Animal studies confirm the dangers of nicotine to the developing fetus. More research needs to be done specifically assessing e-cigarette use, pregnancy, and pregnancy outcomes.

Relevance: The amount of nicotine consumed in cigarette smoking is similar to the amount of nicotine consumed with e-cigarettes. The effects of nicotine exposure during fetal development are well known and include effects on multiple organ systems.
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http://dx.doi.org/10.1097/OGX.0000000000000595DOI Listing
September 2018

Naval Medicine's Involvement in Global Health: The Participation of Women's Healthcare Providers in Continuing Promise 2017.

Mil Med 2019 03;184(3-4):e135-e138

Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, 4301 W. Markham #518, Little Rock, AR.

Introduction: This is a retrospective review of information collected during operation Continuing Promise 2017 from the Wayuu population in Colombia, South America.

Materials And Methods: Team objective was to present an overview of women's health care needs in an isolated underserved population of Colombia by a humanitarian mission of health care providers from the U.S. Navy. We analyzed demographics, contraceptive selection, presenting complaint, diagnosis, and disposition of those female patients presenting for care.

Results: The acute care clinics of this mission saw patients for 10 full clinic days in each of the countries of Guatemala, Honduras, and Colombia. In the Wayuu clinic of Colombia, 356 patients were seen in the acute care women's clinic. These women averaged 36 years of age with an age range of 9-77 years of age and a gravidity of 3 ± 3.3 and a range of 0-18. Of the women less than the age of 50, not permanently sterilized, 186/220 (84.5%) were not using any form of contraception. The most common chief complaints were vaginal discharge and pelvic pain and the most common final diagnosis was bacterial vaginosis. The two most common secondary diagnoses of the pregnant women were urinary tract infection and anemia. Other significant diagnoses included uterine cancer, preterm labor, and fetal posterior urethral valve syndrome.

Conclusions: A majority of Wayuu women presenting to an acute clinic setting in Colombia, South America were in their mid-thirties having had three pregnancies and the majority were not using any form of contraception. The most common diagnoses were straightforward diagnoses such as vaginal infections, urinary tract infections, and abnormal uterine bleeding. Our findings suggest a need for access to routine gynecologic care, general hygiene education, and increased availability of birth control among the Wayuu population.
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http://dx.doi.org/10.1093/milmed/usy208DOI Listing
March 2019

Uterine Inversion: A Review of a Life-Threatening Obstetrical Emergency.

Obstet Gynecol Surv 2018 Jul;73(7):411-417

Professor, Maternal-Fetal Medicine Fellowship Director, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR.

Importance: Uterine inversion is frequently accompanied by postpartum hemorrhage and hypovolemic shock. Morbidity and mortality occur in as many as 41% of cases. Prompt recognition and management are of utmost importance.

Objective: The aim of this review is to describe risk factors, clinical and radiographic diagnostic criteria, and management of this rare but potentially life-threatening complication of pregnancy.

Evidence Acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched.

Results: There were 86 articles identified, with 25 being the basis of review. Multiple risk factors for a uterine inversion have been suggested including a morbidly adherent placenta, short umbilical cord, congenital weakness of the uterine wall or cervix, weakening of the uterine wall at the placental implantation site, fundal implantation of the placenta, uterine tumors, uterine atony, sudden uterine emptying, fetal macrosomia, manual removal of the placenta, inappropriate fundal pressure, excessive cord traction, and the use of uterotonic agents prior to placental removal. The diagnosis is almost exclusively clinical, and successful treatment depends on prompt recognition of the uterine inversion. Treatment options include manual and surgical replacement of the inverted uterus. There is no consensus regarding mode of delivery in subsequent pregnancies as reinversion in a subsequent pregnancy is unpredictable. However, if surgical replacement was required in the index pregnancy and involved an incision into the contractile portion of the uterus, cesarean delivery is a reasonable management option similar to that offered for a prior classic cesarean section.

Conclusions: Successful treatment is dependent on prompt recognition. Management should include resuscitation of maternal hypovolemic shock, as well as repositioning of the inverted uterine fundus.

Relevance: Uterine inversion is a rare but potentially life-threatening obstetrical emergency.
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http://dx.doi.org/10.1097/OGX.0000000000000580DOI Listing
July 2018

The Third Stage of Labour in the Extremely Obese Parturient.

J Obstet Gynaecol Can 2018 09 11;40(9):1148-1153. Epub 2018 Jul 11.

Departments of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR. Electronic address:

Background: Maternal obesity has been associated with an increased risk for an abnormal progression of labour; however, less is known about the length of the third stage of labour and its relation to maternal obesity.

Objective: To determine if the length of the third stage of labour is increased in extremely obese women and its possible correlation with an increased risk for postpartum hemorrhage.

Study Design: This was a retrospective cohort study of deliveries from January 2008 to December 2015 at our university hospital. Women with a BMI ≥40 and a vaginal delivery were compared with the next vaginal delivery of a woman with a BMI <30. There were 147 women with a BMI ≥40 compared with 157 with a BMI <30. Outcomes evaluated the length of the third stage of labour and the risk for postpartum hemorrhage and included antepartum, intrapartum, and perinatal complications.

Results: Subjects in the extreme obese group were more likely to be African American, older, diabetic (pregestational and gestational), hypertensive, pre-eclamptic, had a preterm delivery, and underwent an induction of labour. The overall length of the third stage of labour was significantly longer in the extreme obese group, 5 minutes (3, 8 [25th and 75th percentiles]) compared with 4 minutes (3,7) (P = 0.0374) in the non-obese group. Postpartum hemorrhage occurred more often in the extreme obese group (N = 16/147; 11%) compared with the non-obese group (N = 5/157; 3%) (P = 0.01). There were no differences between groups in respect to the following: gravidity, parity, length of the second stage of labour, birth weight, GA at delivery, Apgar score, cord blood gases, hematocrit change, need for postpartum transfusion, operative delivery, and development of chorioamnionitis. After an adjustment for ethnicity, maternal age, diabetes, preeclampsia, preterm labour, hypertension, and induction/augmentation, the analysis failed to show a significant difference in estimated blood loss and postpartum hemorrhage between the groups.

Conclusions: The length of the third stage of labour is longer in the extreme obese parturient. Postpartum hemorrhage also occurs more often, but after adjustments for confounding variables, it is no longer significant.
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http://dx.doi.org/10.1016/j.jogc.2017.12.008DOI Listing
September 2018

Chronic pain during pregnancy: a review of the literature.

Int J Womens Health 2018 9;10:153-164. Epub 2018 Apr 9.

Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

Background And Purpose: The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery.

Methods: A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016.

Results: The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain.

Conclusion: The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.
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http://dx.doi.org/10.2147/IJWH.S151845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901203PMC
April 2018

Association of the Length of the Third Stage of Labor and Blood Loss Following Vaginal Delivery.

South Med J 2018 03;111(3):178-182

From the Department of Obstetrics and Gynecology, Tripler Army Medical Center, Honolulu, Hawaii, and the Departments of Biostatistics, Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Objectives: The length of the third stage of labor is correlated with blood loss following a vaginal delivery. We aimed to accurately measure blood loss following a vaginal delivery and examine the relation between blood loss and length of the third stage of labor.

Methods: This was a prospective observational study of singleton pregnancies ≥24 weeks undergoing a vaginal delivery. Blood loss was meticulously measured and the length of the third stage of labor was recorded.

Results: The median blood loss of the 600 women was 125 mL (interquartile range 175) and the median length of the third stage of labor was 5 minutes (interquartile range 4). Total blood loss ( = 0.0263) and length of the third stage of labor ( = 0.0120) were greater in pregnancies ≥37 weeks versus <37 weeks. Women with a third stage of labor ≥15 minutes had a significantly greater risk of blood loss >500 mL (relative risk 5.8, 95% confidence interval 8.36-29.88).

Conclusions: The median blood loss following a vaginal delivery is 125 mL and the median length of the third stage of labor is 5 minutes. Total blood loss and the length of the third stage of labor are greater in pregnancies >37 weeks. Women with a third stage of labor >15 minutes are 15.8 times more likely to have total blood loss ≥500 mL. As such, it is prudent to consider manual extraction of the placenta at 15 minutes rather than 30 minutes to minimize the risk of excessive blood loss.
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http://dx.doi.org/10.14423/SMJ.0000000000000778DOI Listing
March 2018

Urethral Diverticulum Presenting as a Large Vaginal Mass Complicating Pregnancy and Delivery.

Am J Case Rep 2017 Oct 13;18:1095-1098. Epub 2017 Oct 13.

Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

BACKGROUND A case report of urethral diverticulum complicating pregnancy is presented. The diagnosis and management are challenging because of the rare nature of this condition, the varied presentations and differential diagnoses, and the possibility of misdiagnosis. CASE REPORT A 25-year-old primigravida with scheduled induction of labor at 39 weeks gestation due to gestational diabetes mellitus presented for a routine antenatal appointment at 38 weeks and four days. On digital cervical examination, she was found to have a large semi-solid anterior vaginal mass, shown by trans-vaginal ultrasound to have a nearly solid appearance of a 5×7 cm mass with septation. Maternal Fetal Medicine and Gynecologic Oncology consultations were obtained primary cesarean section with vaginal biopsy in the Operating Room were recommended. Following an uncomplicated cesarean delivery and with the patient still under spinal anesthesia, the anterior vaginal mass was examined and found to contain 200 ml of purulent material. Because a diagnosis of urethral diverticulum was made, a biopsy was not performed. The patient was placed on antibiotic prophylaxis for the remainder of her hospital course. Follow-up CT scan confirmed a large urethral diverticulum, and she was referred to the Fetal Pelvic Medicine and Reconstructive Surgery (FPMRS) and Urogynecology units for treatment. CONCLUSIONS Early identification of urethral diverticulum during the pregnancy may allow for treatment and a trial of labor with vaginal delivery. MRI is the recommended imaging modality in identifying urethral diverticulum.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5652138PMC
http://dx.doi.org/10.12659/ajcr.905578DOI Listing
October 2017

High transverse skin incisions may reduce wound complications in obese women having cesarean sections: a pilot study.

J Matern Fetal Neonatal Med 2019 Mar 1;32(5):781-785. Epub 2017 Nov 1.

b Department of OB/GYN , University of Arkansas for Medical Sciences , Little Rock , AR , USA.

Objective: Women having cesarean section have a high risk of wound complications. Our objective was to determine whether high transverse skin incisions are associated with a reduced risk of cesarean wound complications in women with BMI greater than 40.

Methods: A retrospective cohort study was undertaken of parturients ages 18-45 with BMI greater than 40 having high transverse skin incisions from January 2010 to April 2015 at a tertiary maternity hospital. Temporally matched controls had low transverse skin incisions along with a BMI greater than 40. The primary outcome, wound complication, was defined as any seroma, hematoma, dehiscence, or infection requiring opening and evacuating/debriding the wound. Secondary outcomes included rates of endometritis, number of hospital days, NICU admission, Apgar scores, birth weight, and gestational age at delivery. Analysis of outcomes was performed using two-sample t-test or Wilcoxon rank-sum test for continuous variables and Fisher's exact test for categorical variables.

Results: Thirty-two women had high transverse incisions and were temporally matched with 96 controls (low transverse incisions). The mean BMI was 49 for both groups. There was a trend toward reduced wound complications in those having high transverse skin incisions, but this did not reach statistical significance (15.63% versus 27.08%, p = .2379). Those having high transverse skin incisions had lower five minute median Apgar scores (8.0 versus 9.0, p = .0021), but no difference in umbilical artery pH values. The high transverse group also had increased NICU admissions (28.13% versus 5.21%, p = .0011), and early gestational age at delivery (36.8 versus 38.0, p = .0272).

Conclusion: High transverse skin incisions may reduce the risk of wound complications in parturients with obesity. A study with more power should be considered.
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http://dx.doi.org/10.1080/14767058.2017.1391780DOI Listing
March 2019

High transverse skin incisions may reduce wound complications in obese women having cesarean sections: a pilot study.

J Matern Fetal Neonatal Med 2019 Mar 1;32(5):781-785. Epub 2017 Nov 1.

b Department of OB/GYN , University of Arkansas for Medical Sciences , Little Rock , AR , USA.

Objective: Women having cesarean section have a high risk of wound complications. Our objective was to determine whether high transverse skin incisions are associated with a reduced risk of cesarean wound complications in women with BMI greater than 40.

Methods: A retrospective cohort study was undertaken of parturients ages 18-45 with BMI greater than 40 having high transverse skin incisions from January 2010 to April 2015 at a tertiary maternity hospital. Temporally matched controls had low transverse skin incisions along with a BMI greater than 40. The primary outcome, wound complication, was defined as any seroma, hematoma, dehiscence, or infection requiring opening and evacuating/debriding the wound. Secondary outcomes included rates of endometritis, number of hospital days, NICU admission, Apgar scores, birth weight, and gestational age at delivery. Analysis of outcomes was performed using two-sample t-test or Wilcoxon rank-sum test for continuous variables and Fisher's exact test for categorical variables.

Results: Thirty-two women had high transverse incisions and were temporally matched with 96 controls (low transverse incisions). The mean BMI was 49 for both groups. There was a trend toward reduced wound complications in those having high transverse skin incisions, but this did not reach statistical significance (15.63% versus 27.08%, p = .2379). Those having high transverse skin incisions had lower five minute median Apgar scores (8.0 versus 9.0, p = .0021), but no difference in umbilical artery pH values. The high transverse group also had increased NICU admissions (28.13% versus 5.21%, p = .0011), and early gestational age at delivery (36.8 versus 38.0, p = .0272).

Conclusion: High transverse skin incisions may reduce the risk of wound complications in parturients with obesity. A study with more power should be considered.
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http://dx.doi.org/10.1080/14767058.2017.1391780DOI Listing
March 2019

Teleultrasound: How Accurate Are We?

J Ultrasound Med 2017 Nov 29;36(11):2329-2335. Epub 2017 Jun 29.

University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Objectives: Ultrasound serves an important role in the prenatal diagnosis of fetal structural anomalies. Recently, there has been increased use of teleultrasound protocols. We aimed to evaluate the sensitivity and accuracy of teleultrasound.

Methods: We conducted an Institutional Review Board-approved retrospective cohort study determining the sensitivity and accuracy of teleultrasound. In addition, we evaluated the number of ultrasound examinations required to complete an anatomic survey. Only ultrasound examinations performed for anatomic surveys were included. Studies were excluded if performed before 16 completed weeks' gestation, if they had multiple gestations, or for reasons other than anatomy (eg, Doppler studies and fluid assessment). Prenatal diagnoses were compared with postnatal diagnoses obtained from a robust mandatory birth defects surveillance program that records all birth defects in the entire state, from deliveries before 20 weeks' gestation through infants up to 2 years of age.

Results: A total of 2499 studies were evaluated; 2368 were included. The teleultrasound cohort had a congenital anomaly prevalence of 5.66%. The sensitivity of teleultrasound was 57.46%; the specificity was 98.21%; and the accuracy was 95.9%. Anatomic surveys were completed after 1 visit in 82% of patients, whereas 63% and 61% of the remaining patients required 2 and 3 visits, respectively.

Conclusions: Teleultrasound for prenatal diagnosis has similar sensitivity and accuracy as the published literature for on-site ultrasound. Further studies are needed to compare the sensitivity and accuracy within the same population and further validate this potentially cost-saving modality.
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http://dx.doi.org/10.1002/jum.14304DOI Listing
November 2017

Addition of Color Doppler Sonography for Detection of Amniotic Fluid Disturbances and Its Implications on Perinatal Outcomes.

J Ultrasound Med 2017 Sep 15;36(9):1875-1881. Epub 2017 May 15.

Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Objectives: To determine whether color Doppler sonography increases the detection of pregnancies at risk for adverse outcomes.

Methods: Participants admitted to labor and delivery with the anticipation of a vaginal delivery underwent measurements of amniotic fluid volume (AFV) using amniotic fluid index (AFI) and single deepest pocket (SDP) techniques by grayscale followed by color Doppler sonography. Oligohydramnios was defined as an AFI of less than 5 cm or an SDP of less than 2 cm. Intrapartum and perinatal outcomes were compared between participants with a diagnosis of a low AFV by grayscale and color Doppler sonography.

Results: Over 42 months, 428 women were enrolled in the study. Color Doppler sonography resulted in lower AFV estimates (mean ± SD by the AFI, 10.7 ± 3.7 cm by grayscale sonography and 8.6 ± 3.6cm by color Doppler sonography; P < .0001). For the SDP, the mean AFVs were 4.6 ± 2.0 cm by grayscale sonography and 3.4 ± 1.4 cm by color Doppler sonography (P < .0001). The level of agreement between grayscale and color Doppler sonography in estimating the AFV was fair, with κ = 0.32 for the AFI and 0.28 for the SDP. Outcome measures of AFVs classified as low based on color Doppler sonography (normal by grayscale sonography) and those classified as low by grayscale sonography (low by color Doppler sonography) were compared. There was no difference in composite perinatal complications, mode of delivery, or composite neonatal complications.

Conclusions: The use of color Doppler sonography leads to the overdiagnosis of low AFVs and does not appear to increase the detection of pregnancies destined for adverse intrapartum or perinatal outcomes.
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http://dx.doi.org/10.1002/jum.14223DOI Listing
September 2017

Normal amniotic fluid volume across gestation: Comparison of statistical approaches in 1190 normal amniotic fluid volumes.

J Obstet Gynaecol Res 2017 Jul 15;43(7):1122-1131. Epub 2017 May 15.

Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas, USA.

Aim: Ultrasound estimation and evaluation of amniotic fluid volume (AFV) is an important component of pregnancy surveillance and fetal well-being. The purpose of this study was to compare and contrast four statistical methods used to construct gestational age-specific reference intervals for the assessment of AFV.

Methods: A total of 1095 normal AFV derived from four studies that measured AFV using dye-dilution or direct measurement at the time of hysterotomy were used to construct reference intervals using polynomial regression, quantile regression, Royston and Wright mean and SD, and Cole's lambda mu sigma (LMS) methods. The 2.5th, 5th, 50th, 95th, and 97.5th centiles were derived for each statistical method.

Results: AFV increased curvilinearly from 15 gestational weeks and onward. Based on the 50th centile, the maximum value occurred at 30 weeks' gestation for the polynomial regression and mean and SD methods while the maximum was achieved at week 31 for the quantile regression and LMS methods. When data were sparse, the quantile regression method produced dramatically different estimates at the higher centile.

Conclusion: The four statistical methods produced similar results at gestational ages in which AFV was high. The quantile regression approach, however, produces results that are more reflective of the data when the data are sparse. Given the flexibility and robustness of the quantile regression method, we recommend its use in constructing reference intervals when the interest lies in the tails of the reference distribution.
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http://dx.doi.org/10.1111/jog.13332DOI Listing
July 2017

in Pregnancy: A Review of the Literature.

Obstet Gynecol Surv 2017 Apr;72(4):242-247

Director of MFM Fellowship, Department of Obstetrics and Gynecology, Madigan Army Medical Center, Tacoma, WA.

Importance: is commonly found in many areas of the body where it derives a benefit without harming the host. When it does infect the host during pregnancy, is that infection a threat to the obstetric patient and does that infection cause adverse pregnancy outcomes?

Objective: The aim of this study was to review what is known about infections and the impact of an infection on pregnancy outcomes.

Evidence Acquisition: A PubMed search was undertaken with the search years unlimited to April 1, 2016, and restricted to articles in English. The search terms included "actinomyces," "pregnancy," "prenatal," "maternal," "actinomyces infection," "pregnancy," "chorioamnionitis," "preterm labor," "premature birth," or "postpartum actinomyces."

Results: Eighteen of the 154 identified articles are the basis of this review. is a rod-like positive bacterium. The diagnosis of an infection can be by culture or Gram stain. is commensal and typically only infects after a mucosal break or lesion. Seventeen cases were identified in pregnancy. Ten cases were complicated by chorioamnionitis and a preterm delivery. A nidus leading to infection was identified in 12 of the cases including women with a cervical cerclage, dental abscesses, appendicitis, renal actinomycosis, and ovarian abscesses. Adverse pregnancy outcomes have been linked with periodontal disease, but treatment did not prevent preterm delivery in a randomized, blinded, controlled trial.

Conclusions: infections in pregnancy are rare but, if they occur, have been linked primarily with preterm deliveries.

Target Audience: Obstetricians and gynecologists, family physicians.

Learning Objectives: After completing this activity, the learner should be better able to identify the areas of the body where infections occur and how the infections typically occur, identify the pathophysiologic changes that occur during pregnancy that might lead to an infection and how that infection may affect pregnancy outcomes, and describe the treatment for mild and severe infections.
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http://dx.doi.org/10.1097/OGX.0000000000000423DOI Listing
April 2017

High-risk obstetrical call center: a model for regions with limited access to care.

J Matern Fetal Neonatal Med 2018 Apr 19;31(7):857-865. Epub 2017 Mar 19.

a Department of Obstetrics and Gynecology , University of Arkansas for Medical Sciences , Little Rock , AR , USA.

Purpose: High-risk obstetrical care can be challenging for women in rural states with limited access.

Materials And Methods: Data were evaluated from 62,342 obstetrical calls from pregnant and postpartum patients within rural Arkansas to a nurse call center. Call center nurses provided triage using evidence-based guidelines to patients across the state. Data were extracted and analyzed using retrospective data collection and descriptive statistical methods.

Results: Women had an average maternal age of 28 years old, average weeks gestation was 27.4, over half had Medicaid 32,513 (52.15%), and the greatest percentage were in their first pregnancy 14,232 (34.1%). The greatest percentage of calls resulted in a recommendation to come to the hospital to be evaluated 25,894 (41.54%) followed by advice with no prescription given 19,442 (31.19%). The most frequent guidelines used included preterm labor 5114 (8.24%) followed by abdominal pain >20 weeks 4,518 (7.28%).

Conclusions: A centralized obstetrical nurse call center model, including 24/7 availability, using triage software for obstetrical care, with experienced labor and delivery nurses to answer and respond to calls and secondary triage performed by OB/GYN physicians or Advance Practice Registered Nurses (APRN) has the potential of improving access to obstetric care in rural areas.
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http://dx.doi.org/10.1080/14767058.2017.1300645DOI Listing
April 2018

Use of antenatal corticosteroids in special circumstances: a comprehensive review.

Acta Obstet Gynecol Scand 2017 Apr;96(4):395-409

Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA.

The aim of this study was to determine, in pregnancies complicated by preterm premature rupture of membranes (PPROM), hypertension, intrauterine growth restriction, multi-fetal gestations and pregnancies 23-26 weeks and ≥34 weeks' gestation, whether antenatal corticosteroids benefit the fetus. Literature review using PubMed, Web of Science, Clinical trials.gov, Cochrane Database of Systematic Reviews (1990-2015). Search terms linked special circumstances with corticosteroids. Randomized clinical trials, retrospective and prospective cohort studies, and case control studies were reviewed. In all, 468 abstracts were identified and 84 added from selected article bibliographies; of these, 503 abstracts were excluded, leaving 49 articles as the basis of review. The literature supports corticosteroids for PPROM up to 32-34 weeks without chorioamnionitis. Antenatal corticosteroids are beneficial for preterm infants of women with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome/severe preeclampsia. Postpartum corticosteroid treatment of HELLP patients results in more rapid correction of liver enzymes, platelet counts, and urinary output, which can reduce maternal morbidity. Corticosteroids in twin pregnancies decrease respiratory distress syndrome but the effect is less than in singleton pregnancies. Corticosteroid effects on intrauterine growth restriction pregnancies are conflicting and steroid use should be individualized. Corticosteroid use for 23-26 weeks reduces neonatal mortality but not morbidity. In pregnancies of 34 weeks to 36  weeks, corticosteroids reduce respiratory distress syndrome, but follow-up studies are unavailable. No long-term adverse child developmental effects have been observed with one or two courses of corticosteroids, but three or more steroid courses lowers birthweight and organ weight, and there may be an increase in neurodevelopmental abnormalities. Longer follow up of corticosteroid-treated fetuses is required.
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http://dx.doi.org/10.1111/aogs.13104DOI Listing
April 2017

Tachysystole Following Cervical Ripening and Induction of Labor Is Not Associated with Adverse Outcomes.

Gynecol Obstet Invest 2017 5;82(5):487-493. Epub 2016 Nov 5.

Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Miss., USA.

Purpose: This study was aimed at determining if significant uterine tachysystole was associated with adverse fetal or neonatal outcomes during cervical ripening and induction of labor.

Methods: Women undergoing cervical ripening and subsequent labor induction (n = 905) were assessed for tachysystole, defined as ≥6 contractions in each of 2 consecutive 10-minute windows. Women with ≥3 episodes of tachysystole were compared to women with no tachysystole.

Results: Over a 5-year period, 70% of the 905 participants (n = 631) had no tachysystole, 143 had 1 or 2 episodes whereas 131 or 15% had ≥3 episodes (p = 0.991). The cesarean delivery rate was lower among those with tachysystole (28.2 vs. 34.1%), but the difference was not significant (p = 0.197). Non-reassuring fetal tracings were more common in the tachysystole group (14.4 vs. 21.4%, p = 0.017), but the Apgar scores at 5 min and the umbilical cord pH and base excess were similar between the 2 groups (p = 0.502, p = 0.435, and p = 0.535, respectively).

Conclusions: Tachysystole was not associated with adverse perinatal outcomes when compared to women with no tachysystole during cervical ripening and induction of labor.
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http://dx.doi.org/10.1159/000452666DOI Listing
June 2018

Incarceration of the Gravid Uterus.

Obstet Gynecol Surv 2016 Oct;71(10):613-619

Professor, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR.

Objective: The aim of this review was to describe the risk factors, clinical and radiographic criteria, and management of this rare complication of pregnancy.

Methods: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched.

Results: There were 60 articles identified, with 53 articles being the basis of this review. Multiple risk factors have been suggested in the literature including retroverted uterus in the first trimester, deep sacral concavity with an overlying sacral promontory, endometriosis, previous abdominal or pelvic surgery, pelvic or uterine adhesions, ovarian cysts, leiomyomas, multifetal gestation, uterine anomalies, uterine prolapse, and uterine incarceration in a prior pregnancy. The diagnosis is difficult to make owing to the nonspecific presenting symptoms. The diagnosis is clinical and confirmed by imaging. Magnetic resonance imaging is superior to ultrasound to accurately diagnose and elucidate the distorted maternal anatomy. Treatment is dictated by gestational age at diagnosis based on risks and benefits. The recommended route of delivery is cesarean delivery when uterine polarity cannot be corrected.

Conclusions: Incarceration of the gravid uterus is a rare but serious complication of pregnancy. The diagnosis is clinical and confirmed with imaging, with magnetic resonance imaging being superior to delineate the distorted maternal anatomy. Reduction of the incarcerated uterus should be attempted to restore polarity and avoid unnecessary cesarean delivery.
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http://dx.doi.org/10.1097/OGX.0000000000000362DOI Listing
October 2016

Intra-Amniotic Hemorrhage Imitating Gastroschisis: A Case Report and Review of the Literature.

Am J Case Rep 2016 Oct 20;17:766-769. Epub 2016 Oct 20.

Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.

BACKGROUND A spontaneous intra-amniotic hemorrhage is rarely encountered during pregnancy. The correct diagnosis and management are problematic because of the infrequency of this condition and the high likelihood of a misdiagnosis. CASE REPORT A primigravida with an uncomplicated pregnancy and a normal targeted ultrasound presented late in the second trimester of pregnancy with antepartum bleeding of unknown origin. A repeat ultrasound was suggestive of an abdominal wall defect (gastroschisis). The patient continued to have antepartum bleeding and developed uterine contractions and abdominal pain necessitating frequent visits to labor and delivery. An MRI ruled out gastroschisis and diagnosed intra-amniotic hematoma. The patient presented with acute abdominal pain and was clinically considered to be having an abruption, and was delivered by cesarean. Old blood was noted in the abdominal cavity and within the uterine cavity. At the time of the cesarean, an area of intra-amniotic hematoma was identified, as well as a retroplacental blood clot. CONCLUSIONS An intra-amniotic hematoma is unusual and may be misdiagnosed. MRI may be helpful in determining the correct diagnosis and subsequent management.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5077291PMC
http://dx.doi.org/10.12659/ajcr.900114DOI Listing
October 2016

Antenatal fetal surveillance "Assessment of the AFV".

Best Pract Res Clin Obstet Gynaecol 2017 Jan 16;38:12-23. Epub 2016 Sep 16.

Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA. Electronic address:

The evaluation of amniotic fluid volume (AFV) is an established part of the antenatal surveillance of pregnancies at risk for an adverse pregnancy outcome. The two most commonly used ultrasound techniques to estimate AFV are the amniotic fluid index (AFI) and the single deepest pocket (SDP). Four studies have defined normal AFVs, and although their normal volumes have similarities, there are also differences primarily due to the statistical methodology used in each study. Dye-determined AFV correlates with ultrasound estimates for normal fluid volumes but correlates poorly for oligohydramnios and polyhydramnios. The addition of color Doppler in estimating AFV leads to the overdiagnosis of oligohydramnios. Neither the AFI nor the SDP is superior in identifying oligohydramnios, but the SDP is a better measurement choice as the use of AFI increases the diagnosis rate of oligohydramnios and labor inductions without an improvement in pregnancy outcomes.
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http://dx.doi.org/10.1016/j.bpobgyn.2016.08.004DOI Listing
January 2017

Antenatal corticosteroid treatment: factors other than lung maturation.

J Matern Fetal Neonatal Med 2017 Jun 30;30(12):1437-1441. Epub 2016 Aug 30.

d OB/GYN and Pediatrics, University of Mississippi Medical Center , Jackson , MS , USA.

Antenatal corticosteroid (CS) therapy improves both fetal lung mechanism and gas exchange due to accelerated morphologic development of type one and two pneumocytes. This therapy also enhances the production of surfactant binding proteins and fetal lung antioxidant enzymes. In women with threatening preterm delivery, a single course is advocated between 24 and 34 weeks' gestation with either betamethasone (two doses of 12 mg 24 h apart) or dexamethasone (four doses of 6 mg at 12-h intervals). Such treatment reduces the rate of respiratory distress syndrome, comorbidity, and mortality in neonates in the first 48 h of life. The optimal time interval between CS administration and delivery is reported to be 1-7 days. Weekly repeat courses reduce the occurrences and severity of respiratory diseases but are associated with reduce fetal growth. Multiple courses should be avoided. However, a repeat course should be considered in women at risk of preterm birth 7 or more days after an initial course in women who remain at risk of preterm birth <34 weeks' gestation. CS may be harmful in growth restricted fetuses associated with an absent or reversed end-diastolic UA flow since they are at increased risk of acidosis and perinatal death. The purpose of this publication is to update and highlight antenatal CS therapy.
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http://dx.doi.org/10.1080/14767058.2016.1219716DOI Listing
June 2017

Non-Invasive Prenatal Testing (NIPT) in Arkansas: Prenatal Genetics Clinic Experience and Lessons Learned.

J Ark Med Soc 2016 08;113(2):38-40, 42

The term NIPT (non-invasive prenata. testing). is used to d Qscribe a relativel new screening test designed to. identit .pregnancies at increased risk for certain fetal aneuploidlies. Since May of 2012, the UAMS Malernal'Tbtal Medicine, division has provided genetic 'counseling, obtiained informed consent; and I ordered NIPT 6n over 400 high-risk pregnancies. We wish to . present data collect6d from, these results,,as well as offer tips for primary obstetricians/practition'ers. Who consider ordering NIPT for some of their patients.
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August 2016

Application of a Telecolposcopy Program in Rural Settings.

Telemed J E Health 2016 10 29;22(10):816-820. Epub 2016 Apr 29.

1 Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences , Little Rock, Arkansas.

Background: Individuals in rural areas are often restricted by the amount of physicians' availability, thus limiting access to healthcare in those settings.

Introduction: While Pap smear screening has increased across the United States, the rural South still reports high rates of cervical cancer and mortality. One solution to improve patient outcomes related to cervical cancer in rural settings is telecolposcopy.

Materials And Methods: Women with abnormal Pap results or an abnormal visual examination needing an evaluation by colposcopy were referred to a hospital-based telecolposcopy program. Descriptive data are provided that include patients' access to care based on travel time and transportation costs.

Results: Over a 15-month time period, 940 unique patients were seen using telecolposcopy. Telecolposcopy was done at eight spoke sites across Arkansas representing patients from 72 of the 75 counties. Data for risk factors that include smoking, first sexual experience, and number of sexual partners in past 12 months and in a lifetime are discussed. Pap results and impression are provided. In addition, avoided transportation costs and travel time have been calculated and included.

Discussion: Cervical cancer is important public health concern especially for women residing in rural areas. We were able to demonstrate that our telecolposcopy program has provided sustainability statewide since its inception and that patients are willing to participate. In addition to providing increased access to care, the program also reduced travel time and costs associated with a face-to-face visit.

Conclusion: Telecolposcopy should be further explored and utilized in rural settings as a way to reduce patient costs and improve cervical cancer outcomes.
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http://dx.doi.org/10.1089/tmj.2015.0260DOI Listing
October 2016

Fish Parasites: A Growing Concern During Pregnancy.

Obstet Gynecol Surv 2016 Apr;71(4):253-9

Professor, MFM Division and Fellowship Director, University of Arkansas for Medical Sciences, Little Rock, AR.

Intestinal parasitic worms affect more than 2 billion people worldwide according to the World Health Organization. Fish-borne parasitic infections are becoming more common with the increasing popularity of sushi, sashimi, Carpaccio, tartare, gefilte, and ceviche. The ingestion of these parasites can cause serve anemia, malabsorption, severe abdominal pain, nausea, vomiting, strong allergic reactions, and gastric ulcers. Knowledge about fish parasites and pregnancy is limited. A literature search on PubMed and Web of Science used the search terms "fish parasites" OR "diphyllobothrium" OR "anisakiasis" OR "pseudoterranova" OR ("food borne parasites" AND "fish") AND "pregnancy" OR "maternal" OR "fetus" OR "fetal" OR "newborn" OR "neonatal" OR "childbirth." No limit was put on the number of years searched. There were 281 publications identified. The abstracts of all of these publications were read. After exclusion of the articles that were not relevant to pregnancy, pregnancy outcome, and fish parasites, there were 24 articles that became the basis of this review. The pathophysiology, altered maternal immunity related to the infection, limited information about fish-borne parasitic infections and pregnancy, and treatments are discussed. The main impact of a fish-borne parasitic infection on pregnant women is anemia and altered immunity, which may increase the risk of a maternal infection. The primary fetal effects include intrauterine growth restriction and preterm delivery.
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http://dx.doi.org/10.1097/OGX.0000000000000303DOI Listing
April 2016
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