Publications by authors named "Frank A Chervenak"

266 Publications

Adverse perinatal outcomes of chlamydia infections: an ongoing challenge.

J Perinat Med 2021 Dec 24. Epub 2021 Dec 24.

Department of Obstetrics and Gynecology, Lenox Hill Hospital - Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.

Objectives: is one of the most common sexually transmitted diseases in the world, but there are limited data on its impact on perinatal outcomes. Our objective was to investigate the association between chlamydia infections and adverse perinatal outcomes.

Methods: This is a retrospective analysis of the United States Centers for Disease Control and Prevention natality live birth database for the years 2016-2019. The rates of adverse perinatal outcomes were compared between patients with a chlamydia infection during pregnancy and patients without such infection, using Pearson's chi-square test with the Bonferroni adjustment. A multivariate logistic regression was then used to adjust outcomes for potential confounders.

Results: Chlamydia infections were associated with small, but statistically significant, increased odds of preterm birth (<37 weeks), early preterm birth (<32 weeks), low birthweight (<2,500 g), congenital anomalies, low 5-min Apgar score (<7), neonatal intensive care unit admission, immediate neonatal ventilation, prolonged (>6 h) neonatal ventilation, and neonatal antibiotic treatment for suspected sepsis.

Conclusions: Chlamydia infections during pregnancy are associated with adverse perinatal outcomes. These results call for increased education regarding the potential risks of pregnancies with a chlamydia infection, as well as for increased antenatal surveillance and post-natal pediatric assessment in these pregnancies.
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http://dx.doi.org/10.1515/jpm-2021-0519DOI Listing
December 2021

Undue Burdens Created by the Texas Abortion Law for Vulnerable Pregnant Women.

Am J Obstet Gynecol 2021 Dec 23. Epub 2021 Dec 23.

Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas.

The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and the other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This paper identifies three populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 U.S. Supreme Court Case, Casey v. Planned Parenthood of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for three populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these three populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these three populations of vulnerable women. For these women it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Casey, because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.
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http://dx.doi.org/10.1016/j.ajog.2021.12.033DOI Listing
December 2021

Worsening risk profiles of out-of-hospital births during the COVID-19 pandemic.

Am J Obstet Gynecol 2022 01 10;226(1):137-138. Epub 2021 Dec 10.

Department of Obstetrics and GynecologyLenox Hill Hospital, New York NY.

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http://dx.doi.org/10.1016/j.ajog.2021.11.1346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8660066PMC
January 2022

The Risk of Readmission after Early Postpartum Discharge during the COVID-19 Pandemic.

Am J Perinatol 2021 Dec 10. Epub 2021 Dec 10.

Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, New York.

Objective:  To determine whether early postpartum discharge during the coronavirus disease 2019 (COVID-19) pandemic was associated with a change in the odds of maternal postpartum readmissions.

Study Design:  This is a retrospective analysis of uncomplicated postpartum low-risk women in seven obstetrical units within a large New York health system. We compared the rate of postpartum readmissions within 6 weeks of delivery between two groups: low-risk women who had early postpartum discharge as part of our protocol during the COVID-19 pandemic (April 1-June 15, 2020) and similar low-risk patients with routine postpartum discharge from the same study centers 1 year prior. Statistical analysis included the use of Wilcoxon's rank-sum and chi-squared tests, Nelson-Aalen cumulative hazard curves, and multivariate logistic regression.

Results:  Of the 8,206 patients included, 4,038 (49.2%) were patients who had early postpartum discharge during the COVID-19 pandemic and 4,168 (50.8%) were patients with routine postpartum discharge prior to the COVID-19 pandemic. The rates of postpartum readmissions after vaginal delivery (1.0 vs. 0.9%; adjusted odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.39-1.45) and cesarean delivery (1.5 vs. 1.9%; adjusted OR: 0.65, 95% CI: 0.29-1.45) were similar between the two groups. Demographic risk factors for postpartum readmission included Medicaid insurance and obesity.

Conclusion:  Early postpartum discharge during the COVID-19 pandemic was associated with no change in the odds of maternal postpartum readmissions after low-risk vaginal or cesarean deliveries. Early postpartum discharge for low-risk patients to shorten hospital length of stay should be considered in the face of public health crises.

Key Points: · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after vaginal delivery.. · Early postpartum discharge was not associated with an increase in odds of hospital readmissions after cesarean delivery.. · Early postpartum discharge for low-risk patients should be considered during a public health crisis..
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http://dx.doi.org/10.1055/s-0041-1740061DOI Listing
December 2021

An immutable truth: planned home births in the United States result in avoidable adverse neonatal outcomes.

Am J Obstet Gynecol 2022 Jan 1;226(1):138-140. Epub 2021 Dec 1.

Department of Obstetrics and Gynecology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.

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http://dx.doi.org/10.1016/j.ajog.2021.11.1347DOI Listing
January 2022

Professional ethics and decision making in perinatology.

Semin Perinatol 2021 Nov 9:151520. Epub 2021 Nov 9.

Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York, USA. Electronic address:

Objective: We describe the essential elements of professional ethics in perinatology and explain how professional ethics in perinatology should guide decision making with pregnant patients and with parents.

Findings: Professional ethics in perinatology draws on two ethical principles, beneficence and respect for patient autonomy, the ethical concept of the fetus as a patient, and the best interests of the child standard and the concept of parental permission. Counseling about intrapartum management should be based on the ethical concept of the fetus as a patient and on the role of the pregnant patient as the ultimate decision maker. Counseling about setting ethically justified limits on perinatal clinical management should be based on four specified concepts of futility, but not on quality-of-life futility. Counseling about innovation and research should emphasize that investigation clinical management is an experiment.

Conclusion: Professional ethics in perinatology is an essential component of perinatal practice, innovation, and research.
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http://dx.doi.org/10.1016/j.semperi.2021.151520DOI Listing
November 2021

Birth certificate study comparing United States birth centers to hospitals: conclusions exceed the evidence: a reply.

Am J Obstet Gynecol 2021 Nov 26. Epub 2021 Nov 26.

Department of Obstetrics and Gynecology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 100 East 77 St., New York, NY 10075.

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http://dx.doi.org/10.1016/j.ajog.2021.11.1364DOI Listing
November 2021

Reversing physician hesitancy to recommend COVID-19 vaccination for pregnant patients.

Am J Obstet Gynecol 2021 Nov 8. Epub 2021 Nov 8.

Department of Obstetrics and Gynecology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY. Electronic address:

Physician hesitancy is said to occur when physicians do not recommend COVID-19 vaccination, and it is a contributing factor for the low vaccination rate for COVID-19 in pregnant women. Physician hesitancy has become a major, unaddressed problem with regard to the quality and safety of obstetrical care. We identify 3 root causes of physician hesitancy and describe how professional ethics in obstetrics should guide in reversing these root causes. They are clinical misapplications of key components of professionally responsible obstetrical practice: therapeutic nihilism, shared decision-making, and respect for patient autonomy. Therapeutic nihilism directs the obstetrician to avoid any clinical interventions during pregnancy to prevent teratogenic effects that might be unknown. Therapeutic nihilism is misapplied when there is a documented net clinical benefit with no evidence of clinical harm. Shared decision directs the obstetrician to only offer but not recommend clinical management. Shared decision-making plays a major role when there is uncertainty in clinical judgment but is misapplied when it becomes a universal model. It does not apply when there is a net clinical benefit. When there is a net clinical benefit, clinical management should be recommended, not simply offered. The ethical principle of respect for patient autonomy plays an indispensable role in decision-making with patients. It is misapplied when it is assumed that respect for autonomy requires physicians not to make recommendations and to defer to and implement patients' decisions without exception. There is evidence that the obstetrician's recommendations about the management of pregnancy are the most important factor in a pregnant woman's decision-making. Simply deferring to the patient's decisions makes for misapplied respect for patient autonomy. Obstetricians must end physician hesitancy about COVID-19 vaccination of pregnant women by reversing these 3 root causes of physician hesitancy. Reversing the root causes of physician hesitancy is an urgent matter of patient safety. The longer physician hesitancy continues and the longer the low vaccine acceptance rate of pregnant women lasts, preventable serious diseases, deaths of pregnant women, intensive care unit admissions, stillbirths, and other maternal and fetal complications of unvaccinated women will continue to occur. Physician hesitancy should not be permitted to influence the response to future pandemics.
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http://dx.doi.org/10.1016/j.ajog.2021.11.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8572733PMC
November 2021

Professionally Responsible Counseling About Fetal Analysis.

Obstet Gynecol Clin North Am 2021 Dec;48(4):777-785

Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell and Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075, USA. Electronic address:

Fetal analysis uses noninvasive and invasive methods to obtain images and tissues for interpretation that supports risk assessment and/or diagnosis of the fetus's condition. This article provides ethically justified, clinically applicable guidance for supporting the pregnant patient's decision making about fetal analysis. Topics include ethical reasoning using key ethical concepts, confidentiality, clarity about the pregnant woman as ultimate decision maker, offering fetal analysis, counseling about results, counseling about accepted maternal-fetal intervention, and counseling about innovation and research on maternal-fetal intervention. Professional ethics is an essential component of counseling pregnant patients about fetal analysis and referral for investigative maternal-fetal intervention.
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http://dx.doi.org/10.1016/j.ogc.2021.06.005DOI Listing
December 2021

Plato unmasks hidden limits of tele-education.

J Perinat Med 2021 Nov 8. Epub 2021 Nov 8.

Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA.

Plato's powerful metaphor of the Cave, from Republic, further advances a critical assessment of the hidden limits of distance learning. In the Cave, individuals are restrained to see only straight ahead to the images projected from behind them onto the wall in front of them. As in the Cave, in tele-education the dynamism of learning is replaced by passive learning. Not only do learners become largely passive with respect to their teacher, but also to each other. These effects are masked from teacher and learner alike by the technical prowess of distance learning and teaching, a version of Plato's Cave. Tele-education has at least three undeniably salient features: safety, convenience, and cost savings. Two and a half millennia after Plato gave us the concept of mimesis and the metaphor of the Cave, we can use these philosophical tools to unmask hidden limits of tele-education.
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http://dx.doi.org/10.1515/jpm-2021-0451DOI Listing
November 2021

Defining Fever.

Open Forum Infect Dis 2021 Jun 31;8(6):ofab161. Epub 2021 Mar 31.

Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.

Although the term "fever" is used liberally in clinical publications, we provide evidence that it is rarely defined in terms of the minimum temperature used to qualify as a fever, the type of thermometer employed in measuring patients' temperatures, or the site at which temperatures are taken. We maintain that in the absence of such information, the term "fever" is meaningless.
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http://dx.doi.org/10.1093/ofid/ofab161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8394829PMC
June 2021

Induced abortion and COVID-19 as contributing factors to declining fertility in Sardinia.

J Perinat Med 2022 Jan 12;50(1):42-45. Epub 2021 Aug 12.

Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell and Lenox Hill Hospital, New York, NY, USA.

Objectives: Decreasing fertility implies considerable public health, societal, political, and international consequences. Induced abortion (IA) and the recent COVID-19 pandemic can be contributing factors to it but these have not been adequately studied so far. The purpose of this paper is to explore the relation of IA incidence and the COVID-19 pandemic to declining rates of delivery, as per our Sardinian experience.

Methods: We analyzed the registered data from the official Italian statistics surveys of deliveries and IA in the last 10 years from 2011 to 2020 in Sardinia.

Results: A total of 106,557 deliveries occurred and a progressive decrease in the birth rate has been observed. A total of 18,250 IA occurred and a progressive decline has been observed here as well. The ratio between IA and deliveries remained constant over the decade. Between 2011 and 2019 a variation of -4.32% was observed for IA while in the last year, during the COVID-19 pandemic the decrease of the procedures was equal to -12.30%. For the deliveries, a mean variation of the -4.8% was observed between the 2011 and the 2019 while in the last year, during the COVID-19 pandemic the decrease was about -9%. Considering the about 30% reduction of live births between 2011 and 2020, there is an almost proportional reduction in IA.

Conclusions: Public policy responses to decreasing fertility, especially pronatalist ones, would be provided with evidence base about trends in delivery and IA and women's decision making.
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http://dx.doi.org/10.1515/jpm-2021-0289DOI Listing
January 2022

John Gregory's medical ethics elucidates the concepts of compassion and empathy.

Med Teach 2021 Aug 9:1-5. Epub 2021 Aug 9.

Professor and Departmental Chair of Obstetrics and Gynecology, Associate Dean for International Education, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.

Purpose: This paper draws on eighteenth-century British medical ethics to elucidate compassion and empathy and explains how compassion and empathy can be taught, to rectify their frequent conflation.

Compassion In The History Of Medical Ethics: The professional virtue of compassion was first described in eighteenth-century British medical ethics by the Scottish physician-ethicist, John Gregory (1724-1773) who built on the moral psychology of David Hume (1711-1776) and its principle of sympathy.

Compassion And Empathy Defined: Compassion is the habitual exercise of the affective capacity to engage, with self-discipline, in the experience of the patient and therefore become driven to provide effective care for the patient. Empathy is the habitual exercise of the cognitive capacity to imagine the experience of patient and to have reasons to care for the patient. There are rare clinical circumstances in which empathy should replace compassion, for example, in responding to abusive patients. Because the abstract concepts of medical ethics are translated into clinical practice by medical educators, we identify the pedagogical implications of these results by setting out a process for teaching compassion and empathy.

The Task Ahead: Eighteenth-century British medical ethics provides a clinically applicable, philosophical response to conflation of the moral virtue of compassion and the intellectual virtue of empathy and applying them clinically.
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http://dx.doi.org/10.1080/0142159X.2021.1960295DOI Listing
August 2021

Neonatal outcomes of births in freestanding birth centers and hospitals in the United States, 2016-2019.

Am J Obstet Gynecol 2022 Jan 1;226(1):116.e1-116.e7. Epub 2021 Jul 1.

Department of Obstetrics and Gynecology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY.

Background: Births in freestanding birth centers have more than doubled between 2007 and 2019. Although birthing centers, which are defined by the American College of Obstetricians and Gynecologists as ". . . freestanding facilities that are not hospitals," are being promoted as offering women fewer interventions than hospitals, there are limited recent data available on neonatal outcomes in these settings.

Objective: To compare several important measures of neonatal safety between 2 United States birth settings and birth attendants: deliveries in freestanding birth centers and hospital deliveries by midwives and physicians.

Study Design: This is a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, and Division of Vital Statistics natality online database for the years 2016 to 2019. All term, singleton, low-risk births were eligible for inclusion. The study outcomes were several neonatal outcomes including neonatal death, neonatal seizures, 5-minute Apgar scores of <4 and <7, and neonatal death in nulliparous and in multiparous women. Outcomes were compared between the following 3 groups: births in freestanding birth centers, in-hospital births by a physician, and in-hospital births by a midwife. The prevalence of each neonatal outcome among the different groups was compared using Pearson chi-squared test, with the in-hospital midwife births being the reference group. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index, maternal weight gain, parity, gestational weeks, and neonatal birthweight and calculated as adjusted odds ratio.

Results: The study population consisted of 9,894,978 births; 8,689,467 births (87.82%) were in-hospital births by MDs and DOs, 1,131,398 (11.43%) were in-hospital births by midwives, and 74,113 (0.75%) were births in freestanding birth centers. Freestanding birth center deliveries were less likely to be to non-Hispanic Black or Hispanic, less likely to women with public insurance, less likely to be women with their first pregnancy, and more likely to be women with advanced education and to have pregnancies at ≥40 weeks' gestation. Births in freestanding birth center had a 4-fold increase in neonatal deaths (3.64 vs 0.95 per 10,000 births: adjusted odds ratio, 4.00; 95% confidence interval, 2.62-6.1), a more than 7-fold increase in neonatal deaths for nulliparous patients (6.8 vs 0.92 per 10,000 births: adjusted odds ratio, 7.7; 95% confidence interval, 4.42-13.76), a more than 2-fold increase in neonatal seizures (3.91 vs 1.94 per 10,000 births: adjusted odds ratio, 2.19; 95% confidence interval, 1.48-3.22), and a more than 7-fold increase of a 5-minute Apgar score of <4 (194.84 vs 28.5 per 10,000 births: adjusted odds ratio, 7.46; 95% confidence interval, 7-7.95). Compared with hospital midwife deliveries, hospital physician deliveries had significantly higher adverse neonatal outcomes (P<0.001).

Conclusion: Births in United States freestanding birth centers are associated with an increased risk of adverse neonatal outcomes such as neonatal deaths, seizures, and low 5-minute Apgar scores. Therefore, when counseling women about the location of birth, it should be conveyed that births in freestanding birth centers are not among the safest birth settings for neonates compared with hospital births attended by either midwives or physicians.
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http://dx.doi.org/10.1016/j.ajog.2021.06.093DOI Listing
January 2022

Reply to professionally responsible COVID-19 vaccination counseling.

Am J Obstet Gynecol 2021 09 9;225(3):355-356. Epub 2021 Jun 9.

Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, 100 East 77th St., New York, NY 10075.

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http://dx.doi.org/10.1016/j.ajog.2021.05.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188769PMC
September 2021

Ethical challenges in management of critically ill pregnant patients with coronavirus disease 2019 (COVID-19).

J Perinat Med 2021 Jun 11. Epub 2021 Jun 11.

Department of Obstetrics and Gynecology, Lenox Hill Hospital - Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.

Despite the overwhelming number of coronavirus disease 2019 (COVID-19) cases worldwide, data regarding the optimal clinical guidance in pregnant patients is not uniform or well established. As a result, clinical decisions to optimize maternal and fetal benefit, particularly in patients with critical COVID-19 in the early preterm period, continue to be a challenge for obstetricians. There is often uncertainty in clinical judgment about fetal monitoring, timing of delivery, and mode of delivery because of the challenge in balancing maternal and fetal interests in reducing morbidity and mortality. The obstetrician and critical care team should empower pregnant patients or their surrogate decision maker to make informed decisions in response to the team's clinical evaluation. A clinically grounded ethical framework, based on the concepts of the moral management of medical uncertainty, beneficence-based obligations, and preventive ethics, should guide the decision-making process.
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http://dx.doi.org/10.1515/jpm-2021-0254DOI Listing
June 2021

Concerning trends in maternal risk factors in the United States: 1989-2018.

EClinicalMedicine 2020 Dec 20;29-30:100657. Epub 2020 Nov 20.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital - Northwell Health/Zucker School of Medicine, New York, NY, United States.

Background: Increased efforts have focused on reducing maternal morbidity and mortality in the United States (US). Hypertensive disorders of pregnancy, chronic hypertension, diabetes mellitus, very advanced maternal age, and grand multiparity are known contributors to various maternal morbidities, as well as maternal mortality. We aimed to evaluate the trends in these risk factors/complications among US pregnancies during the last three decades (1989-2018).

Methods: This is a retrospective study based on the CDC natality database. We calculated the annual prevalence of each risk factor/complication from 1989 to 2018. Joinpoint regression analysis was then used to evaluate the trends. Annual percentage changes (APC) were calculated for each of the segments identified by the joinpoint regression, and average annual percentage changes (AAPC) were calculated for the entire period. Relative risks (RR) comparing the prevalence of each risk factor/complication in 2018 to its prevalence in 1989 were also calculated. Subsequent analyses evaluated the trends of the main risk factors/complications by maternal age groups. Statistical significance was determined at <0·05, and results were presented with 95% confidence intervals.

Findings: Between 1989 and 2018, the prevalence of hypertensive disorders of pregnancy increased by 149% (AAPC 3·2, 95% CI 2·6-3·8), that of chronic hypertension increased by 182% (AAPC 3·7, 95% CI 3·3-4·2), that of diabetes mellitus increased by 261% (AAPC 4·6, 95% CI 4·0-5·2), that of very advanced maternal age increased by 194% (AAPC 3·8, 95% CI 3·6-4·0), and that of grand multiparity increased by 33% (AAPC 1·0, 95% CI 0·8-1·2). Chronic hypertension and diabetes mellitus increased mostly during the past two decades, while hypertensive disorders of pregnancy and grand multiparity increased primarily over the most recent decade. Additionally, women of very advanced maternal age had significantly higher rates of hypertensive disorders of pregnancy, chronic hypertension and diabetes mellitus throughout our study period.

Interpretation: Our study shows a marked increase in the prevalence of five pregnancy risk factors/complications over the past three decades (1989-2018). This may point to a significant deterioration in the health of US pregnant women, which potentially contributes to both maternal morbidity and mortality.

Funding: None.
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http://dx.doi.org/10.1016/j.eclinm.2020.100657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164172PMC
December 2020

Race and ethnicity are among the predisposing factors for fetal malpresentation at term.

Am J Obstet Gynecol MFM 2021 09 4;3(5):100405. Epub 2021 Jun 4.

Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, NY.

Objective: Fetal malpresentation complicates approximately 3% to 4% of all term births. It requires special considerations for delivery and exposes the mother and neonate to obstetrical interventions and potential adverse outcomes, such as umbilical cord prolapse, head entrapment and birth trauma, hypoxic ischemic encephalopathy, cesarean delivery, and cesarean delivery-related complications. We set out to explore the maternal and fetal factors associated with noncephalic malpresentation at term, with specific interest on the impact of maternal race and ethnicity on fetal malpresentation.

Study Design: This was a retrospective analysis of the Centers for Disease Control and Prevention Natality Live Birth database for the years from 2016 through 2018. All term, singleton deliveries for the following racial and ethnic groups were included: non-Hispanic White, non-Hispanic Black, Asian, and Hispanic. Race and ethnicity were assigned based on self-identification and individuals with >1 racial category were excluded from the analysis. Malpresentation was defined as a noncephalic presentation at term and included breech and transverse presentations. The malpresentation group included all noncephalic births and cephalic births that occurred following successful external cephalic version, whereas all other cephalic births served as controls. A multivariable logistic regression analysis was used to assess the rate of malpresentation, with adjustment for potential confounders including maternal age, race and ethnicity, parity, birthweight, fetal malformations, malformations of the central nervous system (CNS), and chromosomal anomalies. The results are displayed as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Statistical significance was set at a P value of <.05. Institutional review board approval was not required because the de-identified data are publicly available through a data use agreement.

Results: There were 9,692,203 term, singleton births during the study period. The malpresentation group included 354,689 births (3.66% of the total). The Table shows the rate of malpresentation for various maternal and fetal factors. We found a substantial racial and ethnic disparity in the malpresentation rates. Non-Hispanic White women had the highest malpresentation risk, whereas non-Hispanic Black women had the lowest risk (3.93% vs 2.81%; aOR, 1.38; 95% CI, 1.36-1.39). Hispanic and Asian women were also at increased risk for malpresentation when compared with non-Hispanic Black women (aOR, 1.30; 95% CI, 1.29-1.32 and aOR, 1.12; 95% CI, 1.10-1.14, respectively). In addition, several maternal and fetal conditions were noted to be associated with an increased risk for malpresentation at term, including older maternal age (aOR, 2.81; 95% CI, 2.74-2.88; for patients >40 years), nulliparity (aOR, 1.50; 95% CI, 1.48-1.51), low birthweight (aOR, 1.80; 95% CI, 1.77-1.83 for birthweight under 2500 g), and fetal malformations of the CNS and chromosomal anomalies (aOR, 3.53; 95% CI, 3.06-4.06 and aOR, 2.32; 95% CI, 2.05-2.63, respectively).

Conclusion: Based on a large US population database, we identified several maternal, fetal, and racial and ethnic factors that are associated with an increased rate of noncephalic malpresentation at term. Specifically, fetal CNS malformations, congenital or chromosomal anomalies, advanced maternal age, low birthweight, and nulliparity are risk factors for noncephalic presentation. Interestingly, non-Hispanic White women have the highest risk for malpresentation, whereas non-Hispanic Black women have the lowest risk. Previous publications found that low birthweight, advanced maternal age, nulliparity, and congenital fetal malformations are risk factors for malpresentation. Nonetheless, the current data available on race and ethnicity are sporadic, with limited reports suggesting that sub-Saharan ethnicity is associated with a lower rate of malpresentation and that White race is associated with a higher rate. We present a large-scale, nationwide US-based study to confirm the racial and ethnic disparity regarding malpresentation in the United States. This may be explained by the known variation in the shape of the bony birth canal in different racial and ethnic groups and populations from different geographic locations. Further investigation is needed to explore the racial and ethnic disparity described.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100405DOI Listing
September 2021

Professional integrity in maternal - fetal innovation and research: an essential component of perinatal medicine.

J Perinat Med 2021 Nov 19;49(9):1027-1032. Epub 2021 May 19.

Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA.

Objectives: Clinical innovation and research on maternal-fetal interventions have become an essential for the development of perinatal medicine. In this paper, we present an ethical argument that the professional virtue of integrity should guide perinatal investigators.

Methods: We present an historical account of the professional virtue of integrity and the key distinction that this account requires between intellectual integrity and moral integrity.

Results: We identify implications of both intellectual and moral integrity for innovation, research, prospective oversight, the role of equipoise in randomized clinical trials, and organizational leadership to ensure that perinatal innovation and research are conducted with professional integrity.

Conclusions: Perinatal investigators and those charged with prospective oversight should be guided by the professional virtue of integrity. Leaders in perinatal medicine should create and sustain an organizational culture of professional integrity in fetal centers, where perinatal innovation and research should be conducted.
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http://dx.doi.org/10.1515/jpm-2021-0090DOI Listing
November 2021

THE PROFESSION OF MEDICINE IS SECULAR: AN EIGHTEENTH-CENTURY IDEA WITH IMPLICATIONS FOR THE BOUNDARY BETWEEN MEDICINE AND RELIGION.

Psychiatr Danub 2021 05;33(Suppl 3):S292-S298

Department of Obstetrics and Gynecology, Lenox Hill Hospital, New York, New York USA.

The aim of this paper is to draw on John Gregory's (1724-1773) professional ethics in medicine to provide guidance to physicians for the responsible management of the potentially contested boundary between medicine and religion. The paper provides a philosophical and clinical interpretation of Gregory's method of argument by persuasion: setting out complementary considerations that together invite agreement. The cumulative effect of this argument by persuasion is that a contested boundary between medicine and religion is not required by the commitment to the evidence-based, scientific practice of medicine. Gregory's legacy to us is the concept of the profession of medicine as secular, in two senses. As scientific, medicine draws on evidence and not on divinity, transcendent reality, or sacred texts and practices. There is no necessary hostility of evidence-based medicine toward religion and faith communities.
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May 2021

Professionally responsible management of the ethical and social challenges of antenatal screening and diagnosis of β-thalassemia in a high-risk population.

J Perinat Med 2021 Sep 16;49(7):847-852. Epub 2021 Mar 16.

Department of Obstetrics and Gynecology, Prenatal and Preimplantation Genetic Diagnosis, Fetal Therapy, Microcitemico Pediatric Hospital "A. Cao", Cagliari, Sardinia, Italy.

Thalassemias are among the most frequent genetic disorders worldwide. They are an important social and economic strain in high-risk populations. The benefit of β-thalassemia screening programs is growing evident but the capacity to diagnose fetal β-thalassemia exceeds the treatment possibilities and even when treatment before birth becomes feasible, difficult decisions about the relative risks will remain. This paper can be of practical and ethically justified aid when counseling women about screening, diagnosis, and treatment of β-thalassemia. It takes in consideration various social challenges, medical issues such as antenatal screening, preimplantation genetic diagnosis, prenatal diagnosis, non-invasive prenatal testing and prenatal therapy. We also describe the Sardinian experience in applying and promoting high-risk population screening and diagnosis programs and future trends in the management of β-thalassemia.
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http://dx.doi.org/10.1515/jpm-2021-0021DOI Listing
September 2021

Cesarean deliveries are decreasing in the United States with increased midwife deliveries.

Am J Obstet Gynecol MFM 2021 07 11;3(4):100348. Epub 2021 Mar 11.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, New York, NY 10075.

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http://dx.doi.org/10.1016/j.ajogmf.2021.100348DOI Listing
July 2021

How fever is defined in COVID-19 publications: a disturbing lack of precision.

J Perinat Med 2021 Mar 24;49(3):255-261. Epub 2020 Dec 24.

Department of Medicine, University of Maryland School of Medicine, Emeritus Professor of Medicine and the Carolyn Frenkil and Selvin Passen History of Medicine Scholar-in-Residence at the University of Maryland School of Medicine, Baltimore, ML, USA.

Objectives: Fever is the single most frequently reported manifestation of COVID-19 and is a critical element of screening persons for COVID-19. The meaning of "fever" varies depending on the cutoff temperature used, the type of thermometer, the time of the day, the site of measurements, and the person's gender and race. The absence of a universally accepted definition for fever has been especially problematic during the current COVID-19 pandemic.

Methods: This investigation determined the extent to which fever is defined in COVID-19 publications, with special attention to those associated with pregnancy.

Results: Of 53 publications identified in which "fever" is reported as a manifestation of COVID-19 illness, none described the method used to measure patient's temperatures. Only 10 (19%) publications specified the minimum temperature used to define a fever with values that varied from a 37.3 °C (99.1 °F) to 38.1 °C (100.6 °F).

Conclusions: There is a disturbing lack of precision in defining fever in COVID-19 publications. Given the many factors influencing temperature measurements in humans, there can never be a single, universally accepted temperature cut-off defining a fever. This clinical reality should not prevent precision in reporting fever. To achieve the precision and improve scientific and clinical communication, when fever is reported in clinical investigations, at a minimum the cut-off temperature used in determining the presence of fever, the anatomical site at which temperatures are taken, and the instrument used to measure temperatures should each be described. In the absence of such information, what is meant by the term "fever" is uncertain.
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http://dx.doi.org/10.1515/jpm-2020-0546DOI Listing
March 2021

Inclusion of pregnant individuals among priority populations for coronavirus disease 2019 vaccination for all 50 states in the United States.

Am J Obstet Gynecol 2021 05 2;224(5):536-539. Epub 2021 Feb 2.

Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York.

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http://dx.doi.org/10.1016/j.ajog.2021.01.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7906826PMC
May 2021

Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients.

Am J Obstet Gynecol 2021 05 1;224(5):470-478. Epub 2021 Feb 1.

Departments of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY.

The development of coronavirus disease 2019 vaccines in the current and planned clinical trials is essential for the success of a public health response. This paper focuses on how physicians should implement the results of these clinical trials when counseling patients who are pregnant, planning to become pregnant, breastfeeding or planning to breastfeed about vaccines with government authorization for clinical use. Determining the most effective approach to counsel patients about coronavirus disease 2019 vaccination is challenging. We address the professionally responsible counseling of 3 groups of patients-those who are pregnant, those planning to become pregnant, and those breastfeeding or planning to breastfeed. We begin with an evidence-based account of the following 5 major challenges: the limited evidence base, the documented increased risk for severe disease among pregnant coronavirus disease 2019-infected patients, conflicting guidance from government agencies and professional associations, false information about coronavirus disease 2019 vaccines, and maternal mistrust and vaccine hesitancy. We subsequently provide evidence-based, ethically justified, practical guidance for meeting these challenges in the professionally responsible counseling of patients about coronavirus disease 2019 vaccination. To guide the professionally responsible counseling of patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed, we explain how obstetrician-gynecologists should evaluate the current clinical information, why a recommendation of coronavirus disease 2019 vaccination should be made, and how this assessment should be presented to patients during the informed consent process with the goal of empowering them to make informed decisions. We also present a proactive account of how to respond when patients refuse the recommended vaccination, including the elements of the legal obligation of informed refusal and the ethical obligation to ask patients to reconsider. During this process, the physician should be alert to vaccine hesitancy, ask patients to express their hesitation and reasons for it, and respectfully address them. In contrast to the conflicting guidance from government agencies and professional associations, evidence-based professional ethics in obstetrics and gynecology provides unequivocal and clear guidance: Physicians should recommend coronavirus disease 2019 vaccination to patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed. To prevent widening of the health inequities, build trust in the health benefits of vaccination, and encourage coronavirus disease 2019 vaccine and treatment uptake, in addition to recommending coronavirus disease 2019 vaccinations, physicians should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, robust educational campaigns, and novel approaches to immunization.
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http://dx.doi.org/10.1016/j.ajog.2021.01.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849424PMC
May 2021

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage.

J Clin Med 2020 Dec 22;10(1). Epub 2020 Dec 22.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital-Northwell Health/Zucker School of Medicine, New York, NY 10075, USA.

Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Our health system's post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as < 0.05. A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, < 0.0001). Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.
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http://dx.doi.org/10.3390/jcm10010007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793107PMC
December 2020

The risk of spontaneous preterm birth in asymptomatic women with a short cervix (≤25 mm) at 23-28 weeks' gestation.

Am J Obstet Gynecol MFM 2020 05 25;2(2):100059. Epub 2019 Oct 25.

Department of Obstetrics and Gynecology, Lenox Hill Hospital-Northwell Health, New York, NY.

Background: Asymptomatic short cervical length is an independent risk factor for spontaneous preterm birth. However, most studies have focused on the associated risk of a short cervical length when encountered between 16 and 23 weeks' gestation. The relationship between cervical length and risk of spontaneous preterm birth after 23 weeks is not well known.

Objective: To evaluate the risk of spontaneous preterm birth in asymptomatic women with a short cervix (≤25 mm) at 23-28 weeks' gestation.

Materials And Methods: A retrospective cohort study of women with asymptomatic short cervix (cervical length ≤25 mm) at extreme prematurity, defined as 23-28 weeks' gestation, was performed at a single center from January 2015 to March 2018. Women with symptoms of preterm labor, multiple gestations, fetal or uterine anomalies, cervical cerclage, or those with incomplete data were excluded from the study. Demographic information as well as data on risk factors for spontaneous preterm birth were collected. Patients were divided into 4 groups based on the cervical length measurement (≤10 mm, 11-15 mm, 16-20 mm, and 21-25 mm). The primary outcome was time interval from enrollment to delivery. Secondary outcomes included delivery within 1 and 2 weeks of enrollment, gestational age at delivery, and delivery prior to 32, 34, and 37 weeks, respectively. Continuous variables were compared using Kruskal-Wallis test, whereas categorical variables were compared using the χ or Fisher exact test as appropriate. The Wilcoxon test for difference in survival time was used to compare gestational age at delivery among the 4 cervical length groups, with data stratified based on gestational age at enrollment.

Results: Of the 126 pregnancies that met inclusion criteria, 22 (17.4%) had a cervical length of ≤10 mm, 23 (18.3%) had a cervical length of 11-15 mm, 37 (29.4%) had a cervical length of 16-20 mm, and 44 (34.9%) had a cervical length of 21-25 mm. Baseline characteristics were similar among all 4 groups. The shorter cervical length group was associated with a shorter time interval from enrollment to delivery (cervical length ≤10 mm, 10 weeks; cervical length 11-15 mm, 12.7 weeks; cervical length of 16-20 mm, 13 weeks; cervical length of 21-25 mm, 13.2 weeks; P = .006). Regardless of the cervical length measurement, delivery within 2 weeks was extremely uncommon (1 patient; 0.8%). The prevalence of spontaneous preterm birth at <32 weeks or <34 weeks was higher in women with a cervical length of ≤10 mm compared to those with a longer cervical length (P < .001).

Conclusions: The risk of spontaneous preterm birth in asymptomatic women with a sonographic short cervix increases as cervical length decreases. The risk is substantially higher in women with a cervical length of ≤10 mm. Women with a cervical length of ≤10 mm also had the shortest time interval to delivery. Nevertheless, delivery within 1 or 2 weeks is highly unlikely, regardless of the cervical length at the time of enrollment. Therefore, based on our data, we suggest that management decisions such as timing of administration of antenatal corticosteroids in asymptomatic patients with a cervical length of ≤25 mm at 23-28 weeks' gestation may be delayed until additional indications are present.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100059DOI Listing
May 2020

Teaching Professional Formation in Response to the COVID-19 Pandemic.

Acad Med 2020 10;95(10):1488-1491

F.A. Chervenak is professor and chair, Department of Obstetrics and Gynecology, and associate dean for international education, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, and chair, Department of Obstetrics and Gynecology, Lenox Hill Hospital, New York, New York.

In response to the COVID-19 pandemic, the Association of American Medical Colleges has called for a temporary suspension of clinical teaching activities for medical students. Planning for the continued involvement of learners in patient care during this pandemic should include teaching learners professional formation. The authors provide an ethical framework to guide such teaching, based on the ethical principle of beneficence and the professional virtues of courage and self-sacrifice from professional ethics in medicine. The authors show that these concepts support the conclusion that learners are ethically obligated to accept reasonable, but not unreasonable, risk. Based on this ethical framework, the authors provide an account of the process of teaching professional formation that medical educators and academic leaders should implement. Medical educators and academic leaders should embrace the opportunity that the COVID-19 pandemic presents for teaching professional formation. Learners should acquire the conceptual vocabulary of professional formation. Learners should recognize that risk of infection from patients is unavoidable. Learners should become aware of established ethical standards for professional responsibility during epidemics from the history of medicine. Learners should master understandable fear. Medical educators and academic leaders should ensure that didactic teaching of professional formation continues when it becomes justified to end learners' participation in the processes of patient care; topics should include the professionally responsible management of scarce medical resources. The COVID-19 pandemic will not be the last major infectious disease that puts learners at risk. Professional ethics in medicine provides powerful conceptual tools that can be used as an ethical framework to guide medical educators to teach learners, who will bear leadership responsibilities in responses to future pandemics, professional formation.
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http://dx.doi.org/10.1097/ACM.0000000000003434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179059PMC
October 2020

Early postpartum discharge during the COVID-19 pandemic.

J Perinat Med 2020 Nov;48(9):1008-1012

Department of Obstetrics and Gynecology, Lenox Hill Hospital - Northwell Health, New York, NY, USA.

Objectives To report our experience with early postpartum discharge to decrease hospital length of stay among low-risk puerperium patients in a large obstetrical service during the COVID-19 pandemic in New York. Methods Retrospective analysis of all uncomplicated postpartum women in seven obstetrical units within a large health system between December 8th, 2019 and June 20th, 2020. Women were stratified into two groups based on date of delivery in relation to the start of the COVID-19 pandemic in New York (Mid-March 2020); those delivering before or during the COVID-19 pandemic. We compared hospital length of stay, defined as time interval from delivery to discharge in hours, between the two groups and correlated it with the number of COVID-19 admissions to our hospitals. Statistical analysis included use of Wilcoxon rank sum test and Chi-squared test with significance defined as p-value<0.05. Results Of the 11,770 patients included, 5,893 (50.1%) delivered prior to and 5,877 (49.9%) delivered during the COVID-19 pandemic. We detected substantial shortening in postpartum hospital length of stay after vaginal delivery (34 vs. 48 h, p≤0.0001) and cesarean delivery (51 vs. 74 h, p≤0.0001) during the COVID-19 pandemic. Conclusions We report successful implementation of early postpartum discharge for low-risk patients resulting in a significantly shorter hospital stay during the COVID-19 pandemic in New York. The impact of this strategy on resource utilization, patient satisfaction and adverse outcomes requires further study.
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http://dx.doi.org/10.1515/jpm-2020-0337DOI Listing
November 2020

Racial and ethnic disparity and spatiotemporal trends in severe acute respiratory syndrome coronavirus 2 prevalence on obstetrical units in New York.

Am J Obstet Gynecol MFM 2020 11 17;2(4):100212. Epub 2020 Aug 17.

Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 376 E Main St., Ste. 202, Bay Shore, NY 11706.

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http://dx.doi.org/10.1016/j.ajogmf.2020.100212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429514PMC
November 2020
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