Publications by authors named "Joseph G Ouzounian"

47 Publications

Evaluation and Management of Fetal Macrosomia.

Obstet Gynecol Clin North Am 2021 Jun;48(2):387-399

Department of Obstetrics and Gynecology, USC/Keck School of Medicine, 2020 Zonal Avenue, IRD 236, Los Angeles, CA 90033, USA. Electronic address:

Macrosomia results from abnormal fetal growth and can lead to serious consequences for the mother and fetus. In cases of suspected macrosomia, patients must be counseled carefully regarding a delivery plan, and Cesarean section should be considered when indicated. Techniques to assess for suspected macrosomia include clinical measurements, ultrasound, and MRI.
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http://dx.doi.org/10.1016/j.ogc.2021.02.008DOI Listing
June 2021

Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States.

Am J Obstet Gynecol 2021 Apr 21. Epub 2021 Apr 21.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA. Electronic address:

Background: Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed.

Objective: This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States.

Study Design: This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation.

Results: Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1).

Conclusion: Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.
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http://dx.doi.org/10.1016/j.ajog.2021.04.233DOI Listing
April 2021

Decreasing Failure-to-Rescue From Severe Maternal Morbidity at Cesarean Delivery: Recent US Trends.

JAMA Surg 2021 Jun;156(6):585-587

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles.

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http://dx.doi.org/10.1001/jamasurg.2021.0600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8060881PMC
June 2021

Fetoscopic Laser Ablation Therapy for Type II Vasa Previa.

Fetal Diagn Ther 2020 6;47(9):682-688. Epub 2020 Jul 6.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: In type II vasa previa, fetoscopic laser ablation has the potential to avoid prolonged hospitalization, elective prematurity, and cesarean delivery associated with traditional conservative management.

Objective: To assess the feasibility and to report perinatal outcomes of type II vasa previa patients treated via fetoscopic laser ablation.

Study Design: This is a retrospective descriptive study of all women with vasa previa treated with laser at our center between 2006 and 2019. After 2010, laser ablation of vasa previa was only offered after 31 gestational weeks. Continuous variables are expressed as means ± SD.

Results: 33 patients were evaluated for laser ablation of suspected vasa previa. Fifteen were not candidates (7 had type I vasa previa and 8 had no vasa previa), and the 18 remaining had type II vasa previa. Ten (56%) elected to undergo in utero laser ablation of the vasa previa vessel(s), which was successful in all patients. The mean gestational age (GA) at the time of the procedure was 28.8 ± 5.4 weeks, and the total operative time was 48.1 ± 21.3 min; there were no perioperative complications. The number of vessels lasered were distributed as follows: 1 (2 cases), 2 (5 cases), and 3 (3 cases). All patients except for 1 were subsequently managed as outpatients. The mean GA at delivery was 35.5 ± 3.2 weeks, and vaginal delivery occurred in 5 cases. The 5 patients with singletons who underwent laser ablation for primary diagnosis of type II vasa previa after the protocol change in 2010 had the following outcomes: mean GA of surgery was 32.5 ± 0.8 weeks, mean GA at delivery was 38.1 ± 1.4 weeks, vaginal delivery occurred in all cases, mean birth weight was 2,965 ± 596 g, and none were admitted to the neonatal intensive care unit.

Conclusion: This cohort represents the largest number of vasa previa cases treated via in utero laser reported to date. Laser occlusion of type II vasa previa was technically achievable in all cases and resulted in favorable outcomes.
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http://dx.doi.org/10.1159/000508044DOI Listing
July 2020

Selective intrauterine growth restriction (SIUGR) type II: proposed subclassification to guide surgical management.

J Matern Fetal Neonatal Med 2020 Mar 31:1-8. Epub 2020 Mar 31.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA.

Optimal surgical management of monochorionic diamniotic twins complicated by selective intrauterine growth restriction (SIUGR) type II is unknown. Surgical management may involve selective laser photocoagulation of communicating vessels (SLPCV), which offers the possibility of dual twin survivors versus umbilical cord occlusion (UCO) of the SIUGR twin. To identify patient characteristics associated with SIUGR twin survival for those undergoing SLPCV. All patients studied were those who underwent fetal treatment for SIUGR type II at our center from 2006-2018. SIUGR type II was defined as an estimated fetal weight <10th percentile with persistent absent and/or reversed end diastolic flow in the umbilical artery of the SIUGR twin, in the absence of twin-twin transfusion syndrome. Patients were offered SLPCV versus UCO, and those undergoing SLPCV, patient characteristics associated with 30-day survival of the SIUGR twin were examined using bivariate analysis and multiple logistic regression models. Fifty-four consecutive SIUGR type II patients were treated, 45 SLPCV and nine UCO. Of the 45 SLPCV cases, there were 16 (35.6%) with SIUGR twin (and dual) survival. SIUGR twin survival appeared associated with middle cerebral artery (MCA) peak systolic velocity (psv) <1.5 multiples of the median, and forward atrial systolic flow in the ductus venosus (DV). In a analysis, we subsequently categorized patients as: SIUGR type IIa ( = 32 (71.1%)): normal MCA psv, and normal DV waveform, versus SIUGR type IIb ( = 13 (28.9%)): MCA psv ≥1.5 multiples of the median, and/or DV with absent or reversed atrial systolic flow. Thirty-day survival of the SIUGR twin was 50% for type IIa and 0% for type IIb. Over one-third of SIUGR type II patients experienced dual survival after treatment with laser surgery. Normal MCA psv and normal DV waveforms were associated with SIUGR type II survival of the SIUGR twin. exploration and subclassification of SIUGR type II patients by preoperative Doppler indices created two groups, one (type IIa) with 50% survival and one (type IIb) with 0% survival of the SIUGR twin after laser surgery. Upon further confirmation, these findings may provide guidance for counseling patients and conducting fetal therapy.
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http://dx.doi.org/10.1080/14767058.2020.1745177DOI Listing
March 2020

Implementation of multidisciplinary practice change to improve outcomes for women with placenta accreta spectrum.

Eur J Obstet Gynecol Reprod Biol 2020 Mar 13;246:194-196. Epub 2020 Jan 13.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA90033, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA90033, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ejogrb.2020.01.010DOI Listing
March 2020

Amylase concentration and activity in the amniotic fluid of fetal rats with retinoic acid induced myelomeningocele.

J Matern Fetal Neonatal Med 2020 Jan 16:1-8. Epub 2020 Jan 16.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

neurologic injury in myelomeningocele (MMC) occurs via a two-hit process: failed neural tube closure followed by neurodegeneration . Meconium in the amniotic fluid contains pancreatic digestive enzymes and is neurotoxic in rat models of MMC. The objectives of this study were to demonstrate the neurotoxicity of α-amylase and to compare the enzyme concentration and activity in the amniotic fluid of rats with retinoic acid induced MMC to a healthy control population. Timed pregnant Sprague Dawley rats were gavage fed all-trans retinoic acid (60 mg/kg) in olive oil on gestational day E10 to induce a MMC defect. Control rats received olive oil. Amniotic fluid was collected on embryonic days E15, E17, E19, and E21. The amniotic fluid amylase concentration and relative activity were measured at each gestational age, and levels were compared between the MMC and control groups using Wilcoxon Rank Sum and Kruskal-Wallis tests. In a subset of dams sacrificed on E10.5, neuroepithelial cells were isolated from control embryos and exposed to α-amylase in increasing concentrations. Percentage of cell survival was assessed with CellProfiler software. Amniotic fluid amylase activity for embryonic days E15, E17, E19, and E21 was determined for MMC and control pups. Amylase activity increased significantly from E15 to E21 in both control ( = 3.0 × 10) and MMC ( = 1.5 × 10) groups. Relative amylase activity was significantly increased in MMC pups compared to controls on E19 (247,792.8 versus 106,263.6;  = .0019) and E21 (772,645.8 versus 481,975.3;  = .021); no difference was detected on E15 (36,646.8 versus 40,179.3;  = .645) or E17 (121,617.5 versus 71,750;  = 1.000). , amylase demonstrated dose-dependent toxicity to fetal rat neuroepithelial cells. Amylase concentration and activity level were higher in the amniotic fluid of rats with retinoic acid induced MMC compared to controls with advancing gestational age. As amylase is toxic to neural epithelial cells, the higher activity of this digestive enzyme in fetuses with MMC may be a contributor to neural tube damage . Future research should focus on amylase and other digestive enzymes in human MMC, as they may serve as potential targets of therapy.
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http://dx.doi.org/10.1080/14767058.2020.1713082DOI Listing
January 2020

Characteristics of referred patients with twin-twin transfusion syndrome who did not undergo fetal therapy.

Prenat Diagn 2019 03 20;39(4):280-286. Epub 2019 Feb 20.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.

Introduction: Abundant research has reported twin-twin transfusion syndrome (TTTS) outcomes following fetal therapy. Our research describes TTTS patients who did not undergo fetal therapy.

Methods: Records from TTTS pregnancies evaluated at 16 to 26 gestational weeks were reviewed between January 2006 and March 2017. The study population comprised subjects who did not undergo fetal therapy. Based on initial consultation, patients were grouped as nonsurgical vs surgical candidates. TTTS progression and perinatal outcomes were assessed.

Results: Of 734 TTTS patients evaluated, 68 (9.3%) did not undergo intervention. Of these, 62% were nonsurgical candidates and 38% were surgical candidates. Nonsurgical candidates were ineligible for treatment because of fetal demise or maternal factors (placental abruption, severe membrane separation, and preterm labor). Of surgical candidates, 11 underwent expectant management, eight elected pregnancy termination, and seven planned fetal intervention but had a complication before the procedure. TTTS progression occurred in 10 (15.2%) of 66 cases. Neonatal survival in 64 cases was as follows: in 41 (64%), no survivors; in 11 (17.2%), one survivor; and in 12 (18.8%), two survivors.

Conclusion: Nine percent of referred TTTS patients did not undergo fetal therapy, with many ineligible because of morbidity between referral and consultation. Studies of TTTS should acknowledge this subgroup and circumstances leading to lack of treatment.
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http://dx.doi.org/10.1002/pd.5427DOI Listing
March 2019

Long-Term Outcomes After Thoracoamniotic Shunt for Pleural Effusions With Secondary Hydrops.

J Surg Res 2019 01 5;233:304-309. Epub 2018 Sep 5.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California. Electronic address:

Background: Congenital pleural effusion is a rare condition with an incidence of approximately one per 15,000 pregnancies. The development of secondary hydrops is a poor prognostic indicator and such cases can be managed with a thoracoamniotic shunt (TAS). Our objective is to describe postnatal outcomes in survivors after TAS placement for congenital pleural effusions.

Materials And Methods: A retrospective study of all cases with fetal pleural effusions treated between 2006 and 2016. Patients with dominant unilateral or bilateral pleural effusions complicated by secondary hydrops fetalis received TAS placement. The results are reported as median (range).

Results: A total of 29 patients with pleural effusion with secondary hydrops underwent TAS placement. The gestational age at the initial TAS placement was 27.6 (20.3-36.9) wk. Before delivery, hydrops resolved in 17 (58.6%) patients. The delivery gestational age was 35.7 (25.4-41.0) wk and the overall survival rate was 72.4%. Among the 21 survivors, 19 (90.5%) required admission to the neonatal intensive care unit for 15 (5-64) d. All 21 survivors had postnatal resolution of the pleural effusions. All 21 children were long-term survivors, with a median age of survivorship of 3 y 3 mo (9 mo-7 y 6 mo) at the time of last reported follow-up.

Conclusions: Thoracoamniotic shunting in fetuses with a dominant pleural effusion(s) and secondary hydrops resulted in a 72% survival rate. Nearly all survivors required admission to the neonatal intensive care unit. However, a majority did not have significant long-term morbidity.
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http://dx.doi.org/10.1016/j.jss.2018.08.022DOI Listing
January 2019

Types II and III congenital pulmonary airway malformation with hydrops treated in utero with percutaneous sclerotherapy.

Prenat Diagn 2018 06 7;38(7):493-498. Epub 2018 May 7.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Objective: To present outcomes of fetuses with congenital pulmonary airway malformation (CPAM) treated with sclerotherapy.

Methods: Retrospective study of 8 patients with a prenatal diagnosis of CPAM type II or III with secondary hydrops treated with percutaneous sclerotherapy using 5% ethanolamine oleate (EO). All patients underwent ultrasonic measurement of the CPAM volume ratio. Results are expressed as median (range).

Results: Gestational age at initial sclerotherapy was 22.0 weeks (19.6-31.4); 3 patients underwent 2 procedures. Intrauterine fetal demise (IUFD) occurred in 4 cases; 2 died on postoperative day #1 (one from inadvertent intravascular EO injection); 2 died >6 weeks after the procedure. Preoperative CPAM volume ratio was 3.6 (1.6-7.8) in survivors and 2.7 (1.7-4.7) in those with IUFD. The volume of EO at the initial sclerotherapy procedure was 3 mL (2-5) in survivors and 7 mL (6-10) in IUFD cases. The gestational age at delivery of the 4 survivors was 38.4 weeks (37.4-39.3); all underwent postnatal resection.

Conclusion: The efficacy of percutaneous sclerotherapy for CPAM types II and III remains in question. Further studies are needed to determine the optimal dose of sclerotherapy agent and the safety and efficacy of this procedure.
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http://dx.doi.org/10.1002/pd.5266DOI Listing
June 2018

Management of twin-twin transfusion syndrome with an extremely short cervix.

J Obstet Gynaecol 2018 Apr 27;38(3):359-362. Epub 2018 Jan 27.

a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA.

The objective of this study was to describe the management and perinatal outcomes of patients with twin-twin transfusion syndrome (TTTS) and an extremely short cervical length (CL). This retrospective study examined 17 patients with TTTS and a preoperative CL ≤1.0 cm who had undergone laser surgery and perioperative cervical cerclage placement successfully. In this subset of patients, the median interval between surgery and delivery was 9.6 (range 2.1-13.9) weeks and only one patient had PPROM within 3 weeks of surgery. The median gestational age at delivery was 30.9 (range 23.1-37.6) weeks, 30-day survival of at-least-one twin was 88.2% and dual survivorship was 82.4%. Overall, patients with TTTS and a preoperative CL ≤1.0 cm who were able to undergo successful laser surgery and emergent cerclage placement had favourable outcomes. Impact statement The management of patients with twin-twin transfusion syndrome (TTTS) and extremely short cervical length (CL) varies between foetal surgery centres. This study demonstrates that laser surgery and cerclage placement in such patients are not only technically feasible, but also can result in favourable perinatal outcomes. Patients with an extremely short CL should not be uniformly excluded from laser surgery for TTTS.
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http://dx.doi.org/10.1080/01443615.2017.1330324DOI Listing
April 2018

Comparison of umbilical cord occlusion methods: Radiofrequency ablation versus laser photocoagulation.

Prenat Diagn 2018 01 9;38(2):110-116. Epub 2018 Jan 9.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA.

Objective: To compare outcomes between 2 umbilical cord occlusion (UCO) methods: radiofrequency ablation (RFA) versus fetoscopic-guided laser photocoagulation.

Methods: Retrospective study of all monochorionic diamniotic multiple gestations that underwent UCO with RFA (preferred after 2014) or laser (preferred before 2014). In bivariate analysis, patients treated with RFA were compared with laser. Risk factors for intrauterine fetal demise (IUFD) and 30-day survival of the co-twin were identified, and multiple logistic models were fitted to examine whether the UCO method was associated with these outcomes.

Results: Of 60 UCO cases, 18 (30%) underwent RFA and 42 (70%) underwent laser surgery. The RFA method was associated with co-twin IUFD after surgery (6/18 [33.3%] vs 1/42 [2.4%], P = 0.0021). In logistic regression models, patients who underwent RFA were more likely than patients who underwent laser to have an IUFD of the co-twin (OR 13.2, 1.23-142.62, P = 0.0331). These patients were also less likely to have 30-day survival of the co-twin, although this was not statistically significant (OR 0.20, 0.04-1.15, P = 0.0710).

Conclusion: Despite clear technical advantages of RFA compared with laser, we found that RFA appeared to be associated with increased risk of post-procedure fetal demise. Further studies should be conducted to confirm these findings.
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http://dx.doi.org/10.1002/pd.5196DOI Listing
January 2018

Midtrimester isolated oligohydramnios in monochorionic diamniotic multiple gestations.

J Matern Fetal Neonatal Med 2019 Feb 12;32(4):590-596. Epub 2017 Oct 12.

a Department of Obstetrics and Gynecology , University of Southern California, Keck School of Medicine, Division of Maternal Fetal Medicine , Los Angeles , CA , USA.

Objective: To describe the natural history and perinatal outcomes of monochorionic diamniotic twins with midtrimester isolated oligohydramnios (iOligo).

Materials And Methods: We performed a retrospective study of iOligo patients who were initially referred for the management of evolving twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR). iOligo was defined as a maximum vertical pocket of amniotic fluid of ≤2 cm in the iOligo twin's sac and normal fluid level (>2 and <8 cm) in the co-twin's sac. "Group A" patients did not subsequently develop TTTS or sIUGR Type II (umbilical artery persistent absent or reversed end-diastolic flow), and "Group B" patients did develop TTTS or sIUGR Type II. Results are reported as median (range).

Results: Of the 828 patients with complicated monochorionic twin gestations referred for possible TTTS or sIUGR, 36 (4.3%) were initially diagnosed with iOligo. After initial consultation, two patients terminated and one was lost to follow-up, resulting in a final study population of 33. Group A had 10 patients (30.3%) and Group B had 23 patients (69.7%). In Group A, nine of the 10 were expectantly managed, resulting in a median gestational age (GA) at delivery of 34.7 (18.0-36.4) weeks, a 30-day perinatal survival of at-least-one twin of 88.9% (8/9), and dual 30-day survivors in 8/9 (88.9%). In Group B, 12 (52.2%) developed TTTS and 11 (47.8%) developed sIUGR Type II. Fifteen Group B patients had laser surgery, resulting in a median GA at delivery of 33.7 (26.4-37.1) weeks, a 30-day perinatal survival of at-least-one twin of 100% (15/15), and dual survivorship of 46.7% (7/15).

Conclusions: Our findings show that the majority of patients with midtrimester iOligo have fetal growth restriction of the affected twin and subsequently progress to TTTS or sIUGR Type II.
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http://dx.doi.org/10.1080/14767058.2017.1387530DOI Listing
February 2019

Clinical Risk Factors Do Not Predict Shoulder Dystocia.

J Reprod Med 2016 Nov-Dec;61(11-12):575-80

Objective: To compare 2 different risk factor models for the prediction of shoulder dystocia.

Study Design: We performed a retrospective study of women with vaginal deliveries at a single institution over an 8-year period. Two distinct multivariable logistic regression models were used to evaluate the occurrence of shoulder dystocia: a traditional model used information based on birthweight and macrosomia, and a clinical model used information based on esti-mated fetal weight and suspected macrosomia.

Results: Of the 13,998 deliveries analyzed, there were 221 cases of shoulder dystocia (1.6%). In addition to the macrosomia or suspected macrosomia variables, the final models included prolonged second stage of labor, diabetes status, and oxytocin use. Neither model was highly sensitive or highly specific, and neither demonstrated a cutoff threshold that yielded a clinically viable PPV.

Conclusion: Despite the presence of 1 or more risk factors for shoulder dystocia, its occurrence remains largely an unpredictable clinical event.
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October 2018

Shoulder Dystocia: Incidence and Risk Factors.

Clin Obstet Gynecol 2016 12;59(4):791-794

University of Southern California, Keck School of Medicine, Los Angeles, California.

Shoulder dystocia complicates ∼1% of vaginal births. Although fetal macrosomia and maternal diabetes are risk factors for shoulder dystocia, for the most part its occurrence remains largely unpredictable and unpreventable.
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http://dx.doi.org/10.1097/GRF.0000000000000227DOI Listing
December 2016

Awaiting blood pressure stabilization in ambulatory pregnant women: is 5 minutes sufficient?

J Matern Fetal Neonatal Med 2017 Aug 26;30(16):1933-1937. Epub 2016 Sep 26.

c Department of Obstetrics and Gynecology , Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California , Los Angeles , CA , USA.

Objective: Current recommendations for timing of blood pressure measurement in ambulatory pregnant women vary and are based on studies in the nonpregnant population. The objective of this study was to determine if there is a difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) between minute-5 and minute-10.

Methods: A prospective study was conducted at our prenatal care clinics. Participants had their blood pressure measured upon sitting and every 5 minutes for 15 minutes. Initial SBP and DBP were compared to measurements at each time point. Additionally, the SBP and DBP at minute-5 were compared to minute-10. All statistical tests were two-sided.

Results: Data from 400 patients were analyzed. Of these, 34.0% were in the first, 30.7% were in the second trimester, and 35.2% were in the third trimester. In each trimester, there was a significant difference in the SBP and DBP at minute-5 compared to minute-0. At minute-10 compared to minute-5, there was no further drop for all trimesters, except for a small drop in DBP in the second trimester (-1.3 ± 6.0, p = 0.012).

Conclusion: In an ambulatory setting, 5 minutes after sitting appears to be an appropriate time point to measure blood pressure in pregnancy.
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http://dx.doi.org/10.1080/14767058.2016.1232710DOI Listing
August 2017

Umbilical Cord Occlusion via Laser Coagulation in Monochorionic Multifetal Gestations before and after 20 Weeks of Gestation.

Fetal Diagn Ther 2017 31;42(1):9-16. Epub 2016 Aug 31.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA.

Introduction: Umbilical cord occlusion (UCO) utilizing laser photocoagulation is often not considered an option for selective termination after 20 weeks of gestation due to reported limitations of the procedure because of umbilical cord size. We compared outcomes after laser umbilical cord occlusion (L-UCO) before and after 20 weeks of gestation.

Materials And Methods: We examined all patients with monochorionic- diamniotic twins and higher-order multiples (monoamniotic excluded) that underwent L-UCO at our facility between 2006 and 2014. Statistical analysis was performed using Fisher's exact and Kruskal-Wallis tests as appropriate.

Results: Of 43 L-UCO cases, 11 cases (25.6%) had a discordant anomaly, and 32 cases (74.4%) had twin reversed arterial perfusion (TRAP) sequence. We achieved complete vascular occlusion in 100% (43/43) of cases of attempted L-UCO. There were 22 cases (51.2%) with gestational age ≤20 weeks, and 21 cases (48.8%) with gestational age >20 weeks. Perioperative patient characteristics and outcomes did not differ between the two groups. Survival rates were 90.9% (20/22) and 100% (21/21) at ≤20 weeks of gestation and >20 weeks of gestation, respectively.

Discussion: The results of this study suggest that L-UCO is a reasonable surgical modality for patients prior to and beyond 20 weeks of gestation.
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http://dx.doi.org/10.1159/000448948DOI Listing
May 2018

Non-specific red cell reactivity in an obstetric population.

J Matern Fetal Neonatal Med 2016 Sep 23;29(17):2848-51. Epub 2015 Nov 23.

d Department of Pathology and Transfusion Medicine , Keck School of Medicine, University of Southern California , Los Angeles , CA , USA.

Objective: To examine non-specific red cell reactivity (NSR) on antibody (Ab) screening of obstetric inpatients.

Methods: Observational study of 5438 obstetric inpatients (2009-2013). Ab-positive patients were identified and their records reviewed for NSR, other antibodies, transfusion reactions or hemolytic disease of the fetus/newborn (HDFN). Evaluation of NSR frequency by test era assessed the impact of an institutional change to solid-phase screening in 2011.

Results: Of obstetric inpatients, 5.3% had at least one positive Ab screen; 1.6% had NSR. Of NSR-positive patients, 16.7% had identifiable Abs that pre-dated NSR; 25% had concurrent Abs and 8.5% had subsequent Ab identification. In 49.1%, NSR resolved during follow-up. The frequency of NSR was higher after the change to solid-phase Ab screening, but specific Ab frequency was similar in both testing periods. No transfusion reactions or cases of HDFN were noted in this cohort.

Conclusions: NSR is found in 1-2% of obstetrical inpatients at our institution, and has more than doubled since the initiation of solid-phase screening. Although likely clinically insignificant by itself, NSR is commonly found in relation to other red cell Abs and may precede their development.
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http://dx.doi.org/10.3109/14767058.2015.1107540DOI Listing
September 2016

Neonatal Outcomes by Mode of Delivery in Preterm Birth.

Am J Perinatol 2015 Dec 7;32(14):1292-7. Epub 2015 Sep 7.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California.

Objective: We set out to test the hypothesis that infants born vaginally at ≤ 30 weeks gestation have less respiratory distress syndrome (RDS) than those born by cesarean delivery.

Study Design: We conducted a retrospective cohort study of 652 infants born between 24 and 30 (6/7) weeks gestation from March 31, 1996 to May 31, 2014. Comparisons of neonatal outcomes by intended and actual mode of delivery were made using chi-square and t-tests (α = 0.05). Multiple logistic regression was performed to control for confounding variables.

Results: Neonates born by cesarean delivery were more likely to have RDS (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.90), require intubation (OR, 1.80; 95% CI, 1.12-2.88), and have longer neonatal intensive care unit stay (70.0 ± 37.1 vs. 57.3 ± 40.1 days, p = 0.02).

Conclusion: Compared with cesarean delivery, vaginal delivery is associated with a significant reduction in RDS among infants born at ≤ 30 weeks gestation.
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http://dx.doi.org/10.1055/s-0035-1562931DOI Listing
December 2015

Maternal and fetal signs and symptoms associated with uterine rupture in women with prior cesarean delivery.

J Matern Fetal Neonatal Med 2015 Jul 10;28(11):1270-1277. Epub 2014 Sep 10.

a Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , LAC + USC Medical Center, Keck School of Medicine, University of Southern California , Los Angeles , CA , USA.

Objective: To describe the association between maternal and fetal physical signs and symptoms (signs/symptoms) and childbirth outcomes in women with prior cesarean delivery (CD).

Methods: Cases of uterine rupture at a single institution were reviewed to examine risk factors for experiencing signs/symptoms and poor childbirth outcomes.

Results: Among 21 014 deliveries, 3252 (15.5%) had prior CD, and 75 (2.3%) had uterine rupture. Of these, 66 (88.0%) labored. Among those who labored, 51 (77.3%) demonstrated signs/symptoms prior to delivery. Signs/symptoms included vaginal bleeding, abdominal pain, fetal bradycardia and decreased fetal heart rate (FHR) variability. Laboring patients with signs/symptoms were seven times more likely than those without them to have poor maternal/neonatal outcome (27/51 [52.9%] versus 2/15 [13.3%], OR = 7.31 [95% CI 1.34-52.43], p = 0.0155). In multivariate analysis, risk factors for poor fetal outcome were cervical ripening (OR 4.99 [95% CI 0.86-28.99, p = 0.0735) and prolonged FHR deceleration/bradycardia (OR 2.78 [95% CI 0.86-9.10], p = 0.0905). Fetal tachycardia was a risk factor for poor maternal outcome (OR 8.10 [95% CI 1.40-46.84], p = 0.0195).

Conclusions: Among laboring women with uterine rupture, 77% demonstrated maternal or fetal signs/symptoms before delivery. The presence of at least one sign/symptom identified nearly all laboring patients (27/29 [93.1%]) with poor outcomes.
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http://dx.doi.org/10.3109/14767058.2014.954537DOI Listing
July 2015

Chorioamniotic membrane separation over the cervical os ("moon sign") in twin-twin transfusion syndrome.

J Ultrasound Med 2014 Jul;33(7):1147-54

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA.

Objectives: To determine whether chorioamniotic membrane separation from the internal cervical os, the "moon sign," is associated with preterm premature rupture of membranes (PPROM) in twin-twin transfusion syndrome (TTTS).

Methods: A retrospective study of patients with TTTS treated with laser surgery was performed. Membrane separation before and after surgery was tested against any PPROM, PPROM within 7 days, and PPROM within 21 days. Because intrauterine fetal demise (IUFD) was weakly associated with PPROM, these cases were studied separately.

Results: Among 304 consecutive patients, 247 patients (81.3%) had no IUFD, and preoperative and postoperative membrane separation rates were 13.4% and 13.0%, respectively. In 7 cases (2.8%), preoperative membrane separation disappeared postoperatively, and in 6 cases (2.4%), membrane separation appeared postoperatively; 26 cases (10.5%) had membrane separation at both times. Rates of PPROM did not differ between those who did and did not have preoperative membrane separation (30.3% versus 28.0%; P= .9511). Among those with and without postoperative membrane separation, the rates of any PPROM were 34.4% and 27.4%, respectively (P = .5473), and the rates of PPROM within 21 days were 15.6% and 5.6% (P = .0524). Those with postoperative membrane separation were 3 times more likely to have PPROM within 21 days (odds ratio, 3.13; 95% confidence interval, 1.02-9.58; P= .0453). Preterm premature rupture of membranes was not associated with preoperative or postoperative membrane separation in patients with IUFD.

Conclusions: The preoperative moon sign does not appear to be associated with PPROM in TTTS. Postoperatively, membrane separation may be weakly associated with PPROM at 21 days, but further research is required to confirm this association.
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http://dx.doi.org/10.7863/ultra.33.7.1147DOI Listing
July 2014

Risk factors for neonatal brachial plexus palsy.

Semin Perinatol 2014 Jun;38(4):219-21

Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 220, Los Angeles, CA 90033. Electronic address:

Neonatal brachial plexus palsy (NBPP) is an unpredictable complication of childbirth. Historic risk factors for the occurrence of NBPP have included shoulder dystocia, fetal macrosomia, labor abnormalities, operative vaginal delivery, and prior NBPP. However, whether studied alone or in combination, these risk factors have not been shown to be reliable predictors. The majority of NBPP cases occur in women with infants <4500 g who are not diabetic and have no other identifiable risk factors. Furthermore, cesarean section reduces but does not completely eliminate the risk for NBPP. In this section, the relationship of these historic obstetric risk factors to the occurrence of NBPP is further explored.
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http://dx.doi.org/10.1053/j.semperi.2014.04.008DOI Listing
June 2014

Midtrimester isolated polyhydramnios in monochorionic diamniotic multiple gestations.

Am J Obstet Gynecol 2014 Sep 23;211(3):303.e1-5. Epub 2014 May 23.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Objective: To identify risk factors for development of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic multiple gestations complicated by midtrimester isolated polyhydramnios (iPoly).

Study Design: A retrospective study of patients referred for possible TTTS between 16 and 26 gestational weeks was performed. IPoly was defined as a maximum vertical pocket of ≥8 cm in the iPoly twin's sac and >2 and <8 cm in the co-twin's sac on the consultative ultrasound.

Results: Of 628 consecutive patients referred for possible TTTS, 74 were diagnosed with iPoly. The majority of these patients (n = 52, 70.3%) were not subsequently diagnosed with TTTS, and of these, 40 were managed expectantly and 12 had amnioreductions because of symptomatic iPoly; 30-day perinatal survival of at-least-one twin in the non-TTTS group was 93.0% (40/43). TTTS developed in the 22 remaining patients, of which 63.6% were of advanced Quintero Stage. Nineteen underwent laser surgery; 30-day perinatal survival of at-least-one twin was 84.2% (16/19). In a multivariate logistic regression model, 2 characteristics were associated with the development of TTTS: (1) gestational age <20 weeks at the time of diagnosis of iPoly (odds ratio, 13.48; 95% confidence interval, 3.40-53.48; P = .0002); and (2) intrauterine growth restriction of the co-twin (odds ratio, 7.28; 95% confidence interval, 1.72-30.88; P = .0071).

Conclusion: Among referred patients with midtrimester iPoly, 29.7% subsequently developed TTTS. Early diagnosis (<20 weeks) and/or co-twin intrauterine growth restriction were significant risk factors for development of TTTS in these patients.
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http://dx.doi.org/10.1016/j.ajog.2014.05.028DOI Listing
September 2014

A case-control review of placentas from patients with intrahepatic cholestasis of pregnancy.

Fetal Pediatr Pathol 2014 Aug 23;33(4):210-5. Epub 2014 Apr 23.

1Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA.

Objective: To compare the incidence of histopathological features in placentas from women with cholestasis of pregnancy to healthy individuals without ICP.

Methods: Placentas from mothers with and without cholestasis of pregnancy were reviewed by a pathologist masked to the study group. Subjects were excluded if they had medical problems already associated with placental histopathology.

Results: Twenty-four cases and 30 controls placentas were reviewed. Seventeen placental histopathological features were found. There was no statistically significant difference between the groups. Amongst patients with cholestasis, there was a decrease in villitis of unknown etiology in those treated with ursodeoxycholic acid.

Conclusion: There is no difference in the placental histopathology in cholestasis of pregnancy compared to normal pregnancies, but treatment of patients with cholestasis of pregnancy with ursodeoxycholic acid may decrease findings of villitis of unknown etiology.
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http://dx.doi.org/10.3109/15513815.2014.899413DOI Listing
August 2014

A comparison of obstetrical outcomes with labor induction agents used at term.

J Matern Fetal Neonatal Med 2014 Apr 27;27(6):592-6. Epub 2013 Aug 27.

Department of Obstetrics and Gynecology at Los Angeles County, University of Southern California (LAC+USC) Medical Center, Los Angeles , CA , USA and.

Objective: To compare the obstetrical outcomes of term pregnancies induced with one of four commonly used labor induction agents.

Methods: This is a retrospective cohort study of induced deliveries between 1 August 1995 and 31 December 2007 occurring at the Los Angeles County + University of Southern California Medical Center. Viable, singleton, term pregnancies undergoing induction were identified. Exclusion criteria included gestational age less than 37 weeks, previous cesarean delivery, breech presentation, stillbirth, premature rupture of membranes, and fetal anomaly. Induction methods studied were oxytocin, misoprostol, dinoprostone and Foley catheter. Our primary outcome was cesarean delivery rate among the four induction agents. Secondary outcomes included rate of failed induction, obstetrical complications, and immediate neonatal complications.

Results: A total of 3707 women were included in the study (1486 nulliparous; 2221 multiparous). Outcomes were compared across induction methods using Chi-square Tests (Pearson or Fisher's, as appropriate). Among the nulliparous patients, there was no statistical difference among the four induction agents with regards to cesarean delivery rate (p = 0.51), frequency of failed inductions (p = 0.49), the cesarean delivery frequency for "fetal distress" (p = 0.82) and five minute Apgar score <7 (p = 0.24). Among parous patients, the cesarean delivery rate varied significantly by induction method (p < 0.001), being lowest among those receiving misoprostol (10%). Those receiving oxytocin and transcervical Foley catheter had cesarean rates of 22%, followed by dinoprostone at 18%. The rate of failed inductions was 2% among those receiving misoprostol, compared to 7-8% among those in the other groups (p < 0.01). Although cases of "fetal distress" between the four induction agents was not significantly different amongst multipara women, the cesarean delivery indication for "fetal distress" was higher among multipara receiving misoprostol (p = 0.004). There was no difference among the different induction agents with regards to five minute Apgar <7 (p = 0.34).

Conclusion: Among nulliparous women, all induction methods have similar rate of cesarean delivery. The use of misoprostol appears to be associated with a lower risk of cesarean birth among parous women induced at our institution.
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http://dx.doi.org/10.3109/14767058.2013.831066DOI Listing
April 2014

Perioperative characteristics associated with preterm birth in twin-twin transfusion syndrome treated by laser surgery.

Am J Obstet Gynecol 2013 Sep 7;209(3):264.e1-8. Epub 2013 Jun 7.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Objective: To identify perioperative risk factors for preterm delivery (PTD) in laser-treated patients with twin-twin transfusion syndrome (TTTS).

Study Design: Twin-twin transfusion syndrome patients who underwent laser surgery were followed prospectively. Univariate and multivariate analyses were performed to identify gestational and surgical characteristics associated with preterm delivery.

Results: Of 318 eligible patients, the mean (SD) gestational age of delivery was 32.8 (4.2) weeks. The number of days from laser surgery to delivery had a bimodal distribution; group I delivered within 21 days and group II delivered after 21 days of surgery. Eighteen patients (5.7%) were in group I and demonstrated the following risk factors for delivery within 21 days: incomplete laser surgery suspected (odds ratio [OR], 11.14; P = .0106), preoperative subchorionic hematoma (OR, 7.92, P = .0361), preoperative cervical length <2.0 cm (OR, 4.71; P = .0117), and recipient's maximum vertical pocket ≥14 cm (OR, 3.23; P = .0335). In group II, 92 of 300 patients (30.7%) delivered <32 weeks, and 25 (8.3%) delivered <28 weeks; multivariate logistic regression analyses identified 5 risk factors for delivery <32 weeks: incomplete laser surgery suspected (OR, 10.0; P = .0506); incidental septostomy (OR, 4.4; P = .0009); triplet gestation (OR, 2.6; P = .0689); postoperative membrane detachment (OR, 2.4; P = .0393); and nonposterior placental location (OR, 1.8; P = .0282).

Conclusion: Timing of delivery after laser for twin-twin transfusion syndrome has a bimodal distribution with distinct gestational and surgical risk factors. This information may be useful in counseling patients and in directing future avenues of research.
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http://dx.doi.org/10.1016/j.ajog.2013.05.025DOI Listing
September 2013

Severe brachial plexus palsy in women without shoulder dystocia. In reply.

Obstet Gynecol 2013 Mar;121(3):686

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Utah School of Medicine, Salt Lake City, Utah Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1097/AOG.0b013e3182855089DOI Listing
March 2013

In reply.

Obstet Gynecol 2013 Jan;121(1):191-2

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http://dx.doi.org/10.1097/aog.0b013e31827b240eDOI Listing
January 2013

Neonatal brachial plexus palsy with vaginal birth after cesarean delivery: a case-control study.

Am J Obstet Gynecol 2013 Mar 2;208(3):229.e1-5. Epub 2012 Dec 2.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA 23507, USA.

Objective: The objective was to determine the rate of neonatal brachial plexus palsy (NBPP) among women with vaginal birth after cesarean delivery (VBAC) and to compare the peripartum characteristics with control subjects.

Study Design: The Maternal-Fetal Medicine Unit cesarean registry data were used to identify nonanomalous singleton pregnancies with VBAC and NBPP at gestational age of ≥37 weeks (term) and 4 control subjects (matched for gestational age and diabetes mellitus status but without brachial injury). Odds ratio (OR) and 95% confidence intervals (CIs) were calculated.

Results: Among 11,313 VBACs at term, there were 23 women with NBPP (rate of 2.0/1000 women). Newborn infants with NBPP, compared with control infants, were significantly more likely to weigh ≥4000 g (48% vs 10%, respectively; OR, 8.45; 95% CI, 2.58-28.44) and to require admission to the neonatal intensive care unit (30% vs 13%; OR, 12.98; 95% CI, 2.61-72.18).

Conclusion: Women who desire VBAC should be informed about the low rate of NBPP and, if eligible, encouraged to have a trial of labor after cesarean delivery.
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http://dx.doi.org/10.1016/j.ajog.2012.11.042DOI Listing
March 2013

Bile acid concentration reference ranges in a pregnant Latina population.

Am J Perinatol 2013 May 16;30(5):389-93. Epub 2012 Nov 16.

Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA.

Objective: The total bile acid (TBA) concentration criterion for diagnosing intrahepatic cholestasis of pregnancy varies in the published literature. The purpose of this study was to establish pregnancy-specific reference ranges for the TBA concentration among Latina women.

Study Design: Self-identified Latina women (n = 211) over 18 years of age with a singleton pregnancy were recruited and had random serum samples drawn during the second and third trimesters. The total and fractionated bile acid concentrations were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and reference ranges were calculated. Laboratory-provided general reference ranges from a general population of adult men and nonpregnant women were used for comparison.

Results: The TBA reference range for our Latina pregnant population (<8.5 µmol/L) was markedly lower than the laboratory-provided reference range (4.5 to 19.2 µmol/L).

Conclusion: These data suggest that the upper TBA concentration reference range in our Latina pregnant population is 8.5 µmol/L, based on LC-MS/MS measurements.
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http://dx.doi.org/10.1055/s-0032-1326982DOI Listing
May 2013