Publications by authors named "Naomi Greene"

46 Publications

Beyond Black and White: race and sexual identity as contributors to healthcare system distrust after breast cancer screening among US women.

Psychooncology 2021 Mar 10. Epub 2021 Mar 10.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Objective: Healthcare system distrust (HCSD) has been linked to poor breast cancer outcomes. Previous HSCD analyses have focused on Black-White disparities; however, focusing only on race ignores the complex set of factors that form identity. We quantified the contributions of race and sexual minority (SM) identity to HCSD among US women who had received breast cancer screening.

Methods: This cross-sectional study used intersectionality decomposition methods to assess the degree to which racial and SM identity contributed to disparate responses to the validated 9-item HCSD Scale. The sample included online survey participants identifying as a Black or White woman living in the US, with a self-reported abnormal breast cancer screening result in the past 24 months and/or breast cancer diagnosis since 2011.

Results: Of 649 participants, 49.4% of Black SM women (n = 85) were in the highest HCSD tertile, followed by 37.4% of White SM women (n = 123), 24.4% of Black heterosexual women (n = 156), and 19% of White heterosexual women. Controlling for age, 72% of the disparity in HCSD between Black SM women and White heterosexual women was due to SM status, 23% was due to racial identity, and 3% was due to both racial and SM identity.

Conclusions: SM identity emerged as the largest driver of HCSD disparities; however, the combined racial and SM disparity persisted. Excluding sexual identity in HCSD studies may miss an important contributor. Interventions designed to increase the HCS's trustworthiness at the provider and system levels should address both racism and homophobia.
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http://dx.doi.org/10.1002/pon.5670DOI Listing
March 2021

State-Level Alcohol Environments and Sexual Identity Disparities in Binge Drinking in the Behavioral Risk Factor Surveillance System.

LGBT Health 2021 Apr 4;8(3):190-200. Epub 2021 Feb 4.

Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

Binge drinking disparities by sexual identity are well documented. Stronger alcohol policy environments reduce binge drinking in the general population. We examined whether state-level alcohol policy environments have the same association with binge drinking among lesbian, gay, and bisexual (LGB) adults as among heterosexual adults. Binge drinking, sexual identity, and demographic characteristics were extracted from the 2015 to 2018 Behavioral Risk Factor Surveillance System. The strength of the alcohol policy environment was measured by using the Alcohol Policy Scale (APS) score. We estimated the association between APS score and binge drinking by using logistic regression and included an interaction term between APS score and sexual identity. The interaction between APS score and sexual identity was not significant, and findings differed between women and men. Among women, a higher APS score was associated with lower odds of binge drinking (adjusted odds ratio [aOR]: 0.96, 95% confidence interval [CI]: 0.94-0.99). Differences in binge drinking by sexual identity remained after adjusting for individual and state-level factors (e.g., the percentage of LGB adults in the state). Compared with heterosexual women, the odds of binge drinking were 43% higher (aOR: 1.43, 95% CI: 1.17-1.75) among lesbian women and 58% higher (aOR: 1.58, 95% CI: 1.40-1.79) among bisexual women. A higher APS score was not associated with binge drinking among men. Stronger state-level alcohol policy environments were associated with lower binge drinking among women. Lesbian and bisexual women were still more likely to engage in binge drinking compared with heterosexual women even in states with stronger alcohol policy environments.
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http://dx.doi.org/10.1089/lgbt.2020.0182DOI Listing
April 2021

Risk factors for re-presentation for postpartum hypertension in patients without a history of hypertension or preeclampsia.

Am J Obstet Gynecol MFM 2021 03 15;3(2):100297. Epub 2020 Dec 15.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: Re-presentation for evaluation of hypertension following discharge after delivery is common. However, a subset of patients who re-present for evaluation of postpartum hypertension do not have a history of hypertension. Identification of those at risk may help guide postpartum management and prevent re-presentations to the hospital.

Objective: This study aimed to establish risk factors for re-presentation for hypertension within 30 days of discharge after delivery in patients without a history of hypertension compared with women who did not re-present and to distinguish from risk factors for re-presentation for another reason.

Study Design: Subjects were identified through data extraction from a single institution between January 2012 and December 2018. We included subjects without an International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision code for (1) chronic hypertension or (2) a hypertensive disorder of pregnancy during their delivery encounter who re-presented to the hospital within 30 days. Thus, the re-presentation group was divided into the following 2 groups: those who re-presented for hypertension and those who re-presented for any other reason. Each re-presentation group was compared with the cohort of patients who delivered within the study window and did not re-present using the Student t test or Wilcoxon tests for continuous variables and chi-square or Fisher's exact tests for categorical variables. Multivariable regression was also performed on all potentially important risk factors.

Results: Factors that emerged as uniquely significant in the re-presentation group for hypertension were maternal age of ≥40 years and antenatal prescription of low-dose aspirin. Black race and body mass index of ≥30 kg/m, although significant in both re-presentation groups, were more strongly predictive of re-presentation for hypertension. These factors remained independently significant when compared with each other in a multivariable analysis.

Conclusion: There are identifiable risk factors for postpartum re-presentation for hypertension in patients without a history of hypertension. Upon discharge, providers may consider close blood pressure monitoring and follow-up in patients who have any of the following risk factors: age of ≥40 years, black race, body mass index of ≥30 kg/m, or those who were prescribed low-dose aspirin in pregnancy.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100297DOI Listing
March 2021

A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance.

Matern Health Neonatol Perinatol 2021 Jan 6;7(1). Epub 2021 Jan 6.

AMF Consulting, Los Angeles, CA, USA.

Background: Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors.

Objective: To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM.

Search Methods: Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term "severe maternal morbidity."

Selection Criteria: Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded.

Data Collection And Analysis: Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed.

Main Results: Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty).

Conclusions: The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.
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http://dx.doi.org/10.1186/s40748-020-00123-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789633PMC
January 2021

Variability in antemortem and postmortem blood alcohol concentration levels among fatally injured adults.

Am J Drug Alcohol Abuse 2021 01 9;47(1):84-91. Epub 2020 Oct 9.

National Study Center for Trauma and Emergency Medical Systems, Shock, Trauma and Anesthesiology Research-Organized Research Center, University of Maryland School of Medicine, Baltimore, MD, USA.

Excessive alcohol use is a risk factor for injury-related deaths. Postmortem blood samples are commonly used to approximate antemortem blood alcohol concentration (BAC) levels. To assess differences between antemortem and postmortem BACs among fatally injured adults admitted to one shock trauma center (STC). Fifty-two adult decedents (45 male, 7 female) admitted to a STC in Baltimore, Maryland during 2006-2016 were included. STC records were matched with records from Maryland's Office of the Chief Medical Examiner (OCME). The antemortem and postmortem BAC distributions were compared. After stratifying by antemortem BACs <0.10 versus ≥0.10 g/dL, differences in postmortem and antemortem BACs were plotted as a function of length of hospital stay. Among the 52 decedents, 22 died from transportation-related injuries, 20 died by homicide or intentional assault, and 10 died from other injuries. The median BAC antemortem was 0.10 g/dL and postmortem was 0.06 g/dL. Thirty-one (59.6%) decedents had antemortem BACs ≥0.08 g/dL versus 22 (42.3%) decedents using postmortem BACs. Postmortem BACs were lower than the antemortem BACs for 42 decedents, by an average of 0.07 g/dL. Postmortem BACs were higher than the antemortem BACs for 10 decedents, by an average of 0.06 g/dL. Postmortem BACs were generally lower than antemortem BACs for the fatally injured decedents in this study, though not consistently. More routine antemortem BAC testing, when possible, would improve the surveillance of alcohol involvement in injuries. The findings emphasize the usefulness of routine testing and recording of BACs in acute care facilities.
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http://dx.doi.org/10.1080/00952990.2020.1822856DOI Listing
January 2021

"This is some mess right here": Exploring interactions between Black sexual minority women and health care providers for breast cancer screening and care.

Cancer 2020 Jan 29;127(1):74-81. Epub 2020 Sep 29.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Background: Few studies have explored how the intersection of race and sexual identity contribute to breast cancer disparities for Black sexual minority women (SMW). Issues within patient-provider relationships, including bias, contribute to health disparities for minority groups. The authors used constructs from self-determination theory (SDT) to explore the nature of health care provider interactions in breast cancer screening and care among Black SMW.

Methods: Participants were sampled nationally through social media, targeted emails, and referrals. Qualitative, in-depth interviews were conducted with 15 Black cisgender SMW, ages 38 to 64 years, who had a breast cancer diagnosis or recent abnormal mammogram. Interviews were conducted face-to-face or online, audio-recorded, and transcribed verbatim. Two analysts coded the interviews. Codes were analyzed across interviews to identify themes salient to SDT.

Results: Themes aligned with the SDT constructs of relatedness and autonomy. Some participants discussed feeling most understood by Black and/or female providers who shared at least 1 of their identities. Feeling understood through shared identity contributed to participants feeling seen and heard by their providers. Participants who discussed negative experiences with providers believed that the provider made negative assumptions about them based on their race and/or sexual orientation.

Conclusions: When interacting with health care providers for breast cancer screening and care, Black SMW face specific challenges related to their multiply marginalized social position. Reducing health care provider bias toward Black SMW may improve patients' desires to continue in care. Providing equitable care while acknowledging and respecting women with multiply marginalized identities may improve the nature of these interactions.
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http://dx.doi.org/10.1002/cncr.33219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865953PMC
January 2020

Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic.

Am J Obstet Gynecol MFM 2020 11 21;2(4):100234. Epub 2020 Sep 21.

Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: In response to the coronavirus disease 2019 pandemic, hospitals nationwide have implemented modifications to labor and delivery unit practices designed to protect delivering patients and healthcare providers from infection with severe acute respiratory syndrome coronavirus 2. Beginning in March 2020, our hospital instituted labor, and delivery unit modifications targeting visitor policy, use of personal protective equipment, designation of rooms for triage and delivery of persons suspected or infected with coronavirus disease 2019, delivery management, and newborn care. Little is known about the ramifications of these modifications in terms of maternal and neonatal outcomes.

Objective: The objective of this study was to determine whether labor and delivery unit policy modifications we made during the coronavirus disease 2019 pandemic were associated with differences in outcomes for mothers and newborns.

Study Design: We conducted a retrospective cohort study of all deliveries occurring in our hospital between January 1, 2020, and April 30, 2020. Patients who delivered in January and February 2020 before labor and delivery unit modifications were instituted were designated as the preimplementation group, and those who delivered in March and April 2020 were designated as the postimplementation group. Maternal and neonatal outcomes between the pre- and postimplementation groups were compared. Differences between the 2 groups were then compared with the same time period in 2019 and 2018 to assess whether any apparent differences were unique to the pandemic year. We hypothesized that maternal and newborn lengths of stay would be shorter in the postimplementation group. Statistical analysis methods included Student's -tests and Wilcoxon tests for continuous variables and chi-square or Fisher exact tests for categorical variables.

Results: Postpartum length of stay was significantly shorter after implementation of labor unit changes related to coronavirus disease 2019. A postpartum stay of 1 night after vaginal delivery occurred in 48.5% of patients in the postimplementation group compared with 24.9% of the preimplementation group (<.0001). Postoperative length of stay after cesarean delivery of ≤2 nights occurred in 40.9% of patients in the postimplementation group compared with 11.8% in the preimplementation group (<.0001). Similarly, after vaginal delivery, 49.0% of newborns were discharged home after 1 night in the postimplementation group compared with 24.9% in the preimplementation group (<.0001). After cesarean delivery, 42.5% of newborns were discharged after ≤2 nights in the postimplementation group compared with 12.5% in the preimplementation group (<.0001). Slight differences in the proportions of earlier discharge between mothers and newborns were due to multiple gestations. There were no differences in cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the 2 groups.

Conclusion: Labor and delivery unit policy modifications to protect pregnant patients and healthcare providers from coronavirus disease 2019 indicate that maternal and newborn length of stay in the hospital were significantly shorter after delivery without increases in the rate of adverse maternal or neonatal outcomes. In the absence of long-term adverse outcomes occurring after discharge that are tied to earlier release, our study results may support a review of our discharge protocols once the pandemic subsides to move toward safely shortening maternal and newborn lengths of stay.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505067PMC
November 2020

Routine Multidisciplinary Review of Severe Maternal Morbidity Is Associated with a Reduction in Preventable Cases of Severe Maternal Morbidity.

Am J Perinatol 2020 Aug 30. Epub 2020 Aug 30.

Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.

Objective:  Severe maternal morbidity (SMM) has increased by 45% in the United States and is estimated to affect up to 1.5% of all deliveries. Research has not yet been conducted that demonstrates a benefit to multidisciplinary review of SMM. The aim of our study was to determine if standardized, routine review of the cases of SMM by a multidisciplinary committee results in a reduction of potentially preventable cases of SMM.

Study Design:  A retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from March 1, 2012 to September 30, 2016. Our cohort was separated into two groups: a preintervention group composed of women admitted for delivery prior to the implementation of the obstetric Quality and Peer Review Committee (OBQPRC), and a postintervention group where the committee had been well established. Cases of confirmed SMM were presented to a multidisciplinary research committee, and the committee determined whether opportunities for improvement in care existed. The groups were compared with determine if there was a decreased incidence of preventable SMM following the implementation of the OBQPRC standardized review process.

Results:  There were 30,319 deliveries during the study period; 13,120 deliveries in the preintervention group; and 13,350 deliveries in the postintervention group (2,649 deliveries during the transition period). There was no difference in the rate of SMM between the preintervention (125; 0.95%) and postintervention (129; 0.97%) groups, ( = 0.91). There was a significantly lower rate of opportunity for the improvement in care in the postintervention group (29.5%) compared with the preintervention group (46%;  = 0.005).

Conclusion:  We demonstrated a significant reduction in the rate of potentially preventable SMM following the implementation of routine review of all SMM suggesting that this process plays an important role in improving maternal care and outcomes.

Key Points: · Benefit to routine review of SMM has not been demonstrated.. · Routine review of SMM is associated with 36% reduction in potentially preventable SMM.. · This is the first study to demonstrate the benefit of routine review of SMM..
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http://dx.doi.org/10.1055/s-0040-1715846DOI Listing
August 2020

Examining Disparities in Excessive Alcohol Use Among Black and Hispanic Lesbian and Bisexual Women in the United States: An Intersectional Analysis.

J Stud Alcohol Drugs 2020 07;81(4):462-470

Departments of Epidemiology and Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Objective: Sexual minority (i.e., lesbian, bisexual) women and racial-ethnic minority groups in the United States are disproportionately harmed by excessive alcohol use. This study examined disparities in excessive alcohol use at the intersection of race-ethnicity and sexual identity for non-Hispanic Black and Hispanic sexual minority women.

Method: Using data from the 2015 National Survey on Drug Use and Health, we compared the age-adjusted prevalence of binge drinking and heavy alcohol use among sexual minority women of color, sexual minority White women, and heterosexual women of color with that of White heterosexual women. The joint disparity is the difference in the prevalence of excessive alcohol use between sexual minority women of color and White heterosexual women. The excess intersectional disparity is the portion of the joint disparity that is due to being both a racial-ethnic minority and a sexual minority woman.

Results: Black and Hispanic sexual minority women reported the highest prevalence of binge drinking (45.4% and 43.4%, respectively), followed by White sexual minority women (35.7%) and White heterosexual women (23%). Black and Hispanic heterosexual women reported the lowest prevalence of binge drinking (20.8% and 20.2%, respectively). The joint disparity in binge drinking between Black sexual minority women and White heterosexual women was 21.2%, and the excess intersectional disparity was 17.7%. The joint disparity in binge drinking between Hispanic sexual minority women and White heterosexual women was 16.8%, and the excess intersectional disparity was 10.8%.

Conclusions: Disparities in excessive alcohol consumption for Black and Hispanic sexual minority women, compared with White heterosexual women, were larger than what would be expected when considering differences by race or sexual identity individually.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437553PMC
July 2020

Postoperative Urinary Retention after Benign Gynecologic Surgery with a Liberal versus Strict Voiding Protocol.

J Minim Invasive Gynecol 2021 02 8;28(2):351-357. Epub 2020 Jul 8.

Department of Obstetrics & Gynecology (all authors); Division of Minimally Invasive Gynecologic Surgery (Drs. Siedhoff and Wright), Cedars-Sinai Medical Center, Los Angeles, California.

Study Objective: Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void before discharge). The primary objective of this study was to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol with more strict voiding protocols. Secondary outcomes included length of hospital stay (LOS) and urinary tract infection (UTI).

Design: Retrospective cohort study.

Setting: Quaternary-care academic hospital in the United States.

Patients: Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n = 652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded.

Interventions: Hysterectomy, myomectomy.

Measurements And Main Results: POUR, defined as the need for recatheterization within 24 hours of catheter removal, along with UTI and LOS were compared between liberal and strict voiding protocols. A subgroup analysis was performed for those undergoing minimally invasive surgery (MIS). A total of 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) women with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different between the groups (2.6% liberal vs. 4.9% strict, p = .14). UTIs also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p = .86). Similar results were seen specifically among those who underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p = .17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p = .28). The median LOS (interquartile range) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall [interquartile range 15 hours], 9 [4] hours liberal vs. 36 [34] hours strict, p <.01). Among those discharged the same day (72.6% of the MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean [standard deviation] 9.4 [2.5] hours vs. 10.6 [35] hours, p <.01). Postoperative complications occurred less frequently in those with MIS procedures (11.8% in MIS vs. 20.2% in laparotomies, p <.01) and those with liberal voiding protocols (11.2% liberal vs. 16.9% strict p = .04).

Conclusion: Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ between those with liberal and strict voiding protocols. Our data suggest that same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the postanesthesia recovery unit and may contribute to enhanced recovery after surgery protocols.
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http://dx.doi.org/10.1016/j.jmig.2020.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790839PMC
February 2021

Risk of Urinary Tract Infection Symptoms after Posthysterectomy Cystoscopy with 50% Dextrose as Compared with Saline Cystoscopy with Indigo Carmine.

J Minim Invasive Gynecol 2021 02 29;28(2):282-287. Epub 2020 May 29.

Department of Obstetrics & Gynecology, Cedars-Sinai Medical Center, Los Angeles, California (Drs. Misal, Wright, Greene, and Siedhoff).

Study Objective: Compare odds of postoperative urinary symptoms in women who had cystoscopy after benign laparoscopic hysterectomy with 50% dextrose and with normal saline solution with intravenous indigo carmine.

Design: Retrospective cohort study.

Setting: Two tertiary care centers.

Patients: All women who underwent benign laparoscopic hysterectomy and intraoperative cystoscopy carried out by a single surgeon.

Interventions: We compared postoperative urinary symptoms in patients who received 50% dextrose cystoscopy fluid (January 2016-June 2017) with those who received saline cystoscopy with intravenous indigo carmine (November 2013-April 2014).

Measurements And Main Results: A total of 96 patients had cystoscopy with 50% dextrose and 104 with normal saline with intravenous indigo carmine. Differences in baseline characteristics of the two groups of participants mainly reflected institutional population diversity: age (45.2 vs 41.9, p = .01), body mass index (26.9 vs 33.4, p <.01), race, current smoking status (1% vs 7.8%, p = .04), diabetes (2.1% vs 11.5%, p = .01), history of abdominal surgery (53.1% vs 74%, p <.01), hysterectomy type, receipt of intraoperative antibiotics (92.7% vs 100%, p <.01), recatheterization (10.4% vs 0%, p <.01), and removal of catheter on postoperative day 0 (66.7% vs 12.5%, p <.01). Urinary symptoms were similar for 50% dextrose and saline (12.5% vs 7.7%, p = .19). After adjusting for age, body mass index, race, diabetes, and day of catheter removal, there remained no significant differences in urinary symptoms between the groups (odds ratio 3.19 [95% confidence interval, 0.82-12.35], p = .09). One immediate bladder injury was detected in the saline group and 1 delayed lower urinary tract injury in the 50% dextrose group.

Conclusion: Overall, most women experienced no urinary symptoms after benign laparoscopic hysterectomy. There were no significant differences in postoperative urinary symptoms or empiric treatment of urinary tract infection after the use of 50% dextrose cystoscopy fluid as compared with normal saline. The previous finding of increased odds of urinary tract infection after dextrose cystoscopy may be due to use in a high-risk population.
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http://dx.doi.org/10.1016/j.jmig.2020.05.023DOI Listing
February 2021

Alcohol Advertising and Violence.

Am J Prev Med 2020 03 21;58(3):343-351. Epub 2020 Jan 21.

Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts.

Introduction: Numerous studies have found associations between alcohol outlet density and violence, but it is unknown whether alcohol advertisements visible outside outlets are also associated with violent crime. Baltimore City, MD enacted restrictions on retail alcohol establishment advertising practices as of June 5, 2017. This study examines the association between alcohol advertisements visible outside off-premise alcohol outlets and violent crime before this restriction.

Methods: Outlet observations (n=683) were conducted in summer 2015, and violent crime data (n=24,085) were from June 5, 2015, through June 4, 2017. The number of violent crimes per square mile within 1,000 feet of outlets was summed using kernel density estimation. In 2018-2019, authors used mixed models with a Simes-Benjamini-Hochberg correction for multiple testing.

Results: Roughly half (47%, n=267) of the outlets with complete data (n=572) had alcohol advertisements visible from the exterior. Outlets with alcohol advertisements had 15% more violent crimes per square mile within 1,000 feet (e=1.15, 95% CI=1.07, 1.25, q<0.001) after adjusting for neighborhood context. All associations between alcohol advertisements and specific types of violent crime were significant, with the association strongest for homicides (e=1.28, 95% CI=1.13, 1.46, q<0.001). There was no association between cigarette advertisements and violent crime (e=1.08, 95% CI=0.92, 1.26, q=0.43).

Conclusions: Alcohol advertisements visible outside off-premise outlets were associated with increased violent crime over and above the association between the outlets themselves and violent crime. Reducing alcohol advertising visible from the street may decrease risk of violent crime that is associated with alcohol outlets.
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http://dx.doi.org/10.1016/j.amepre.2019.10.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140760PMC
March 2020

Alcohol Advertising and Violence.

Am J Prev Med 2020 03 21;58(3):343-351. Epub 2020 Jan 21.

Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts.

Introduction: Numerous studies have found associations between alcohol outlet density and violence, but it is unknown whether alcohol advertisements visible outside outlets are also associated with violent crime. Baltimore City, MD enacted restrictions on retail alcohol establishment advertising practices as of June 5, 2017. This study examines the association between alcohol advertisements visible outside off-premise alcohol outlets and violent crime before this restriction.

Methods: Outlet observations (n=683) were conducted in summer 2015, and violent crime data (n=24,085) were from June 5, 2015, through June 4, 2017. The number of violent crimes per square mile within 1,000 feet of outlets was summed using kernel density estimation. In 2018-2019, authors used mixed models with a Simes-Benjamini-Hochberg correction for multiple testing.

Results: Roughly half (47%, n=267) of the outlets with complete data (n=572) had alcohol advertisements visible from the exterior. Outlets with alcohol advertisements had 15% more violent crimes per square mile within 1,000 feet (e=1.15, 95% CI=1.07, 1.25, q<0.001) after adjusting for neighborhood context. All associations between alcohol advertisements and specific types of violent crime were significant, with the association strongest for homicides (e=1.28, 95% CI=1.13, 1.46, q<0.001). There was no association between cigarette advertisements and violent crime (e=1.08, 95% CI=0.92, 1.26, q=0.43).

Conclusions: Alcohol advertisements visible outside off-premise outlets were associated with increased violent crime over and above the association between the outlets themselves and violent crime. Reducing alcohol advertising visible from the street may decrease risk of violent crime that is associated with alcohol outlets.
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http://dx.doi.org/10.1016/j.amepre.2019.10.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140760PMC
March 2020

Maternal and Neonatal Morbidity After 4 and 6 Hours of Protracted Active Labor in Nulliparous Term Pregnancies.

Obstet Gynecol 2020 01;135(1):185-193

Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.

Objective: To evaluate whether women with protracted active phase labor longer than 6 hours have an increased risk of adverse maternal and neonatal outcomes after the implementation of new labor management guidelines.

Methods: This was a retrospective study of nulliparous, term, singleton, vertex deliveries at Cedars Sinai Medical Center from August 2016 to September 2017. Women were included if they progressed to active phase labor, defined by cervical dilation of 6 cm or more. Women then were divided into three groups based on the time course of cervical change between 6 and 10 cm: 1) normal active phase: cervical change 1 cm or more within 4 hours throughout active labor; 2) mildly protracted active phase: cervical change 1 cm or less over 4-6 hours; and 3) very protracted active phase: cervical change 1 cm or less over 6 hours. Rate of change was assessed between cervical examinations. Primary outcome was a composite of maternal morbidity by study group. Secondary outcome was a composite of neonatal morbidity. We hypothesized that women with very protracted active phase had higher rates of adverse outcomes when compared with normal active phase. Regression analyses were performed to compare maternal and neonatal outcomes by study group.

Results: There were 2,559 deliveries, of which 2,378 (90.8%) were vaginal deliveries. Composite maternal and neonatal morbidity was higher with longer labor. Maternal morbidity-very protracted active phase (42.0%) compared with normal active phase (22.6%) adjusted odds ratio (aOR) 2.15 (95% CI 1.62-2.86); mildly protracted active phase (39.5%) compared with normal active phase (22.6%) aOR 2.18 (95% CI 1.67-2.84). Neonatal morbidity: very protracted active phase (19.8%) compared with normal active phase (13.8%) aOR 1.38 (95% CI 0.98-1.96); mildly protracted active phase (19.4%) compared with normal active phase (13.8%) aOR 1.44; (95% CI 1.04-1.99). Composite maternal and neonatal morbidity was not different between mildly protracted and very protracted groups.

Conclusion: Composite maternal morbidity was greater in women with cervical change consistent with mildly protracted (4-6 hours) and very protracted (more than 6 hours) labor compared with cervical change in the normal active phase (less than 4 hours) group. However, composite maternal and neonatal morbidity was not different between mildly protracted and very protracted groups.
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http://dx.doi.org/10.1097/AOG.0000000000003587DOI Listing
January 2020

Patient Discharge without an Order to Void in the Outpatient Gynecologic Surgery Setting.

J Minim Invasive Gynecol 2020 Jul - Aug;27(5):1059-1062. Epub 2019 Sep 11.

Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California (Drs. Siedhoff, Greene, and Wright).

Study Objective: To evaluate if there is a difference in hospital readmission when patients are required to void versus not required to void before discharge after a same-day gynecologic procedure.

Design: A retrospective cohort study.

Setting: An urban tertiary care hospital.

Patients: A total of 4743 patients undergoing same-day gynecologic surgery.

Interventions: The readmission rates of patients discharged home without an order to void were compared with those with an order to void. Chart review was performed for readmission within 30 days and time to discharge from the postanesthesia recovery unit.

Measurements And Main Results: There was no statistically significant difference in the readmission rate between patients with or without an order to void before discharge (0.4% vs 0.9%, p = .08). Only 3 patients were readmitted for urinary retention, all with an order to void before discharge. Compared with gynecologic surgeons treating benign conditions, gynecologic oncologists were 23% more likely to place an order to void before discharge. Patients without an order to void spent approximately 59 minutes more in the postanesthesia care unit compared with those required to void (p <.01).

Conclusion: Discharge without an order to void is a safe practice in patients undergoing same-day gynecologic procedures. The risk of postdischarge urinary retention is low, consistent with previously reported rates in the literature.
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http://dx.doi.org/10.1016/j.jmig.2019.09.770DOI Listing
December 2020

Antibiotics during Intrauterine Balloon Tamponade Is Associated with a Reduction in Endometritis.

Am J Perinatol 2019 10 20;36(12):1211-1215. Epub 2019 Mar 20.

Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.

Objective: To evaluate whether prophylactic antibiotics at the time of placement of an intrauterine balloon tamponade (IBT) is associated with a reduction in postpartum endometritis.

Study Design: Retrospective cohort study of patients who received an IBT from January 1, 2012, to December 12, 2016. Patients were included if the IBT remained in place at least 2 hours and excluded if chorioamnionitis was present. Patients who received prophylactic antibiotics at the time of IBT placement were compared with those who did not.

Results: A total of 149 subjects received an IBT; 36 were excluded due to early removal or chorioamnionitis. Of the remaining, 59 received prophylactic antibiotics and 54 did not. Baseline characteristics were similar between the groups except mode of delivery. The majority (65%) of those who did not receive prophylactic antibiotics had a cesarean delivery ( = 0.03). The overall incidence of endometritis was 15%. The incidence of endometritis was greater among those patients who did not receive prophylactic antibiotics compared with those who did (5 vs. 26%;  < 0.002; odds ratio [OR]: 6.53; 95% confidence interval [CI]: 1.76-24.25). This association remained after adjustment for mode of delivery and receiving group B antibiotics prior to delivery (adjusted OR: 5.9; 95% CI: 1.58-22.35).

Conclusion: Prophylactic antibiotics were associated with a reduction in postpartum endometritis among patients receiving an IBT.
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http://dx.doi.org/10.1055/s-0039-1683888DOI Listing
October 2019

Timely treatment of severe maternal hypertension and reduction in severe maternal morbidity.

Pregnancy Hypertens 2018 Oct 31;14:55-58. Epub 2018 Jul 31.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, United States.

Objective: To determine if timely treatment within 60 min of confirmed diagnosis of severe maternal hypertension with antihypertensive medications was associated with reduction in severe maternal morbidity.

Study Design: Medical records of women with severe hypertension (at least two severe blood pressures, systolic ≥160 mmHg and/or diastolic ≥110 mmHg, within 60 min) were accessed for timing of severe blood pressures, timing of treatment, and blood pressure response to treatment. Severe maternal morbidity was confirmed by multidisciplinary case review. We compared the incidence of severe maternal morbidity between women who received timely (within 60 min of diagnosis) vs. not-timely treatment.

Results: Of 465 women with severe hypertension, 29 (6.2%) experienced severe maternal morbidity. Fifty-six percent of women received timely treatment, of whom 1.9% had severe maternal morbidity, compared with 6.4% of women who did not receive timely treatment (p = 0.02). Timely treatment was associated with a 72% reduction in relative risk of severe maternal morbidity (p = 0.02). No significant difference was seen in median pre-treatment systolic pressures (p = 0.20) between the groups.

Conclusion: Antihypertensive treatment within 60 min of confirmed diagnosis of severe hypertension was associated with reduction in severe maternal morbidity. Our findings support current recommendations to treat all women with severe hypertension with antihypertensive medications in a timely fashion.
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http://dx.doi.org/10.1016/j.preghy.2018.07.010DOI Listing
October 2018

Childbirth-specific patient-reported outcomes as predictors of hospital satisfaction.

Am J Obstet Gynecol 2019 02 4;220(2):201.e1-201.e19. Epub 2018 Nov 4.

AMF Consulting, Los Angeles, CA.

Background: Under value-based payment programs, patient-reported experiences and outcomes can impact hospital and physician revenue. To enable obstetrical providers to improve the childbirth experience, a framework for understanding what women expect and desire during childbirth is needed.

Objective: The purpose of this study was to identify key predictors of childbirth hospital satisfaction with the use of the Childbirth Experiences Survey.

Study Design: This study builds on a larger effort that used Patient-Reported Outcomes Management Information System methods to develop a childbirth-specific preliminary patient-reported experiences and outcomes item bank. These efforts led to the development of an antepartum and postpartum survey (Childbirth Experiences Survey Parts 1 and 2). All phases of the study were conducted with the participation of a community-based research team. We conducted a prospective observational study using national survey response panels that was organized through Nielsen to identify women's antepartum values and preferences for childbirth (Childbirth Experiences Survey Part 1). Eligible participants were pregnant women in the United States (English or Spanish speaking) who were ≥18 years old and ≥20 weeks pregnant. Women were recontacted and invited to participate in a postpartum follow-up survey to collect information about their childbirth patient-reported experiences and outcomes, which included childbirth satisfaction (Childbirth Experiences Survey Part 2). In bivariate analyses, we tested whether predisposing conditions (eg, patient characteristics or previous experiences), values and preferences, patient-reported experiences and outcomes, and the "gaps" between values and preferences and patient-reported experiences and outcomes were predictors of women's satisfaction with hospital childbirth services. Multivariable logistic regression models were fitted to examine the simultaneous effect of predictors on hospital satisfaction, which were adjusted for key predisposing conditions.

Results: From 500 women who anticipated a vaginal delivery at the time of the antepartum survey, who labored before delivery, and who answered the postpartum survey, key findings included the following responses: (1) the strongest predictors of women's satisfaction with hospital childbirth services were items in the domains of staff communication, compassion, empathy, and respect, and (2) 23 childbirth-specific patient-reported experiences and outcomes were identified. Examples of these patient-reported experiences and outcomes (such as being told about progress in labor and being involved in decisions regarding labor pain management) appeared especially relevant to women who experienced childbirth. A final model that predicted women's satisfaction with hospital childbirth services included a total of 8 items that could be optimized by doctors, midwives, and hospitals. These included the patient's report of how well she coped with labor pain, whether the hospital provided adequate space and food for their support person, and whether she received practical support for feeding the newborn infant.

Conclusion: This study identified 23 childbirth-specific patient-reported experiences and outcomes that were predictors of childbirth hospital satisfaction. The implementation of the Childbirth Experiences Survey Parts 1 and 2 in a multihospital setting may lead to the development of childbirth hospital performance measures and strategies for improvement of the childbirth experience.
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http://dx.doi.org/10.1016/j.ajog.2018.10.093DOI Listing
February 2019

The Development of a Conceptual Framework and Preliminary Item Bank for Childbirth-Specific Patient-Reported Outcome Measures.

Health Serv Res 2018 10 24;53(5):3373-3399. Epub 2018 May 24.

Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Burns Allen Research Institute, Los Angeles, CA.

Objective: To develop a conceptual framework and preliminary item bank for childbirth-specific patient-reported outcome (PRO) domains.

Data Sources: Women, who were U.S. residents, ≥18 years old, and ≥20 weeks pregnant, were surveyed regarding their childbirth values and preferences (V&P) using online panels.

Study Design: Using community-based research techniques and Patient-Reported Outcomes Management Information System (PROMIS ) methodology, we conducted a comprehensive literature review to identify self-reported survey items regarding patient-reported V&P and childbirth experiences and outcomes (PROs). The V&P/PRO domains were validated by focus groups. We conducted a cross-sectional observational study and fitted a multivariable logistic regression model to each V&P item to describe "who" wanted each item.

Principal Findings: We identified 5,880 V&P/PRO items that mapped to 19 domains and 58 subdomains. We present results for the 2,250 survey respondents who anticipated a vaginal delivery in a hospital. Wide variation existed regarding each V&P item, and personal characteristics, such as maternal confidence and ability to cope well with pain, were frequent predictors in the models. The resulting preliminary item bank consisted of 60 key personal characteristics and 63 V&P/PROs.

Conclusions: The conceptual framework and preliminary (PROMIS ) item bank presented here provide a foundation for the development of childbirth-specific V&P/PROs.
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http://dx.doi.org/10.1111/1475-6773.12856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153166PMC
October 2018

Mode of conception does not appear to affect placental volume in the first trimester.

Fertil Steril 2017 06 10;107(6):1341-1347.e1. Epub 2017 May 10.

Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Cedars-Sinai Medical Center, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles, California. Electronic address:

Objective: To study whether infertility treatments, including IVF and non-IVF fertility treatments, are associated with diseases of placental insufficiency in early gestation. First trimester placental volumes by ultrasound and chorionic villi weight during sampling (CVS) were performed to detect differences between pregnancies conceived spontaneously versus with fertility treatments.

Design: Retrospective cohort.

Setting: Academic tertiary center.

Patient(s): Women with singleton pregnancies undergoing CVS and first trimester ultrasound from April 2007 to November 2015.

Intervention(s): Estimated placental volume (EPV) was calculated from ultrasound images using a validated computation and CVS estimated tissue weight was performed using a validated visual analogue scale.

Main Outcome Measure(s): Adjusted linear regression was used to compare EPV and CVS weight based on mode of conception.

Result(s): A total of 1,977 spontaneous and 334 conceived with fertility treatments (133 non-IVF and 201 IVF) pregnancies were included. Significant differences in maternal age, gravidity, hypertension, and smoking status were identified. EPV and CVS weight were correlated with maternal age, gestational age, and maternal hypertension. Adjusted linear regression showed no difference in EPV in pregnancies conceived with fertility treatments versus spontaneously. The CVS weight was significantly lower in the IVF conceptions in unadjusted univariate analyses. However, after adjusted regression, this was no longer significant.

Conclusion(s): Mode of conception does not appear to affect first trimester placental size. As differences in maternal age, hypertension, and smoking status differ among the groups and are correlated to placental size, it may be the underlying patient population leading to abnormal placentation and insufficiency, not the fertility treatments used.
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http://dx.doi.org/10.1016/j.fertnstert.2017.04.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628758PMC
June 2017

Abnormal implantation after fresh and frozen in vitro fertilization cycles.

Fertil Steril 2017 05 19;107(5):1153-1158. Epub 2017 Apr 19.

Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California. Electronic address:

Objective: To determine whether fresh embryo transfers are at a higher risk of abnormal implantation compared with frozen embryo transfers while accounting for the embryo stage at transfer.

Design: Retrospective cohort study.

Setting: Not applicable.

Patient(s): We used data from the Society for Assisted Reproductive Technologies to identify all fresh and frozen autologous IVF cycles from 2004-2013 resulting in a positive pregnancy test. The cycles were parameterized into a four-level predictor of [1] fresh blastocyst transfer, [2] fresh non-blastocyst transfer, [3] frozen blastocyst transfer, and [4] frozen non-blastocyst transfer.

Intervention(s): None.

Main Outcome Measure(s): We examined a composite outcome of abnormal implantation, defined as biochemical pregnancy, ectopic/heterotopic pregnancy, and first-trimester pregnancy loss. Regression modeling was performed with repeated measures multivariable logistic regression, adjusted for age, parity, number of embryos transferred, infertility diagnosis, and calendar year of treatment.

Result(s): Of 509,938 cycles analyzed, 31.8% resulted in abnormal implantation. Compared with a fresh blastocyst transfer, a fresh non-blastocyst transfer had a 22% increase risk of abnormal implantation, a frozen blastocyst transfer had a 36% increase risk, and a frozen non-blastocyst transfer had a 57% increase risk. When individual outcomes were analyzed, fresh embryo transfers had a lower risk of biochemical pregnancy and pregnancy loss but a higher risk for ectopic/heterotopic pregnancy.

Conclusion(s): Fresh blastocyst transfers had the lowest overall risk of abnormal implantation but a higher risk of ectopic/heterotopic pregnancy. Although embryo cryopreservation is indicated in certain treatment cycles, elective embryo cryopreservation may not be the optimal strategy to adopt for all cycles.
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http://dx.doi.org/10.1016/j.fertnstert.2017.03.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628741PMC
May 2017

Gene-Environment Interaction in Parkinson's Disease: Coffee, ADORA2A, and CYP1A2.

Neuroepidemiology 2016 31;47(3-4):192-200. Epub 2016 Jan 31.

Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), USA.

Background And Purpose: Drinking caffeinated coffee has been reported to provide protection against Parkinson's disease (PD). Caffeine is an adenosine A2A receptor (encoded by the gene ADORA2A) antagonist that increases dopaminergic neurotransmission and Cytochrome P450 1A2 (gene: CYP1A2) metabolizes caffeine; thus, gene polymorphisms in ADORA2A and CYP1A2 may influence the effect coffee consumption has on PD risk.

Methods: In a population-based case-control study (PASIDA) in Denmark (1,556 PD patients and 1,606 birth year- and gender-matched controls), we assessed interactions between lifetime coffee consumption and 3 polymorphisms in ADORA2A and CYP1A2 for all subjects, and incident and prevalent PD cases separately using logistic regression models. We also conducted a meta-analysis combining our results with those from previous studies.

Results: We estimated statistically significant interactions for ADORA2A rs5760423 and heavy vs. light coffee consumption in incident (OR interaction = 0.66 [95% CI 0.46-0.94], p = 0.02) but not prevalent PD. We did not observe interactions for CYP1A2 rs762551 and rs2472304 in incident or prevalent PD. In meta-analyses, PD associations with daily coffee consumption were strongest among carriers of variant alleles in both ADORA2A and CYP1A2.

Conclusion: We corroborated results from a previous report that described interactions between ADORA2A and CYP1A2 polymorphisms and coffee consumption. Our results also suggest that survivor bias may affect results of studies that enroll prevalent PD cases.
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http://dx.doi.org/10.1159/000450855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5465963PMC
December 2017

Can We Accurately Time the Administration of Antenatal Corticosteroids for Preterm Labor?

Obstet Gynecol Int 2016 7;2016:5054037. Epub 2016 Nov 7.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.

. Accurate timing of antenatal corticosteroids (ACS) has resulted in improved neonatal outcomes. . Our primary objective was to determine predictors for optimal timing of ACS in women presenting with spontaneous preterm labor. . A retrospective cohort study of women receiving ACS for spontaneous preterm birth was conducted. Women were included if they presented with preterm labor or preterm premature rupture of membranes. Accurate timing of ACS was defined as administration within 7 days of delivery. Maternal demographic and obstetrics characteristics were compared between the groups receiving ACS ≤7 days and >7 days from delivery. Statistical analyses were performed using parametric and nonparametric tests. < 0.05 was considered significant. . The study included 215 subjects. Median latency from ACS administration to delivery was 6 days (IQR 32). Accurate timing of ACS occurred in 113 (53%) women and was associated with rupture of membranes (OR 13.8, 95% CI 5.9-32.6), cervical change (OR 7.1, 95% CI 3.0-17.1), and cervical dilation ≥ 2 cm (OR 3.9, 95% CI 1.5-10.3). . Rupture of membranes, cervical change, and cervical dilation ≥ 2 cm were strong predictors of optimal timing. 53% of women with preterm labor received ACS optimally.
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http://dx.doi.org/10.1155/2016/5054037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116493PMC
November 2016

Oral labetalol compared to oral nifedipine for postpartum hypertension: A randomized controlled trial.

Hypertens Pregnancy 2017 Feb 27;36(1):44-47. Epub 2016 Oct 27.

a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Cedars-Sinai Medical Center , Los Angeles , California , USA.

Objective: To determine whether oral labetalol is associated with a shorter time to blood pressure control compared to oral extended release nifedipine for management of persistent postpartum hypertension.

Study Design: This randomized controlled trial conducted between June 2014 and June 2015 included women who delivered at ≥32 weeks' gestation with persistent postpartum hypertension (sustained blood pressure ≥150/100 mmHg) requiring an oral antihypertensive agent. We included women with gestational hypertension, preeclampsia, or chronic hypertension not previously on medication. Women were randomized to labetalol or nifedipine, and the allocated study drug was incrementally increased to achieve blood pressure control. The primary outcome was time to sustained blood pressure control defined as the absence of severe hypertension for at least 12 hours. Secondary outcomes included postpartum length of stay, need for increased dosing, need for additional oral antihypertensive agents, and patient reported side effects. Twenty women were needed in each group as determined by the sample size calculation.

Results: We randomized 25 women to oral labetalol and 25 women to oral extended release nifedipine. The time to achieve BP control was similar between labetalol and nifedipine groups (37.6 hours versus 38.2 hours, p = 0.51). Secondary outcomes including postpartum length of stay, need for increased dosing, and need for additional oral antihypertensive agents were similar between groups. For women discharged on a single agent, significantly more subjects in the labetalol group (16/21) compared to the nifedipine group (10/22) achieved BP control with the initial starting dose (76% versus 46%, p = 0.04). No major side effects were observed. Minor side effects were significantly more common in women taking nifedipine compared to labetalol (48% versus 20%, p = 0.04).

Conclusions: Both labetalol and nifedipine were effective for control of persistent postpartum hypertension. However, labetalol achieved control significantly more often with the starting dose and had fewer side effects.

Clinical Trial Registration: Oral nifedipine versus oral labetalol, NCT02168309. https://clinicaltrials.gov/ct2/show/NCT02168309?term=labetalol+versus+nifedipine&rank=2.
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http://dx.doi.org/10.1080/10641955.2016.1231317DOI Listing
February 2017

Opportunities for improvement in care among women with severe maternal morbidity.

Am J Obstet Gynecol 2016 10 19;215(4):509.e1-6. Epub 2016 May 19.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: Severe maternal morbidity is increasing in the United States and has been estimated to occur in up to 1.3% of all deliveries. A standardized, multidisciplinary approach has been recommended to identify and review cases of severe maternal morbidity to identify opportunities for improvement in maternal care.

Objective: The aims of our study were to apply newly described gold standard guidelines to identify true severe maternal morbidity and to utilize a recently recommended multidisciplinary approach to determine the incidence of and characterize opportunities for improvement in care.

Study Design: We conducted a retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from Jan. 1, 2012, through June 30, 2014. Electronic medical records were screened for severe maternal morbidity using the following criteria: International Classification of Diseases, Ninth Revision codes for severe illness identified by the Centers for Disease Control and Prevention; prolonged length of stay; intensive care unit admission; transfusion of ≥4 U of packed red blood cells; or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in-depth review of each medical record that screened positive for severe maternal morbidity to determine if true severe maternal morbidity occurred. Each true case of severe maternal morbidity was presented to a multidisciplinary committee to determine a consensus opinion about the morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible, or none. The incidence of opportunity for improvement was determined and categorized as system, provider, and/or patient. Morbidity was classified by primary cause, organ system, and underlying medical condition.

Results: There were 16,323 deliveries of which 386 (2%) screened positive for severe maternal morbidity. Following review of each case, true severe maternal morbidity was present in 150 (0.9%) deliveries. We determined by multidisciplinary committee review that there was opportunity for improvement in care in 66 (44%) cases. The 2 most common underlying causes of severe maternal morbidity were hemorrhage (71.3%) and preeclampsia/eclampsia (10.7%). In cases with opportunity for improvement in care, provider factors were present in 78.8%, followed by patient (28.8%) and system (13.6%) factors.

Conclusion: We demonstrated the feasibility of a recently recommended review process of severe maternal morbidity at a large, academic medical center. We demonstrated that opportunity for improvement in care exists in 44% of cases and that the majority of these cases had contributing provider factors.
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http://dx.doi.org/10.1016/j.ajog.2016.05.022DOI Listing
October 2016

Impact of fertility treatment on severe maternal morbidity.

Fertil Steril 2016 Aug 7;106(2):423-6. Epub 2016 Apr 7.

Cedars-Sinai Medical Center, Los Angeles, California.

Objective: To determine if fertility treatment is associated with increased risk of severe maternal morbidity (SMM) compared with spontaneous pregnancies.

Design: Retrospective cohort study.

Setting: Academic medical center.

Patient(s): In 2012, 6,543 women delivered live births >20 weeks gestation at our center. Women were categorized based on mode of conception: in vitro fertilization (IVF), non-IVF fertility treatment (NIFT), or spontaneous pregnancies.

Intervention(s): None.

Main Outcome Measure(s): The main outcome was presence of true SMM, such as eclampsia, respiratory failure, and peripartum hysterectomy. Deliveries were screened with the use of: 1) International Classification of Diseases 9 codes; 2) prolonged postpartum stay; 3) maternal intensive care unit admissions, and 4) blood transfusion. The charts of women meeting the screening criteria were reviewed to identify true SMM based on a previously validated method, recognizing that medical record review is the criterion standard.

Result(s): Of the 6,543 deliveries, 246 (3.8%) were IVF conceptions and 109 (1.7%) NIFT conceptions. Sixty-nine cases of true SMM were identified (1.1%). In multivariate analyses, any fertility treatment (IVF + NIFT) was associated with increased risk of SMM compared with spontaneous conceptions. In a subset analysis of singletons only, the association between any fertility treatment (IVF + NIFT) and SMM was not statistically significant.

Conclusion(s): Overall, fertility treatment increased risk for SMM events. Given the limited sample size, the negative finding with singleton gestations is inconclusive. Larger multicenter studies with accurate documentation of fertility treatment and SMM cases are needed to further clarify the risk associated with singletons.
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http://dx.doi.org/10.1016/j.fertnstert.2016.03.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975660PMC
August 2016

Risks of parenteral antihypertensive therapy for the treatment of severe maternal hypertension are low.

Hypertens Pregnancy 2016 24;35(1):123-8. Epub 2016 Feb 24.

a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology , Cedars-Sinai Medical Center , Los Angeles , CA , USA.

Objective: To determine whether the incidence of hypotension or adverse fetal heart tracing (FHT) category change differed following antepartum administration of intravenous (IV) labetalol versus hydralazine.

Methods: Blood pressure and FHT categories were assessed one hour before and after medication administration. Hypotension was defined as ≥30% reduction in baseline systolic blood pressure (SBP) or SBP <90 mmHg. Changes in mean arterial pressure (MAP) were also compared. The National Institute for Child Health and Human Development (NICHD) three-tier category system was used to describe the FHT. For all category II tracings, Parer and Ikeda's system was also used.

Results: Sixty-nine women received hydralazine and 31 women received labetalol during the study period. The incidence of hypotension (≥30% reduction in SBP) was similar between the labetalol (10%) and hydralazine (11%) groups (p = 0.98). No women experienced post-treatment SBP <90 mmHg. No association was observed between fetal heart rate category change and drug used. No women required emergent delivery for fetal indications.

Conclusions: The incidence of maternal hypotension was low and did not differ following antepartum IV labetalol versus hydralazine use. These data should reassure providers about the use of parenteral labetalol and hydralazine for the treatment of severe hypertension.
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http://dx.doi.org/10.3109/10641955.2015.1117098DOI Listing
January 2017

Confirmed severe maternal morbidity is associated with high rate of preterm delivery.

Am J Obstet Gynecol 2016 08 17;215(2):233.e1-7. Epub 2016 Feb 17.

California Maternal Quality Care Collaborative, Stanford University, Palo Alto, CA.

Background: Because severe maternal morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce maternal morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care.

Objective: Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery.

Study Design: In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation.

Results: In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P < .0001), be African American (14.1 vs 7.9%; P < .0001), have had a multiple gestation (9.7 vs 2.1%; P < .0001), and, for the multiparous women, have had a prior cesarean delivery (58 vs 30.2%; P < .0001). Preterm delivery was significantly more common in SMM women compared to SMM-negative women (41 vs 8%; P < .0001), including delivery <32 weeks (18 vs 2%; P < .0001). The most common underlying disease was obstetric hemorrhage (42%) followed by hypertensive disorders (20%) and placental hemorrhage (14%). Only 1.6% of women with SMM had cardiovascular disease as the underlying disease category.

Conclusion: An extremely high proportion of women with severe morbidity (42.5%) delivered preterm with 17.8% delivering <32 weeks, which underscores the importance of access to appropriate-level care for mothers with SMM and their newborns. Further, the extremely high rate of preterm delivery (75%) in women with placental hemorrhage in combination with their 63% prior cesarean delivery rate highlights another risk of prior cesarean delivery: subsequent preterm delivery. These data provide a reminder that a cesarean delivery could be a contributing factor to not only hemorrhage-related SMM, but also to increased subsequent preterm delivery, more reason to continue national efforts to safely reduce initial cesarean deliveries.
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http://dx.doi.org/10.1016/j.ajog.2016.02.026DOI Listing
August 2016