Publications by authors named "Sara N Iqbal"

29 Publications

  • Page 1 of 1

Educational Video on Pain Management and Subsequent Opioid Use After Cesarean Delivery: A Randomized Controlled Trial.

Obstet Gynecol 2021 08;138(2):253-259

Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC; the Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia; and the Department of Business Management, National Sun Yat-Sen University, Kaohsiung, Taiwan.

Objective: To evaluate whether viewing an educational video on pain management reduces opioid use after cesarean delivery.

Methods: We conducted a randomized, controlled trial of women aged 18 years or older who underwent cesarean delivery at a tertiary care center. Eligible women were randomized in a 1:1 ratio to usual discharge pain medication instructions plus an educational video on pain management or to usual discharge pain medication instructions alone. All women received the same opioid prescription at discharge: Twenty 5-mg oxycodone tablets. Participants were contacted at 7 days and at 14 days after delivery to assess the number of oxycodone tablets used, adjunct medication (acetaminophen and ibuprofen) use, pain scores, and overall satisfaction of pain control. The primary outcome was the number of oxycodone tablets used from discharge through postpartum day 14. A sample size of 23 per group (n=46) was planned to detect a 25% difference in mean number of oxycodone tablets used between groups, as from 20 to 15.

Results: From July 2019 through December 2019, 61 women were screened and 48 were enrolled-24 in each group. Women who viewed the educational video used significantly fewer opioid tablets from discharge through postpartum day 14 compared with women who received usual pain medication instructions (median 1.5, range 0-20 vs median 10, range 0-24, P<.001). Adjunct medication use, pain scores, and satisfaction with pain control did not differ significantly between groups.

Conclusion: Among women who underwent cesarean delivery, viewing an educational video on pain management reduced postdischarge opioid use.

Clinical Trial Registration: ClinicalTrials.gov, NCT03959969.
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http://dx.doi.org/10.1097/AOG.0000000000004468DOI Listing
August 2021

Incidence of Hypertensive Disorders of Pregnancy in Women with COVID-19.

Am J Perinatol 2021 07 3;38(8):766-772. Epub 2021 May 3.

Obstetrics and Gynecology, Division of Maternal Fetal Medicine, MedStar Washington Hospital Center, Washington, District of Columbia.

Objective: The study aimed to examine the incidence of hypertensive disorders of pregnancy in women diagnosed with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2, also known as COVID-19).

Study Design: This was a retrospective cohort study of all women who delivered at MedStar Washington Hospital Center in Washington, DC from April 8, 2020 to July 31, 2020. Starting April 8, 2020, universal testing for COVID-19 infection was initiated for all women admitted to labor and delivery. Women who declined universal testing were excluded. Hypertensive disorders of pregnancy were diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions.1 Maternal demographics, clinical characteristics, and labor and delivery outcomes were examined. Neonatal outcomes were also collected. Laboratory values from admission were evaluated. Our primary outcome was the incidence of hypertensive disorders of pregnancy among women who tested positive for COVID-19. The incidence of hypertensive disorders of pregnancy was compared between women who tested positive for COVID-19 and women who tested negative.

Results: Of the 1,008 women included in the analysis, 73 (7.2%) women tested positive for COVID-19, of which 12 (16.4%) were symptomatic at the time of admission. The incidence of hypertensive disorders of pregnancy was 34.2% among women who tested positive for COVID-19 and 22.9% women who tested negative for COVID-19 ( = 0.03). After adjusting for race, antenatal aspirin use, chronic hypertension, and body mass index >30, the risk of developing any hypertensive disorder of pregnancy was not statistically significant (odds ratio: 1.58 [0.91-2.76]).

Conclusion: After adjusting for potential confounders, the risk of developing a hypertensive disorder of pregnancy in women who tested positive for COVID-19 compared with women who tested negative for COVID-19 was not significantly different.

Key Points: · There is an increased incidence of hypertensive disorders in women who test positive for COVID-19.. · Characteristics of pregnant women with COVID-19 are similar to those with hypertensive disorders.. · Liver function tests were similar between pregnant women with COVID-19 and women without COVID-19..
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http://dx.doi.org/10.1055/s-0041-1727167DOI Listing
July 2021

Refining the clinical definition of active phase arrest of dilation in nulliparous women to consider degree of cervical dilation as well as duration of arrest.

Am J Obstet Gynecol 2021 09 31;225(3):294.e1-294.e14. Epub 2021 Mar 31.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC.

Background: Maternal and neonatal outcomes associated with duration of arrest of dilation beyond 4 hours are not well known. In addition, the current definition of arrest does not consider the degree of cervical dilation (6 cm vs 7 cm vs 8 cm vs 9 cm) when arrest occurs.

Objective: We sought to examine maternal and neonatal outcomes in nulliparous women who achieved the active phase of labor according to the duration they required to achieve a cervical change of at least 1 cm (<4 hours vs 4-5.9 hours vs ≥6 hours) beginning at 6, 7, 8 and 9 cm.

Study Design: This was a retrospective cohort study of nulliparous women with term singleton cephalic pregnancies in spontaneous or induced active labor (≥6 cm). To evaluate the effect of labor duration on maternal and fetal outcomes at different degrees of cervical dilation, we categorized women based on time intervals they required to achieve a cervical change of at least 1 cm after membrane rupture ("<4 hours," "4-5.9 hours," and "≥6 hours"), and we correlated each time interval with referent cervical dilation status (6 cm, 7 cm, 8 cm, and 9 cm). Maternal and neonatal outcomes were analyzed according to the duration to progress at least 1 cm starting from each degree of cervical dilation. Our primary outcome was a composite of neonatal outcomes, including intensive care unit admission, neonatal death, seizure, ventilator use, birth injury, and neonatal asphyxia. In addition, we examined maternal outcomes. Adjusted odds ratios with 95% confidence intervals were calculated, controlling for predefined covariates.

Results: Of 31,505 nulliparous women included in this study, 13,142 (42%), 10,855 (34%), 11,761 (37%), and 17,049 (54%) reached documented cervical dilation of 6, 7, 8, and 9 cm, respectively. At cervical dilation of 6 or 7 cm, the arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal outcomes. When cervical dilation was 8 or 9 cm, arrest of dilation of <4 hours compared with arrest of dilation of 4 to 5.9 hours was associated with decreased risks of adverse maternal and neonatal outcomes. For example, women starting at a cervical dilation of 8 cm who required <4 hours to achieve a cervical change of 1 cm compared with those who required 4 to 5.9 hours had lower rates of cesarean delivery (adjusted odds ratio, 0.40; 95% confidence interval, 0.28-0.55), chorioamnionitis (adjusted odds ratio, 0.42; 95% confidence interval, 0.29-0.60), and the neonatal composite outcome (adjusted odds ratio, 0.51; 95% confidence interval, 0.36-0.72).

Conclusion: When cervical dilation is 6 or 7 cm, allowing arrest of dilation of ≥4 hours is reasonable because it was not associated with increased risks of adverse neonatal outcomes. When cervical dilation is 8 or 9 cm, the benefit of allowing arrest of dilation of ≥4 hours should be balanced against the risk of adverse maternal and neonatal outcomes.
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http://dx.doi.org/10.1016/j.ajog.2021.03.029DOI Listing
September 2021

Evaluation of the Maternal-Fetal Triage Index in a tertiary care labor and delivery unit.

Am J Obstet Gynecol MFM 2021 07 20;3(4):100351. Epub 2021 Mar 20.

Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC (Drs Kodama, Mokhtari, Iqbal, and Kawakita); Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Kawakita). Electronic address:

Background: The Maternal-Fetal Triage Index is a 5-level system to facilitate the care of pregnant women seeking care in an obstetrical triage unit (priority 1 being the highest acuity and priority 5 being the lowest acuity). Although the American College of Obstetricians and Gynecologists recommends implementing labor and delivery triage tools, it remains unclear whether the Maternal-Fetal Triage Index facilitates the timely evaluation of high-acuity pregnant women.

Objective: We sought to examine the duration of a labor and delivery triage evaluation before and after the implementation of the Maternal-Fetal Triage Index. We also sought to examine the duration of a labor and delivery triage evaluation according to priority levels by the Maternal-Fetal Triage Index.

Study Design: This was a retrospective quality improvement study of all women presenting to an urban, tertiary labor and delivery triage unit at 16 weeks' gestation or later from December 2017 to February 2018 (historical cohort) and December 2018 to February 2019 (study cohort). As part of a quality improvement initiative, the Maternal-Fetal Triage Index was implemented in the labor and delivery unit in May 2018. All registered nurses who worked in the labor and delivery unit completed a formal education course and assigned the priority levels at the time of triage presentation. The primary outcome was the duration of a labor and delivery triage evaluation, which was defined as the time interval from triage presentation to the completion of history and physical examination in the electronic medical record. Secondary outcomes included the rates of labor and delivery unit admissions.

Results: There were 1305 and 1374 women in the historical cohort and study cohort, respectively. The duration of labor and delivery triage evaluation was longer for the study cohort than for the historical cohort (64 minutes vs 61 minutes; P=.02). Of the 1374 women in the study cohort, there were 28 (2%), 290 (21%), 459 (33%), 462 (34%), and 135 (10%) women with priority levels 1, 2, 3, 4, and 5 assigned, respectively. Women with a higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation (priority 1, 57 minutes; priority 2, 66 minutes; priority 3, 63 minutes; priority 4, 62 minutes; and priority 5, 83 minutes; P<.001). The rates of admission were higher in the priority 1 and 5 groups (priority 1, 89.3%; priority 2, 41.4%; priority 3, 57.3%; priority 4, 53.3%; and priority 5, 92.6%; P<.001).

Conclusion: Compared with the historical cohort, the duration of labor and delivery triage evaluation was longer in the study cohort. However, in the study cohort, women classified as higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation. Our study supports the American College of Obstetricians and Gynecologists' recommendation on the implementation and utilization of labor and delivery triage tools such as the Maternal-Fetal Triage Index.
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http://dx.doi.org/10.1016/j.ajogmf.2021.100351DOI Listing
July 2021

Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage.

Obstet Gynecol 2020 11;136(5):882-891

NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York; The Ohio State University, Columbus, Ohio; University of Utah Health, Salt Lake City, Utah; the University of Pittsburgh Medical Center-Magee Women's Hospital, Pittsburgh, Pennsylvania; NewYork-Presbyterian/Queens, Flushing, New York; the University of Alabama, UAB Center for Women's Reproductive Health, Birmingham, Alabama; MetroHealth Medical Center, Cleveland, Ohio; Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; the University of Texas Medical Branch at Galveston, Galveston, Texas; the University of Virginia, Charlottesville, Virginia; MedStar Washington Hospital Center, Washington, DC; Geisinger Medical Center, Danville, Pennsylvania; Massachusetts General Hospital, Boston, Massachusetts; the Cleveland Clinic, Cleveland, Ohio; Oregon Health & Science University, Portland, Oregon; Alydia Health, Menlo Park, California; McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; Northwestern University/Northwestern Memorial Hospital, Chicago, Illinois; and the Indiana University School of Medicine, Indianapolis, Indiana.

Objective: To evaluate the effectiveness and safety of an intrauterine vacuum-induced hemorrhage-control device for postpartum hemorrhage treatment.

Methods: A multicenter, prospective, single-arm treatment study of a novel intrauterine device that uses low-level vacuum to induce uterine myometrial contraction to achieve control of abnormal postpartum uterine bleeding and postpartum hemorrhage was undertaken at 12 centers in the United States. The primary effectiveness endpoint was the proportion of participants in whom use of the intrauterine vacuum-induced hemorrhage-control device controlled abnormal bleeding without requiring escalating interventions. The primary safety endpoint was the incidence, severity, and seriousness of device-related adverse events. Secondary outcomes included time to bleeding control, rate of transfusion, and device usability scored by each investigator using the device.

Results: Of 107 participants enrolled with primary postpartum hemorrhage or abnormal postpartum uterine bleeding, 106 received any study treatment with the device connected to vacuum, and successful treatment was observed in 94% (100/106, 95% CI 88-98%) of these participants. In those 100 participants, definitive control of abnormal bleeding was reported in a median of 3 minutes (interquartile range 2.0-5.0) after connection to vacuum. Eight adverse events deemed possibly related to the device or procedure were reported, all of which were outlined as risks in the study and all of which resolved with treatment without serious clinical sequelae. Transfusion of 1-3 units of red blood cells was required in 35 participants, and five participants required 4 or more units of red blood cells. The majority of investigators reported the intrauterine vacuum-induced hemorrhage-control device as easy to use (98%) and would recommend it (97%).

Conclusion: Intrauterine vacuum-induced hemorrhage control may provide a new rapid and effective treatment option for abnormal postpartum uterine bleeding or postpartum hemorrhage, with the potential to prevent severe maternal morbidity and mortality.

Funding Source: Alydia Health, Inc.

Clinical Trial Registration: ClinicalTrials.gov, NCT02883673.
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http://dx.doi.org/10.1097/AOG.0000000000004138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575019PMC
November 2020

Intraamniotic Infection Rates after Intrauterine Pressure Catheter with and without Amnioinfusion.

Am J Perinatol 2021 02 13;38(3):212-217. Epub 2020 Aug 13.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia.

Objective: This study aimed to examine the rates of intraamniotic infection between intrauterine pressure catheter with amnioinfusion and intrauterine pressure catheter alone.

Study Design: This was a retrospective cohort study of all women who had an intrauterine pressure catheter placement during labor at a tertiary referral hospital from January 2016 to June 2018. Outcomes were compared between women who had an intrauterine pressure catheter with amnioinfusion and intrauterine pressure catheter placement alone. The primary outcome was the rate of intraamniotic infection. Secondary outcomes included postpartum endometritis, postpartum hemorrhage (blood loss of ≥1,000 mL), quantitative blood loss (mL), and cesarean delivery. Multivariable logistic regression analysis was performed to calculate adjusted odds ratios (aOR) and 95% confidence interval (95% CI), controlling for age, race, body mass index, gestational age, and length of time of rupture of membranes.

Results: Of 1,268 women with an intrauterine pressure catheter, 298 (23.5%) also had an amnioinfusion. Women who had amnioinfusion through an intrauterine pressure catheter compared with those who had intrauterine pressure catheter alone had similar rates of intraamniotic infection (5.4 vs. 8.0%, crude  = 0.12, aOR 0.69; 95% CI 0.39-1.21), as well as secondary outcomes such as postpartum endometritis (3.0 vs. 2.5%, crude  = 0.61, aOR 1.12; 95% CI 0.49-2.53), postpartum hemorrhage (16.1 vs. 15.8%, crude  = 0.89, aOR 1.07; 95% CI 0.75-1.54), blood loss (479.5 vs. 500 mL, adjusted  = 0.89), and cesarean delivery (40.6 vs. 43.1%, crude  = 0.45, aOR 0.90; 95% CI 0.68-1.19).

Conclusion: Amnioinfusion was not associated with increased odds of intraamniotic infection compared with intrauterine pressure catheter placement alone.

Key Points: · Amnioinfusion involves instilling fluid into the amniotic cavity to relieve variable decelerations.. · Amnioinfusion is not associated with increased odds of chorioamnionitis compared to IUPC alone.. · Amnioinfusion is not associated with increased odds of PPH compared to IUPC placement alone..
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http://dx.doi.org/10.1055/s-0040-1715558DOI Listing
February 2021

Characterizing placental stiffness using ultrasound shear-wave elastography in healthy and preeclamptic pregnancies.

Arch Gynecol Obstet 2020 11 16;302(5):1103-1112. Epub 2020 Jul 16.

School of Medicine and Health Sciences, The George Washington University, Washington, D.C., USA.

Purpose: To measure the stiffness of the placenta in healthy and preeclamptic patients in the second and third trimesters of pregnancy using ultrasound shear-wave elastography (SWE). We also aimed to evaluate the effect of age, gestational age, gravidity, parity and body mass index (BMI) on placental stiffness and a possible correlation of stiffness with perinatal outcomes.

Methods: In a case-control study, we recruited a total of 47 singleton pregnancies in the second and third trimesters of which 24 were healthy and 23 were diagnosed with preeclampsia. In vivo placental stiffness was measured once at the time of recruitment for each patient. Pregnancies with posterior placentas, multiple gestation, gestational hypertension, chronic hypertension, diabetes, autoimmune disease, fetal growth restriction and congenital anomalies were excluded.

Results: The mean placental stiffness was significantly higher in preeclamptic pregnancies compared to controls in the third trimester (difference of means = 16.8; 95% CI (9.0, 24.5); P < 0.001). There were no significant differences in placental stiffness between the two groups in the second trimester or between the severe preeclampsia and preeclampsia without severe features groups (difference of means = 9.86; 95% CI (-5.95, 25.7); P ≥ 0.05). Peripheral regions of the placenta were significantly stiffer than central regions in the preeclamptic group (difference of means = 10.67; 95% CI (0.07, 21.27); P < 0.05), which was not observed in the control group (difference of means = 0.55; 95% CI (- 5.25, 6.35); P > 0.05). We did not identify a correlation of placental stiffness with gestational age, maternal age, gravidity or parity. However, there was a statistically significant correlation with BMI (P < 0.05). In addition, pregnancies with higher placental stiffness during the 2nd and 3rd trimesters had significantly reduced birth weight (2890 ± 176 vs. 2420 ± 219 g) and earlier GA (37.8 ± 0.84 vs. 34.3 ± 0.98 weeks) at delivery (P < 0.05).

Conclusion: Compared to healthy pregnancies, placentas of preeclamptic pregnancies are stiffer and more heterogeneous. Placental stiffness is not affected by gestational age or the severity of preeclampsia but there is a correlation with higher BMI and poor perinatal outcomes.
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http://dx.doi.org/10.1007/s00404-020-05697-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646518PMC
November 2020

Racial Disparity in Postpartum Readmission due to Hypertension among Women with Pregnancy-Associated Hypertension.

Am J Perinatol 2021 10 2;38(12):1297-1302. Epub 2020 Jun 2.

Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, District of Columbia.

Objective: Postpartum hypertension is a leading cause of readmission in the postpartum period. We aimed to examine the prevalence of racial/ethnic differences in postpartum readmission due to hypertension in women with antepartum pregnancy-associated hypertension.

Study Design: This was a multi-institutional retrospective cohort study of all women with antepartum pregnancy-associated hypertension diagnosed prior to initial discharge from January 2009 to December 2016. Antepartum pregnancy-associated hypertension, such as gestational hypertension, preeclampsia (with or without severe features), hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome, and eclampsia was diagnosed based on American College of Obstetricians and Gynecologists Task Force definitions. Women with chronic hypertension and superimposed preeclampsia were excluded. Our primary outcome was postpartum readmission defined as a readmission due to severe hypertension within 6 weeks of postpartum. Risk factors including maternal age, gestational age at admission, insurance, race/ethnicity (self-reported), type of antepartum pregnancy-associated hypertension, marital status, body mass index (kg/m), diabetes (gestational or pregestational), use of antihypertensive medications, mode of delivery, and postpartum day 1 systolic blood pressure levels were examined. Multivariable logistic regression models were performed to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

Results: Of 4,317 women with pregnancy-associated hypertension before initial discharge, 66 (1.5%) had postpartum readmission due to hypertension. Risk factors associated with postpartum readmission due to hypertension included older maternal age (aOR = 1.44; 95% CI: 1.20-1.73 for every 5 year increase) and non-Hispanic black race (aOR = 2.12; 95% CI: 1.16-3.87).

Conclusion: In women with pregnancy-associated hypertension before initial discharge, non-Hispanic black women were at increased odds of postpartum readmission due to hypertension compared with non-Hispanic white women.
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http://dx.doi.org/10.1055/s-0040-1712530DOI Listing
October 2021

Neonatal and maternal outcomes of pregnancies with a fetal diagnosis of congenital heart disease using a standardized delivery room management protocol.

J Perinatol 2020 02 14;40(2):316-323. Epub 2019 Oct 14.

Division of Maternal Fetal Medicine, MedStar Washington Hospital Center, Washington, D.C., USA.

Objective: We sought to determine if fetuses with prenatally diagnosed congenital heart disease (CHD) were more likely to undergo cesarean delivery in the setting of a non-reassuring fetal heart rate tracing (NRFHT) and to determine if those fetuses were more likely to have a fetal acidosis.

Study Design: A retrospective cohort study of neonates prenatally diagnosed with CHD from August 2010 to July 2016. The control group consisted of gestational age matched controls without CHD.

Results: Each group consisted of 143 patients. The most common reason for cesarean delivery was a NRFHT (control 31% vs CHD 35%, p = 0.67). Fetal acidosis was a rare outcome occurring in only five controls (3.5%) and 11 cases (7.7%) (p = 0.12).

Conclusion: These findings demonstrate that with multidisciplinary care coordination, fetuses with a prenatal diagnosis of CHD have similar cesarean rates, labor and delivery management, and delivery room compromise as healthy fetuses.
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http://dx.doi.org/10.1038/s41372-019-0528-1DOI Listing
February 2020

Umbilical Cord Blood Gas in Newborns with Prenatal Diagnosis of Congenital Heart Disease: Insight into In-Utero and Delivery Hemodynamics.

Pediatr Cardiol 2019 Dec 30;40(8):1575-1583. Epub 2019 Aug 30.

Division of Cardiology, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010, USA.

The primary objective was to determine if newborns with congenital heart disease (CHD) are at a higher risk for acidosis at delivery as determined by cord blood gas analysis. The secondary objective was to determine whether specific fetal cardiac diagnosis, delivery method, or duration of labor is associated with an increased risk for acidosis. This was a retrospective study of newborns with CHD diagnosed prenatally and comparable patients without a CHD diagnosis. Study participants included 134 CHD-affected newborns and 134 controls. Median UA pH in CHD newborns was 7.22 (CI 7.2-7.4) and in controls it was 7.22 (CI 7.21-7.24), p = 0.91. There was no difference in median UA pH comparing newborns with single-ventricle CHD and two-ventricle CHD [7.23 (CI 7.2-7.26) vs. 7.22 (CI 7.22-7.24), p = 0.77], or newborns with CHD with aortic obstruction and those without aortic obstruction [7.23 (CI 7.21-7.26) vs. 7.22 (CI 7.2-7.24), p = 0.29]. After controlling for delivery method and duration of labor, CHD patients who underwent a spontaneous vaginal delivery were found to have a declining median UA pH as labor progressed. Our results show that newborns with CHD have a normal UA pH at delivery suggesting a compensated circulation in utero. Spontaneous vaginal delivery with a progressively longer duration of labor in CHD newborns was associated with lower UA pH. This suggests that fetuses with CHD may be at risk for hemodynamic instability at birth with a longer duration of labor as a potentially modifiable factor to improve outcome.
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http://dx.doi.org/10.1007/s00246-019-02189-xDOI Listing
December 2019

Negative pressure wound therapy system in extremely obese women after cesarean delivery compared with standard dressing.

J Matern Fetal Neonatal Med 2021 Feb 5;34(4):634-638. Epub 2019 May 5.

Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medstar Washington Hospital Center, Washington, DC, USA.

Data regarding the use of the negative pressure wound therapy (NPWT) system in extremely obese women (body mass index [BMI] ≥ 50 kg/m) undergoing cesarean delivery are limited. We sought to examine the rate of wound complications in extremely obese women according to postcesarean dressings (NPWT [PICO, Smith & Nephew, St. Peterburg, FL] versus standard dressings). This was a retrospective cohort study of all extremely obese women (BMI ≥ 50 kg/m) at 23 weeks' gestation or greater who underwent cesarean delivery at an academic teaching hospital in Washington, DC, between January 2009 and September 2017. During this period, a PICO Single Use NPWT system was used at our institution. Women who missed a postpartum follow-up were excluded. Since 2014, Medstar Washington Hospital Center recommended the use of a PICO Single Use NPWT system for extremely obese women at the time of delivery. However, the ultimate decision to use the NPWT was made by attending physicians, considering the cost of the device and the risk of wound complication. Our primary outcome was a composite of cellulitis, hematoma/seroma, and wound dehiscence. Coarsened exact matching with k-to-k solution was performed using BMI, rupture of membranes, and labor. Of 179 extremely obese women, 73 (40.8%) and 106 (59.2%) received NPWT and standard dressings, respectively; 61 women who received NPWT were matched to 61 women who received standard dressings. The rates of the primary outcome in the unmatched cohort were similar between women who received NPWT and those who received standard dressings (20.6 versus 16.0%;  = .44). The rates of primary outcome remained similar between women who received NPWT and those who received standard dressings after matching (18.0 versus 18.0%;  = 1.00). In extremely obese women undergoing cesarean delivery, prophylactic PICO NPWT was not associated with a decreased risk of the primary outcome compared with standard dressings. A large prospective randomized controlled trial would be useful to answer if NPWT is beneficial for extremely obese women.
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http://dx.doi.org/10.1080/14767058.2019.1611774DOI Listing
February 2021

Reducing Cesarean Delivery Surgical Site Infections: A Resident-Driven Quality Initiative.

Obstet Gynecol 2019 02;133(2):282-288

Departments of Obstetrics and Gynecology, MedStar Washington Hospital Center and MedStar Georgetown University Hospital, Washington, DC; the Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, Maryland; and Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC.

Objective: To examine the association of a resident-driven quality initiative with cesarean delivery surgical site infections.

Methods: This was a quasi-experimental, preintervention and postintervention study of women undergoing cesarean delivery at 23 weeks of gestation or greater between January 2015 and June 2018 at a single tertiary care center. We implemented a resident-driven, evidence-based surgical bundle, excluding women who underwent emergency cesarean or had chorioamnionitis. The bundle included routine prophylactic antibiotics (both cefazolin and azithromycin), chlorhexidine alcohol skin preparation, use of clippers instead of a razor, vaginal cleansing with povidone iodine, placental removal by umbilical cord traction, subcutaneous tissue closure if wound thickness greater than 2 cm, suture skin closure, dressing removal between 24 and 48 hours, and use of postoperative chlorhexidine soap. Our primary outcome was surgical site infections (superficial incisional, deep incisional, and organ or space surgical site infections) occurring up to 6 weeks postpartum. Outcomes were compared between the preimplementation period (January 2015-August 2016) and postimplementation period (December 2016-June 2018). Coarsened Exact Matching with k-to-k solution was performed using age, race-ethnicity, body mass index, rupture of membranes, and labor.

Results: In total, 1,624 underwent cesarean delivery in the preimplementation and 1,523 postimplementation periods, respectively; 1,100 women in the postimplementation period were matched to 1,100 women in the preimplementation period. The rate of surgical site infections in the unmatched cohort was significantly lower in the postimplementation period compared to those in the preimplementation period (2.2% [33/1,523] vs 4.5% [73/1,624]; odds ratio [OR] 0.47 [95% CI 0.31-0.71]; P<.001). This decrease in the rate of surgical site infections remained statistically significant after matching (1.9% [21/1,100] vs 4.1% [45/1,100]; OR 0.46 [0.27-0.77]; P<.001).

Conclusion: After implementation of a resident-driven quality initiative using a surgical bundle, we observed a significant decrease in cesarean surgical site infections.
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http://dx.doi.org/10.1097/AOG.0000000000003091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6353635PMC
February 2019

Early preterm preeclampsia outcomes by intended mode of delivery.

Am J Obstet Gynecol 2019 01 28;220(1):100.e1-100.e9. Epub 2018 Sep 28.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, MedStar Washington Hospital Center, Washington, DC.

Background: The optimal route of delivery in early-onset preeclampsia before 34 weeks is debated because many clinicians are reluctant to proceed with induction for perceived high risk of failure.

Objective: Our objective was to investigate labor induction success rates and compare maternal and neonatal outcomes by intended mode of delivery in women with early preterm preeclampsia.

Study Design: We identified 914 singleton pregnancies with preeclampsia in the Consortium on Safe Labor study for analysis who delivered between 24 0/7 and 33 6/7 weeks. We excluded fetal anomalies, antepartum stillbirth, or spontaneous preterm labor. Maternal and neonatal outcomes were compared between women undergoing induction of labor (n = 460) and planned cesarean delivery (n = 454) and women with successful induction of labor (n = 214) and unsuccessful induction of labor (n = 246). We calculated relative risks and 95% confidence intervals to determine outcomes by Poisson regression model with propensity score adjustment. The calculation of propensity scores considered covariates such as maternal age, gestational age, parity, body mass index, tobacco use, diabetes mellitus, chronic hypertension, hospital type and site, birthweight, history of cesarean delivery, malpresentation/breech, simplified Bishop score, insurance, marital status, and steroid use.

Results: Among the 460 women with induction (50%), 47% of deliveries were vaginal. By gestational age, 24 to 27 6/7, 28 to 31 6/7, and 32 to 33 6/7, the induction of labor success rates were 38% (12 of 32), 39% (70 of 180), and 54% (132 of 248), respectively. Induction of labor compared with planned cesarean delivery was less likely to be associated with placental abruption (adjusted relative risk, 0.33; 95% confidence interval, 0.16-0.67), wound infection or separation (adjusted relative risk, 0.23; 95% confidence interval, 0.06-0.85), and neonatal asphyxia (0.12; 95% confidence interval, 0.02-0.78). Women with vaginal delivery compared with those with failed induction of labor had decreased maternal morbidity (adjusted relative risk, 0.27; 95% confidence interval, 0.09-0.82) and no difference in neonatal outcomes.

Conclusion: About half of women with preterm preeclampsia who attempted an induction had a successful vaginal delivery. The rate of successful vaginal delivery increases with gestational age. Successful induction has the benefit of preventing maternal and fetal comorbidities associated with previous cesarean deliveries in subsequent pregnancies. While overall rates of a composite of serious maternal and neonatal morbidity/mortality did not differ between induction of labor and planned cesarean delivery groups, women with failed induction of labor had increased maternal morbidity highlighting the complex route of delivery counseling required in this high-risk population of women.
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http://dx.doi.org/10.1016/j.ajog.2018.09.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605098PMC
January 2019

Third trimester ultrasound for fetal macrosomia: optimal timing and institutional specific accuracy.

J Matern Fetal Neonatal Med 2019 Apr 28;32(8):1337-1341. Epub 2017 Nov 28.

a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Medstar Washington Hospital Center , Washington , DC , USA.

Purpose: To determine the performance of third trimester ultrasound in women with suspected fetal macrosomia.

Materials And Methods: We performed a retrospective cohort study of fetal ultrasounds from January 2004 to December 2014 with estimated fetal weight (EFW) between 4000 and 5000 g. We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, accounting for diabetic status and time between ultrasound and delivery.

Results: There were 405 ultrasounds evaluated. One hundred and twelve (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) were performed in diabetics. Sonographic identification of EFW over 4000 g at less than 38 weeks was associated with higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 versus 259.4 g, p < .024). EFW to birth weight correlation was within 1.7% of birth weight for ultrasound performed less than 38 weeks and within 6.5% of birth weight for ultrasound performed at greater than 38 weeks.

Conclusions: Identification of EFW with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed later in gestation. EFW to birth weight correlation was more accurate than previous reports.
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http://dx.doi.org/10.1080/14767058.2017.1405385DOI Listing
April 2019

Nonmedically indicated induction in morbidly obese women is not associated with an increased risk of cesarean delivery.

Am J Obstet Gynecol 2017 10 31;217(4):451.e1-451.e8. Epub 2017 May 31.

Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC.

Background: The prevalence of morbid obesity (body mass index ≥40 kg/m) in women aged 20-39 years was 7.5% in 2009 through 2010. Morbid obesity is associated with an increased risk of stillbirth compared with normal body mass index, especially >39 weeks' gestation. The data regarding increased risk of cesarean delivery associated with nonmedically indicated induction of labor compared to expectant management in morbidly obese women are limited.

Objective: We sought to compare the cesarean delivery rate of nonmedically indicated induction of labor with expectant management in morbidly obese women without other comorbidity.

Study Design: This was a retrospective cohort study from the Consortium on Safe Labor of morbidly obese women with singleton, cephalic gestations without previous cesarean, chronic hypertension, or gestational or pregestational diabetes between 37 0/7 and 41 6/7 weeks' gestation. We examined maternal outcomes including cesarean delivery, operative delivery, third- or fourth-degree laceration, postpartum hemorrhage, and composite maternal outcome (any of: transfusion, intensive care unit admission, venous thromboembolism). We also examined neonatal outcomes including shoulder dystocia, macrosomia (>4000 g), neonatal intensive care unit admission, and composite neonatal outcome (5-min Apgar score <5, stillbirth, neonatal death, or asphyxia or hypoxic-ischemic encephalopathy). Adjusted odds ratios with 95% confidence intervals were calculated, controlling for maternal characteristics, hospital type, and simplified Bishop score. Analyses were conducted at early and full term (37 0/7 to 38 6/7 and 39 0/7 to 40 6/7 weeks' gestation, respectively). Women who delivered between 41 0/7 and 41 6/7 weeks' gestation were included as expectant management group.

Results: Of 1894 nulliparous and 2455 multiparous morbidly obese women, 429 (22.7%) and 791 (32.2%) had nonmedically indicated induction, respectively. In nulliparas, nonmedically indicated induction was not associated with increased risks of cesarean delivery and was associated with decreased risks of macrosomia (2.2% vs 11.0%; adjusted odds ratio, 0.24; 95% confidence interval, 0.05-0.70) at early term and decreased neonatal intensive care unit admission (5.1% vs 8.9%; adjusted odds ratio, 0.59; 95% confidence interval, 0.33-0.98) at full term compared with expectant management. In multiparas, nonmedically indicated induction compared with expectant management was associated with a decreased risk of macrosomia at early term (4.2% vs 14.3%; adjusted odds ratio, 0.30; 95% confidence interval, 0.13-0.60), cesarean delivery at full term (5.4% vs 7.9%; adjusted odds ratio, 0.64; 95% confidence interval, 0.41-0.98), and composite neonatal outcome (0% vs 0.6%; adjusted odds ratio, 0.10; 95% confidence interval, <.01-0.89) at full term.

Conclusion: In morbidly obese women without other comorbidity, nonmedically indicated induction was not associated with an increased risk of cesarean delivery.
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http://dx.doi.org/10.1016/j.ajog.2017.05.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614804PMC
October 2017

Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route.

Am J Obstet Gynecol 2017 10 31;217(4):469.e1-469.e12. Epub 2017 May 31.

Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC.

Background: Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown.

Objective: We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity.

Study Design: Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use.

Results: Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85-3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77-1.27) cardiac anomalies.

Conclusion: Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.
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http://dx.doi.org/10.1016/j.ajog.2017.05.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793863PMC
October 2017

Correlation of placental pathology and perinatal outcomes with Hemoglobin A1c in early pregnancy in gravidas with pregestational diabetes mellitus.

Placenta 2017 04 1;52:94-99. Epub 2017 Mar 1.

Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology & Laboratory Medicine, Women & Infants Hospital of Rhode Island, Providence, RI, USA; Department of Pathology & Immunology, Washington University School of Medicine, St Louis, MO, USA. Electronic address:

Introduction: Data on the correlation among Hemoglobin A1c (HbA1c), placental pathology, and perinatal outcome in the pregestational diabetic population is severely lacking. We believe that this knowledge will enhance the management of pregnancies complicated by pregestational diabetes. We hypothesize that placental pathology correlates with glycemic control at an early gestational age.

Methods: This is a retrospective cohort study conducted from 2003 to 2011 at a large tertiary care center. Women included had a singleton gestation, preexisting diabetes mellitus, and information about delivery and placental pathology available for review. Placental pathology and perinatal outcomes were compared across three groups of patients with differing HbA1c levels (<6.5%, 6.5-8.4%, and ≥8.5%).

Results: 293 placentas were examined. HbA1c was measured at a mean of 9.5week gestation. Median HbA1c was 7.5%, interquartile range 6.5%-8.9%. 23% of the cohort had HbA1c <6.5%, 41.9% between 6.5% and 8.4%, and 34.8% > 8.5%. BMI varied significantly by group (35.4 vs. 34.4 vs. 32.0 respectively, P = 0.04). Individual placental lesions did not vary with HbA1c levels. The incidence of acute chorioamnionitis differed significantly in the type 1 population and "distal villous hypoplasia" varied in the type 2 population.

Discussion: The results show that HbA1c values in early pregnancy are poor predictors of future placental pathologies. As a result, HbA1c values obtained during early gestation (which reflect the level of glycemic control over an extended period of time) do not correlate with any particular placental pathology, despite reflecting the potential for placental insults secondary to pre-gestational diabetes.
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http://dx.doi.org/10.1016/j.placenta.2017.02.024DOI Listing
April 2017

Maternal outcomes associated with early preterm cesarean delivery.

Am J Obstet Gynecol 2017 Mar 10;216(3):312.e1-312.e9. Epub 2016 Nov 10.

Obstetrics and Gynecology at MedStar Washington Hospital Center, Washington, DC.

Background: Data on complications associated with classic cesarean delivery are conflicting. In extremely preterm cesarean delivery (22 0/7-27 6/7 weeks' gestation), the lower uterine segment is thicker. It is plausible that the rates of maternal complications may not differ between classic and low transverse cesarean.

Objective: We sought to compare maternal outcomes associated with classic versus low transverse cesarean after stratifying by gestation (23 0/7-27 6/7 and 28 0/7-31 6/7 weeks' gestation).

Study Design: We conducted a multihospital retrospective cohort study of women undergoing cesarean delivery at 23 0/7 to 31 6/7 weeks' gestation from 2005 through 2014. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and intensive care unit admission) was compared between classic and low transverse cesarean. Outcomes were calculated using multivariable logistic regression models yielding adjusted odds ratios with 95% confidence intervals and adjusted P values controlling for maternal characteristics, emergency cesarean delivery, and comorbidities. Analyses were stratified by gestational age categories (23 0/7-27 6/7 and 28 0/7-31 6/7 weeks' gestation).

Results: Of 902 women, 221 (64%) and 91 (16%) underwent classic cesarean between 23 0/7 and 27 6/7 and between 28 0/7 and 31 6/7 weeks' gestation, respectively. There was no increase in maternal complications for classic cesarean versus low transverse cesarean between 23 0/7 and 27 6/7 weeks' gestation. However, between 28 0/7 and 31 6/7 weeks' gestation, classic cesarean was associated with increased risks of the composite maternal outcome (adjusted odds ratio, 1.95; 95% confidence interval, 1.10-3.45), transfusion (adjusted odds ratio, 2.42; 95% confidence interval, 1.06-5.52), endometritis (adjusted odds ratio, 3.23; 95% confidence interval, 1.02-10.21), and intensive care unit admission (adjusted odds ratio, 5.05; 95% confidence interval, 1.37-18.52) compared to low transverse cesarean.

Conclusion: Classic cesarean delivery compared with low transverse was associated with higher maternal complication rates between 28 0/7 and 31 6/7 weeks, but not between 23 0/7 and 27 6/7 weeks' gestation.
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http://dx.doi.org/10.1016/j.ajog.2016.11.1006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334149PMC
March 2017

Duration of Oxytocin and Rupture of the Membranes Before Diagnosing a Failed Induction of Labor.

Obstet Gynecol 2016 08;128(2):373-380

Departments of Obstetrics and Gynecology, MedStar Washington Hospital Center and MedStar Georgetown University Hospital, and the Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC; the Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, Maryland; and the Department of Maternal Fetal Medicine, Christiana Care Health System, Newark, Delaware.

Objective: To compare maternal and neonatal outcomes based on length of the latent phase during induction with rupture of membranes before 6 cm dilation.

Methods: This is a retrospective cohort study using data from the Consortium of Safe Labor study, including 9,763 nulliparous and 8,379 multiparous women with singleton, term pregnancies undergoing induction at 2 cm dilation or less with rupture of membranes before 6 cm dilation after which the latent phase ended. Outcomes were evaluated according to duration of oxytocin and rupture of membranes.

Results: At time points from 6 to 18 hours of oxytocin and rupture of membranes, the rates of nulliparous women remaining in the latent phase declined (35.9-1.4%) and the rates of vaginal delivery for those remaining in the latent phase at these time periods decreased (54.1-29.9%) Nulliparous women remaining in the latent phase for 12 hours compared with women who had exited the latent phase had significantly increased rates of chorioamnionitis (12.1% compared with 4.1%) and endometritis (3.6% compared with 1.3%) and increased rates of neonatal intensive care unit admission (8.7% compared with 6.3%). Similar patterns were present for multiparous women at 15 hours.

Conclusion: Based on when neonatal morbidity increased, in an otherwise uncomplicated induction of labor with rupture of membranes, a latent phase after initiation of oxytocin of at least 12 hours for nulliparous women and 15 hours in multiparous women is a reasonable criterion for diagnosing a failed induction.
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http://dx.doi.org/10.1097/AOG.0000000000001527DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4959965PMC
August 2016

Glycemic control, compliance, and satisfaction for diabetic gravidas in centering group care.

J Matern Fetal Neonatal Med 2017 May 21;30(10):1221-1226. Epub 2016 Jul 21.

d Department of Obstetrics & Gynecology , Center for Pregnancy and Newborn Research, University of Texas Health Sciences Center at San Antonio , San Antonio , TX , USA.

Purpose: To determine if diabetic gravidas enrolled in Centering® group care have improved glycemic control compared to those attending standard prenatal care. To compare compliance and patient satisfaction between the groups.

Materials And Methods: We conducted a prospective cohort study of diabetics enrolled in centering group care from October 2013 to December 2015. Glycemic control, compliance and patient satisfaction (five-point Likert scale) were evaluated. Student's t-test, Chi-Square and mixed effects model were used to compare outcomes.

Results: We compared 20 patients in centering to 28 standard prenatal care controls. Mean fasting blood sugar was lower with centering group care (91.0 versus 105.5 mg/dL, p =0.017). There was no difference in change in fasting blood sugar over time between the two groups (p = 0.458). The percentage of time patients brought their blood glucose logs did not differ between the centering group and standard prenatal care (70.7 versus 73.9%, p = 0.973). Women in centering group care had better patient satisfaction scores for "ability to be seen by a physician" (5 versus 4, p = 0.041) and "time in waiting room" (5 versus 4, p =0.001).

Conclusion: Fasting blood sugar was lower for patients in centering group care. Change in blood sugar over time did not differ between groups. Diabetic gravidas enrolled in centering group care report improved patient satisfaction.
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http://dx.doi.org/10.1080/14767058.2016.1209650DOI Listing
May 2017

Indications for primary cesarean delivery relative to body mass index.

Am J Obstet Gynecol 2016 Oct 20;215(4):515.e1-9. Epub 2016 May 20.

Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC.

Background: Obesity is a known risk factor for cesarean delivery. Limited data are available regarding the reasons for the increased rate of primary cesarean in obese women. It is important to identify the factors leading to an increased risk of cesarean to identify opportunities to reduce the primary cesarean rate.

Objective: We evaluated indications for primary cesarean across body mass index (kg/m(2)) classes to identify the factors contributing to the increased rate of cesarean among obese women.

Study Design: In the Consortium of Safe Labor study from 2002 through 2008, we calculated indications for primary cesarean including failure to progress or cephalopelvic disproportion, nonreassuring fetal heart tracing, malpresentation, elective, hypertensive disease, multiple gestation, placenta previa or vasa previa, failed induction, HIV or active herpes simplex virus, history of uterine scar, fetal indication, placental abruption, chorioamnionitis, macrosomia, and failed operative delivery. For women with primary cesarean for failure to progress or cephalopelvic disproportion, dilation at the last recorded cervical examination was evaluated. Women were categorized according to body mass index on admission: normal weight (18.5-24.9), overweight (25.0-29.9), and obese classes I (30.0-34.9), II (35.0-39.9), and III (≥40). Cochran-Armitage trend test and χ(2) tests were performed.

Results: Of 66,502 nulliparous and 76,961 multiparous women in the study population, 19,431 nulliparous (29.2%) and 7329 multiparous (9.5%) women underwent primary cesarean. Regardless of parity, malpresentation, failure to progress or cephalopelvic disproportion, and nonreassuring fetal heart tracing were the common indications for primary cesarean. Regardless of parity, the rates of primary cesarean for failure to progress or cephalopelvic disproportion increased with increasing body mass index (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 33.2%, 41.6%, 46.4%, 47.4%, and 48.9% [P < .01] and multiparous women: 14.5%, 20.3%, 22.8%, 27.2%, and 25.3% [P < .01]), whereas the rates for malpresentation decreased (normal weight, overweight, and classes I, II, and III obesity in nulliparous women: 23.7%, 17.2%, 14.6%, 12.0%, and 9.1% [P < .01] and multiparous women: 35.6%, 30.6%, 26.5%, 24.3%, and 22.9% [P < .01]). Rates of primary cesarean for nonreassuring fetal heart tracing were not statistically different for nulliparous (P > .05) or multiparous (P > .05) women. Among nulliparous women who had a primary cesarean for failure to progress or cephalopelvic disproportion, rates of cesarean prior to active labor (6 cm) increased as body mass index increased, accounting for 39.3% of women with class I, 47.1% of women with class II, and 56.8% of women with class III obesity compared to 35.2% for normal-weight women (P < .01).

Conclusion: Similar to normal-weight women, the indication of cesarean for failure to progress or cephalopelvic disproportion was the major factor contributing to the increase in primary cesarean in obese women, but was even more prevalent with increasing obesity class. The rates of intrapartum primary cesarean prior to achieving active labor increased with increasing obesity class in nulliparous women.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5045770PMC
http://dx.doi.org/10.1016/j.ajog.2016.05.023DOI Listing
October 2016

Maternal and Neonatal Outcomes by Attempted Mode of Operative Delivery From a Low Station in the Second Stage of Labor.

Obstet Gynecol 2015 Dec;126(6):1265-1272

Departments of Obstetrics and Gynecology, MedStar Washington Hospital Center and MedStar Georgetown University Hospital, Washington, DC, and the University of Texas Health Sciences Center at San Antonio, San Antonio, Texas; and the Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, Maryland.

Objective: To evaluate maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor.

Methods: Retrospective study of 2,518 women carrying singleton fetuses at 37 weeks of gestation or greater who underwent attempted forceps-assisted delivery, attempted vacuum-assisted vaginal delivery, or cesarean delivery from a low station in the second stage of labor. Primary outcomes were stratified by parity and included a maternal adverse outcome composite (postpartum hemorrhage, transfusion, endometritis, peripartum hysterectomy, or intensive care unit admission) and a neonatal adverse outcome composite (5-minute Apgar score less than 4, respiratory morbidity, neonatal intensive care unit admission, shoulder dystocia, birth trauma, or sepsis).

Results: In nulliparous patients, the maternal adverse composite was not significantly different between women who underwent attempted forceps (12.1% compared with 10.8%, adjusted odds ratio [OR] 0.77, 95% confidence interval [CI] 0.40-1.34) or vacuum (8.3% compared with 10.8%, adjusted OR 0.68, 95% CI 0.40-1.16) delivery compared with cesarean delivery. Among parous women, the maternal adverse composite was not significantly different with attempted forceps (10.7% compared with 12.5%, adjusted OR 0.40, 95% CI 0.09-1.71) or vacuum (11.3% compared with 12.5%, adjusted OR 0.44, 95% CI 0.11-1.72) compared with cesarean delivery. Compared with neonates delivered by cesarean, the neonatal adverse composite was significantly lower among neonates born to nulliparous women who underwent attempted forceps (9.4% compared with 16.7%, adjusted OR 0.44, 95% CI 0.27-0.72) but not among those who underwent vacuum delivery (11.9% compared with 16.7%, adjusted OR 0.68, 95% CI 0.44-1.04). Among parous women, the neonatal adverse composite was not significantly different after attempted forceps (4.1% compared with 12.5%, adjusted OR 0.28, 95% CI 0.06-1.35) or vacuum (12.5% compared with 12.5%, adjusted OR 1.03, 95% CI 0.28-3.87) compared with cesarean delivery.

Conclusion: A trial of forceps delivery from a low station compared with cesarean delivery was associated with decreased neonatal morbidity among neonates born to nulliparous women.

Level Of Evidence: II.
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http://dx.doi.org/10.1097/AOG.0000000000001156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4683158PMC
December 2015

Catecholaminergic Ventricular Tachycardia, Pregnancy and Teenager: Are They Compatible?

Pediatr Cardiol 2015 Oct 18;36(7):1542-7. Epub 2015 Aug 18.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC, USA.

Arrhythmias in pregnancy are becoming more common given more available and effective medical, ablation and device treatment options. Several changes associated with pregnancy, increased blood volume, cardiac output, and heart rate secondary to an increased sympathetic state, facilitate more frequent occurrences of arrhythmias throughout the pregnancy and during labor and delivery. We present a case of successful pregnancy in a teenage female with a previous diagnosis of CPVT, followed by a review of the literature.
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http://dx.doi.org/10.1007/s00246-015-1232-3DOI Listing
October 2015

Outcomes of Triplets reduced to Twins versus non-reduced Triplet Pregnancies.

J Clin Gynecol Obstet 2015;4(1):160-163

Abington Memorial Hospital, Department of Obstetrics and Gynecology, Abington, PA.

Introduction: This study examined the outcomes of triplet pregnancies selectively reduced to twin pregnancies, compared with non-reduced triplet pregnancies using a standardized approach.

Material And Methods: This study is an observational retrospective study of all women who presented to the Fetal Diagnostic Center between 1999-2009, had triplet pregnancies in the first trimester, received prenatal care and delivered at Abington Memorial Hospital. Data analysis was performed with SPPS version 15 for Windows using analysis of variance and Fisher's Exact test.

Results: 132 triplet pregnancies were identified. In the reduced group ( = 30) compared to the non-reduced triplet group ( = 102) average gestational age of delivery was longer 34.6 weeks versus 31.2 weeks gestation ( = <0.0005) and days in hospital were less 9.0 versus 26.7 days ( = .001). There was a significantly lower incidence of gestational diabetes and preterm labor in reduced pregnancies. Rate of loss, defined as delivery less than 24 weeks, were similar [3.3% versus 4.9%].

Discussion: Women electing to reduce a triplet pregnancy to twins have higher gestational ages at delivery, lower rates of gestational diabetes and preterm labor, and spent fewer days in hospital than non-reduced triplet pregnancies.
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http://dx.doi.org/10.14740/jcgo322wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4492531PMC
January 2015

Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy.

Am J Obstet Gynecol 2015 Oct 10;213(4):570.e1-8. Epub 2015 Jun 10.

Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC.

Objective: We sought to determine predictors of adverse neonatal outcomes in women with intrahepatic cholestasis of pregnancy (ICP).

Study Design: This study was a multicenter retrospective cohort study of all women diagnosed with ICP across 5 hospital facilities from January 2009 through December 2014. Obstetric and neonatal complications were evaluated according to total bile acid (TBA) level. Multivariable logistic regression models were developed to evaluate predictors of composite neonatal outcome (neonatal intensive care unit admission, hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, transient tachypnea of the newborn, mechanical ventilation use, oxygen by nasal cannula, pneumonia, and stillbirth). Predictors including TBA level, hepatic transaminase level, gestational age at diagnosis, underlying liver disease, and use of ursodeoxycholic acid were evaluated.

Results: Of 233 women with ICP, 152 women had TBA levels 10-39.9 μmol/L, 55 had TBA 40-99.9 μmol/L, and 26 had TBA ≥100 μmol/L. There was no difference in maternal age, ethnicity, or prepregnancy body mass index according to TBA level. Increasing TBA level was associated with higher hepatic transaminase and total bilirubin level (P < .05). TBA levels ≥100 μmol/L were associated with increased risk of stillbirth (P < .01). Increasing TBA level was also associated with earlier gestational age at diagnosis (P < .01) and ursodeoxycholic acid use (P = .02). After adjusting for confounders, no predictors were associated with composite neonatal morbidity. TBA 40-99.9 μmol/L and TBA ≥100 μmol/L were associated with increased risk of meconium-stained amniotic fluid (adjusted odds ratio, 3.55; 95% confidence interval, 1.45-8.68 and adjusted odds ratio, 4.55; 95% confidence interval, 1.47-14.08, respectively).

Conclusion: In women with ICP, TBA level ≥100 μmol/L was associated with increased risk of stillbirth. TBA ≥40 μmol/L was associated with increased risk of meconium-stained amniotic fluid.
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http://dx.doi.org/10.1016/j.ajog.2015.06.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5199141PMC
October 2015

HELLP Syndrome at 17 Weeks Gestation: A Rare and Catastrophic Phenomenon.

J Clin Gynecol Obstet 2014 Dec;3(4):147-150

Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, MedStar Washington Hospital Center, 106 Irving Street Northwest, POB South, Suite 108, Washington, DC 20010, USA.

HELLP syndrome is a collection of symptoms described as hemolysis, elevated liver enzymes and low platelets. HELLP syndrome complicates 0.01-0.6% of pregnancies and can be considered a severe variant of preeclampsia. The occurrence of HELLP syndrome diagnosed before the 20th week of gestation has been most commonly reported in association with antiphospholipid antibody syndrome (APS) or triploid chromosomal anomalies. A 41-year-old primigravida was admitted at 17 weeks and 6 days gestation with hypertension, proteinuria, hemolytic anemia and acute renal injury. She was diagnosed with HELLP syndrome, and subsequently suffered from an intrauterine fetal demise. After delivery, the clinical manifestations of HELLP syndrome resolved within 7 days with the exception of her acute renal failure. Interdisciplinary teams of physicians were able to exclude other imitators of preeclampsia, such as hemolytic uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), APS, lupus and acute fatty liver of pregnancy. This case is difficult to diagnose, given the similar presentation of several microangiopathic hemolytic anemias. The clinical manifestations and laboratory findings of HELLP and its mimicking conditions seem as if they are mirror images of each other. However, the discrete differences in our patient presentation, clinical findings, laboratory results and overall postpartum course leave HELLP syndrome as the most consistent diagnosis. It is imperative to investigate for all possible etiologies as HELLP syndrome at 17 weeks gestation is extremely rare and mimicking conditions may require alternative management strategies.
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http://dx.doi.org/10.14740/jcgo297wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4369395PMC
December 2014

Understanding the Limitations of Circulating Cell Free Fetal DNA: An Example of Two Unique Cases.

J Clin Gynecol Obstet 2014 May;3(2):38-70

Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC, USA.

Circulating cell free fetal DNA (cffDNA) is an effective screening modality for fetal aneuploidy. We report two cases of false positive results. The first case involves a female, with self-reported Down syndrome. CffDNA returned positive for trisomy 18 leading to a maternal diagnosis of mosaicism chromosome 18 with normal fetal karyotype. The second case involves a patient with an anomalous fetal ultrasound and cffDNA positive for trisomy 13. Amniocentesis demonstrated a chromosome 8p duplication/deletion. False positive cffDNA may arise in clinical scenarios where diagnostic testing is clearly indicated. Practitioners should recognize the limitations of cffDNA.
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http://dx.doi.org/10.14740/jcgo229wDOI Listing
May 2014

Predictors of fetal growth in maternal HIV disease.

Am J Perinatol 2010 Aug 3;27(7):517-23. Epub 2010 Mar 3.

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland, Baltimore, Maryland 21201-1703, USA.

We sought to determine predictors of fetal growth restriction in maternal HIV disease. Pregnant HIV-positive women on antiretroviral therapy were monitored with serial viral load and CD4 counts. Individualized growth potential (GP) percentile was calculated for birth weight (BW). BW <10th GP percentile defined fetal growth restriction (FGR). Multiple medical and social factors, CD4 count, viral load, and antiretroviral therapy were tested for impact on fetal growth using chi-square and multiple regression analysis. Two hundred eleven women were studied. CD4 count <200 in the first trimester was strongly associated with FGR (odds ratio 8.75, 95% confidence interval 2.88 to 26.52). Maternal age ( P = 0.02) and smoking ( P = 0.03) were independent cofactors for FGR (Nagelkerke R(2) = 0.33). No other factors demonstrated an independent effect. Severity of maternal HIV disease as indicated by the CD4 count, rather than placental exposure to viral load, predicts FGR. Smoking has an independent detrimental effect on fetal growth.
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http://dx.doi.org/10.1055/s-0030-1248937DOI Listing
August 2010
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