Publications by authors named "Sarah J Kilpatrick"

45 Publications

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

Cardiovascular and pregnancy outcomes in women with coronary microvascular dysfunction: a case series.

Eur Heart J Case Rep 2019 Jun;3(2)

Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S. San Vicente Boulevard, Suite A3600, Los Angeles, CA, USA.

Background: Coronary microvascular dysfunction (CMD) is associated with adverse cardiovascular outcomes. Coronary microvascular dysfunction is observed in women of childbearing age, however, the frequency of adverse pregnancy outcomes (APO) is unknown.

Case Summary: Women previously enrolled in a single centre prospective CMD registry diagnosed using invasive coronary reactivity testing were included. Among 279 women enrolled, 5 of 47 (10.6%) of childbearing age (18-44 years) subsequently became pregnant, representing a fertility rate of 36.8 births per 1000 women-years. None had history of hypertension, diabetes, or smoking. Four (80%) had a history of prior spontaneous miscarriage. Median age at CMD diagnosis was 32 years (IQR: 32-35). During pregnancy, most reported stable or improved angina, while one reported increased angina frequency, an emergency room visit and accelerated anti-anginal therapy. None experienced gestational hypertension, diabetes, pre-eclampsia, myocardial infarction, or death. Two (40%) experienced APO of preterm delivery and small neonate for gestational age. Following pregnancy, angina severity scores, and/or functional capacity decreased in three women (60%).

Discussion: In this first case-series of five women with CMD who became pregnant, increased angina and accelerated care during pregnancy and post-partum was not commonly observed. Fertility rates were lower than the national average, while prior spontaneous miscarriage and subsequent APO were higher. Further studies are warranted to understand and manage pregnancy in women with CMD, as well as the impact of pregnancy on longer term angina, functional capacity, and outcomes.
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http://dx.doi.org/10.1093/ehjcr/ytz071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601184PMC
June 2019

Obstetric Care Consensus #9: Levels of Maternal Care: (Replaces Obstetric Care Consensus Number 2, February 2015).

Am J Obstet Gynecol 2019 12 25;221(6):B19-B30. Epub 2019 Jul 25.

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.
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http://dx.doi.org/10.1016/j.ajog.2019.05.046DOI Listing
December 2019

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States.

Am J Obstet Gynecol 2019 10 5;221(4):311-317.e1. Epub 2019 Mar 5.

University of Arizona College of Medicine Phoenix at Banner University Medical Center Phoenix, Phoenix, AZ.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.
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http://dx.doi.org/10.1016/j.ajog.2019.02.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6728226PMC
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

Levels of Maternal Care Verification Pilot: Translating Guidance Into Practice.

Obstet Gynecol 2018 12;132(6):1401-1406

American College of Obstetricians and Gynecologists, Washington, DC; the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Cedars-Sinai Medical Center, Los Angeles, California; the University of North Carolina School of Medicine, Chapel Hill, North Carolina; and the Society for Maternal-Fetal Medicine, Washington, DC.

Development of systems for perinatal regionalization and for the provision of risk-appropriate maternal care is a key strategy to decrease maternal morbidity and mortality. Regionalized systems pertaining to neonatal care are broadly implemented in many states, but networks for risk-appropriate maternal care are lacking. In response to increases in maternal morbidity and mortality over the past decade, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) developed and published the levels of maternal care guidelines in 2015. The guidelines are designed to promote collaboration among maternal facilities and health care providers with the goal that pregnant women receive care at a facility appropriate for their risk. The Centers for Disease Control and Prevention (CDC) developed the Levels of Care Assessment Tool in 2013 to assist states and jurisdictions in assessing maternal and neonatal levels of care in alignment with the national guidelines published by ACOG and SMFM and the American Academy of Pediatrics, respectively. With the goal of promoting levels of maternal care, ACOG and SMFM developed and piloted the levels of maternal care verification program. Fourteen facilities across three states (Georgia, Illinois, and Wyoming) participated in the pilot. A multidisciplinary team representing organizations with expertise in maternal risk-appropriate care performed an onsite comprehensive review of the maternal services available in each facility using the results from the CDC Levels of Care Assessment Tool as a previsit screening. A verification program that could be implemented on a local, state, or regional scale is being developed leveraging the lessons learned from the pilot.
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http://dx.doi.org/10.1097/AOG.0000000000002952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432627PMC
December 2018

Maternal Mortality in the Twenty-First Century.

Obstet Gynecol Clin North Am 2018 Jun;45(2):175-186

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 160-W, Los Angeles, CA 90048, USA.

Maternal mortality plagues much of the world. There were 303,000 maternal deaths in 2015 representing an overall global maternal mortality ratio of 216 maternal deaths per 100,000 live births. In the United States, the maternal mortality ratio had been decreasing until 1987, remained stable until 1999, and then began to increase. Racial disparities exist in the rates of maternal mortality in the United States with maternal death affecting a higher proportion of black women compared with white women. To reduce maternal mortality, national organizations in the United States have called for standardized review of cases of maternal morbidity and mortality.
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http://dx.doi.org/10.1016/j.ogc.2018.01.004DOI Listing
June 2018

Understanding Severe Maternal Morbidity: Hospital-based Review.

Clin Obstet Gynecol 2018 06;61(2):340-346

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

Cases of severe maternal morbidity (SMM) share similarities to maternal deaths, including increasing in frequency and having similar rates of preventability. This article will review steps to organizing and implementing standard reviews of all cases of SMM. These steps include create multidisciplinary SMM review committee; identify potential SMM cases and confirm true SMM; identify the morbidity; abstract and summarize data; present case to review committee for discussion; determine events leading to morbidity; determine opportunities to improve outcome; assess provider, system and patient factors in cases with opportunities to improve outcome; make recommendations; and effect change and evaluate improvement.
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http://dx.doi.org/10.1097/GRF.0000000000000351DOI Listing
June 2018

Trauma in pregnancy: an underappreciated cause of maternal death.

Am J Obstet Gynecol 2017 11;217(5):499-500

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

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http://dx.doi.org/10.1016/j.ajog.2017.09.012DOI Listing
November 2017

Prospective parents' perspectives on antenatal decision making for the anticipated birth of a periviable infant.

J Matern Fetal Neonatal Med 2019 Mar 5;32(5):820-825. Epub 2017 Nov 5.

g Wayne State University College of Nursing and the Children's Hospital of Michigan , Detroit , MI , USA.

Objective: To examine prospective parents' perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions during this period.

Study Design: Qualitative analysis of 46 antenatal interviews conducted at three tertiary-care hospitals with 54 prospective parents (40 pregnant women, 14 partners) who had received counseling for threatened periviable delivery (40 cases).

Results: Participants most often recalled being involved in resuscitation, cerclage, and delivery mode decisions. Over half (63.0%) desired a shared decision-making role. Most (85.2%) recalled hearing about morbidity and mortality, with many reiterating terms like "brain damage", "disability", and "handicap". The potential for disability influenced decision making to variable degrees. In describing what mattered most, participant spoke of giving their child a "fighting chance"; others voiced concerns about "best interest", a "healthy baby", "pain and suffering", and religious faith.

Conclusions: Our findings underscore the importance of presenting clear information on disability and eliciting the factors that parents deem most important in making decisions about periviable birth.
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http://dx.doi.org/10.1080/14767058.2017.1393066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6810652PMC
March 2019

Birth plans-Impact on mode of delivery, obstetrical interventions, and birth experience satisfaction: A prospective cohort study.

Birth 2018 03 2;45(1):43-49. Epub 2017 Nov 2.

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

Objective: To examine whether the presence of a birth plan was associated with mode of delivery, obstetrical interventions, and patient satisfaction.

Methods: This was a prospective cohort study of singleton pregnancies greater than 34 weeks' gestation powered to evaluate a difference in mode of delivery. Maternal characteristics, antenatal factors, neonatal characteristics, and patient satisfaction measures were compared between groups. Differences between groups were analyzed using chi-squared for categorical variables, Fisher exact test for dichotomous variables, and Wilcoxon rank sum test for continuous or ordinal variables.

Results: Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61-2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan.

Conclusion: Women with and without a birth plan had similar odds of cesarean delivery. Though they had fewer obstetrical interventions, they were less satisfied with their birth experience, compared with women without birth plans. Further research is needed to understand how to improve childbirth-related patient satisfaction.
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http://dx.doi.org/10.1111/birt.12320DOI Listing
March 2018

Postpartum Hypertension: Etiology, Diagnosis, and Management.

Obstet Gynecol Surv 2017 Apr;72(4):248-252

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

Importance: Postpartum hypertension complicates approximately 2% of pregnancies and, similar to antepartum severe hypertension, can have devastating consequences including maternal death.

Objective: This review aims to increase the knowledge and skills of women's health care providers in understanding, diagnosing, and managing hypertension in the postpartum period.

Results: Hypertension complicating pregnancy, including postpartum, is defined as systolic blood pressure 140 mm Hg or greater and/or diastolic blood pressure 90 mm Hg or greater on 2 or more occasions at least 4 hours apart. Severe hypertension is defined as systolic blood pressure 160 mm Hg or greater and/or diastolic blood pressure 110 mm Hg or greater on 2 or more occasions repeated at a short interval (minutes). Workup for secondary causes of hypertension should be pursued, especially in patients with severe or resistant hypertension, hypokalemia, abnormal creatinine, or a strong family history of renal disease. Because severe hypertension is known to cause maternal stroke, women with severe hypertension sustained over 15 minutes during pregnancy or in the postpartum period should be treated with fast-acting antihypertension medication. Labetalol, hydralazine, and nifedipine are all effective for acute management, although nifedipine may work the fastest. For persistent postpartum hypertension, a long-acting antihypertensive agent should be started. Labetalol and nifedipine are also both effective, but labetalol may achieve control at a lower dose with fewer adverse effects.

Conclusions And Relevance: Providers must be aware of the risks associated with postpartum hypertension and educate women about the symptoms of postpartum preeclampsia. Severe acute hypertension should be treated in a timely fashion to avoid morbidity and mortality. Women with persistent postpartum hypertension should be administered a long-acting antihypertensive agent.

Target Audience: Obstetricians and gynecologists, family physicians.

Learning Objectives: After completing this activity, the learner should be better able to assist patients and providers in identifying postpartum hypertension; provide a framework for the evaluation of new-onset postpartum hypertension; and provide instructions for the management of acute severe and persistent postpartum hypertension.
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http://dx.doi.org/10.1097/OGX.0000000000000424DOI Listing
April 2017

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

Birth Plans: What Matters for Birth Experience Satisfaction.

Birth 2016 06 25;43(2):144-50. Epub 2016 Feb 25.

Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Background: To categorize individual birth plan requests and determine if number of requests and request fulfillment is associated with birth experience satisfaction.

Methods: This is a sub-analysis of a prospective cohort study of 302 women with singleton pregnancies with and without birth plans. Women with a hard copy of their birth plans who completed a postdelivery satisfaction survey were included in this study. We described the number and type of birth plan requests and associated the number of requests and request fulfillment with overall satisfaction, expectations met, and sense of control. Differences between groups were analyzed using chi-square, Spearman rank correlation, and logistic regression.

Results: One hundred and nine women presented to Labor and Delivery with a hard copy of their prewritten birth plan. We identified 23 unique requests. The most common requests were no intravenous analgesia (82%) and exclusive breastfeeding (74%). The requests most fulfilled were avoidance of episiotomy (100%) and no operative vaginal delivery (89%). Having a higher number of requests fulfilled correlated with greater overall satisfaction (p = 0.03), higher chance of expectations being met (p < 0.01), and feeling more in control (p < 0.01). Having a high number of requests was associated with an 80 percent reduction in overall satisfaction with the birth experience (p < 0.01).

Conclusions: Having a higher number of requests fulfilled was positively associated with birth experience satisfaction, while having a high number of requests was inversely associated with birth experience satisfaction. Further research is needed to understand how to improve birth plan-related birth experience satisfaction.
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http://dx.doi.org/10.1111/birt.12226DOI Listing
June 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

Easy as ABC: A System to Stratify Category II Fetal Heart Rate Tracings.

Am J Perinatol 2016 06 12;33(7):688-95. Epub 2016 Feb 12.

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

Objective To evaluate whether a subcategory system for category II tracings can improve team communication and perinatal outcomes. Study Design We collected data prospectively for 15 months, first using the NICHD system, followed by the ABC system, which divides category II tracings into subcategories A, B, and C, each representing increased risk for metabolic acidemia. We surveyed providers about communication effectiveness and agreement on tracing interpretation for each system. In cases where the communication system was used to alert an off-site physician about a category II tracing, we compared arrival to L&D and NICU admissions. Results The ABC system was preferred (69%, n = 152) and considered a more effective tool for communicating concerning fetal status (80% vs. 43%, p < 0.01). Participants also reported greater agreement on tracing interpretation (79% for ABC vs. 64% for NICHD, p = 0.046). When an off-site physician was contacted about a category II tracing (n = 95), they were more likely to arrive to L&D (44% vs. 20%, p < 0.01) and have fewer NICU admissions (0% vs. 6%, p < 0.01) with the ABC system. Conclusion The ABC system resulted in improved team communication, increased physician response, and decreased NICU admissions. Using standardized communication may offer a useful strategy for identifying and expediting care.
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http://dx.doi.org/10.1055/s-0036-1571325DOI Listing
June 2016

Severe maternal morbidity in a large cohort of women with acute severe intrapartum hypertension.

Am J Obstet Gynecol 2016 07 30;215(1):91.e1-7. Epub 2016 Jan 30.

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

Background: Hypertensive diseases of pregnancy are associated with severe maternal morbidity and remain common causes of maternal death. Recently, national guidelines have become available to aid in recognition and management of hypertension in pregnancy to reduce morbidity and mortality. The increased morbidity related to hypertensive disorders of pregnancy is presumed to be associated with the development of severe hypertension. However, there are few data on specific treatment or severe maternal morbidity in women with acute severe intrapartum hypertension as opposed to severe preeclampsia.

Objective: The study aimed to characterize maternal morbidity associated with women with acute severe intrapartum hypertension, and to determine whether there was an association between various first-line antihypertensive agents and posttreatment blood pressure.

Study Design: This retrospective cohort study of women delivering between July 2012 and August 2014 at 15 hospitals participating in the California Maternal Quality Care Collaborative compared women with severe intrapartum hypertension (systolic blood pressure >160 mm Hg or diastolic blood pressure >105 mm Hg) to women without severe hypertension. Hospital Patient Discharge Data and State of California Birth Certificate Data were used. Severe maternal morbidity using the Centers for Disease Control and Prevention criteria based on International Classification of Diseases-9 codes was compared between groups. The efficacy of different antihypertensive medications in meeting the 1-hour posttreatment goal was determined. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression.

Results: There were 2252 women with acute severe intrapartum hypertension and 93,650 women without severe hypertension. Severe maternal morbidity was significantly more frequent in the women with severe hypertension (8.8%) compared to the control women (2.3%) (P < .0001). Severe maternal morbidity rates did not increase with increasing severity of blood pressures (P = .90 for systolic and .42 for diastolic). There was no difference in severe maternal morbidity between women treated (8.6%) and women not treated (9.5%) (P = .56). Antihypertensive treatment rates were significantly higher in hospitals with a level IV neonatal intensive care unit (85.8%) compared to a level III neonatal intensive care unit (80.2%) (P < .001), and in higher-volume hospitals (84.5%) compared to lower-volume hospitals (69.1%) (P < .001). Severe maternal morbidity rates among severely hypertensive women were significantly higher in hospitals with level III neonatal intensive care unit level compared to hospitals with a level IV neonatal intensive care unit (10.6% vs 5.7%, respectively; P < .001), and significantly higher in low-delivery volume hospitals compared to high-delivery volume hospitals (15.5% vs 7.6%, respectively; P < .001). Only 53% of women treated with oral labetalol as first-line medication met the posttreatment goal of nonsevere hypertension, significantly less than those treated with intravenous hydralazine, intravenous labetalol, or oral nifedipine (68%, 71%, and 82%, respectively) (P = .001). Severe intrapartum hypertension remained untreated in 17% of women.

Conclusion: Women with acute severe intrapartum hypertension had a significantly higher risk of severe maternal morbidity compared to women without severe hypertension. Significantly lower antihypertensive treatment rates and higher severe maternal morbidity rates were seen in lower-delivery volume hospitals.
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http://dx.doi.org/10.1016/j.ajog.2016.01.176DOI Listing
July 2016

Next steps to reduce maternal morbidity and mortality in the USA.

Womens Health (Lond) 2015 Mar;11(2):193-9

Maternal mortality is rising in the USA. The pregnancy-related maternal mortality ratio increased from 10/100,000 to 17/100,000 live births from the 1990s to 2012. A large proportion of maternal deaths are preventable. This review highlights a national approach to reduce maternal death and morbidity and discusses multiple efforts to reduce maternal morbidity, death and improve obstetric safety. These efforts include communication and collaboration between all stake holders involved in perinatal health, creation of national bundles addressing key maternal care areas such as hemorrhage management, call for all obstetric hospitals to review and analyze all cases of severe maternal morbidity, and access to contraception. Implementation of interventions based on these efforts is a national imperative to improve obstetric safety.
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http://dx.doi.org/10.2217/whe.14.80DOI Listing
March 2015

In Reply: for Dr. Lockhart.

Obstet Gynecol 2014 Sep;124(3):634-635

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California California Maternal Quality Care Collaborative, Palo Alto, California Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New york.

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http://dx.doi.org/10.1097/AOG.0000000000000438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291839PMC
September 2014

Standardized severe maternal morbidity review: rationale and process.

J Obstet Gynecol Neonatal Nurs 2014 Jul-Aug;43(4):403-8

Severe maternal morbidity and mortality have been rising in the United States. To begin a national effort to reduce morbidity, a specific call to identify all pregnant and postpartum women experiencing admission to an intensive care unit or receipt of four or more units of blood for routine review has been made. While advocating for review of these cases, no specific guidance for the review process was provided. Therefore, the aim of this expert opinion is to present guidelines for a standardized severe maternal morbidity interdisciplinary review process to identify systems, professional, and facility factors that can be ameliorated, with the overall goal of improving institutional obstetric safety and reducing severe morbidity and mortality among pregnant and recently pregnant women. This opinion was developed by a multidisciplinary working group that included general obstetrician–gynecologists, maternal–fetal medicine subspecialists, certified nurse–midwives, and registered nurses all with experience in maternal mortality reviews. A process for standardized review of severe maternal morbidity addressing committee organization, review process, medical record abstraction and assessment, review culture, data management, review timing, and review confidentiality is presented. Reference is made to a sample severe maternal morbidity abstraction and assessment form.
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http://dx.doi.org/10.1111/1552-6909.12478DOI Listing
November 2015

Standardized severe maternal morbidity review: rationale and process.

Obstet Gynecol 2014 Aug;124(2 Pt 1):361-366

Departments of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, Montefiore Medical Center, Bronx, New York, University of Florida College of Medicine, Gainesville, Florida, Virginia Commonwealth University, Richmond, Virginia, California Pacific Hospital, San Francisco, California, Medical College of Wisconsin, Milwaukee, Wisconsin, and Wake Forest University, Winston-Salem, North Carolina; the Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Obstetricians and Gynecologists, Washington, DC; the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California; the University of Colorado College of Nursing, Aurora, Colorado; and the Cooper University Hospital, Cooper Medical School, Rowan University, Camden, New Jersey.

Severe maternal morbidity and mortality have been rising in the United States. To begin a national effort to reduce morbidity, a specific call to identify all pregnant and postpartum women experiencing admission to an intensive care unit or receipt of 4 or more units of blood for routine review has been made. While advocating for review of these cases, no specific guidance for the review process was provided. Therefore, the aim of this expert opinion is to present guidelines for a standardized severe maternal morbidity interdisciplinary review process to identify systems, professional, and facility factors that can be ameliorated, with the overall goal of improving institutional obstetric safety and reducing severe morbidity and mortality among pregnant and recently pregnant women. This opinion was developed by a multidisciplinary working group that included general obstetrician-gynecologists, maternal-fetal medicine subspecialists, certified nurse-midwives, and registered nurses all with experience in maternal mortality reviews. A process for standardized review of severe maternal morbidity addressing committee organization, review process, medical record abstraction and assessment, review culture, data management, review timing, and review confidentiality is presented. Reference is made to a sample severe maternal morbidity abstraction and assessment form.
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http://dx.doi.org/10.1097/AOG.0000000000000397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293011PMC
August 2014

Facility-based identification of women with severe maternal morbidity: it is time to start.

Obstet Gynecol 2014 May;123(5):978-981

Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; the Departments of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, Cedars-Sinai Medical Center, Los Angeles, California, and Columbia University College of Physicians and Surgeons, New York, New York; and the California Maternal Quality Care Collaborative, Palo Alto, California.

Although maternal deaths have been the traditional indicator of maternal health, these events are the "tip of the iceberg" in that there are many women who have significant complications of pregnancy, labor, and delivery. Identifying women who experience severe maternal morbidity and reviewing their care can provide critical information to inform quality improvement in obstetrics. In this commentary, we review methods to identify women who experienced severe complications of pregnancy. We propose a simple validated approach based on transfusion of four or more units of blood products, admission to an intensive care unit, or both as a starting point for identification and review of severe maternal morbidity in health care settings for the purpose of understanding successes and failures in systems of care.
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http://dx.doi.org/10.1097/AOG.0000000000000218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293012PMC
May 2014

Influence of gestational age and body weight on the pharmacokinetics of labetalol in pregnancy.

Clin Pharmacokinet 2014 Apr;53(4):373-83

Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 S Wood Street, Room 164, Chicago, IL, 60612, USA,

Background And Objectives: Labetalol is frequently prescribed for the treatment of hypertension during pregnancy; however, the influence of pregnancy on labetalol pharmacokinetics is uncertain, with inconsistent findings reported by previous studies. This study examined the population pharmacokinetics of oral labetalol during and after pregnancy in women receiving labetalol for hypertension.

Methods: Data were collected from 57 women receiving the drug for hypertension from the 12th week of pregnancy through 12 weeks postpartum using a prospective, longitudinal design. A sparse sampling strategy guided collection of plasma samples. Samples were assayed for labetalol by high-performance liquid chromatography. Estimation of population pharmacokinetic parameters and covariate effects was performed by nonlinear mixed effects modeling using NONMEM. The final population model was validated by bootstrap analysis and visual predictive check. Simulations were performed with the final model to evaluate the appropriate body weight to guide labetalol dosing.

Results: Lean body weight (LBW) and gestational age, i.e. weeks of pregnancy, were identified as significantly influencing oral clearance (CL/F) of labetalol, with CL/F ranging from 1.4-fold greater than postpartum values at 12 weeks' gestational age to 1.6-fold greater at 40 weeks. Doses adjusted for LBW provide more consistent drug exposure than doses adjusted for total body weight. The apparent volumes of distribution for the central compartment and at steady-state were 1.9-fold higher during pregnancy.

Conclusions: Gestational age and LBW impact the pharmacokinetics of labetalol during pregnancy and have clinical implications for adjusting labetalol doses in these women.
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http://dx.doi.org/10.1007/s40262-013-0123-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310214PMC
April 2014