Publications by authors named "Steven L Clark"

112 Publications

Massive Transfusion Protocols in Obstetric Hemorrhage: Theory versus Reality.

Am J Perinatol 2021 May 14. Epub 2021 May 14.

Depatment of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

Objective:  Massive transfusion protocols are widely implemented in obstetrical practice in case of severe hemorrhage; however, different recommendations exist regarding the appropriate ratios of blood product components to be transfused. We report our extensive experience with massive component transfusion in a referral center in which the standard massive transfusion protocol is modified by ongoing clinical and laboratory evaluation.

Study Design:  A retrospective chart review of all patients who had massive transfusion protocol activation in a level 4 referral center for obstetrical practice was performed from January 2014 to January 2020. Data collected included the etiology of obstetrical hemorrhage, number of blood products of each type transfused, crystalloid infusion, and several indices of maternal morbidity and mortality. Data are presented with descriptive statistics.

Results:  A total of 62 patients had massive transfusion protocol activation, of which 97% received blood products. Uterine atony was found to be the most common etiology for massive hemorrhage (34%), followed by placenta accreta spectrum (32%). The mean estimated blood loss was 1,945 mL. A mean of 6.5 units of packed red blood cells, 14.8 units of fresh frozen plasma and cryoprecipitate, and 8.3 units of platelets were transfused per patient. No maternal deaths were seen.

Conclusion:  The ratios of transfused packed red blood cell to fresh frozen plasma/cryoprecipitate and of packed red blood cell to platelet units varied significantly from the fixed initial infusion ratio called for by our massive transfusion protocol resulting in universally favorable maternal outcomes. When rapid laboratory evaluation of hematologic and clotting parameters is available, careful use of this information may facilitate safe modification of an initial fixed transfusion ratio based on etiology of the hemorrhage and individual patient response.

Key Points: · Massive transfusion protocols in obstetrics follow fixed ratios of blood products.. · Actual usage of blood components is different than the standardized protocols.. · We recommend to modify the initial fixed transfusion ratio according to clinical response..
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http://dx.doi.org/10.1055/s-0041-1728833DOI Listing
May 2021

Trimester-specific thromboelastic values and coagulation activation markers in pregnancy compared across trimesters and compared to the nonpregnant state.

Int J Lab Hematol 2021 Jan 25. Epub 2021 Jan 25.

The Department of Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA.

Introduction: Rotational thromboelastometry (ROTEM) rapidly identifies deficits underlying coagulopathy during massive hemorrhage. Prompt coagulopathy correction is balanced with the risk of blood product overutilization, making the ability to quickly target therapy highly desirable. However, data about ROTEM reference ranges in pregnancy are limited. We hypothesized that ROTEM parameters change across trimesters of pregnancy and differ from the nonpregnant state. Also, we sought to identify which hemostatic test best predicts coagulation activation during pregnancy.

Methods: A prospective cohort study in healthy pregnant patients in the first (n = 34), second (n = 34), and third trimesters (n = 41) against healthy, nonpregnant controls (n = 33) was performed. Citrated blood was collected, and ROTEM, complete blood count, and plasma-based assays of coagulation were performed. Mean ± SD or median [IQR] were compared across trimesters and between each trimester against the nonpregnant state. ROTEM parameters vs. plasma-based assays were also compared.

Results: Maximum clot firmness and A10 in FIBTEM correlated strongly with fibrinogen level. INTEM and EXTEM values demonstrated only weak to modest correlation with corresponding tests using plasma assays. Thrombin antithrombin complex (TAT) increased from the first trimester onward, whereas other coagulation activation markers did not show difference compared with control group.

Conclusion: Rotational thromboelastometry parameters differ variably across trimesters of pregnancy and compared with the nonpregnant state. The development and use of pregnancy-specific values are critical to the proper clinical interpretation of ROTEM in women with serious hemorrhage during different stages in pregnancy. TAT was the earliest laboratory marker for coagulation activation among others.
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http://dx.doi.org/10.1111/ijlh.13472DOI Listing
January 2021

In Reply.

Obstet Gynecol 2021 01;137(1):180-181

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,Baylor College of Medicine,Houston, Texas.

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http://dx.doi.org/10.1097/AOG.0000000000004222DOI Listing
January 2021

Intrapartum Maternal Oxygen Supplementation-Friend or Foe?

JAMA Pediatr 2021 Mar;175(3):236-237

Texas Children's Fetal Center, Department of Obstetrics and Gynecology, Baylor College of Medicine & Texas Children's Hospital, Houston.

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http://dx.doi.org/10.1001/jamapediatrics.2020.5363DOI Listing
March 2021

Amniotic fluid embolism syndrome: analysis of the Unites States International Registry.

Am J Obstet Gynecol MFM 2020 05 9;2(2):100083. Epub 2020 Jan 9.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX.

Background: Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality.

Objective: The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism.

Materials And Methods: The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4.

Results: A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non-amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P < .05).

Conclusion: Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.
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http://dx.doi.org/10.1016/j.ajogmf.2019.100083DOI Listing
May 2020

Neuropathophysiology of preeclampsia and eclampsia: A review of cerebral hemodynamic principles in hypertensive disorders of pregnancy.

Pregnancy Hypertens 2021 Mar 1;23:104-111. Epub 2020 Nov 1.

Department of Anesthesiology, Baylor College of Medicine, United States.

Preeclampsia and eclampsia are hypertensive disorders of pregnancy associated with abnormal placental vascular development. The systemic angiogenic imbalance, endothelial dysfunction and proinflammatory state caused by abnormal placental development results in abnormalities in renal, hepatic, pulmonary and neurologic function. Neurosensory symptoms related to pregnancy induced hypertension (PIH), the most devastating of which are intracranial hemorrhage and seizure, are among the leading causes of maternal and perinatal morbidity and mortality globally, yet risk stratification strategies and targeted therapies remain elusive. Current treatment for preeclampsia with severe features is limited to delivery, antihypertensive therapy, and magnesium sulfate seizure prophylaxis. Magnesium sulfate reduces seizure rates among severe preeclamptics, but predisposes patients to weakness, uterine atony, pulmonary edema and respiratory depression. Therefore, this drug should ideally be administered only to the subset of preeclamptics who are at increased risk for neurologic complications. While there are no objective methods validated to predict eclampsia, we hypothesize that measurement of optic nerve sheath diameters, optic disc height and middle cerebral artery transcranial doppler resistance indices may be useful in identifying subclinical cerebral edema, potentially allowing us to recognize those patients at highest risk for seizures. This summary of the current literature provides an initial framework for developing more sophisticated and noninvasive methods for identifying, monitoring and treating parturients who are at highest risk for neurologic complications from preeclampsia.
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http://dx.doi.org/10.1016/j.preghy.2020.10.013DOI Listing
March 2021

Pathophysiologic Origins of Brachial Plexus Injury.

Obstet Gynecol 2020 10;136(4):725-730

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

Objective: To analyze the origins and consequences of cases of brachial plexus injuries and their relationship to shoulder dystocia.

Methods: We conducted a retrospective cohort study and identified all neonates with brachial plexus injury delivered at our institution between March 2012 and July 2019. A review was performed of the maternal and neonatal records of each neonate to identify obstetric antecedents, including the occurrence of shoulder dystocia and persistence of the injury. Experience of the delivering clinician was also examined. Statistical analysis was performed with the Fisher exact test, χ test for trends, and two-tailed t tests.

Results: Thirty-three cases of brachial plexus injury were identified in 41,525 deliveries (0.08%). Fourteen (42%) of these cases were not associated with shoulder dystocia; three (9%) followed cesarean delivery. Brachial plexus injury without shoulder dystocia was related to the absence of maternal diabetes, lower birth weights, and a longer second stage of labor. Persistent brachial plexus injury at the time of discharge was seen with equal frequency among neonates with (17/19, 89%, 95% CI 0.52-100%) and without shoulder dystocia (10/14, 71%, 95% CI 34-100%), P=.36). Whether brachial plexus injury was transient or persistent after shoulder dystocia was unrelated to the years of experience of the delivering clinician. Despite ongoing training and simulation, the already low incidence of brachial plexus injury did not decrease over time at our institution.

Conclusion: Brachial plexus injury and shoulder dystocia represent two complications of uterine forces driving a fetus through the maternal pelvis in the presence of disproportion between the passage and the shoulder girdle of the passenger. Either or both of these complications may occur, but often are not causally related.
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http://dx.doi.org/10.1097/AOG.0000000000004013DOI Listing
October 2020

Intravenous labetalol versus oral nifedipine for acute hypertension in pregnancy: effects on cerebral perfusion pressure.

Am J Obstet Gynecol 2020 09 13;223(3):441.e1-441.e8. Epub 2020 Jun 13.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.

Background: Pregnant women with preeclampsia have been found to have elevated cerebral perfusion pressure and impaired cerebral autoregulation compared with normal pregnant women. Transcranial Doppler is a noninvasive technique used to estimate cerebral perfusion pressure. The effects of different antihypertensive medications on cerebral perfusion pressure in preeclampsia are unknown.

Objective: To compare the change in cerebral perfusion pressure before and after intravenous labetalol vs oral nifedipine in the setting of acute severe hypertension in pregnancy.

Study Design: This is a prospective cohort study of pregnant women between 24 and 42 weeks' gestation with severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg). Women who consented to the study and received either intravenous labetalol or oral nifedipine were included. Exclusion criteria included active labor or receipt of any antihypertensive medication within 2 hours of initial cerebral perfusion pressure measurement. Peripheral blood pressure and transcranial Doppler studies for middle cerebral artery hemodynamics were performed prior to the administration of antihypertensive medications and repeated 30 minutes after medication administration.

Results: A total of 16 women with acute severe hypertension were enrolled; 8 received intravenous labetalol and 8 received oral nifedipine. There were no significant differences between the labetalol and nifedipine groups in baseline characteristics such as maternal age, race and ethnicity, payment, hospital site, body mass index, nulliparity, gestational age, preexisting diabetes mellitus or chronic hypertension, fetal growth restriction, magnesium sulfate administration, and symptomatology (P>.05). When examined 30 minutes after the administration of either intravenous labetalol or oral nifedipine, there was a significantly greater decrease in systolic blood pressure (-9.8 mm Hg vs -39 mm Hg; P=.003), mean arterial pressure (-7.1 mm Hg vs -22.3 mm Hg; P=.02), and cerebral perfusion pressure (-2.5 mm Hg vs -27.7 mm Hg; P=.01) in the nifedipine group. There was no statistically significant decrease in diastolic blood pressure (-12.9 mm Hg vs -5.4 mm Hg; P=.15). The change in middle cerebral artery velocity by transcranial Doppler was compared between the groups and was not different (0.07 cm/s vs 0.16 cm/s; P=.64).

Conclusion: Oral nifedipine resulted in a significant decrease in cerebral perfusion pressure, whereas labetalol did not, after administration for acute severe hypertension among women with preeclampsia. This decrease seems to be driven by a decrease in peripheral arterial blood pressure rather than a direct change in cerebral blood flow.
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http://dx.doi.org/10.1016/j.ajog.2020.06.018DOI Listing
September 2020

In vitro fertilization as an independent risk factor for placenta accreta spectrum.

Am J Obstet Gynecol 2020 10 30;223(4):568.e1-568.e5. Epub 2020 Apr 30.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX. Electronic address:

Background: Placenta accreta spectrum is well known for its association with catastrophic maternal outcomes. However, its pathophysiology is not well defined. There have been emerging data that in vitro fertilization may be a risk factor for placenta accreta spectrum.

Objective: We investigated the hypothesis that in vitro fertilization is an independent risk factor for placenta accreta spectrum.

Study Design: A retrospective analysis of all deliveries in a prospective, population-based cohort (2012-2019) was performed in a tertiary academic center. Primary outcome variable was placenta accreta spectrum. Univariate analysis was performed on potential risk factors for predicting placenta accreta spectrum, and a multivariate model was designed to best fit the prediction of placenta accreta spectrum adjusted for risk factors such as cesarean delivery, placenta previa, age, and parity. History of previous cesarean delivery was known as a risk factor for both placenta previa and placenta accreta spectrum; hence, the interaction between "placenta previa" and "previous cesarean delivery" was included in the final model. Odds ratios were calculated as exponential of beta coefficients from the multivariate regression analysis.

Results: A total of 37,461 deliveries were included in this analysis, 5464 (15%) of which had a history of cesarean delivery, 281 (0.7%) had placenta previa in their index pregnancy, and 571 (1.5%) had in vitro fertilization pregnancy. The frequency of placenta accreta spectrum was 230 (0.6%). Independent risk factors for placenta accreta spectrum were in vitro fertilization pregnancy (adjusted odds ratio, 8.7; 95% confidence interval, 3.8-20.3), history of previous cesarean delivery (adjusted odds ratio, 21.1; 95% confidence interval, 11.4-39.2), and presence of placenta previa (adjusted odds ratio, 94.6; 95% confidence interval, 29.3-305.1). After adjustment for number of previous cesarean deliveries, the correlation persisted for in vitro fertilization (adjusted odds ratio, 6.7; 95% confidence interval, 2.9-15.6).

Conclusion: Our data suggested that in vitro fertilization is an independent risk factor for placenta accreta spectrum, although its relative clinical importance compared with that of the presence of placenta previa and history of cesarean delivery is small. The pathophysiology behind this relationship remains to be investigated.
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http://dx.doi.org/10.1016/j.ajog.2020.04.026DOI Listing
October 2020

Diagnostic Imaging and Outcomes for Nonobstetric Surgery During Pregnancy.

Clin Obstet Gynecol 2020 06;63(2):364-369

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, Texas.

A surgical disease occurring during pregnancy can present a diagnostic dilemma due to the desire to make a timely and accurate diagnosis within the constraints of limiting radiation exposure to the fetus. However, required diagnostic imaging should be pursued when indicated and attempts made to minimize the radiation dose by utilizing abdominal shielding and low-dose protocols when feasible. When surgery is indicated due to disease processes, treatment should not be altered or delayed due to pregnancy as the evidence for adverse pregnancy outcomes including early pregnancy loss and preterm delivery are overall of low quality due to substantial confounding by the disease process itself.
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http://dx.doi.org/10.1097/GRF.0000000000000525DOI Listing
June 2020

Pregnancy-related mortality in the United States, 2003-2016: age, race, and place of death.

Am J Obstet Gynecol 2020 May 25;222(5):489.e1-489.e8. Epub 2020 Feb 25.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.

Background: Pregnancy-related deaths in the United States are increasing. Medical, social, economic, and cultural issues have all been implicated in this trend, but few data exist to differentiate the relative contributions of these various factors.

Objective: The objective of the study was to examine trends in US pregnancy-related mortality by place of death and maternal race and age. We hypothesized that such an analysis may allow some distinction between deaths related to medical performance and those more closely related to social, cultural, or environmental issues.

Study Design: We conducted a retrospective, cross-sectional study for the years 2003-2016 using multiple cause-of-death mortality data provided by the Centers for Disease Control and Natality Data provided by National Vital Statistics System of the National Center for Health Statistics. Temporal trends analyses for the place of death, race/ethnicity, and age at the time of death were performed using joinpoint regression over the study period.

Results: Approximately one third of pregnancy-related deaths occurred outside a medical facility. The fraction of maternal deaths occurring in inpatient facilities fell by 20% over the study period, from 53% to 44% of all maternal deaths (P < .0001). Maternal deaths in an outpatient facility or emergency room demonstrated a similar decline (24%) in relative frequency (P < .0001). In contrast, there was a significant increase in the relative frequency of maternal mortality in other settings, particularly within the descendant's home, with a doubling over this time period. However, overall pregnancy-related deaths continued to increase in all settings. These increases were particularly striking in non-Hispanic black and white women and among women in the youngest and oldest age groups.

Conclusion: Against a background of rising US pregnancy-related mortality, stratification of such deaths by place of death and maternal age and race highlights both the need for ongoing improvements in the quality of medical care and the potential contribution of events occurring outside a medical facility to the overall morality ratio. Current trends in pregnancy-related mortality in the United States are, in part, driven by social, cultural, and financial issues beyond the direct control of the medical community.
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http://dx.doi.org/10.1016/j.ajog.2020.02.020DOI Listing
May 2020

In Reply.

Obstet Gynecol 2019 11;134(5):1117-1118

Baylor College of Medicine/Texas Children's Hospital, Houston, Texas.

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http://dx.doi.org/10.1097/AOG.0000000000003546DOI Listing
November 2019

Reluctance to Operate on Pregnant Women.

J Am Coll Surg 2019 09;229(3):326

Houston, TX.

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http://dx.doi.org/10.1016/j.jamcollsurg.2019.04.024DOI Listing
September 2019

Amniotic fluid embolism: principles of early clinical management.

Am J Obstet Gynecol 2020 01 31;222(1):48-52. Epub 2019 Jul 31.

Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX.

Amniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. Where available, we recommend performing transthoracic or transesophageal echocardiography as soon as possible because this is an easy and reliable method of identifying a failing right ventricle. If such failure is identified, treatment that is tailored at improving right ventricular performance should be initiated with the use of inotropic agents and pulmonary vasodilators. Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism-related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of >150-200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given.
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http://dx.doi.org/10.1016/j.ajog.2019.07.036DOI Listing
January 2020

Vasa previa: a multicenter retrospective cohort study.

Am J Obstet Gynecol 2019 12 13;221(6):644.e1-644.e5. Epub 2019 Jun 13.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX. Electronic address:

Objective: The objective of the study was to describe the characteristics and outcomes of patients with antenatal diagnosis of vasa previa and evaluate the predictive factors of resolution in a contemporary large, multicenter data set.

Study Design: This was a retrospective multicenter cohort study of all antenatally diagnosed cases of vasa previa, identified via ultrasound and electronic medical record, between January 2011 and July 2018 in 5 US centers. Records were abstracted to obtain variables at diagnosis, throughout pregnancy, and outcomes, including maternal and neonatal variables. Data were reported as median [range] or n (percentage). Descriptive statistics, receiver-operating characteristics, and logistic regression analysis were used as appropriate.

Results: One hundred thirty-six cases of vasa previa were identified in 5 centers during the study period, 19 (14%) of which resolved spontaneously at median estimated gestational age of 27 weeks [19-34]. All subjects with unresolved vasa previa underwent cesarean delivery at a median estimated gestational age of 34 weeks [27-39] with the median estimated blood loss of 800 mL [250-2000]. Rates for vaginal bleeding, preterm labor, premature rupture of membrane, and need for blood product transfusion were not different between the resolved and unresolved group (P = NS). The odds ratio for resolution in those with the estimated gestational age of less than 24 weeks at the time of diagnosis was 7.9 (95% confidence interval, 2.1-29.4) after adjustment for confounding variables.

Conclusion: Our data suggest that outcomes in antenatally diagnosed cases of vasa previa are excellent. Furthermore, our data report a higher chance of resolution when the condition is diagnosed before 24 weeks of gestation.
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http://dx.doi.org/10.1016/j.ajog.2019.06.006DOI Listing
December 2019

Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team.

Am J Obstet Gynecol 2019 10 4;221(4):337.e1-337.e5. Epub 2019 Jun 4.

Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX. Electronic address:

Objective: In a 2015 Maternal-Fetal Medicine Units Network study, only half of placenta accreta spectrum cases were suspected before delivery, and the outcomes in the anticipated cases were paradoxically poorer than in unanticipated placenta accreta spectrum cases. This was possibly because the antenatally suspected cases were of greater severity. We sought to compare the outcomes of expected vs unexpected placenta accreta spectrum in a single large US center with multidisciplinary management protocol.

Study Design: This was a retrospective cohort study carried out between Jan. 1, 2011, and June 30, 2018, of all histology-proven placenta accreta spectrum deliveries in an academic referral center. Patients diagnosed at the time of delivery were cases (unexpected placenta accreta spectrum), and those who were antentally diagnosed were controls (expected placenta accreta spectrume). The primary and secondary outcomes were the estimated blood loss and the number of red blood cell units transfused, respectively. Variables are reported as median and interquartile range or number (percentage). Analyses were made using appropriate parametric and nonparametric tests.

Results: Fifty-four of the 243 patients (22.2%) were in the unexpected placenta accreta spectrum group. Patients in the expected placenta accreta spectrum group had a higher rate of previous cesarean delivery (170 of 189 [89.9%] vs 35 of 54 [64.8%]; P < .001) and placenta previa (135 [74.6%] vs 19 [37.3%]; P < .001). There was a higher proportion of increta/percreta in expected placenta accreta spectrum vs unexpected placenta accreta spectrum (125 [66.1%] vs 9 [16.7%], P < .001). Both primary outcomes were higher in the unexpected placenta accreta spectrum group (estimated blood loss, 2.4 L [1.4-3] vs 1.7 L [1.2-3], P = .04; red blood cell units, 4 [1-6] vs 2 [0-5], P = .03).

Conclusion: Our data contradict the Maternal-Fetal Medicine Units results and instead show better outcomes in the expected placenta accreta spectrum group, despite a high proportion of women with more severe placental invasion. We attribute this to our multidisciplinary approach and ongoing process improvement in the management of expected cases. The presence of an experienced team appears to be a more important determinant of maternal morbidity in placenta accreta spectrum than the depth of placental invasion.
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http://dx.doi.org/10.1016/j.ajog.2019.05.035DOI Listing
October 2019

Coagulopathy in surgical management of placenta accreta spectrum.

Eur J Obstet Gynecol Reprod Biol 2019 Jun 19;237:126-130. Epub 2019 Apr 19.

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.

Background: One of the major complications of the placenta accreta spectrum (PAS) is the development of coagulopathy. The detection, prevention and prompt treatment of coagulopathy may be lifesaving.

Objective: Our objective was to study selected factors associated with coagulopathy in the management of PAS by a well-established multidisciplinary team.

Study Design: This is a retrospective review of all patients with pathologically proven PAS (including placenta accreta, increta or percreta) who underwent surgery by our multidisciplinary team between January 2011 and February 2017. Coagulopathy in this setting was defined as a platelet count of <100,000/mm, international normalized ratio >1.5, and/or fibrinogen <300 mg/dL based on institutional protocols developed by our Division of Transfusion Medicine & Coagulation. The outcomes of those patients with and without coagulopathy were compared with appropriate adjustments. Receiver operating characteristics curves (ROCs) were constructed to assess the ability of select variables to discriminate between women with and without coagulopathy, and the area under the curves (AUCs) were calculated.

Results: Of 123 singleton patients with PAS, 37 (30.1%; 95%CI 22.1-39.0) developed coagulopathy and 86 (69.9%; 95%CI 61.0-77.9) did not. Baseline patient demographic characteristics did not differ significantly between these groups. Estimated blood loss (median and Inter-quartile range) was 2100cc (1800, 400) and 1400 (1000, 2500) in the presence and absence of coagulopathy, respectively (P < 0.01). The overall number of units of red blood cells (RBC) transfused was greatest in the coagulopathy group [3 (2, 9) vs. 1 (0, 4); P < 0.01]. Univariate regression analysis confirmed the association between coagulopathy and (i) the number of units of RBC's transfused, and (ii) the estimated blood loss. ROC curves showed that an estimated blood loss ≥ 1500 mL had the best discriminating power. Depth and/or severity of placental invasion were not associated with coagulopathy in patients with PAS.

Conclusions: Coagulopathy in patients with PAS undergoing hysterectomy is strongly associated with blood loss and replacement. It may be prudent to establish protocols that aggressively monitor for, and treat, coagulopathy when EBL exceeds 1500 mL in such surgeries, prior to the development of clinical coagulopathy which if uncorrected may lead to massive blood loss.
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http://dx.doi.org/10.1016/j.ejogrb.2019.04.026DOI Listing
June 2019

Opportunities for hospitals, hospital systems and leadership to improve VTE prophylaxis.

Semin Perinatol 2019 06 9;43(4):218-221. Epub 2019 Mar 9.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite F420, Houston, Texas.

A sustained increase in the maternal death rate in the U.S. remains one of the most challenging issues of the twenty-first century. Ten years ago, we investigated the major conditions contributing to the maternal death rate between the years 2000 and 2006. The leading causes of death in the U.S. at that time were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage and cardiac disease. Venous thromboembolism accounted for 9% of all maternal death, and an overall pregnancy-related mortality risk of 0.9 maternal deaths per 100,000 live births. VTE was the most common preventable cause of maternal death noted during that time period. In this paper, we will review and summarize changes in obstetric health care over the last ten years implemented to prevent VTE and its related morbidity. We will then examine opportunities for hospitals and hospital systems to improve VTE prophylaxis.
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http://dx.doi.org/10.1053/j.semperi.2019.03.007DOI Listing
June 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

Validation of the Siggaard-Andersen Acid-Base Nomogram for Hemoglobin F: Implications for Fetal Cord Blood Gas Analysis.

Am J Perinatol 2019 12 23;36(14):1481-1484. Epub 2019 Jan 23.

Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.

Objective: The calculation of HCO and base excess in current blood gas analysis is based on the Siggaard-Andersen equation. One of the constants in this equation is dependent on the known buffering capacity of hemoglobin A. We sought to investigate differences in buffering capacity between adult hemoglobin A and fetal hemoglobin F as a potential explanation for the observed poor correlation between calculated base excess in umbilical cord blood and newborn outcomes. Such differences would influence a key constant in the Van Slyke/Siggaard-Andersen equation used to calculate HCO and base excess and could be an explanation of these observations.

Study Design: This was a prospective observational study. We analyzed umbilical cord blood bicarbonate levels both as calculated values from a traditional blood gas analyzer and as measured values in 20 women giving birth at term. Since the calculated value is dependent upon the concentration and known buffering capacity of hemoglobin A, significant differences in these two analyses would imply differences in the buffering capacity of hemoglobins A and F.

Results: The mean calculated HCO value was 25 mEq/L (25.3 ± 1.9) compared with a mean measured value of 25 mEq/L (24.6 ± 1.7) over a range of pH levels of 7.16 to 7.42. This difference was not significant ( = 0.07).

Conclusion: The buffering capacity of hemoglobin F, for clinical purposes, is not different than that of hemoglobin A and is not an explanation for the recognized poor correlation between base excess and neonatal outcome.
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http://dx.doi.org/10.1055/s-0039-1677800DOI Listing
December 2019

Evaluation of proposed criteria for research reporting of amniotic fluid embolism.

Am J Obstet Gynecol 2019 03 24;220(3):285-287. Epub 2018 Nov 24.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX.

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http://dx.doi.org/10.1016/j.ajog.2018.11.1099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497410PMC
March 2019

In Reply.

Obstet Gynecol 2018 12;132(6):1506

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, Texas.

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http://dx.doi.org/10.1097/AOG.0000000000002994DOI Listing
December 2018

Antepartum Testing for the Prevention of Stillbirth: Where Do We Go From Here?

Obstet Gynecol 2018 12;132(6):1407-1411

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

Unexpected antepartum fetal demise remains one of the most tragic complications of pregnancy. Various approaches to antepartum fetal assessment have been developed as a means of either reassuring the clinician of fetal well-being or identifying potential fetal jeopardy and the need for delivery. As additional high-risk groups of women are identified, indications for antenatal testing continue to expand despite a paucity of good-quality data linking such testing to improved outcomes for women with these additional risk factors. The expansion of established antepartum testing protocols to include women with conditions such as advanced maternal age or obesity without additional, well-established indications for testing is not warranted, particularly because baseline rates of stillbirth seen with these conditions before 39 weeks of gestation are already lower than stillbirth rates achieved with current antepartum testing protocols. Beyond 39 weeks of gestation, if the established risks of stillbirth are deemed unacceptable, delivery is a more rational and evidence-based approach than antepartum testing.
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http://dx.doi.org/10.1097/AOG.0000000000002967DOI Listing
December 2018

Chlorhexidine-Alcohol Compared with Povidone-Iodine Preoperative Skin Antisepsis for Cesarean Delivery: A Systematic Review and Meta-Analysis.

Am J Perinatol 2019 01 5;36(2):118-123. Epub 2018 Sep 5.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

Objective: To compare chlorhexidine-alcohol with povidone-iodine solutions for skin antisepsis prior to cesarean delivery for the prevention of surgical site infection.

Study Design: Electronic databases MEDLINE, Embase, Scopus, and Clinicaltrials.gov were searched from inception to August 2017. Eligible studies included randomized controlled trials comparing chlorhexidine-alcohol with povidone-iodine skin preparation solutions for women undergoing cesarean delivery. The primary outcome was surgical site infection including superficial or deep wound infection. Meta-analysis was performed, and risk ratios (RRs) with 95% confidence interval (CI) were calculated using the Mantel-Haenszel random effects model. Statistical heterogeneity was assessed using Higgin's .

Results: Of 61 abstracts identified in the primary search, four studies (3,059 women) met the eligibility criteria. The risk of surgical site infection was significantly reduced with chlorhexidine-alcohol (RR: 0.72; 95% CI: 0.52-0.98). No heterogeneity across studies was observed with  = 0%. Subgroup analysis of superficial infection only or deep infection only showed no statistically significant difference (RR: 0.76, 95% CI: 0.54-1.08; and RR: 0.50, 95% CI: 0.23-1.10, respectively).

Conclusion: Preoperative skin cleansing prior to cesarean delivery with chlorhexidine-alcohol reduces surgical site infection as compared with povidone-iodine solutions.
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http://dx.doi.org/10.1055/s-0038-1669907DOI Listing
January 2019

Maternal and Fetal Death on Weekends.

Am J Perinatol 2019 01 17;36(2):184-190. Epub 2018 Jul 17.

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.

Background: Higher mortality rates have been reported in patients admitted to the hospital on weekends. This study aimed to compare maternal mortality ratio (MMR), fetal mortality ratio, and other maternal and neonatal outcomes by day of death or delivery in the United States.

Methods: Our database consisted of a population-level analysis of live births and maternal and fetal deaths between 2004 and 2014 in the United States from the Centers for Disease Control and Prevention's National Center for Health Statistics. We also examined the relationship between these deaths and various documented maternal and fetal clinical conditions.

Results: A total of 2,061 maternal deaths occurred on weekends and 5,510 deaths on weekdays. During the same period of time, 65,063 and 210,851 cases of fetal demise were delivered on weekends and on weekdays, respectively. Maternal mortality was significantly higher on weekends than weekdays (22.9 vs. 15.3/100,000 live births,  < 0.001) as was fetal mortality (7.21 vs. 5.85/100,000,  < 0.001), despite a lower frequency of serious comorbidities among women delivering on weekends.

Conclusion: Our data demonstrate a significant increase in the U.S. MMR and stillbirth delivery on weekends. Relative representation of antepartum, intrapartum, and postpartum deaths cannot be ascertained from these data.
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http://dx.doi.org/10.1055/s-0038-1667030DOI Listing
January 2019

Nonobstetric Surgery During Pregnancy.

Obstet Gynecol 2018 08;132(2):395-403

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, and the Department of Surgery, Baylor College of Medicine, Houston, Texas.

One percent to 2% of pregnant women undergo nonobstetric surgery during pregnancy. Historically, there has been a reluctance to operate on pregnant women based on concerns for teratogenesis, pregnancy loss, or preterm birth. However, a careful review of published data suggests four major flaws affecting much of the available literature. Many studies contain outcomes data from past years in which diagnostic testing, surgical technique, and perioperative maternal-fetal care were so different from current experience as to make these data of limited utility today. This issue is further compounded by a tendency to combine experience from vastly disparate types of surgery into a single report. In addition, reports in nonobstetric journals often focus on maternal outcomes and contain insufficient detail regarding perinatal outcomes to allow distinction between complications associated with surgical disease and those attributable to surgery itself. Finally, most series are either uncontrolled or use the general population of pregnant women as controls rather than women with surgical disease who are managed nonsurgically. Consideration of these factors as well as our own extensive experience suggests that when the risks of maternal hypotension or hypoxia are minimal, or can be adequately mitigated, indicated surgery during any trimester does not appear to subject either the mother or fetus to risks significantly beyond those associated with the disease itself or the complications of surgery in nonpregnant individuals. In some cases, reluctance to operate during pregnancy becomes a self-fulfilling prophecy in which delay in surgery contributes to adverse perinatal outcomes traditionally attributed to surgery itself.
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http://dx.doi.org/10.1097/AOG.0000000000002748DOI Listing
August 2018

"Doing something" about the cesarean delivery rate.

Am J Obstet Gynecol 2018 09 5;219(3):267-271. Epub 2018 May 5.

Baylor College of Medicine, Houston TX; University of California, Irvine, Irvine, CA; McGill University, Montreal, Quebec, Canada; University of Texas Medical Branch, Galveston, TX.

There is a general consensus that the cesarean delivery rate in the United States is too high, and that practice patterns of obstetricians are largely to blame for this situation. In reality, the US cesarean delivery rate is the result of 3 forces largely beyond the control of the practicing clinician: patient expectations and misconceptions regarding the safety of labor, the medical-legal system, and limitations in technology. Efforts to "do something" about the cesarean delivery rate by promulgating practice directives that are marginally evidence-based or influenced by social pressures are both ineffective and potentially harmful. We examine both the recent American Congress of Obstetricians and Gynecologists (ACOG)/Society for Maternal-Fetal Medicine Care Consensus Statement "Safe Prevention of Primary Cesarean Delivery" document and the various iterations of the ACOG guidelines for vaginal birth after cesarean delivery in this context. Adherence to arbitrary time limits for active phase or second-stage arrest without incorporating other clinical factors into the decision-making process is unwise. In a similar manner, ever-changing practice standards for vaginal birth after cesarean driven by factors other than changing data are unlikely to be effective in lowering the cesarean delivery rate. Whether too high or too low, the current US cesarean delivery rate is the expected result of the unique demographic, geographic, and social forces driving it and is unlikely to change significantly given the limitations of current technology to otherwise satisfy the demands of these forces.
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http://dx.doi.org/10.1016/j.ajog.2018.04.044DOI Listing
September 2018

Health Care Disparity and Pregnancy-Related Mortality in the United States, 2005-2014.

Obstet Gynecol 2018 Apr;131(4):707-712

Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; and the Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.

Objective: To quantitate the contribution of various demographic factors to the U.S. maternal mortality ratio.

Methods: This was a retrospective observational study. We analyzed data from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) from 2005 to 2014 that contains mortality and population counts for all U.S. counties. Bivariate correlations between the maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P<.05) in the univariate analysis to deal with multicollinearity among the existing variables.

Results: The United States has experienced an increase in maternal mortality ratio since 2005 with rates increasing from 15 per 100,00 live births in 2005 to 21-22 per 100,000 live births in 2013 and 2014. (P<.001) This increase in mortality was most pronounced in non-Hispanic black women, with ratios rising from 39 to 49 per 100,000 live births. A significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population was demonstrated. Cesarean deliveries, unintended births, unmarried status, percentage of deliveries to non-Hispanic black women, and four or fewer prenatal visits were significantly (P<.05) associated with the increased maternal mortality ratio.

Conclusion: The current U.S. maternal mortality ratio is heavily influenced by a higher rate of death among non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability and access or utilization by underserved populations are important issues faced by states seeking to decrease maternal mortality.
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http://dx.doi.org/10.1097/AOG.0000000000002534DOI Listing
April 2018

Outcomes of Planned Compared With Urgent Deliveries Using a Multidisciplinary Team Approach for Morbidly Adherent Placenta.

Obstet Gynecol 2018 02;131(2):234-241

Divisions of Maternal-Fetal Medicine and Gynecologic Oncology and Inpatient Women's Service, Department of Obstetrics and Gynecology, the Department of Pediatrics and Neonatology, the Department of Urology, and the Division of Transfusion Medicine, Department of Pathology & Immunology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas.

Objective: To compare outcomes between planned and urgent cesarean hysterectomy for morbidly adherent placenta managed by a multidisciplinary team.

Methods: This is a retrospective case-control study of women with singleton pregnancies with antenatally suspected and pathologically confirmed morbidly adherent placenta who underwent cesarean hysterectomy between January 1, 2011, and February 30, 2017. Timing of delivery was classified as either planned (delivery at 34-35 weeks of gestation) or urgent (need for urgent delivery as a result of uterine contractions, bleeding, or both). The primary outcome variable was composite maternal morbidity. Logistic regression analysis was used to evaluate risk factors for urgent delivery.

Results: One hundred thirty patients underwent hysterectomy. Sixty (46.2%) required urgent delivery. Composite maternal morbidity was identified in 34 (56.7%) of the urgent and 26 (37.1%) of the planned deliveries (P=.03). Fewer units of red blood cells and fresh frozen plasma were transfused in the planned delivery group (red blood cells, median interquartile range 3 [0-8] versus 1 [0-4], P=.02; fresh frozen plasma, median interquartile range 1 [0-2] versus 0 [0-0], P=.001). Rates of low Apgar score and respiratory distress syndrome were higher in the urgent compared with the planned delivery group (5-minute Apgar score less than 7, 34 [59.6%] versus 14 [23.3%], P<.01; respiratory distress syndrome, 34 [61.8%] versus 16 [27.1%], P<.01). A history of two or more prior cesarean deliveries was an independent predictor of urgent delivery (adjusted odds ratio 11.4, 95% CI 1.8-71.1).

Conclusion: Women with morbidly adherent placenta requiring urgent delivery have a worse outcome than women with planned delivery. Women with morbidly adherent placenta and two or more prior cesarean deliveries are at increased risk for urgent delivery. In such women, scheduling delivery before the standard 34- to 35-week timeframe may be reasonable.
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http://dx.doi.org/10.1097/AOG.0000000000002442DOI Listing
February 2018

Cyanotic congenital heart disease following fertility treatments in the United States from 2011 to 2014.

Heart 2018 06 16;104(11):945-948. Epub 2017 Nov 16.

Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA.

Objective: To examine the risk for cyanotic congenital heart diseases (CCHDs) among live births in the USA, resulting from various forms of infertility treatments.

Methods: This study is a cross-sectional analysis of live births in the USA from 2011 to 2014. Infertility treatments are categorised into two of the following groups on birth certificates: assisted reproductive technology (ART) fertility treatment (surgical egg removal; eg, in vitro fertilisation and gamete intrafallopian transfer) and non-ART fertility treatment (eg, medical treatment and intrauterine insemination). We compared the risk for CCHD in ART and non-ART fertility treatment groups with those infants whose mothers received no documented fertility treatment and were naturally conceived (NC).

Results: Among 14 242 267 live births from 2011 to 2014, a total of 101 494 live births were in the ART and 81 242 resulted from non-ART fertility treatments. CCHD prevalence in ART, non-ART and NC groups were 393/100 892 (0.39%), 210/80 884 (0.26%) and 10 749/14 020 749 (0.08%), respectively. As compared with naturally conceiving infants, risk for CCHD was significantly higher among infants born in ART (adjusted relative risk (aRR) 2.4, 95% CI 2.1 to 2.7) and non-ART fertility treatment groups (aRR 1.9, 95% CI 1.6 to 2.2). Absolute risk increase in CCHD due to ART and non-ART treatments were 0.03% and 0.02%, respectively. A similar pattern was observed when the analysis was restricted to twins, newborns with birth weights under 1500 g and gestational age of less than 32 weeks.

Conclusions: Our findings suggest an increased risk for CCHD in infants conceived after all types of infertility treatment.
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http://dx.doi.org/10.1136/heartjnl-2017-312015DOI Listing
June 2018