Livergood M.C.,Mercy Hospital St Louis |
LeChien K.A.,Mercy Hospital St Louis |
Trudell A.S.,Mercy Hospital St Louis |
Trudell A.S.,Obstetrix Medical Group
American Journal of Obstetrics and Gynecology | Year: 2017
Background Cell-free DNA screen failures or “no calls” occur in 1-12% of samples and are frustrating for both clinician and patient. The rate of “no calls” has been shown to have an inverse relationship with gestational age. Recent studies have shown an increased risk for “no calls” among obese women. Objective We sought to determine the optimal gestational age for cell-free DNA among obese women. Study Design We performed a retrospective cohort study of women who underwent cell-free DNA at a single tertiary care center from 2011 through 2016. Adjusted odds ratios with 95% confidence intervals for a “no call” were determined for each weight class and compared to normal-weight women. The predicted probability of a “no call” with 95% confidence intervals were determined for each week of gestation for normal-weight and obese women and compared. Results Among 2385 patients meeting inclusion criteria, 105 (4.4%) had a “no call”. Compared to normal-weight women, the adjusted odds ratio of a “no call” increased with increasing weight class from overweight to obesity class III (respectively: adjusted odds ratio, 2.31; 95% confidence interval, 1.21–4.42 to adjusted odds ratio, 8.55; 95% confidence interval, 4.16–17.56). A cut point at 21 weeks was identified for obesity class II/III women at which there is no longer a significant difference in the probability of a “no call” for obese women compared to normal weight women. From 8-16 weeks, there is a 4.5% reduction in the probability of a “no call” for obesity class II/III women (respectively: 14.9%; 95% confidence interval, 8.95–20.78 and 10.4%; 95% confidence interval, 7.20–13.61; Ptrend <.01). Conclusion The cut point of 21 weeks for optimal sampling of cell-free DNA limits reproductive choices. However, a progressive fall in the probability of a “no call” with advancing gestational age suggests that delaying cell-free DNA for obese women is a reasonable strategy to reduce the probability of a “no call”. © 2017 Elsevier Inc.
Ehsanipoor R.M.,Johns Hopkins University |
Ehsanipoor R.M.,University of California at Irvine |
Haydon M.L.,Hoag Memorial Hospital Presbyterian |
Lyons Gaffaney C.,Obstetrix Medical Group |
And 4 more authors.
Ultrasound in Obstetrics and Gynecology | Year: 2012
Objectives: To estimate the risk of preterm delivery of twin pregnancies based upon sonographic cervical length measurement and gestational age at measurement. Methods: Twin pregnancies that delivered between 1999 and 2005 and that underwent sonographic measurement of cervical length between 13 and 34 + 6 weeks' gestation were identified and a retrospective review performed. Women with anomalous pregnancies, multifetal reduction, cerclage placement or medically indicated deliveries before 35 weeks were excluded. Logistic regression analysis was used to estimate the risk of preterm delivery before 35 weeks. Results: A total of 561 women underwent 2975 sonographic cervical length measurements during the study period. The rate of preterm delivery before 35 weeks was 19.4%. The risk of delivery before 35 weeks decreased by approximately 5% for each additional mm of cervical length (odds ratio (OR) 0.95 (95% CI, 0.93-0.97); P < 0.001) and by approximately 6% for each additional week at which the cervical length was measured (OR 0.94 (95% CI, 0.92-0.96); P < 0.001). Conclusion: The gestational age at which cervical length is measured is an important consideration when estimating the risk of spontaneous preterm birth in twins. The risk of preterm delivery is increased at earlier gestational ages and as cervical length decreases. Copyright © 2012 ISUOG.
PubMed | Thomas Jefferson University and Obstetrix Medical Group
Type: Journal Article | Journal: Acta obstetricia et gynecologica Scandinavica | Year: 2016
Our objective was to evaluate the possible additive effect of quantitative fetal fibronectin to transvaginal ultrasound cervical length measurement between 18(0/7) and 23(6/7) weeks for prediction of spontaneous preterm birth at <37(0/7) weeks among asymptomatic low-risk women.A prospective observational study was performed of asymptomatic women with singleton gestations between 18(0/7) and 23(6/7) weeks and no prior spontaneous preterm birth. Women with multiple gestations, rupture of membranes, vaginal bleeding, intercourse or vaginal exam within 48h of enrollment were excluded. Physicians were blinded to the quantitative fetal fibronectin levels, but the cervical length measurements were made available. The primary outcome was spontaneous preterm birth at <37(0/7) weeks.Of the 528 asymptomatic low-risk women who were prospectively enrolled, 36 (6.82%) had spontaneous preterm birth at <37(0/7) weeks. Using the receiver-operating characteristic curve, fetal fibronectin value of 5ng/mL was identified as the optimal cut-off for predicting spontaneous preterm birth at <37(0/7) weeks. As compared with cervical length 20mm alone, with the use of cervical length 20mm or quantitative fetal fibronectin 5ng/mL as screening criteria for prediction of spontaneous preterm birth at <37(0/7) weeks; sensitivity improved from 11.11 to 61.11%, specificity decreased from 99.59 to 55.08%, positive predictive value decreased from 66.67 to 9.05%, negative predictive value marginally improved from 93.87 to 95.09% and predictive accuracy decreased from 93.56 to 55.49%.Although the sensitivity improved, other predictive statistics and predictive accuracy did not improve by the addition of mid-trimester quantitative fetal fibronectin to cervical length measurement. Therefore, addition of mid-trimester quantitative fetal fibronectin to cervical length measurement cannot be recommended at this time for prediction of spontaneous preterm birth at <37(0/7) weeks in asymptomatic low-risk women.
Combs C.A.,Obstetrix Medical Group |
Fishman A.,Obstetrix Medical Group
American Journal of Obstetrics and Gynecology | Year: 2016
Three steps must be followed to prevent the transmission of infection via a contaminated transvaginal ultrasound probe: cleaning the probe after every use, high-level disinfection, and covering the probe with a single-use barrier during the examination. There may be critical flaws in at least 2 of these steps as they are currently practiced. First, 2 widely used disinfectants, glutaraldehyde and orthophthalaldehyde, have recently been found to be ineffective at neutralizing human papilloma virus type 16 and type 18. Second, commercial ultrasound probe covers have an unacceptable rate of leakage (8-81%) compared to condoms (0.9-2%). We recommend the use of a sonicated hydrogen peroxide disinfectant system rather than aldehyde-type disinfectants. We recommend that the probe be covered with a condom rather than a commercial probe cover during transvaginal ultrasound examination. Combined with probe cleaning, these 2 steps are estimated to result in an 800 million- to 250 billion-fold reduction in human papilloma virus viral load, which should translate to greatly enhanced patient safety. © 2016 Elsevier Inc. All rights reserved.
Finberg H.J.,Obstetrix Medical Group
Journal of Ultrasound in Medicine | Year: 2010
Objective. The sonographic analysis of amniotic fluid in twin pregnancies can be complex and difficult, particularly when one twin has oligohydramnios or anhydramnios. This article describes a pitfall, the "amniotic wrinkle," which can lead to the erroneous impression that both twins have adequate fluid when one actually has little or none. Methods. Sonograms of twin pregnancies in which the sonographer's initial assessment was of adequate fluid for each twin but imaging by the author on the same day showed one twin to have oligohydramnios were analyzed to identify recurring image patterns related to the intertwin membrane that may create this misleading impression. Results.With oligohydramnios of one twin, the intertwin membrane may become redundant, folding on itself, creating an amniotic wrinkle: a short linear structure extending perpendicularly away from the twin with decreased amniotic fluid in toward the amniotic space of the other twin. A variation of this occurs when this fetus moves an extremity into the fold, with the two layers of the fold apposing each other between the limb and torso or between two limbs. An additional pattern is also described: an intrauterine sling or "cocoon" in which a fetus appears to be suspended within the amniotic space of the other twin. Conclusions. To avoid pitfalls in assessing amniotic fluid for twins, the intertwin membrane should be shown in every image that is used to document fluid ascribed to each twin, and images at right angles to the initial image can help identify an amniotic wrinkle. © 2010 by the American Institute of Ultrasound in Medicine.
Combs C.A.,Obstetrix Medical Group
Journal of Maternal-Fetal and Neonatal Medicine | Year: 2012
Continuous glucose monitoring (CGM) systems and continuous subcutaneous insulin infusion (CSII) systems, or insulin pumps, offer great promise for improved glycemic control during pregnancy. Combined, these two devices could potentially constitute an artificial pancreas, where real-time blood glucose readings are relayed to an insulin pump that uses a personalized algorithm to decide how much insulin is needed by the patient's body. However, the promise of these two systems have not yet been proven individually or in combination in controlled clinical trials to improve pregnancy outcomes. Such trials are urgently needed before the widespread use of these devices in pregnancy can be justified. © 2012 Informa UK, Ltd.
Olson R.,Peacehealth St Joseph Medical Center |
Garite T.J.,University of California at Irvine |
Garite T.J.,Sunrise Medical |
Fishman A.,Sunrise Medical |
And 2 more authors.
American Journal of Obstetrics and Gynecology | Year: 2012
Over the last 5 years, a new obstetric-gynecologic hospitalist model has emerged rapidly, the primary focus of which is the care and safety of the laboring patient. The need for this type of practitioner has been driven by a number of factors: various types of patient safety programs that require a champion and organizer; the realization that bad outcomes and malpractice lawsuits often result from the lack of immediate availability of a physician in the labor and delivery suite; the desire for many younger practicing physicians to seek a balance between their personal and professional lives; the appeal of shift work as opposed to running a busy private practice; the waning amount of training that new residency graduates receive in critical skills that are needed on labor and delivery; the void in critical care of the laboring patient that is created by the outpatient focus of many physicians in maternal-fetal medicine; the need for hospitals to have a group of physicians to implement protocols and policies on the unit, and the need for teaching in all hospitals, not just academic centers. By having a dedicated group of physicians whose practice is limited mostly to the care of the labor and delivery aspects of patient care, there is great potential to address many of these needs. There are currently 164 known obstetrician/gynecologist hospitalist programs across the United States, with 2 more coming on each month; the newly formed Society of Obstetrician/Gynecologist Hospitalists currently has >80 individual members. This article addresses the advantages, challenges, and variety of Hospitalist models and will suggest that what may be considered an emerging trend is actually a sustainable model for improved patient care and safety. © 2012 Mosby, Inc. All rights reserved.
Patel A.K.,Obstetrix Medical Group |
Lazar D.A.,Baylor College of Medicine |
Burrin D.G.,Baylor College of Medicine |
Smith E.O.,Baylor College of Medicine |
And 7 more authors.
Pediatric Critical Care Medicine | Year: 2014
Objective: Near-infrared spectroscopy is a noninvasive method of measuring local tissue oxygenation (Sto2). Abdominal Sto2 measurements in preterm piglets are directly correlated with changes in intestinal blood flow and markedly reduced by necrotizing enterocolitis. The objectives of this study were to use near-infrared spectroscopy to establish normal values for abdominal Sto2 in preterm infants and test whether these values are reduced in infants who develop necrotizing enterocolitis.Design: We conducted a 2-year prospective cohort study where we prospectively measured abdominal Sto2 in preterm infants, to establish reference values for preterm infants, and compared the near-infrared spectroscopy values with preterm infants in the cohort that developed necrotizing enterocolitis.Setting: Two neonatal ICUs: one at Texas Children's Hospital and the other at Ben Taub General Hospital in Houston, TX.Patients: We enrolled 100 preterm infants (< 32 weeks' gestation and < 1,500 g birth weight) between January 2007 and November 2008.Interventions: None.Measurements and Main Results: Eight neonates with incomplete data were excluded. Mean abdominal Sto2 in normal preterm infants (n = 78) during the first week of life was significantly higher than in those who later developed necrotizing enterocolitis (n = 14) (77.3% ± 14.4% vs 70.7% ± 19.1%, respectively, p = 0.002). An Sto2 less than or equal to 56% identified preterm infants progressing to necrotizing enterocolitis with 86% sensitivity, 64% specificity, 96% negative predictive value, and 30% positive predictive value. Using logistic regression, Sto2 less than or equal to 56% was independently associated with a significantly increased risk of necrotizing enterocolitis (odds ratio, 14.1; p = 0.01). Furthermore, infants with necrotizing enterocolitis demonstrated significantly more variation in Sto2 both during and after feeding in the first 2 weeks of life.Conclusions: This study establishes normal values for abdominal Sto2 in preterm infants and demonstrates decreased values and increased variability in those with necrotizing enterocolitis. Abdominal near-infrared spectroscopy monitoring of preterm infants may be a useful tool for early diagnosis and guiding treatment of necrotizing enterocolitis. (Pediatr Crit Care Med 2014; 15:735-741). Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Garite T.J.,University of California at Irvine |
Garite T.J.,Sunrise Medical |
Combs C.A.,Sunrise Medical |
Combs C.A.,Obstetrix Medical Group
Clinics in Perinatology | Year: 2012
Although improvements in neonatal care have continued to result in reduced mortality and morbidity of prematurely delivering newborns for decades, the results of a myriad of obstetric efforts and interventions have failed to reduce the overall rate of prematurity or prolong pregnancy at any gestational age. A few new developments or refinements of established interventions give increased hope for an improved obstetric contribution to the problem of prematurity. These include a better understanding of how best to use antenatal corticosteroids, and the newer options of magnesium sulfate to ameliorate or avoid cerebral palsy associated with prematurity and maternal progesterone administration to selected at-risk populations to decrease the likelihood of premature delivery. © 2012 Elsevier Inc.
PubMed | Obstetrix Medical Group
Type: Journal Article | Journal: American journal of obstetrics and gynecology | Year: 2016
Three steps must be followed to prevent the transmission of infection via a contaminated transvaginal ultrasound probe: cleaning the probe after every use, high-level disinfection, and covering the probe with a single-use barrier during the examination. There may be critical flaws in at least 2 of these steps as they are currently practiced. First, 2 widely used disinfectants, glutaraldehyde and orthophthalaldehyde, have recently been found to be ineffective at neutralizing human papilloma virus type 16 and type 18. Second, commercial ultrasound probe covers have an unacceptable rate of leakage (8-81%) compared to condoms (0.9-2%). We recommend the use of a sonicated hydrogen peroxide disinfectant system rather than aldehyde-type disinfectants. We recommend that the probe be covered with a condom rather than a commercial probe cover during transvaginal ultrasound examination. Combined with probe cleaning, these 2 steps are estimated to result in an 800 million- to 250 billion-fold reduction in human papilloma virus viral load, which should translate to greatly enhanced patient safety.