1
|
Yoselevsky EM, Seely EW, Celi AC, Robinson JN, McElrath TF. A randomized controlled trial comparing the efficacy of nifedipine and enalapril in the postpartum period. Am J Obstet Gynecol MFM 2023; 5:101178. [PMID: 37806651 DOI: 10.1016/j.ajogmf.2023.101178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/13/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Postpartum hypertension is a common medical complication of pregnancy and is associated with increased healthcare use, including unplanned interactions with the medical system and readmission, which can add significant stress to both a newly postpartum patient and the medical care delivery system. We currently do not know what the best antihypertensive treatment for postpartum hypertension is and tend to use antihypertensives commonly used during pregnancy. However, the mechanism of action of angiotensin-converting enzyme inhibitors may be well suited for the pathophysiology of hypertension in the postpartum period and may help to provide better control of hypertension and, in turn, decrease healthcare use. OBJECTIVE This study aimed to determine if enalapril is superior to nifedipine in preventing prolonged hospitalizations, unplanned medical visits, and/or readmission among women with postpartum hypertension. STUDY DESIGN We performed an open-label, randomized controlled trial (ClinicalTrials.gov registered: NCT04236258) in which patients ≥18 years with chronic hypertension, gestational hypertension, or preeclampsia were recruited to receive either 10 mg enalapril daily or 30 mg extended-release nifedipine daily as an initial antihypertensive agent in the period from delivery to 6 weeks postpartum. Recruitment occurred at a tertiary academic hospital from January 2020 to February 2021. Exclusion criteria included being on an antihypertensive when pregnancy started or requiring ≥2 daily antihypertensives during pregnancy. The antihypertensive regimen was managed by the participants' obstetrical provider after the initial randomization. The primary outcome was a composite of prolonged hospitalization, unplanned clinic visits, triage visits, and/or readmission. A total of 40 patients in each arm were needed to detect a decrease in the primary outcome rate from 70% to 40% (α=0.05; power 0.80). Analyses were performed based on the intention-to-treat principal, and each arm was oversampled because of the risk for participant dropout. RESULTS A total of 47 patients were randomized to each arm. Aside from the mode of delivery and twin gestation, the maternal demographics were similar between the 2 groups. The primary outcome occurred in 31 of 47 patients (66%) randomized to the nifedipine group and in 30 of 47 (64%) randomized to the enalapril group (P=.83). There was no significant difference in the primary outcome after controlling for mode of delivery and twin gestation. More patients in the enalapril arm had a second antihypertensive added during their primary hospitalization (16 vs 6) and more patients in the nifedipine arm were still on their antihypertensive at 2 weeks postpartum (42 vs 36). There were no adverse events in either group. CONCLUSION Enalapril was not superior to nifedipine when used as an initial antihypertensive in the immediate postpartum period in terms of decreasing healthcare use.
Collapse
Affiliation(s)
- Elizabeth M Yoselevsky
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, MA (Drs Yoselevsky, Robinson, and McElrath).
| | - Ellen W Seely
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Woman's Hospital, Boston, MA (Dr Seely)
| | - Ann C Celi
- Division of Internal Medicine, Brigham and Women's Hospital, Boston, MA (Dr Celi)
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, MA (Drs Yoselevsky, Robinson, and McElrath)
| | - Thomas F McElrath
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, MA (Drs Yoselevsky, Robinson, and McElrath)
| |
Collapse
|
2
|
Nassr AA, Berghella V, Hessami K, Bibbo C, Bellussi F, Robinson JN, Marsoosi V, Tabrizi R, Safari-Faramani R, Tolcher MC, Shamshirsaz AA, Clark SL, Belfort MA, Shamshirsaz AA. Intrapartum ultrasound measurement of angle of progression at the onset of the second stage of labor for prediction of spontaneous vaginal delivery in term singleton pregnancies: a systematic review and meta-analysis. Am J Obstet Gynecol 2022; 226:205-214.e2. [PMID: 34384775 DOI: 10.1016/j.ajog.2021.07.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/11/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aimed to investigate the diagnostic performance of transperineal ultrasound-measured angles of progression at the onset of the second stage of labor for the prediction of spontaneous vaginal delivery in singleton term pregnancies with cephalic presentation. DATA SOURCES We performed a predefined systematic search in PubMed, Embase, Scopus, Web of Science, and Google Scholar from inception to February 5, 2021. STUDY ELIGIBILITY CRITERIA Prospective cohort studies that evaluated the diagnostic performance of transperineal ultrasound-measured angles of progression (index test) at the onset of the second stage of labor (ie, when complete cervical dilation is diagnosed) for the prediction of spontaneous vaginal delivery (reference standard) were eligible for inclusion. Eligible studies were limited to those published as full-text articles in the English language and those that included only parturients with a singleton healthy fetus at term with cephalic presentation. STUDY APPRAISAL AND SYNTHESIS METHODS Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Summary receiver operating characteristic curves, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios were calculated using the Stata software. Subgroup analyses were done based on angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°. RESULTS A total of 8 studies reporting on 887 pregnancies were included. Summary estimates of the sensitivity and specificity of transperineal ultrasound-measured angle of progression at the onset of the second stage of labor for predicting spontaneous vaginal delivery were 94% (95% confidence interval, 88%-97%) and 47% (95% confidence interval, 18%-78%), respectively, for an angle of progression of 108° to 119°, 81% (95% confidence interval, 70%-89%) and 73% (95% confidence interval, 57%-85%), respectively, for an angle of progression of 120° to 140°, and 66% (95% confidence interval, 56%-74%) and 82% (95% confidence interval, 66%-92%), respectively, for an angle of progression of 141° to 153°. Likelihood ratio syntheses gave overall positive likelihood ratios of 1.8 (95% confidence interval, 1-3.3), 3 (95% confidence interval, 2-4.7), and 3.7 (95% confidence interval, 1.7-8.1) and negative likelihood ratios of 0.13 (95% confidence interval, 0.07-0.22), 0.26 (95% confidence interval, 0.18-0.38), and 0.42 (95% confidence interval, 0.29-0.60) for angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°, respectively. CONCLUSION Angle of progression measured by transperineal ultrasound at the onset of the second stage of labor may predict spontaneous vaginal delivery in singleton, term, cephalic presenting pregnancies and has the potential to be used along with physical examinations and other clinical factors in the management of labor and delivery.
Collapse
Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Carolina Bibbo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Federica Bellussi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA
| | - Vajiheh Marsoosi
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran; Clinical Research Development Unit, Vali Asr Hospital, Fasa University of Medical Sciences, Fasa, Iran; Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Roya Safari-Faramani
- Department of Epidemiology, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | | |
Collapse
|
3
|
Yoselevsky E, Seely EW, Celi AC, Robinson JN, McElrath TF. A randomized controlled trial comparing the efficacy of nifedipine and enalapril in the postpartum period. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
|
4
|
Little SE, Robinson JN, Zera CA. Changes in Delivery Timing for High-Risk Pregnancies in the United States. Am J Perinatol 2021; 38:1373-1379. [PMID: 32526779 DOI: 10.1055/s-0040-1712965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study was aimed to assess whether the "39-week" rule is being extended to high-risk pregnancies and if so whether this has led to changes in neonatal morbidity or stillbirth. STUDY DESIGN Birth certificate data between 2010 and 2014 from 23 states (55% of births in the United States) were used. Pregnancies were classified as high risk if they had any one of the following: maternal age greater than or equal to 40 years, prepregnancy body mass index (BMI) greater than or equal to 40 kg/m2, chronic (prepregnancy) hypertension, or diabetes (pregestational or gestational). Delivery timing changes for all pregnancies at term (37 weeks or greater) were compared with changes in the high-risk population. Neonatal morbidities (neonatal intensive care unit [NICU] admission, need for assisted ventilation, 5-minute Apgar score, and macrosomia), maternal morbidities (intensive care unit [ICU] admission, cesarean delivery, operative vaginal delivery, chorioamnionitis, and severe perineal laceration), and stillbirth rates were compared across time periods. Multivariate logistic regression was used to analyze whether gestational age-specific morbidity changes were due to shifts in delivery timing. RESULTS For the overall population, there was a shift in delivery timing between 2010 and 2014, a 2.5% decrease in 38-week deliveries, and a 2.3% increase in 39-week deliveries (p < 0.01). This gestational age shift was identical in the high-risk population (2.7% decrease in 38-week deliveries and 2.9% increase in 39-week deliveries). For the high-risk population, NICU admission increased from 5.4 to 6.3% in 2014 (p < 0.01) and assisted ventilation rates declined from 3.8 to 2.9% (p < 0.01). These changes, however, were independent of changes in delivery timing. There was no increase in the rate of stillbirth (0.23% in 2010 and 0.23% in 2014; p = 0.50). CONCLUSION There was a significant shift in delivery timing for high-risk pregnancies in the United States between 2010 and 2014. This shift, however, did not result in statistically significant changes in either neonatal morbidity or stillbirth. KEY POINTS · From 2010 to 2014, term deliveries for high-risk pregnancies shifted towards 39 weeks.. · The shift towards 39 weeks in high-risk pregnancies was not accompanied by any improvement in neonatal morbidity.. · The shift towards 39 weeks in high-risk pregnancies did not result in an increase in the stillbirth rate..
Collapse
Affiliation(s)
- Sarah E Little
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chloe A Zera
- Division of Maternal-Fetal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
5
|
Clapp MA, Daw JR, James KE, Little SE, Robinson JN, Bates SV, Kaimal AJ. Association between morbidity among term newborns and low-risk caesarean delivery rates. BJOG 2021; 129:627-635. [PMID: 34532943 DOI: 10.1111/1471-0528.16925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the association between county-level caesarean delivery (CD) rates among women at low risk and morbidity among term newborns. DESIGN Cross-sectional study. SETTING Population-based study of US county-level birth data from 2015 to 2017. POPULATION Nulliparous women with term, singleton, vertex-presenting infants (NTSV) at low risk for morbidity. METHODS The primary exposure was county-level CD rates. MAIN OUTCOME MEASURES The outcome was morbidity among the low-risk NTSV cohort, categorised as severe (5-minute Apgar score of ≤3, assisted ventilation for ≥6 hours, severe neurologic injury or seizure, transfer or death) or moderate (5-minute Apgar score of <7 but >3, administration of antibiotics or assisted ventilation at delivery). We used linear regression models to determine the association between county NTSV CD and neonatal morbidity rates with cluster robust standard errors. RESULTS The analysis included data from 2 753 522 births in 952 counties from all 48 states. The mean NTSV CD rate was 23.6% (standard deviation 4.8%). The median severe and moderate neonatal morbidity rates were 15.2 (interquartile range, IQR 9.4-23.6) and 52.5 (IQR 33.4-75.7) per 1000 births, respectively. In the unadjusted analysis using the risk-adjusted exposure and outcome, every percentage point increase in the CD rate of a county was associated with 0.6 (95% CI -0.9, -0.3) and 2.3 fewer (95% CI -3.4, -1.1) cases of severe and moderate neonatal morbidity per 1000 live births. After adjustment for other county factors, the relationships remained significant. These findings were tested in multiple sensitivity analyses. CONCLUSIONS Lower county-level NTSV CD rates were associated with a small increase in morbidity among term newborns in the USA. TWEETABLE ABSTRACT Lower county-level caesarean delivery rates were associated with an increase in morbidity among term newborns in the USA.
Collapse
Affiliation(s)
- M A Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Harvard University, Boston, MA, USA
| | - J R Daw
- Department of Health Policy & Management, Columbia University Mailman School of Public Health, New York, NY, USA
| | - K E James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - S E Little
- Harvard Medical School, Harvard University, Boston, MA, USA.,Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - J N Robinson
- Harvard Medical School, Harvard University, Boston, MA, USA.,Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA, USA
| | - S V Bates
- Harvard Medical School, Harvard University, Boston, MA, USA.,Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - A J Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Harvard University, Boston, MA, USA
| |
Collapse
|
6
|
Clapp MA, James KE, Little SE, Robinson JN, Kaimal AJ. Association between hospital-level cesarean delivery rates and severe maternal morbidity and unexpected newborn complications. Am J Obstet Gynecol MFM 2021; 3:100474. [PMID: 34481997 DOI: 10.1016/j.ajogmf.2021.100474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although there are many indications for a cesarean delivery, the "optimal" cesarean delivery rate is unknown. Neonatal and maternal morbidity have largely not been considered in the generation of hospital-level cesarean delivery rate targets. OBJECTIVE We sought to examine if the widely adopted and reported markers of maternal and neonatal morbidity were associated with hospital cesarean delivery rates to provide context for potential comparison and consideration for defining cesarean delivery rate targets. We hypothesized that hospitals with higher cesarean delivery rates would have increased rates of severe maternal morbidity, though we were less certain of the associations of the cesarean delivery rates with unexpected newborn complications. STUDY DESIGN This is a cross-sectional, ecological study using data from the 2016 Nationwide Readmission Database of hospitals with at least 100 deliveries per year. The exposure of interest was hospital cesarean delivery rate. The outcomes were (1) severe maternal morbidity with and without transfusion-in accordance with the Centers for Disease Control and Prevention's definition, and (2) neonatal morbidity-defined using The Joint Commission's Perinatal Quality metric of moderate and severe unexpected newborn complications among term, singleton, and nonanomalous neonates. Before assuming a single linear relationship to model the associations between morbidity and cesarean delivery rates, the Joinpoint Regression Analysis program was used to examine for potential splines in the relationships with both severe maternal morbidity (with and without transfusion) and severe and moderate unexpected newborn complications. Poisson regression model was then used to determine the association between morbidity and cesarean delivery rates. RESULTS The analysis included 831,111 deliveries from 621 hospitals. The mean cesarean delivery rate was 30.5%. The median severe maternal morbidity rate was 1.40 per 100 deliveries (interquartile range, 0.71-2.21 per 1000 deliveries). Excluding transfusion, the median severe maternal morbidity rate was 0.47 per 100 deliveries (interquartile range, 0.22-0.73 per 100 deliveries). The median rate of severe and moderate unexpected newborn complications was 1.01 per 100 low-risk newborns (interquartile range, 0.64-1.69 per 100 low-risk newborns) and 1.79 per 1000 low-risk newborns (interquartile range, 0.94-2.93 per 100 low-risk newborns), respectively. In the unadjusted analysis, every percentage point increase in a hospital's cesarean delivery rate was associated with a 3.4% (95% confidence interval, 2.3%-4.4%) and a 2.3% (95% confidence interval, 1.0%-3.5%) increase in severe maternal morbidity including and excluding transfusion, respectively. After adjustment for the case mix and hospital factors, only the relationship with severe maternal morbidity including transfusion remained significant: 3.3% (95% confidence interval, 1.7%-4.9%) increase in severe maternal morbidity per 1 percentage point increase in the cesarean delivery rate. There was no observed association between cesarean delivery rates and unexpected newborn complications CONCLUSION: Severe maternal morbidity and unexpected newborn complications occur in fewer than 5 in 100 births. Findings from this analysis of hospitals with cesarean delivery rates ranging from 6.8%-56.3% suggest that those with lower cesarean delivery rates have lower severe maternal morbidity (which includes transfusion) and similar unexpected newborn complications compared with hospitals with higher cesarean delivery rates. This work may provide a helpful context to providers, hospitals, and policymakers who are measuring and reporting outcomes. Regarding neonatal morbidity in particular, the Joint Commission manual notes that the unexpected newborn complication metric was specifically designed to be compared against maternal-focused metrics such as cesarean delivery rates. More work is needed to define and identify appropriate measures of maternal and neonatal morbidity for these types of comparisons.
Collapse
Affiliation(s)
- Mark A Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Drs Clapp, James, and Kaimal); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Clapp, Little, Robinson, and Kaimal); Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Little); Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA (Dr Robinson).
| | - Kaitlyn E James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Drs Clapp, James, and Kaimal); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Clapp, Little, Robinson, and Kaimal); Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Little); Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA (Dr Robinson)
| | - Sarah E Little
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Drs Clapp, James, and Kaimal); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Clapp, Little, Robinson, and Kaimal); Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Little); Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA (Dr Robinson)
| | - Julian N Robinson
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Drs Clapp, James, and Kaimal); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Clapp, Little, Robinson, and Kaimal); Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Little); Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA (Dr Robinson)
| | - Anjali J Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Drs Clapp, James, and Kaimal); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Clapp, Little, Robinson, and Kaimal); Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Little); Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA (Dr Robinson)
| |
Collapse
|
7
|
Easter SR, Gilmore KC, Schulkin J, Robinson JN. Provider Attitudes on Regionalization of Maternity Care: A National Survey. Matern Child Health J 2021; 25:1402-1409. [PMID: 34097190 DOI: 10.1007/s10995-021-03179-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To explore provider perspectives surrounding national guidelines proposing regionalization of maternal care. METHODS An 18-item survey focused on provider attitudes and practices surrounding regionalized maternity care was administered to a national sample of practicing obstetricians. We classified respondants reporting less than 500 annual deliveries at their hospital as low-volume providers and those practicing at hospitals performing 500 or more annual deliveries as high-volume providers. We compared responses according to hospital delivery volume using univariate analysis. RESULTS Of the 497 physicians surveyed, 278 people responded (56%) with 229 currently practicing obstetrics. The median annual delivery volume amongst respondents was 200 (interquartile range 100-1900) with 146 (63.7%) practicing in low-volume delivery centers. The need for medical or surgical expertise was the most commonly reported indication for maternal transfer (19.7%) and independent of practice setting. Ninety-six percent of providers agreed with the concept of regionalization, but respondents in high-volume centers reported higher familiarity with the levels of maternal care paradigm compared to their low-volume counterparts (81.9% v. 62.3%, p < 0.01). Financial factors (60.3%), geography (48.9%), and access to care (43.2%) were the most cited major barriers to regionalization. High-volume providers endorsed geography as a major barrier more often than low-volume providers (57.8% v. 43.8%, p = 0.04). CONCLUSIONS FOR PRACTICE Obstetricians may agree with the concept of regionalized maternity care but also identify significant barriers to its implementation. Early and frequent engagement of providers reflecting the diversity of delivery centers in a region is a simple but necessary step in any attempts to designate levels of maternal care.
Collapse
Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02215, USA.
| | - Kelly C Gilmore
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02215, USA
| |
Collapse
|
8
|
Andriotti T, Ranjit A, Hamlin L, Koehlmoos T, Robinson JN, Lutgendorf MA. Psychiatric Conditions During Pregnancy and Postpartum in a Universally Insured American Population. Mil Med 2021; 187:e795-e801. [PMID: 33881522 DOI: 10.1093/milmed/usab154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/16/2021] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mental health conditions are common and can have significant effects during the perinatal period. Our objective was to determine the incidences and predictors of psychiatric conditions during pregnancy and postpartum among universally insured American women. MATERIAL AND METHODS This was an Institutional Review Board (IRB)-approved protocol using a retrospective cohort of 104,866 deliveries covered by TRICARE from 2005 to 2014. We used TRICARE claims data to identify pregnant women without current psychiatric conditions who developed new psychiatric condition(s) during pregnancy or postpartum compared with those who did not, as identified by International Classification of Diseases (ICD)-9 CM codes. Predictors of psychiatric conditions during pregnancy or postpartum were determined using stepwise logistic regression models. RESULTS A total of 104,866 women met the inclusion criteria; of these, 35% (n = 36,192) were diagnosed with a new psychiatric condition during pregnancy or within 1 year of delivery, 15% (n = 15,636) with a psychiatric condition during pregnancy, and 20% (n = 20,556) with a psychiatric condition within 1 year of delivery. We demonstrated that the African-American race (odds ratio [OR] 1.16, 95% CI 1.10-1.22), active duty status (OR 1.20, 95% CI 1.14-1.25), and severe maternal morbidity during delivery (OR 1.18, 95% CI 1.02-1.35) were significantly associated with the occurrence of a psychiatric condition within 1 year of delivery. For Asian women, there was a 28% higher odds of developing a psychiatric disorder during pregnancy (adjusted OR 1.28, 95% CI 1.17-1.40) compared with White women. Active duty women were twice as likely to be diagnosed with post-traumatic stress disorder (adjusted OR 2.31, 95% CI 1.83-2.90). CONCLUSION In a universally insured population, the incidences of psychiatric conditions in pregnancy and within a year of delivery were similar to the American population. Additionally, the development of psychiatric conditions in pregnancy and within a year of delivery may be associated with race, active duty status, and complicated births.
Collapse
Affiliation(s)
| | - Anju Ranjit
- Department of Obstetrics and Gynecology, Howard University, Washington, DC 20060, USA
| | - Lynette Hamlin
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Tracey Koehlmoos
- Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Department of Preventive Medicine and Biostatistics, Uniformed Services University, Bethesda, MD 20814, USA
| | - Julian N Robinson
- Department of Obstetrics, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Monica A Lutgendorf
- Department of Obstetrics and Gynecology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| |
Collapse
|
9
|
Cole NM, Abushoshah I, Fields KG, Carusi DA, Robinson JN, Bateman BT, Farber MK. The interrater reliability and agreement of a 0 to 10 uterine tone score in cesarean delivery. Am J Obstet Gynecol MFM 2021; 3:100342. [PMID: 33652161 DOI: 10.1016/j.ajogmf.2021.100342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Postpartum hemorrhage is a leading source of maternal morbidity and mortality worldwide with uterine atony identified as the underlying cause in up to 80% of cases. Several measures have been utilized to report uterine tone. The most commonly reported measure is a 0 to 10 numeric rating scale, but this scale has not been tested for reliability or agreement between different raters. OBJECTIVE The primary purpose of this study was to evaluate the interrater reliability and agreement of the 0 to 10 visual numeric rating scale of uterine tone during cesarean delivery. A secondary purpose was to obtain estimates of scale responsiveness and minimal clinically important difference. STUDY DESIGN Between August and November of 2018, obstetricians used a 0 to 10 numeric rating score to independently rate uterine tone at 3 and 10 minutes after cesarean delivery by palpation of the uterus. Of note, "0" represented "no tone" and "10" represented excellent tone. Each obstetrician independently and blinded to the other's score pointed to a numeric rating scale held by the anesthesiologist through a clear sterile drape. Intraclass correlation coefficients and Bland-Altman analysis were used to assess interrater reliability and agreement, respectively. Standardized response mean and standard error of measurement were used to obtain estimates of responsiveness and minimal clinically important difference, respectively. RESULTS A total of 82 and 84 pairs of scores were collected at 3 and 10 minutes, respectively, from pairs of 62 unique obstetricians. The mean±standard deviation difference in scores between rater 1 and rater 2 was 0.4±1.4 at 3 minutes and 0.1±1.1 at 10 minutes. Intraclass correlation coefficients for a future single rater (intraclass correlation coefficient [1, 1]) at 3 and 10 minutes were 0.67 (95% confidence interval, 0.53-0.77) and 0.61 (95% confidence interval, 0.46-0.73), and for the average between 2 future raters (intraclass correlation coefficient [1, 2]), they were 0.80 (95% confidence interval, 0.71-0.87) and 0.76 (95% confidence interval, 0.63-0.84), indicating good and excellent reliability, respectively. Bland-Altman analysis estimated 95% limit of agreement between raters of -2.4 (95% confidence interval, -3.0 to -1.9) to 3.1 (95% confidence interval, 2.6-3.7) at 3 minutes and -2.1 (95% confidence interval, -2.5 to -1.7) to 2.4 (95% confidence interval, 2.0-2.8) at 10 minutes, consistent with good interrater agreement at both time points. The standardized response mean from 3 to 10 minutes after delivery was 1.1 (n=81). Standard error of measurement was 1.0 (95% confidence interval, 0.9-1.1) at 3 minutes and 0.8 (95% confidence interval, 0.7-0.9) at 10 minutes. CONCLUSION The 0 to 10 numeric rating scale for uterine tone demonstrated good to excellent interrater reliability with 1 and 2 raters, respectively, and good interrater agreement. The scale was responsive to within-parturient change in tone, and preliminary estimates of the minimal clinically important difference were obtained. The 0 to 10 numeric rating scale for uterine tone may be a reliable, standardized tool for future research in reporting degree of uterotonic contraction during cesarean delivery.
Collapse
Affiliation(s)
- Naida M Cole
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber).
| | - Ibrahim Abushoshah
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber); Department of Anesthesia and Critical Care, King Abdulaziz University, King Abdulaziz University Hospital, Jeddhah, Saudi Arabia (Dr Abushoshah)
| | - Kara G Fields
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber)
| | | | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (Dr Robinson)
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber); Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (Dr Bateman), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michaela K Farber
- Department of Anesthesiology, Perioperative and Pain Medicine (Drs Cole and Abushoshah, Ms Fields, and Drs Bateman and Farber)
| |
Collapse
|
10
|
Lumbreras-Marquez MI, Farber MK, Kim J, Bibbo C, Robinson JN, Carusi DA, Easter SR. 913 Prediction of vaginal delivery in twins using machine learning. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
11
|
Lassey SC, Haber H, Kanbergs AN, Robinson JN, Little SE. 44 Six vs. Twelve Hours of Foley Catheter Placement for Induction: A Randomized Controlled Trial. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Papadakis LM, Taha B, Yoselevsky E, Robinson JN, Easter SR. 529 The impact of insurance on antenatal and postnatal maternal transfers. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Reale SC, Lumbreras‐Marquez MI, King CH, Burns SL, Fields KG, Diouf K, Goldfarb IT, Ciaranello AL, Robinson JN, Gregory KE, Huybrechts KF, Bateman BT. Patient characteristics associated with SARS-CoV-2 infection in parturients admitted for labour and delivery in Massachusetts during the spring 2020 surge: A prospective cohort study. Paediatr Perinat Epidemiol 2021; 35:24-33. [PMID: 33496995 PMCID: PMC8014491 DOI: 10.1111/ppe.12743] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/18/2020] [Accepted: 11/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND While studies from large cities affected by coronavirus disease 2019 (COVID-19) have reported on the prevalence of SARS-CoV-2 in the context of universal testing during admission for delivery, the patient demographic, social and clinical factors associated with SARS-CoV-2 infection in pregnant women are not fully understood. OBJECTIVE To evaluate the epidemiological factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in women admitted for labour and delivery, in the context of universal screening at four Boston-area hospitals. METHODS In this prospective cohort study, we reviewed the health records of all women admitted for labour and delivery at four hospitals from the largest health system in Massachusetts between 19 April 2020 and 27 June 2020. We calculated the risk of SARS-CoV-2 infection, including asymptomatic infection. We calculated associations between SARS-CoV-2 infection and demographic and clinical characteristics. RESULTS A total of 93 patients (3.2%, 95% confidence interval 2.5, 3.8) tested positive for SARS-CoV-2 infection on admission for labour and delivery out of 2945 patients included in the analysis; 80 (86.0%) of the patients who tested positive were asymptomatic at the time of testing. Factors associated with SARS-CoV-2 infection included the following: younger age, obesity, African American or Hispanic race/ethnicity, residence in heavily affected communities (as measured in cases reported per capita), presence of a household member with known SARS-CoV-2 infection, non-health care essential worker occupation and MassHealth or Medicaid insurance compared to commercial insurance. 93.8% of patients testing positive for SARS-CoV-2 on admission had one or more identifiable factors associated with disease acquisition. CONCLUSIONS In this large sample of deliveries during the height of the surge in infections during the spring of 2020, SARS-CoV-2 infection was largely concentrated in patients with distinct demographic characteristics, those largely from disadvantaged communities. Racial disparities seen in pregnancy persist with respect to SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Sharon C. Reale
- Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Mario I. Lumbreras‐Marquez
- Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Chih H. King
- Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Stacey L. Burns
- Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Kara G. Fields
- Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Khady Diouf
- Department of Obstetrics and GynecologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Ilona T. Goldfarb
- Department of Obstetrics and GynecologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Andrea L. Ciaranello
- Division of Infectious Disease and the Medical Practice Evaluation CenterMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Julian N. Robinson
- Department of Obstetrics and GynecologyBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Katherine E. Gregory
- Department of Newborn MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Krista F. Huybrechts
- Division of PharmacoepidemiologyDepartment of MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| |
Collapse
|
14
|
Colletta A, Lassey S, Pomerleau M, Robinson JN. Double-Blind Randomized Controlled Trial of a Cephalic Elevation Device for Second-Stage Cesarean Birth. J Obstet Gynecol Neonatal Nurs 2020. [DOI: 10.1016/j.jogn.2020.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
15
|
Affiliation(s)
- Brian T Bateman
- Dr. Bateman is from the Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts. Dr. Robinson is from the Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts;
| | | |
Collapse
|
16
|
Abaci Turk E, Abulnaga SM, Luo J, Stout JN, Feldman HA, Turk A, Gagoski B, Wald LL, Adalsteinsson E, Roberts DJ, Bibbo C, Robinson JN, Golland P, Grant PE, Barth WH. Corrigendum to "Placental MRI: Effect of maternal position and uterine contractions on placental BOLD MRI measurements" [Placenta 95 (2020) 69-77]. Placenta 2020; 100:171-172. [PMID: 32771391 DOI: 10.1016/j.placenta.2020.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Esra Abaci Turk
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - S Mazdak Abulnaga
- Computer Science and Artificial Intelligence Laboratory (CSAIL), Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jie Luo
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jeffrey N Stout
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Henry A Feldman
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ata Turk
- Electrical Computer Engineering Department, Boston University, Boston, MA, USA
| | - Borjan Gagoski
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence L Wald
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Radiology, Harvard Medical School, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Elfar Adalsteinsson
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Carolina Bibbo
- Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Julian N Robinson
- Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Polina Golland
- Computer Science and Artificial Intelligence Laboratory (CSAIL), Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - P Ellen Grant
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - William H Barth
- Maternal-Fetal Medicine, Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
17
|
Abaci Turk E, Abulnaga SM, Luo J, Stout JN, Feldman HA, Turk A, Gagoski B, Wald LL, Adalsteinsson E, Roberts DJ, Bibbo C, Robinson JN, Golland P, Grant PE, Barth WH. Placental MRI: Effect of maternal position and uterine contractions on placental BOLD MRI measurements. Placenta 2020; 95:69-77. [PMID: 32452404 DOI: 10.1016/j.placenta.2020.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Before using blood-oxygen-level-dependent magnetic resonance imaging (BOLD MRI) during maternal hyperoxia as a method to detect individual placental dysfunction, it is necessary to understand spatiotemporal variations that represent normal placental function. We investigated the effect of maternal position and Braxton-Hicks contractions on estimates obtained from BOLD MRI of the placenta during maternal hyperoxia. METHODS For 24 uncomplicated singleton pregnancies (gestational age 27-36 weeks), two separate BOLD MRI datasets were acquired, one in the supine and one in the left lateral maternal position. The maternal oxygenation was adjusted as 5 min of room air (21% O2), followed by 5 min of 100% FiO2. After datasets were corrected for signal non-uniformities and motion, global and regional BOLD signal changes in R2* and voxel-wise Time-To-Plateau (TTP) in the placenta were measured. The overall placental and uterine volume changes were determined across time to detect contractions. RESULTS In mothers without contractions, increases in global placental R2* in the supine position were larger compared to the left lateral position with maternal hyperoxia. Maternal position did not alter global TTP but did result in regional changes in TTP. 57% of the subjects had Braxton-Hicks contractions and 58% of these had global placental R2* decreases during the contraction. CONCLUSION Both maternal position and Braxton-Hicks contractions significantly affect global and regional changes in placental R2* and regional TTP. This suggests that both factors must be taken into account in analyses when comparing placental BOLD signals over time within and between individuals.
Collapse
Affiliation(s)
- Esra Abaci Turk
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - S Mazdak Abulnaga
- Computer Science and Artificial Intelligence Laboratory (CSAIL), Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jie Luo
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jeffrey N Stout
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Henry A Feldman
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ata Turk
- Electrical Computer Engineering Department, Boston University, Boston, MA, USA
| | - Borjan Gagoski
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lawrence L Wald
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Radiology, Harvard Medical School, Boston, MA, United States; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, United States
| | - Elfar Adalsteinsson
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Harvard-MIT Health Sciences and Technology; Massachusetts Institute of Technology, Cambridge, MA, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Carolina Bibbo
- Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Julian N Robinson
- Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Polina Golland
- Computer Science and Artificial Intelligence Laboratory (CSAIL), Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - P Ellen Grant
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - William H Barth
- Maternal-Fetal Medicine, Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
18
|
Lumbreras-Marquez MI, Reale SC, Carusi DA, Robinson JN, Scharf N, Fields KG, Farber MK. Introduction of a Novel System for Quantitating Blood Loss After Vaginal Delivery. Anesth Analg 2020; 130:857-868. [DOI: 10.1213/ane.0000000000004560] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
19
|
Seifert S, Molitor R, Holland E, Bateman BT, Robinson JN, Farber M. 951: Delays in administration of antihypertensive medication for hypertensive emergencies at a tertiary care center. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
20
|
Easter SR, Saadeh M, Sweeney VH, Manganaro K, Reiff E, Bateman BT, Robinson JN. 884: Comparison of strategies to screen for severe maternal morbidity. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
21
|
Clapp MA, James KE, Little SE, Robinson JN, Bates SV, Kaimal AJ. 788: The assoication between county-level NTSV cesarean delivery rates and severe unexpected newborn complications. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
22
|
Little SE, Clapp MA, Lassey S, Bukowski R, Barth W, Robinson JN. 1195: Severe newborn morbidity in the second stage of labor. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.1207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
23
|
Torres Yordán NC, Yost EL, Hillenbrand CM, Robinson JN, McElrath TF, Greenberg J. 411: Effects of labor on metabolic indicators of fetal stress in newborns delivered via cesarean section. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
24
|
Torres Yordán NC, Valentin EE, Lewis AG, Gordon DA, Robinson JN, Greenberg J. 336: Effects of intrapartum fever on umbilical artery pH, lactate and base excess. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
25
|
Panelli DM, Robinson JN, Kaimal AJ, Terry KL, Yang J, Clapp MA, Little SE. Using Cervical Dilation to Predict Labor Onset: A Tool for Elective Labor Induction Counseling. Am J Perinatol 2019; 36:1485-1491. [PMID: 30695793 DOI: 10.1055/s-0039-1677866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate whether cervical dilation predicts the timing and likelihood of spontaneous labor at term. STUDY DESIGN This was a retrospective cohort of nulliparous women with singleton pregnancies who delivered at term from 2013 to 2015. Outpatient cervical examinations performed after 37 weeks and prior to labor onset were collected. Survival analysis was used to analyze time to spontaneous labor with cervical dilation as the primary predictor, modeled as continuous and categorical variables (<1 cm, 1 cm, >1 cm). RESULTS Our cohort included 726 women; 407 (56%) spontaneously labored, 263 (36%) were induced, and 56 (8%) had an unlabored cesarean delivery. Women with >1-cm dilation were three times more likely to spontaneously labor (adjusted hazard ratio [aHR]: 3.1; 95% confidence interval [CI]: 2.4-4) than those with <1-cm dilation. At 39 weeks, 60% of women with >1-cm dilation went into spontaneous labor as compared with only 28% of those with <1-cm dilation (aHR: 2.9; 95% CI: 2-4.4). CONCLUSION In our cohort of nulliparous women at term, those with cervical dilation > 1 cm were significantly more likely to go into labor in the following week. This information can aid in counseling about elective induction of labor.
Collapse
Affiliation(s)
- Danielle M Panelli
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anjali J Kaimal
- Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathryn L Terry
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jiaxi Yang
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark A Clapp
- Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
26
|
Luo J, Abaci Turk E, Gagoski B, Copeland N, Zhou IY, Young V, Bibbo C, Robinson JN, Zera C, Barth WH, Roberts DJ, Sun PZ, Grant PE. Preliminary evaluation of dynamic glucose enhanced MRI of the human placenta during glucose tolerance test. Quant Imaging Med Surg 2019; 9:1619-1627. [PMID: 31728306 DOI: 10.21037/qims.2019.09.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To investigate dynamic glucose enhanced (DGE) chemical exchange saturation transfer (CEST) MRI as a means to non-invasively image glucose transport in the human placenta. Methods Continuous wave (CW) CEST MRI was performed at 3.0 Tesla. The glucose contrast enhancement (GCE) was calculated based on the magnetization transfer asymmetry (MTRasym), and the DGE was calculated with the positive side of Z-spectra in reference to the first time point. The glucose CEST (GlucoCEST) was optimized using a glucose solution phantom. Glucose solution perfused ex vivo placenta tissue was used to demonstrate GlucoCEST MRI effect. The vascular density of ex vivo placental tissue was evaluated with yellow dye after MRI scans. Finally, we preliminarily demonstrated GlucoCEST MRI in five pregnant subjects who received a glucose tolerance test. For human studies, the dynamic R2* change was captured with T2*-weighted echo planar imaging (EPI). Results The GCE effect peaks at a saturation B1 field of about 2 μT, and the GlucoCEST effect increases linearly with the glucose concentration between 4-20 mM. In ex vivo tissue, the GlucoCEST MRI was sensitive to the glucose perfusate and the placenta vascular density. Although the in vivo GCE baseline was sensitive to field inhomogeneity and motion artifacts, the temporal evolution of the GlucoCEST effect showed a consistent and positive response after oral glucose tolerance drink. Conclusions Despite the challenges of placental motion and field inhomogeneity, our study demonstrated the feasibility of DGE placenta MRI at 3.0 Tesla.
Collapse
Affiliation(s)
- Jie Luo
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai 200240, China.,Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | - Esra Abaci Turk
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | - Borjan Gagoski
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | - Natalie Copeland
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | - Iris Y Zhou
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Vanessa Young
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | - Carolina Bibbo
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Julian N Robinson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Chloe Zera
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - William H Barth
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Phillip Zhe Sun
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - P Ellen Grant
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
27
|
De Tina A, Chau A, Carusi DA, Robinson JN, Tsen LC, Farber MK. Identifying Barriers to Implementation of the National Partnership for Maternal Safety Obstetric Hemorrhage Bundle at a Tertiary Center. Anesth Analg 2019; 124:1045-1050. [DOI: 10.1213/ane.0000000000003451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
28
|
Turk EA, Stout JN, Ha C, Luo J, Gagoski B, Yetisir F, Golland P, Wald LL, Adalsteinsson E, Robinson JN, Roberts DJ, Barth WH, Grant PE. Placental MRI: Developing Accurate Quantitative Measures of Oxygenation. Top Magn Reson Imaging 2019; 28:285-297. [PMID: 31592995 PMCID: PMC7323862 DOI: 10.1097/rmr.0000000000000221] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The Human Placenta Project has focused attention on the need for noninvasive magnetic resonance imaging (MRI)-based techniques to diagnose and monitor placental function throughout pregnancy. The hope is that the management of placenta-related pathologies would be improved if physicians had more direct, real-time measures of placental health to guide clinical decision making. As oxygen alters signal intensity on MRI and oxygen transport is a key function of the placenta, many of the MRI methods under development are focused on quantifying oxygen transport or oxygen content of the placenta. For example, measurements from blood oxygen level-dependent imaging of the placenta during maternal hyperoxia correspond to outcomes in twin pregnancies, suggesting that some aspects of placental oxygen transport can be monitored by MRI. Additional methods are being developed to accurately quantify baseline placental oxygenation by MRI relaxometry. However, direct validation of placental MRI methods is challenging and therefore animal studies and ex vivo studies of human placentas are needed. Here we provide an overview of the current state of the art of oxygen transport and quantification with MRI. We suggest that as these techniques are being developed, increased focus be placed on ensuring they are robust and reliable across individuals and standardized to enable predictive diagnostic models to be generated from the data. The field is still several years away from establishing the clinical benefit of monitoring placental function in real time with MRI, but the promise of individual personalized diagnosis and monitoring of placental disease in real time continues to motivate this effort.
Collapse
Affiliation(s)
- Esra Abaci Turk
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children’s Hospital, MA, USA
| | - Jeffrey N. Stout
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children’s Hospital, MA, USA
| | - Christopher Ha
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children’s Hospital, MA, USA
| | - Jie Luo
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Borjan Gagoski
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children’s Hospital, MA, USA
| | - Filiz Yetisir
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children’s Hospital, MA, USA
| | - Polina Golland
- Computer Science and Artificial Intelligence Laboratory (CSAIL), Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Electrical Engineering and Computer Science Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Lawrence L. Wald
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Elfar Adalsteinsson
- Department of Electrical Engineering and Computer Science Massachusetts Institute of Technology, Cambridge, MA, United States
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Julian N. Robinson
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, USA
| | | | - William H. Barth
- Maternal-Fetal Medicine, Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - P. Ellen Grant
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children’s Hospital, MA, USA
| |
Collapse
|
29
|
Affiliation(s)
- J N Robinson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - R M Ryan
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
30
|
Easter SR, Bateman BT, Sweeney VH, Manganaro K, Lassey SC, Gagne JJ, Robinson JN. A comorbidity-based screening tool to predict severe maternal morbidity at the time of delivery. Am J Obstet Gynecol 2019; 221:271.e1-271.e10. [PMID: 31229427 DOI: 10.1016/j.ajog.2019.06.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The obstetric comorbidity index summarizes the burden of maternal comorbidities into a single number and holds promise as a maternal risk-assessment tool. OBJECTIVE The aim of this study was to assess the clinical performance of this comorbidity-based screening tool to accurately identify women on labor and delivery who are at risk of severe maternal morbidity on labor and delivery in real time. STUDY DESIGN All patients with pregnancies ≥23 weeks gestation presenting to labor and delivery at a single tertiary-care center from February through July 2018 were included in the study. The patient's primary labor and delivery nurse assessed patient comorbidities and calculated the patient's obstetric comorbidity index. The score was recalculated at each 12-hour shift change. A multidisciplinary panel of clinicians determined whether patients experienced severe maternal morbidity based on the American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine consensus definition, blinded to the patient's obstetric comorbidity index score. We analyzed the association between the obstetric comorbidity index score and the occurrence of severe maternal morbidity. RESULTS The study included 2828 women, of whom 1.73% experience severe maternal morbidity (n=49). The obstetric comorbidity index ranged from 0-15 for women in the study cohort, with a median obstetric comorbidity index of 1 (interquartile range, 0-3). The median obstetric comorbidity index score for women who experienced the severe maternal morbidity was 5 (interquartile range, 3-7) compared with a median of 1 (interquartile range, 0-3) for those without severe maternal morbidity (P<.01). The frequency of severe maternal morbidity increased from 0.41% for those with a score of 0 to 18.75% for those with a score ≥9. For every 1-point increase in the score, patients experienced a 1.55 increase in odds of severe maternal morbidity (95% confidence interval, 1.42-1.70). The c-statistic for the obstetric comorbidity index score was 0.83 (95% confidence interval, 0.76-0.89), which indicated strong discrimination. CONCLUSION The obstetric comorbidity index can prospectively identify women at risk of severe maternal morbidity in a clinical setting. A particular strength of the obstetric comorbidity index is its ability to integrate multiple compounding comorbidities and highlight the cumulative risk that is associated with the patients' conditions. Routine clinical use of the obstetric comorbidity index has the potential to identify at-risk women whose condition warrants increased surveillance and targeted care to prevent adverse maternal outcomes.
Collapse
|
31
|
Sweeney VH, Manganaro K, Easter SR, Bateman BT, Robinson JN, Lassey SC. An Innovative, Nurse-Driven Approach for Identifying Women at Risk for Severe Maternal Morbidity. J Obstet Gynecol Neonatal Nurs 2019. [DOI: 10.1016/j.jogn.2019.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
32
|
Rahman SA, Bibbo C, Olcese J, Czeisler CA, Robinson JN, Klerman EB. Relationship between endogenous melatonin concentrations and uterine contractions in late third trimester of human pregnancy. J Pineal Res 2019; 66:e12566. [PMID: 30739346 PMCID: PMC6453747 DOI: 10.1111/jpi.12566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/17/2019] [Accepted: 01/25/2019] [Indexed: 01/06/2023]
Abstract
In humans, circulating levels of the hormone melatonin and the initiation of spontaneous labor are both higher at night than during the day. Since activation of uterine melatonin receptors can stimulate human in vitro uterine contractions and these receptors are only expressed on the uterine tissue of women in labor, we hypothesized that circulating melatonin concentrations would affect uterine contractions in vivo. We evaluated the impact of light-induced modulation of melatonin secretion on uterine contractions in women during late third trimester (~36-39 weeks) of pregnancy in two inpatient protocols. We found a significant (P < 0.05) positive linear association between circulating melatonin concentrations and the number of uterine contractions under both protocols. On average, uterine contractions increased between 1.4 and 2.1 contractions per 30 minutes for every 10 pg/mL*h increase in melatonin concentration. These findings have both basic science and clinical implications for pregnant women, since endogenous melatonin levels and melatonin receptor activity can be altered by light and/or pharmaceutical agents.
Collapse
Affiliation(s)
- Shadab A Rahman
- Division of Sleep Medicine, Harvard Medical School, Boston MA
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston MA
| | - Carolina Bibbo
- Department of Obstetrics, Brigham and Women’s Hospital, Boston MA
| | - James Olcese
- Florida State University College of Medicine, Tallahassee FL
| | - Charles A Czeisler
- Division of Sleep Medicine, Harvard Medical School, Boston MA
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston MA
| | | | - Elizabeth B Klerman
- Division of Sleep Medicine, Harvard Medical School, Boston MA
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston MA
| |
Collapse
|
33
|
Bibbo C, Easter SR, Saadeh M, Little SE, Robinson JN. Timing of Antenatal Corticosteroid Administration in Monoamniotic Twins. AJP Rep 2019; 9:e153-e159. [PMID: 31044097 PMCID: PMC6491365 DOI: 10.1055/s-0039-1687872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 12/11/2018] [Indexed: 11/17/2022] Open
Abstract
Objective This study was aimed to determine if different strategies of antenatal corticosteroid (ACS) administration in monoamniotic twins leads to receipt within 7 days of delivery. Study Design This is a retrospective cohort of monoamniotic twins managed at a single institution from 2007 to 2017. Patients were classified as to whether ACS were administered upon admission or at a predetermined gestational age (grouped together as "routine") or for a change in clinical status ("indicated"). We used univariate analyses to associate ACS administration strategies with our primary outcome: receipt of ACS within 7 days of delivery. We then used generalized estimating equations to examine associations between fetal monitoring patterns and delivery within 1 week. Results Twenty-four patients were included: eighteen patients in the "routine" group and six patients in the "indicated" group. There was no difference in optimal timing of ACS administration. Women experiencing delivery within the week were thrice more likely to spend on average more than 3 hours/day on the fetal monitor when compared with those who remained undelivered. Conclusion Administration of ACS on admission is not effective. Fetal heart rate tracing surveillance might be a better methodology to predict delivery and guide ACS administration.
Collapse
Affiliation(s)
- Carolina Bibbo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah R Easter
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Saadeh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian N Robinson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
34
|
Easter SR, Sweeney V, Manganaro K, Lassey SC, Bateman BT, Robinson JN. 278: Prospective clinical validation of the obstetric comorbidity index for maternal risk assessment. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
35
|
Holland E, Yao Y, Bateman BT, Taggart A, Sugrue R, Sequist TD, Robinson JN. 53: Evaluation of a quality improvement intervention to decrease post-cesarean opioid use across a multi-hospital system. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
36
|
Mehta PK, Easter SR, Potter J, Castleberry N, Schulkin J, Robinson JN. Lesbian, Gay, Bisexual, and Transgender Health: Obstetrician–Gynecologists' Training, Attitudes, Knowledge, and Practice. J Womens Health (Larchmt) 2018; 27:1459-1465. [DOI: 10.1089/jwh.2017.6912] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pooja K. Mehta
- Department of Obstetrics and Gynecology, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana
- Program in Health Policy and Systems Management, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer Potter
- Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, The Fenway Institute, Boston, Massachusetts
| | - Neko Castleberry
- Research Department, The American College of Obstetricians and Gynecologists, Washington, District of Columbia
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Julian N. Robinson
- Division of Maternal-Fetal Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
37
|
Greenberg JA, Robinson JN, Carabuena JM, Farber MK, Carusi DA. Use of a Fibrin Sealant Patch at Cesarean for Conservative Management of Morbidly Adherent Placenta. AJP Rep 2018; 8:e325-e327. [PMID: 30443434 PMCID: PMC6235679 DOI: 10.1055/s-0038-1675848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/06/2018] [Indexed: 11/04/2022] Open
Abstract
Background Morbidly adherent placenta represents a surgical challenge and source of maternal morbidity and mortality. We report the use of a fibrin sealant patch to address hemorrhage associated with a morbidly adherent placenta during cesarean delivery. Case A patient underwent repeat cesarean delivery with complete anterior placenta previa and anticipated morbidly adherent placenta. Bleeding persisted following delivery and removal of the placenta, despite uterine artery embolization. A fibrin sealant patch was applied as an adjuvant intervention to the placental bed and hemostasis was achieved without resorting to a hysterectomy. Conclusion Postpartum hemorrhage is an ongoing leading source of maternal morbidity and mortality. A case is presented in which a fibrin sealant patch provided control of focal placental bed bleeding, allowing removal of a focal morbidly adherent placenta and avoidance of hysterectomy.
Collapse
Affiliation(s)
- James A Greenberg
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian N Robinson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jean M Carabuena
- Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michaela K Farber
- Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
38
|
Abstract
OBJECTIVE The objective of this study was to investigate the relationship between preterm birth in a prior pregnancy and preterm birth in a twin pregnancy. STUDY DESIGN We performed a secondary analysis of a randomized controlled trial evaluating 17-α-hydroxyprogesterone caproate in twins. Women were classified as nulliparous, multiparous with a prior term birth, or multiparous with a prior preterm birth. We used logistic regression to examine the odds of spontaneous preterm birth of twins before 35 weeks according to past obstetric history. RESULTS Of the 653 women analyzed, 294 were nulliparas, 310 had a prior term birth, and 49 had a prior preterm birth. Prior preterm birth increased the likelihood of spontaneous delivery before 35 weeks (adjusted odds ratio [aOR]: 2.44, 95% confidence interval [CI]: 1.28-4.66), whereas prior term delivery decreased these odds (aOR: 0.55, 95% CI: 0.38-0.78) in the current twin pregnancy compared with the nulliparous reference group. This translated into a lower odds of composite neonatal morbidity (aOR: 0.38, 95% CI: 0.27-0.53) for women with a prior term delivery. CONCLUSION For women carrying twins, a history of preterm birth increases the odds of spontaneous preterm birth, whereas a prior term birth decreases odds of spontaneous preterm birth and neonatal morbidity for the current twin pregnancy. These results offer risk stratification and reassurance for clinicians.
Collapse
Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hector Mendez-Figueroa
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Suneet P Chauhan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| |
Collapse
|
39
|
Robinson JN. WHO recommendations, dollars and sense. BJOG 2018; 125:1068. [DOI: 10.1111/1471-0528.15284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- JN Robinson
- Obstetrics and Gynecology; Brigham and Women's Hospital; Boston MA USA
| |
Collapse
|
40
|
Lassey SC, Robinson JN, Kaimal AJ, Little SE. Outcomes of Spontaneous Labor in Women Undergoing Trial of Labor after Cesarean as Compared with Nulliparous Women: A Retrospective Cohort Study. Am J Perinatol 2018; 35:852-857. [PMID: 29365328 DOI: 10.1055/s-0037-1619448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to compare spontaneous labor outcomes in women undergoing trial of labor after cesarean (TOLAC) and nulliparas to better counsel women. STUDY DESIGN A 4-year retrospective cohort. We included women at term in spontaneous labor with vertex singletons and no more than one prior cesarean delivery. In planned secondary analysis, we focused on a subset of women with a prior cesarean and a predicted likelihood of a successful vaginal delivery of 70% or more based on the Maternal-Fetal Medicine Units-vaginal birth after cesarean (VBAC) calculator. RESULTS Our cohort included 606 TOLACS and 606 nulliparas. Women undergoing TOLAC were more likely to undergo cesarean delivery (25.7 vs. 14.7%; p < 0.001). Severe maternal hemorrhage (1.5 vs. 0.2%; p = 0.02) and uterine rupture (1.9 vs. 0.0%; p < 0.01) were more likely in the TOLAC group. For the subset of women with a predicted likelihood of VBAC of 70% or more, there were no differences in cesarean delivery (16.7 vs. 14.7%; p = 0.51), maternal, or immediate neonatal complications. CONCLUSION Women undergoing TOLAC were more likely to have a cesarean delivery, hemorrhage, or uterine rupture. Those with more than 70% predicted likelihood of VBAC were no more likely to experience these outcomes. These findings help contextualize the risks of TOLAC for women considering this option.
Collapse
Affiliation(s)
- Sarah C Lassey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anjali J Kaimal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
41
|
Clapp MA, Little SE, Zheng J, Robinson JN, Kaimal AJ. The relative effects of patient and hospital factors on postpartum readmissions. J Perinatol 2018; 38:804-812. [PMID: 29795320 DOI: 10.1038/s41372-018-0125-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/03/2018] [Accepted: 04/12/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the relative effects of patient and hospital factors on a hospital's postpartum readmission rate. STUDY DESIGN This retrospective cohort study was conducted using State Inpatient Databases from California, Florida, and New York between 2004 and 2013. We compared patient and hospital characteristics among hospitals with low and high readmission rates using χ2 tests. Risk-adjusted 30-day readmission rates were calculated for patient, delivery, and hospital characteristics to understand factors affecting readmission using fixed and random effects models. RESULTS Patients in hospitals with low readmission rates were more likely to be white, to have private insurance and higher incomes, and to have fewer comorbidities. The patient comorbidities with the highest risk-adjusted readmission rates included hypertension (range, 2.14-3.04%), obesity (1.78-2.94%), preterm labor/delivery (2.50-2.60%), and seizure disorder (1.78-3.35%). Delivery complications were associated with increased risk-adjusted readmission rates. Compared to patient characteristics, hospital characteristics did not have a profound impact on readmission risk. CONCLUSION Obstetric readmissions were more attributable to patient and demographic characteristics than to hospital characteristics. Readmission metric-based incentives may ultimately penalize hospitals providing high-quality care due to patient characteristics specific to their catchment area.
Collapse
Affiliation(s)
- Mark A Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA.
| | - Sarah E Little
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jie Zheng
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Julian N Robinson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Anjali J Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
42
|
|
43
|
|
44
|
Bibbo C, Rouse CE, Cantonwine DE, Little SE, McElrath TF, Robinson JN. Angle of Progression on Ultrasound in the Second Stage of Labor and Spontaneous Vaginal Delivery. Am J Perinatol 2018; 35:413-420. [PMID: 29112996 DOI: 10.1055/s-0037-1608633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to assess the association between the angle of progression (AoP) measured by transperineal ultrasound and mode of delivery and duration of the second stage. STUDY DESIGN This is a prospective observational study of nulliparous women with a singleton gestation at term in which serial transperineal ultrasound examinations were obtained during the second stage of labor. Multivariable logistic regression and adjusted survival models were used for the analysis. RESULTS A total of 137 patients were included in the analysis and median AoP for the study group was 153 degrees. The adjusted odds ratio (aOR) of requiring an operative delivery was 2.6 times higher for those patients who had an AoP < 153 degrees and the aOR of requiring a cesarean delivery was almost six times higher when compared with those patients who had an AoP ≥ 153 degrees (95% confidence interval [CI]: 1.0, 6.2; p = 0.04; aOR: 5.8, 95% CI: 1.2-28.3; p = 0.03, respectively). Those patients with an AoP < 153 degrees were at a higher hazard of staying pregnant longer (adjusted hazard ratio: 1.8, 95% CI: 1.2-2.8, p = 0.005). CONCLUSION The AoP has the potential to predict spontaneous vaginal delivery and the duration of the second stage of labor which may be useful in counseling patients and managing their labor.
Collapse
Affiliation(s)
- Carolina Bibbo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Caroline E Rouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - David E Cantonwine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Thomas F McElrath
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
45
|
Abstract
OBJECTIVE The objective of this study was to test whether hospitals experienced in twin delivery have lower rates of cesarean delivery for twins. METHODS We divided obstetric hospitals in the 2011 National Inpatient Sample by quartile of annual twin deliveries and compared twin cesarean delivery rates between hospitals with weighted linear regression. We used Pearson's coefficients to correlate a hospital's twin cesarean delivery rate to its overall cesarean delivery and vaginal birth after cesarean (VBAC) rates. RESULTS Annual twin delivery volume ranged from 1 to 506 across the 547 analyzed hospitals with a median of 10 and mode of 3. Adjusted rates of cesarean delivery were independent of delivery volume with a rate of 75.5 versus 74.8% in the lowest and highest volume hospitals (p = 0.09 across quartiles). A hospital's cesarean delivery rate for twins moderately correlated with the overall cesarean rate (r = 0.52, p < 0.01) and inversely correlated with VBAC rate (r = - 0.42, p < 0.01). CONCLUSION Most U.S. obstetrical units perform a low volume of twin deliveries with no decrease in cesarean delivery rates at higher volume hospitals. Twin cesarean delivery rates correlate with other obstetric parameters such as singleton cesarean delivery and VBAC rates suggesting twin cesarean delivery rate is more closely related to a hospital's general obstetric practice than its twin delivery volume.
Collapse
Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julian N Robinson
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniela Carusi
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
46
|
Panelli D, Robinson JN, Kaimal AJ, Melamed A, Clapp MA, Little SE. 405: Utilizing cervical dilation to predict labor onset: A tool for elective induction counseling. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
47
|
Little SE, Robinson JN, Zera CA. 51: Changes in delivery timing for high-risk pregnancies in the United States. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
48
|
Clapp MA, Little SE, Zheng J, Robinson JN, Kaimal AJ. 928: Case mix and the utility of postpartum readmission rates as a marker of quality in obstetrics. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
49
|
Easter SR, Panelli D, Bibbo C, Saadeh M, Little SE, Carusi D, Robinson JN. 58: Association between twin vaginal delivery promotion and twin vaginal birth. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
50
|
Ranjit A, Jiang W, Zhan T, Kimsey L, Staat B, Witkop CT, Little SE, Haider AH, Robinson JN. Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE. Birth 2017; 44:337-344. [PMID: 28833512 DOI: 10.1111/birt.12298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/09/2017] [Accepted: 06/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE. METHODS TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care. RESULTS A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care. CONCLUSION Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.
Collapse
Affiliation(s)
- Anju Ranjit
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Wei Jiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Tiannan Zhan
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Linda Kimsey
- Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, GA, USA
| | - Bart Staat
- Department of Obstetrics and Gynecology, Uniformed Health Services University, Bethesda, MD, USA
| | - Catherine T Witkop
- Department of Preventive Medicine and Biostatistics, Uniformed Health Services University, Bethesda, MD, USA
| | - Sarah E Little
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard School of Medicine and Harvard School of Public Health, Boston, MA, USA
| | - Julian N Robinson
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|