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Dellapiana G, Mok T, Platt LD, Silverman NS, Han CS, Esakoff TF. Sensitivity of antenatal ultrasound in diagnosing posterior placenta accreta spectrum disorders. J Perinat Med 2024; 52:288-293. [PMID: 38243911 DOI: 10.1515/jpm-2023-0491] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/01/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Optimal management of placenta accreta spectrum (PAS) requires antenatal diagnosis. We sought to evaluate the sensitivity of ultrasound findings suggestive of PAS in detecting posterior PAS. METHODS Cohort study of patients with posterior placentation and pathology-confirmed PAS from 2011 to 2020 at a tertiary center. Patients were excluded if ultrasound images were unavailable. Ultrasounds were reviewed for presence of lacunae, hypervascularity, myometrial thinning, loss of the hypoechoic zone, bridging vessels, abnormal uterine serosa-bladder interface, placental bulge, placental extension into/beyond the myometrium, and an exophytic mass. Risk factors, postpartum outcomes, and ultrasound findings were compared by antepartum suspicion for PAS. Sensitivity was calculated for each ultrasound finding. RESULTS Thirty-three patients were included. PAS was not suspected antenatally in 70 % (23/33). Patients with unsuspected PAS were more likely to be non-Hispanic, have in vitro fertilization, no prior Cesarean deliveries, no placenta previa, and delivered later in gestation. Depth of invasion and estimated blood loss were less for unsuspected PAS, but there was no difference in hysterectomy between groups. Ultrasound findings were less frequently seen in those who were not suspected antenatally: lacunae 17.4 vs. 100 % (p<0.001), hypervascularity 8.7 vs. 80 % (p<0.001), myometrial thinning 4.4 vs. 70 % (p<0.001), and placental bridging vessels 0 vs. 60 % (p<0.001). There was poor sensitivity (0-42.4 %) for all findings. CONCLUSIONS Posterior PAS is less likely to be detected antenatally due to a lower sensitivity of typical ultrasound findings in the setting of a posterior placenta. Further studies are needed to better identify reliable markers of posterior PAS.
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Affiliation(s)
- Gabriela Dellapiana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Thalia Mok
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lawrence D Platt
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Center for Fetal Medicine & Women's Ultrasound, Los Angeles, CA, USA
| | - Neil S Silverman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Center for Fetal Medicine & Women's Ultrasound, Los Angeles, CA, USA
| | - Christina S Han
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tania F Esakoff
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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VanHise K, Dellapiana G, Silverman NS. Intra-amniotic instillation of indocyanine green in uncertain cases of preterm rupture of membranes. Am J Obstet Gynecol MFM 2022; 4:100638. [PMID: 35398582 DOI: 10.1016/j.ajogmf.2022.100638] [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] [Received: 01/10/2022] [Revised: 03/17/2022] [Accepted: 03/31/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Katherine VanHise
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Ste. 3622, Los Angeles, CA 90048.
| | - Gabriela Dellapiana
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Neil S Silverman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA; Center for Fetal Medicine & Women's Ultrasound, Los Angeles, CA
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Burwick RM, Dellapiana G, Newman RA, Smithson SD, Naqvi M, Williams J, Wong MS, Bautista M, Gaden A, Kazani SD, Dunn DA, Ma MH, Mitter S, Monteleone JPR, Ortiz SR, Ghandehari S, Merin N, Zakowski MI, Karumanchi SA. Complement blockade with eculizumab for treatment of severe Coronavirus Disease 2019 in pregnancy: A case series. Am J Reprod Immunol 2022; 88:e13559. [PMID: 35514201 PMCID: PMC9347938 DOI: 10.1111/aji.13559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 03/03/2022] [Accepted: 04/25/2022] [Indexed: 12/16/2022] Open
Abstract
Problem We evaluated eculizumab, a complement protein C5 inhibitor, for treatment of severe COVID‐19 in pregnant and postpartum individuals. Method of Study Protocol ECU‐COV‐401 (clinicaltrials.gov NCT04355494) is an open label, multicenter, Expanded Access Program (EAP), evaluating eculizumab for treatment of severe COVID‐19. Participants enrolled at our center from August 2020 to February 2021. Hospitalized patients were eligible if they had severe COVID‐19 with bilateral pulmonary infiltrates and oxygen requirement. Eculizumab was administered on day 1 (1200 mg IV) with additional doses if still hospitalized (1200 mg IV on Days 4 and 8; 900 mg IV on Days 15 and 22; optional doses on Days 12 and 18). The primary outcome was survival at Day 15. Secondary outcomes included survival at Day 29, need for mechanical ventilation, and duration of hospital stay. We evaluated pharmacokinetic and pharmacodynamic data, safety, and adverse outcomes. Results Eight participants were enrolled at the Cedars‐Sinai Medical Center, six during pregnancy (mean 30 ± 4.0 weeks) and two in the postpartum period. Baseline oxygen requirement ranged from 2 L/min nasal cannula to 12 L/min by non‐rebreather mask. The median number of doses of eculizumab was 2 (range 1–3); the median time to hospital discharge was 5.5 days (range 3–12). All participants met the primary outcome of survival at Day 15, and all were alive and free of mechanical ventilation at Day 29. In three participants we demonstrated that free C5 and soluble C5b‐9 levels decreased following treatment. There were no serious adverse maternal or neonatal events attributed to eculizumab at 3 months. Conclusion We describe use of eculizumab to treat severe COVID‐19 in a small series of pregnant and postpartum adults. A larger, controlled study in pregnancy is indicated.
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Affiliation(s)
- Richard M Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gabriela Dellapiana
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rachel A Newman
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sarah D Smithson
- Department of Obstetrics and Gynecology, Loma Linda Medical Center, Los Angeles, California, USA
| | - Mariam Naqvi
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - John Williams
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Melissa S Wong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martha Bautista
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Anna Gaden
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shamsah D Kazani
- Clinical Development & Translational Sciences, Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Derek A Dunn
- Clinical Development & Translational Sciences, Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Mark H Ma
- Bioanalytical and Biomarker Development, Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Sanjay Mitter
- Biostatistics - Quantitative Sciences, Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Jonathan P R Monteleone
- Clinical Development & Translational Sciences, Pharmacometrics, Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Stephan R Ortiz
- Clinical Development & Translational Sciences, Clinical Pharmacology, Alexion, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Sara Ghandehari
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Noah Merin
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mark I Zakowski
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - S Ananth Karumanchi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Dellapiana G, Gupta M, Burwick RM, Greene N, Gregory KD. Elevated blood pressures during epidural placement are associated with increased risk of hypertensive disorders of pregnancy. J Matern Fetal Neonatal Med 2022; 35:9282-9287. [PMID: 35078390 DOI: 10.1080/14767058.2022.2026918] [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] [Indexed: 10/19/2022]
Abstract
BACKGROUND Many providers ignore hypertensive blood pressures (BPs) during epidural placement, attributing them to patient pain or malposition. We aimed to determine if an elevated BP during epidural placement was associated with increased risk for developing a hypertensive disorder of pregnancy (HDP). METHODS Cohort study of previously normotensive nulliparous, singleton, term patients who received neuraxial analgesia and delivered at our institution in 2016. Primary exposure was BP during epidural window (one hour before and after epidural procedure start time). Primary outcome was HDP (gestational hypertension, preeclampsia, eclampsia, or HELLP syndrome) prior to discharge. Statistics included χ2, t-test, and multivariable logistic regression; α = 0.05. RESULTS One thousand and eight hundred patients met study criteria. Patients with elevated BP during epidural window (n = 566, 31.4%) were more likely to develop HDP than patients who remained normotensive during epidural window (20.1% vs. 6.4%, adjusted OR 3.57 [95% CI 2.61-4.89]). The incidence of HDP increased in association with BP severity during epidural window: 7.3% for maximum systolic blood pressure (SBP) <140 mmHg; 18.4% for maximum SBP 140-159 mmHg (OR 2.9, 95% CI 2.0-4.0); and 29.9% for maximum SBP ≥160 mmHg (OR 5.4, 95% CI 2.9-9.8). The trend was similar for maximum diastolic BP. The magnitude of increased odds for HDP was highest for Black patients with elevated BP during epidural window (40.9% vs. 10.1%, OR 6.1, 95% CI 2.4-16). CONCLUSIONS Previously normotensive patients with an elevated BP during labor epidural placement are significantly more likely to develop HDP than patients who remain normotensive. Elevated BP during epidural placement should not be disregarded to ensure timely diagnosis and treatment.
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Affiliation(s)
- Gabriela Dellapiana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center & Burnes Allen Research Institute, Los Angeles, CA, USA
| | - Megha Gupta
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Richard M Burwick
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center & Burnes Allen Research Institute, Los Angeles, CA, USA
| | - Naomi Greene
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center & Burnes Allen Research Institute, Los Angeles, CA, USA
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center & Burnes Allen Research Institute, Los Angeles, CA, USA.,The Helping Hands of Los Angeles Miriam Jacobs Chair in Maternal Fetal Medicine, Los Angeles, CA, USA
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Dellapiana G, Waldman W, Govindappagari S, Burwick RM. Use of oxytocin as a low-dose intravenous push at time of cesarean delivery. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1050] [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]
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Smithson S, Mirocha J, Dellapiana G, Accortt E. Emergent cesarean delivery and immediate postpartum depression symptoms and social work consultation rates. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.792] [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]
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Dellapiana G, Gonzales S, Burwick RM. Calculated blood loss overestimates diagnosis of postpartum hemorrhage in patients with hypertensive disorders of pregnancy. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.553] [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]
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Dellapiana G, Gregory KD. Postpartum Hemorrhage Carts: Saving Time Can Save Lives. Jt Comm J Qual Patient Saf 2021; 48:67-68. [PMID: 34887199 DOI: 10.1016/j.jcjq.2021.11.005] [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: 10/19/2022]
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Dellapiana G, Levian C, Gubernick L, Burwick RM. Prophylactic postoperative antibiotics after emergent cesarean delivery and risk of postpartum infection or wound complication. J Matern Fetal Neonatal Med 2021; 35:6830-6835. [PMID: 34008468 DOI: 10.1080/14767058.2021.1926449] [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] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergent cesarean delivery (CD) carries a high risk for postpartum infection. In cases with a "splash" povidone-iodine (PI) skin preparation, prophylactic postoperative antibiotics (PP-Abx) are sometimes utilized, but the benefit is unclear. OBJECTIVE To evaluate if the use of PP-Abx decreases postpartum infection after emergent CD with "splash" PI skin preparation. STUDY DESIGN Cohort study of patients undergoing emergent CD with PI skin preparation from July 2012 to April 2020 at a single institution. Cases were identified using a natural language search engine, DEEP-6, with key terms "emergent" and "cesarean delivery." Patients with chorioamnionitis or non-PI skin preparation (e.g. chlorhexidine) were excluded. The primary exposure was use of PP-Abx. The primary outcome was postpartum infection or wound complication, defined as a composite: endometritis, wound infection, cellulitis, seroma, hematoma, or intra-abdominal abscess. Rates of postpartum infection or wound complication were stratified by use of PP-Abx. Demographic and labor characteristics were evaluated as confounders. Statistics by χ2, t-test, and logistic regression (α = 0.05). RESULTS In total, 481 patients underwent emergent CD; of those, 370 had PI skin preparation and were included. PP-Abx were given in 43% (160/370) of cases, including: cefazolin (n = 137), gentamicin/clindamycin (n = 18), azithromycin (n = 3), and vancomycin (n = 2). Those receiving PP-Abx were similar to those who did not, except the PP-Abx group was younger with longer CD duration. The rate of postpartum infection or wound complication was no different in patients who received PP-Abx compared to those who did not (12.6% vs. 9.5%, p = .34). This finding remained unchanged after multivariable adjustment (aOR 1.2, CI 0.61-2.4, p = .60). Moreover, the rate of postpartum infection or wound complication did not vary by antibiotic choice. CONCLUSIONS After emergent CD with PI skin preparation, routine use of prophylactic postoperative antibiotics does not appear to reduce the rate of postpartum infection or wound complication, which is important as we consider antibiotic stewardship. More studies are needed to identify treatments that decrease infectious morbidity with emergent CD.
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Affiliation(s)
- Gabriela Dellapiana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Candace Levian
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lindsay Gubernick
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard M Burwick
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Levian C, Dellapiana G, Govindappagari S, Burwick RM. 272 Patient factors and impact on NTSV cesarean delivery rate among individual physicians. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.294] [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: 11/30/2022]
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Levian C, Dellapiana G, Govindappagari S, Burwick RM. 113 Advanced maternal age and its impact on the NTSV cesarean delivery rate. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.135] [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: 10/22/2022]
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Dellapiana G, Naqvi M, Leggett C, Tholemeier L, Burwick RM. Preferential use of dexamethasone for fetal lung maturation in severe coronavirus disease 2019. Am J Obstet Gynecol MFM 2020; 2:100218. [PMID: 32844157 PMCID: PMC7439817 DOI: 10.1016/j.ajogmf.2020.100218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Gabriela Dellapiana
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Cedars Sinai Medical Center, Los Angeles, CA 90048
| | - Mariam Naqvi
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Cedars Sinai Medical Center, Los Angeles, CA 90048
| | - Cecilia Leggett
- Department of Obstetrics & Gynecology, Cedars Sinai Medical Center, Los Angeles, CA 90048
| | - Lauren Tholemeier
- Department of Obstetrics & Gynecology, Cedars Sinai Medical Center, Los Angeles, CA 90048
| | - Richard M Burwick
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Cedars Sinai Medical Center, 8635 W 3 St., Ste. 160W, Los Angeles, CA 90048
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Abstract
OBJECTIVE To evaluate whether prophylactic antibiotics at the time of placement of an intrauterine balloon tamponade (IBT) is associated with a reduction in postpartum endometritis. STUDY DESIGN Retrospective cohort study of patients who received an IBT from January 1, 2012, to December 12, 2016. Patients were included if the IBT remained in place at least 2 hours and excluded if chorioamnionitis was present. Patients who received prophylactic antibiotics at the time of IBT placement were compared with those who did not. RESULTS A total of 149 subjects received an IBT; 36 were excluded due to early removal or chorioamnionitis. Of the remaining, 59 received prophylactic antibiotics and 54 did not. Baseline characteristics were similar between the groups except mode of delivery. The majority (65%) of those who did not receive prophylactic antibiotics had a cesarean delivery (p = 0.03). The overall incidence of endometritis was 15%. The incidence of endometritis was greater among those patients who did not receive prophylactic antibiotics compared with those who did (5 vs. 26%; p < 0.002; odds ratio [OR]: 6.53; 95% confidence interval [CI]: 1.76-24.25). This association remained after adjustment for mode of delivery and receiving group B Streptococcus antibiotics prior to delivery (adjusted OR: 5.9; 95% CI: 1.58-22.35). CONCLUSION Prophylactic antibiotics were associated with a reduction in postpartum endometritis among patients receiving an IBT.
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Affiliation(s)
- Melissa S Wong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gabriela Dellapiana
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Naomi Greene
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
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