RRD Program 2014 - Stony Brook University School of Medicine

Department of Obstetrics,
Gynecology and Reproductive Medicine
THIRTY FOURTH
ANNUAL
RESIDENTS & FELLOWS
RESEARCH DAY
JUNE 13, 2014
Stony Brook University Hospital
Stony Brook, New York
PROGRAM OBJECTIVES
The purpose of this program is to provide a forum for discussion of original
research findings and for the introduction, development, and review of new
and most accepted approaches to the discipline of Obstetrics and Gynecology.
Upon completion of the program, participants should be able to apply medical
problem-solving skills, practice new approaches to manual and surgical skills,
and utilize skills in evaluating new information.
CONTINUING MEDICAL EDUCATION CREDITS
The School of Medicine, State University of New York at Stony Brook, is
accredited by the Accreditation Council for Continuing Medical Education to
sponsor continuing medical education for physicians.
The School of Medicine, State University of New York at Stony Brook
designates this activity for a maximum of 5.5 AMA PRA Category 1
Credit(s)™. Physicians should only claim credit commensurate with the extent
of their participation in the activity.
Dorothy S. Lane, M.D.
Associate Dean for Continuing Medical Education
(631) 444-2094
The American College of Obstetricians and Gynecologists has assigned 6
cognate credits to this program.
DISCLOSURE POLICY
All those in control of CME content are expected to disclose any relevant
financial relationship with the provider of commercial products or services
discussed in the educational presentation or that have directly supported the
CME activity through an educational grant to the sponsoring organization(s).
All commercial relationships that create a conflict with the planners, speakers
and author’s control of content must be resolved before the educational activity
occurs.
Department of Obstetrics, Gynecology
and Reproductive Medicine
Stony Brook Medicine
Thirty Fourth Annual Residents and Fellows Research Day
Chair:
Todd Griffin, MD
Residency Program Director:
Associate Residency Program Director:
Melissa Henretta, MD, MPH
Elizabeth Garduno, MD, MPH
RRD Program Director:
Richard Bronson, MD
RRD Program Committee:
Deborah Duttge
Catherine Connelly
Terry Leonbruno
Darlene Swords
Department Faculty:
Kristen Alarcon, NP
Susan Altman, CNM, DNP
Cecilia Avila, MD, MPH
David Baker, MD
James Bernasko, MD, CDE
Richard Bronson, MD
Lauri Budnick, MD
Joseph Chappelle, MD
Kristen Clemens, CM
Christine Conway, MD
Michael Demishev, MD
James Droesch, MD
Evangelia Falkner, CNM
Heather Findletar, CNM, DNP
Maria Fisher, CNM
Elizabeth Garduno, MD, MPH
Jennifer Griffin, NP
Todd Griffin, MD
Rosemary Griffith, NP
Melissa Henretta, MD, MPH
Jessica Hilsenroth, CNM
Pamela Koch, CNM
Christina Kocis, CNM, DNP
Dorota Kowalska, MD
Inna Landres, MD
Laura Lesch, NP
Goldie McBride, CM
Juliana Opatich, MD
Christina Pardo-Maxis, MD, MPH
Michael Pearl, MD
J. Gerald Quirk, MD, PhD
Lisa Rimpel, MD
Michelle Salz, CNM
Carrie Semelsberger, NP
Natalie Semenyuk, MD
Amanda Sini, CNM
Melissa Strafford, MD
Eva Swoboda, MD
Joyce Varughese, MD
Ann Visser, CNM
Lee Weiss, MD
Martin L. Stone, MD - Deceased
Professor Emeritus
Linda Tseng, PhD
Professor Emeritus
LECTURERS AND JUDGES
THIRTY FOURTH ANNUAL RESIDENTS & FELLOWS RESEARCH DAY
THE MARTIN L. STONE, MD VISITING LECTURER AND JUDGE
David Keefe, MD
Chairman, Department of Obstetrics & Gynecology
New York University
New York, NY
JUDGES
Vincent W. Yang, MD, PhD
Simons Chair of Medicine
Professor, Department of Medicine
Professor, Department of Physiology & Biophysics
Stony Brook Medicine
Stony Brook, NY
John Wagner, MD
WGM Ob/Gyn
East Northport, NY
RESIDENTS
CHIEFS
Fabiola Balmir, MD
Daniela Carlos Pons, MD
Deepti Nahar, MD
Jane So, MD, Administrative Chief
Melanie Van Sise, MD, Administrative Chief
PGY-3
Emily Blanton, MD
Julie Lian, MD
Malini Persad, MD, MPH
Kristin Sharar, MD
Ruth Wei, MD
PGY-2
Kir-Wei Chen, MD
Kelly Danyshylyn-Adams, MD
Sarah Park, MD
Angeline Seah, MD
Cynthia Ugbomah-Shepard, MD
PGY-1
Amy DeMarco, MD
Jessica Nunziato, MD
Jessica Parker, MD
Andre Plair, MD
Jenny Zhang, MD
FELLOWS
Maternal Fetal Medicine
Corinne Yeh, MD
Tracy Adams, DO
Nadia Kunzier, DO
3rd year
2nd year
1st year
Minimally Invasive Surgery
Jennifer Blaber, MD
1st year
PROGRAM
8:30 – 8:35
Welcome & Introduction - Richard Bronson, MD,
Residents & Fellows Research Day Program Director
8:35 – 8:50
Pulling the Trigger Safely: A Comparison of 4 Suppression-Trigger
Protocols for In Vitro Fertilization Treatment
Malini Persad , MD, MPH
Faculty Advisor: James Stelling, MD
8:50 – 9:00
Discussion & Questions - Discussant: Richard Bronson, MD
9:00 – 9:15
Uterine Myomectomy: Comparing Robotic-Assisted, Laparoscopic
and Open Techniques
Emily Blanton, MD
Faculty Advisors: Todd Griffin, MD, Joseph Chappelle, MD,
Cara Ninivaggio, MD
Contributor: Dorothy Carter, MD
9:15 – 9:25
Discussion & Questions - Discussant: Melissa Henretta, MD, MPH
9:25 – 9:40
Evaluation of a Simplified Methotrexate Protocol in the Treatment
of Ectopic Pregnancy
Kristen Sharar, MD
Faculty Advisors: Jennifer Blaber, MD, Cara Ninivaggio, MD
9:40 – 9:50
Discussion & Questions - Discussant: Lee Weiss, MD
9:50 – 10:05
Therapeutic Rest in Pregnancy
Xun Lian, MD
Faculty Advisor: Joseph Chappelle, MD
10:05 – 10:15
Discussion and Questions - Discussant: Christina Pardo-Maxis, MD
10:15 – 11:15
~ Poster Presentations ~
11:15 – 11:30
Peripartum Hysterectomy: A Retrospective Study on Incidence, Risk
Factors, Indications and Complications Before and After the
Implementation of a Standardized Multidisciplinary Protocol
Ruth Wei, MD
Faculty Advisor: Cecilia Avila, MD, MPH
11:30 – 11:40
Discussion & Questions - Eva Swoboda, MD
11:40 – 11:55
The Timing of Administration of Antenatal Corticosteroids in Women
with Indicated Preterm Birth
Tracy Adams, DO
Faculty Advisors: Wendy Kinzler, MD, Martin Chavez, MD,
Anthony Vintzileos, MD
11:55 – 12:05
Discussion & Questions - Discussant: James Bernasko, MD
12:05 – 1:05
Reproductive Aging in Women
David Keefe, MD
PROGRAM (CONTINUED)
1:05 – 2:20
~ Lunch ~
2:20 – 2:35
The Use of Cervical Sonography to Differentiate
True versus False Labor in Term Gestations
Nadia Kunzier, DO
Faculty Advisors: Wendy Kinzler, MD, Jolene Muscat, MD,
Martin Chavez, MD, Anthony Vintzileos, MD
2:35 – 2:45
Discussion and Questions- Discussant: Michael Demishev, MD
2:45 – 3:00
The Effect of Polybrominated Diphenyl Ethers on Placental
Proinflammatory Cytokine Production
Corinne Yeh, MD
Faculty Advisor: Morgan Peltier, PhD
3:00 – 3:10
Discussion and Questions- Discussant: J. Gerald Quirk, MD, PhD
~
Poster Presentations ~
Defining the Normal Uterus
Kir-Wei Chen, MD
Faculty Advisor: James Stelling, MD
Time From Skin Incision to Delivery in Cesarean Sections
and Associated Neonatal Outcomes
Kelly Danylyshyn-Adams, MB, BCh, BAO,
Faculty Advisors: Joseph Chappelle, MD
Contributor: Melanie Van Sise, MD
Surgical Approach to Hysterectomy
Sarah Park, MD
Faculty Advisor: Joseph Chappelle, MD
Does Butorphanol Affect Intrapartum Blood Pressures?
Angeline Seah, MD
Faculty Advisor: Joseph Chappelle, MD
The Relationship Between Pregnancy Associated Plasma Protein A (PAPP-A) and the Subsequent Diagnosis of Gestational Diabetes
Cynthia Ugbomah Shepard, MD
Faculty Advisor: Cecilia Avila, MD, MPH
Pulling the Trigger Safely: A Comparison of 4 Suppression-Trigger
Protocols for In Vitro Fertilization Treatment
Malini Persad, MD MPH, James Stelling, MD
Background:
Although IVF is the most effective form of assisted reproductive
technology available, undergoing this procedure is not without risk. Severe OHSS is a
major complication that affects 10% of cycles. While the antagonist-agonist trigger
protocol is effective in reducing the incidence of OHSS, associated pregnancy
outcomes remain ill defined. Furthermore, no one study has simultaneously compared
the three most commonly utilized suppression-trigger protocols and assessed the role of
the dual trigger, luteal phase support, and pregnancy outcomes.
Objective: The objective of this study was to compare the cycle features and
pregnancy outcomes of the antagonist-hCG trigger, antagonist-agonist trigger, and
antagonist-dual trigger protocols to the traditional agonist-hCG trigger protocol.
Design: A retrospective study of IVF cycles was performed from January 2010 to
March 2013 to compare age, BMI, infertility diagnosis, gonadotropin used, number of
stimulation days, number of follicles on the day of ovulation trigger, number of oocytes
retrieved, number of oocytes fertilized, luteal phase support, pregnancy rate,
implantation rate, ongoing pregnancy rate, spontaneous abortion rate, multiple
gestation rate, hospitalization rate, and incidence of severe OHSS of three
suppression-trigger protocols to the traditional agonist-hCG trigger protocol.
Materials and Methods: Data was collected from the electronic medical record of a
private infertility clinic in Long Island. Only fresh autologous cycles with a day 3
FSH<15 mIU/ml, sufficient ovarian response (>10 follicles on the day of ovulation
trigger), embryo transfer, and no more than 3 previous IVF cycles were included.
Natural, clomid, and agonist-flare cycles were excluded. A sub-analysis of 50 cases
from each suppression-trigger protocol was performed to assess the best agent and
route of administration for luteal phase support (i.e., use of progesterone +/- estradiol).
The data was analyzed via Chi Square, ANOVA, and Post Hoc Analyses with
SPSS®V21.
Results: Only 581 cycles met study criteria. There were no significant differences in
age, BMI, primary infertility diagnosis, gonadotropins used, stimulation days, follicles
visualized on the day of trigger, or multiple gestation rate across groups (ρ>0.05).
There were significantly more oocytes retrieved and oocytes fertilized in the antagonist
-agonist and the antagonist-dual trigger groups when compared to the agonist-hCG
trigger group (ρ<0.05). Compared to agonist-hCG trigger group, the antagonist-agonist
trigger group had a marginally significant lower pregnancy rate and spontaneous abortion rate (ρ=0.06, ρ=0.09 respectively) and a statistically significant lower implantation
rate and ongoing pregnancy rate (ρ<0.05). The antagonist-hCG and antagonist-dual
trigger groups had comparable pregnancy outcomes to the agonist-hCG trigger group
(ρ>0.05). There were no hospitalizations or cases of severe OHSS in the studied
groups. Of the 581 cycles studied, 174 were selected to assess pregnancy outcomes by
luteal phase support. In the agonist-hCG, antagonist-hCG, and antagonist-dual trigger
groups there were no significant difference in pregnancy outcomes in regard to luteal
phase support (ρ>0.05). In the antagonist-agonist trigger group, intramuscular administration of progesterone was associated with a significantly higher implantation and
ongoing pregnancy rates (ρ<0.05).
Continued
Pulling the Trigger Safely: A Comparison of 4 Suppression-Trigger
Protocols for In Vitro Fertilization Treatment
(continued)
Malini Persad, MD MPH, James Stelling, MD
Conclusions: The antagonist-hCG trigger and the antagonist-dual trigger groups had
comparable cycle outcomes to the traditional agonist-hCG trigger group. While it is
known that the antagonist-agonist trigger protocol is associated with a significantly
lower risk for severe OHSS, this group also had a significantly lower implantation and
ongoing pregnancy rate. The antagonist-dual trigger group therefore is a great
alternative as it ensures both patient safety and cycle efficacy given comparable
pregnancy outcomes to the traditional agonist-hCG trigger group and similar severe
OHSS incidence as the antagonist-agonist trigger group. For luteal phase support,
intramuscular administration of progesterone is preferred in the antagonist-agonist
trigger group because of improved pregnancy outcomes. The route of administration of
progesterone for luteal phase support in the other suppression-trigger groups does not
change pregnancy outcomes. Unfortunately, there was insufficient data to determine
the best agent and route of administration of estradiol for luteal phase support in all
groups. Therefore, future studies should focus on determining the best agent and route
of administration of estradiol supplementation during the luteal phase.
Uterine Myomectomy: Comparing Robotic-Assisted,
Laparoscopic and Open Techniques
Emily Blanton, MD, Todd Griffin, MD, Joseph Chappelle, MD
Cara Ninivaggio, MD, Dorothy Carter, MD
Objective: To determine whether a robot-assisted approach offers an advantage over
laparotomy or traditional laparoscopy when performing uterine myomectomies.
Methods: A retrospective chart review of women undergoing a uterine myomectomy
at Stony Brook University Hospital from January 2008 to August 2012 was performed.
Data collected included patient demographics, tumor characteristics and perioperative
outcomes. Specifically, we examined the number of myomas removed, location, depth
of infiltration, and myoma weight. Surgical endpoints were operating time, blood loss,
length of stay and complications. Statistical comparisons were performed using
ANOVA, Student’s t-test and the c2 test.
Results: 145 women qualified for this study who underwent open (26), laparoscopic
(36) and robot-assisted (83) procedures. Data collected included patient demographics,
tumor characteristics and perioperative outcomes. Specifically, we examined the
number of myomas removed, location, depth of infiltration, and myoma weight.
Surgical endpoints were operating time, estimated blood loss, length of stay and
complications. No significant differences in patient demographics between surgical
approaches were noted. The number of myomas removed per case was similar across
all techniques. The largest myoma extracted was significantly greatest via laparotomy
(14.1cm) than either of the two minimally invasive approaches (7.3cm in both
laparoscopic and robotic-assisted). Similarly, the combined weight was also found to
be significantly greatest in the laparotomy group (816.8g) compared to both minimally
invasive techniques (223.5g laparoscopy, 218.8g robot-assisted). Intramural and
submucosal myomas were more often removed robotically (70 robot-assisted, 23
laparoscopy, 22 laparotomy). The perioperative outcomes of estimated blood loss and
length of stay were the least with the minimally invasive techniques, while the
laparotomy procedures had a shorter OR time.
Conclusion: Despite the fact that larger myomas were more often removed by
laparotomy, robotics allows for removal of myomas of greater depth of infiltration
without sacrificing surgical outcomes.
Evaluation of a Simplified Methotrexate Protocol
in the Treatment of Ectopic Pregnancy
Kristin Sharar, MD, Jennifer Blaber, MD,
Cara Ninivaggio, MD
Objective: To identify if the use of two blood hormone values can adequately and
reliably predict successful methotrexate treatment of ectopic pregnancy.
Introduction: Improved imaging modalities and the ability to trend pregnancy
hormone levels have increased the frequency of diagnosis of ectopic pregnancy prior to
rupture. This has therefore improved overall maternal morbidity, future fertility and
decreased the need for invasive surgical interventions. Current protocols require strict
physician and patient adherence to precautions and deliberate testing of serum Beta
HCG levels on defined days such as the first (day of treatment), fourth and seventh
days after methotrexate (MTX) administration. Many patients have poor access to care
and follow up and hence, may not be offered less invasive management options. As
such, eliminating an extra blood test in the appropriate patient may increase patient
adherence and long term success of medically managed ectopic pregnancies.
Methods: The charts for all women who presented to Stony Brook University Hospital
Emergency Department from 2009 to present with ICD-9 codes of ectopic or tubal
pregnancy or MTX administration were reviewed. Demographics, ectopic risk factors,
beta HCG levels, and sonographic findings, and success of treatment was collected.
Unsuccessful treatment was defined as any woman who needed additional MTX doses
or surgical intervention. Endpoints include days 1, 4 and 7 beta HCG levels, need for
additional MTX administration, or need for surgical intervention. Mann-Whitney,
student t, chi-square tests, and ROC analyses were used for analysis.
Results: 219 women were identified who met inclusion criteria. Complete records
were available for 28 of the women and they were included in the final analysis.
Demographics, ectopic risk factors, and sonographic findings were not significantly
different between the successfully and unsuccessfully treated groups. Women who
were successfully treated had a greater decline in beta HCG levels from day 4 to day 7
(-38.5% vs. -4.3%, p<0.0001) and a decline from day 1 to day 7, while the unsuccessful
group experienced an increase in these values (-44% versus increase by +52%, p
<0.0001). ROC analyses were performed to determine the optimal cut-off value for
each comparison. The analysis for day 4 to day 7 determined that a 15% decrease
correctly identified treatment success with a sensitivity of 95% and a specificity of
87.5%. Day 1 to Day 7 analysis found that a 10% increase was optimal with a
sensitivity of 95% and a specificity of 87.5%.
Conclusions: Optimizing the MTX protocol will reduce testing and may allow more
women to have conservative treatment. A less than 10% increase in HCG levels
between days 1 and 7 was found to be almost as accurate as a 15% from day 4 to day 7
in determining treatment success. This may point towards a new alternative method of
MTX follow-up and warrants further study.
Therapeutic Rest in Pregnancy
Xun Lian MD, Joseph Chappelle MD
Objective: Determine the characteristics associated with admission after therapeutic
rest.
Background: Latent labor can be a long and painful process, lasting up to 20 hours in
a nulliparous woman with a normal labor curve. The optimal management of women
with a prolonged latent phase has not been established. When conservative measures
fail, therapeutic rest with intravenous (IV) narcotic medications is often offered. After
IV narcotics are administered, some women will be admitted in active labor while
others will be sent home if they demonstrate no cervical change. Knowing which
women are more likely to progress to active labor may enable us to offer these women
admission and epidural for pain control, thus decreasing their length of stay and the
resources needed to monitor them.
Materials and Methods: This was a retrospective chart review analyzing the medical
records of patients with term pregnancies who received IV narcotics for therapeutic rest
between January 2010 and January 2013. Demographic, pregnancy, and labor
information will be recorded as well as cervical exam before and after IV narcotic
administration and disposition. Data collected was analyzed via univariate and
multivariate analysis.
Results: 122 patients with term pregnancies received narcotics for therapeutic rest.
Length of time from medication administration to disposition ranged from 2 hours to 19
hours. Approximately 78% of patients were admitted, of whom 82% had vaginal
deliveries. Gestational age > 39 weeks was associated with subsequent admission with
an odds ratio of 4.9 (p<0.05). Other factors such as parity, age, and BMI were not
associated with admission.
Conclusion: Therapeutic rest is offered to women who experience painful and
prolonged latent labor. While this intervention can provide temporary relief to patients,
it can increase hospital costs and length of stay. Determining the patient characteristics
associated with progress in labor and admission may be useful in providing efficient
care to patients. This preliminary study suggests that women greater than 39 weeks
gestation may benefit from admission instead of therapeutic rest.
Peripartum Hysterectomy: A Retrospective Study on Incidence,
Risk Factors, Indications and Complications Before and After the
Implementation of a Standardized Multidisciplinary Protocol
Ruth Wei, MD, Cecilia Avila, MD, MPH
Objective: To determine the effect of a standardized peripartum multidisciplinary
protocol on incidence, indications, risk factors and complications associated with
peripartum hysterectomy in a tertiary care institution.
Background: Peripartum Hysterectomy, defined as a hysterectomy performed at the
time of delivery and up to 6 weeks postpartum, is traditionally performed as a
life-saving procedure for uncontrolled hemorrhage after failed medical and/or
conservative management. Since 2007, the Stony Brook University Hospital has
implemented a protocol for management of acute obstetric hemorrhage.
Method: A retrospective cohort analysis of all cases of peripartum hysterectomies at
Stony Brook University Hospital from 2002 to 2012 was conducted. All patients who
underwent a peripartum hysterectomy since 2002 were identified by the hysterectomy
specimen logbook from the Department of Pathology through Dr. Cynthia Kaplan. A
retrospective chart review was performed via hospital electronic medical records and
paper records, including progress notes, operative notes and pathology reports were
used to confirm the final indication for procedure. Patient demographics, risk factors,
intra and post-operative data were reviewed. Chart review was performed on patients 6
years prior to implementation of the multidisciplinary protocol (2002-2007) and 6 years
after (2007-2013).
Result: 54.2 % in pre-implementation group and 43.3% in post-implementation group
for suspected accreta (p=.368). Calculated blood loss was 4074cc in pre-implementation
group and 4198cc in post-implementation group (p=0.827). The only statistical
significance is BMI, with BMI of 29.9 for pre-implementation group, BMI of 33.25 for
post-implementation group (P= 0.002).
Conclusion: There was no difference in the incidence, indications, and risk factors
associated with peripartum hysterectomy before and after the implantation of the
multidisciplinary protocol.
The Timing of Administration of Antenatal Corticosteroids in
Women with Indicated Preterm Birth
Tracy Adams, DO, Wendy Kinzler, MD,
Martin Chavez, MD, Anthony Vintzileos, MD
Methods: This was a retrospective cohort of patients who received AS in anticipation
of indicated PTB between 2009 and 2012. Charts on patients who received AS, as
identified through the hospital pharmacy database, were reviewed. Patients were included if they had a singleton or twin gestation and they received AS for maternal or fetal
indications. Maternal indications included: preeclampsia (PE) with or without
intraauterine growth restriction (IUGR), bleeding previa, or other maternal illness. Fetal
indications included idiopathic IUGR, abnormal Dopplers, oligohydramnios, nonreassuring fetal status, or placental anomaly. Maternal demographic and obstetrical
characteristics were compared between those who received AS ≤7d (optimal timing)
vs>7d from delivery (suboptimal timing) using the appropriate parametric and nonparametric tests. P<0.05 was considered significant. Relative risks and 95% confidence
intervals were calculated.
Results: 193 patients were included in this study. Median latency from AS to delivery
was 9 days (range 0-83); 93 patients (48%) received AS within 7d of delivery. There
were no significant differences between the two groups with regards to maternal
demographic characteristics. The mean gestational age at delivery was 30.7±2.7 wks
vs34.7±3.0 wks (p<0.01) for those delivered in ≤7d vs>7d. Table 1 compares the indications for PTB between the two groups.
Conclusions: Only 48% of patients with an indication for PTB received AS within 7d
of its administration. Patients who received AS for maternal indications, especially suspected PE, were more likely to be delivered within 7d. Patients with fetal indications
(idiopathic IUGR or abnormal Doppler studies) were more likely to be delivered in
>7 d. AS appear to be more optimally timed when maternal versus fetal indications exist
for PTB.
Table 1
INDICATION
>7 DAYS
N= 100
53 (53%)
P VALUE
RR (95% CI)
MATERNAL
≤7 DAYS
N= 93
78 (84%)
<0.01
1.5 (1.3,1.9)
Preeclampsia
71 (76%)
41 (41%)
<0.01
1.9 (1.4,2.4)
Bleeding previa
4 (4%)
11 (11%)
0.04
0.4 (0.1,1.2)
Other*
4 (4%)
1 (1%)
0.09
4.3 (0.5,38)
FETAL
15 (16%)
47 (47%)
<0.01
0.3 (0.2,0.6)
IUGR/ Abnormal
Dopplers
Oligohydramnios
Otherⱡ
8 (9%)
31 (31%)
<0.01
0.3 (0.1,0.6)
2 (2%)
5 (5%)
7 (7%)
9 (9%)
0.06
0.18
0.3 (0.1,1.4)
0.6 (0.2,1.7)
* Includes: Maternal acute abdomen, Maternal SVT and TTP
ⱡ Includes: Non-reassuring fetal status, and placental anomalies
The Use of Cervical Sonography to Differentiate
True versus False Labor in Term Gestations
Nadia Kunzier, DO, Wendy Kinzler, MD, Jolene Muscat, MD,
Martin Chavez, MD, Anthony Vintzileos, MD
Objective: Cervical length (CL) by transvaginal ultrasound (TVUS) to predict preterm
labor is widely used in clinical practice. Virtually no data exist on CL measurement to
differentiate true vs false labor at term. Incorrect diagnosis of true labor at term may
lead to unnecessary hospital admissions, obstetrical interventions, resource utilization
and cost. Our objective is to determine if CL by TVUS can differentiate true vs false
labor at term.
Study Design: This is a prospective observational study of women presenting to labor
and delivery with labor symptoms at 37-42 weeks, singleton cephalic gestation, regular
uterine contractions (≥4/20 minutes), intact membranes, and cervix ≤4cm dilated and
≤80% effaced. Those patients with placenta previa and indications for immediate
delivery were excluded. The shortest best CL of 3 collected images was chosen by a
single investigator. Providers managing labor were blinded to the CL. True labor was
defined as spontaneous rupture of membranes or spontaneous cervical dilation ≥4 cm
and ≥80% effaced within 24 hours of CL. In the absence of these outcomes, labor status
was assigned false labor. An ROC curve was generated to assess the use of CL to
differentiate true vs false labor at term. CL vs time to delivery was also analyzed.
Results: Thirty-seven patients met criteria for analysis; 21/37 (57%) patients were in
true labor. The median (range) CL was 1.9cm (0.7-4.3cm). The area under the ROC
curve showed a concordance of 0.72. CL cutoff of ≤1.5 cm to predict true labor
produces a specificity of 87%, positive predictive value (PPV) of 82% and false
positive rate (FPR) of 13% (Table 1). CL was positively correlated with time to
delivery.
Conclusion: In differentiating true vs false labor at term, CL of ≤1.5cm is the most
clinically optimal cutoff with the highest specificity, PPV and discriminant ability, and
the lowest FPR. Its use to decide admission in patients at term may prevent unnecessary
admissions, obstetrical interventions, resource utilization and cost.
Diagnostic accuracy of CL cutoffs in differentiating true vs false labor in term
gestations
CL
≤1.5cm
CL ≤ 2cm
CL ≤
2.5cm
CL ≤ 3cm
CL ≤
3.5cm
Sensitivity
45%
75%
90%
90%
95%
Specificity
87%
56%
37%
22%
6%
FPR
13%
44%
63%
78%
94%
PPV
82%
70%
64%
59%
56%
NPV
56%
65%
75%
63%
50%
66%
65.5%
63.5%
56%
50.5%
Discriminant ability
(Sensitivity+
Specificity/2)
Effect of Polybrominated Diphenyl Ethers
on Placental Proinflammatory Cytokine Production
Corinne Yeh, MD, Morgan Peltier, PhD
Background: Polybrominated diphenyl ethers (PBDEs) are widespread pollutants from
their use as flame retardants in everyday objects. Limited studies reported an association
with adverse pregnancy outcomes. They are detectable in nearly all women tested, and
2nd trimester placental explants exposed to PBDEs in-vitro demonstrated enhanced
inflammation. PBDEs may modify the risk of inflammation-mediated preterm birth by
enhancing a proinflammatory environment at the maternal-fetal interface. However, it is
not known whether PBDEs exert similar immunomodulatory properties in
3rd-trimester placentas.
Objective: To evaluate the effects of different PBDE congeners on the production of
proinflammatory cytokines and COX-2 in third trimester placental explants.
Methods: Third-trimester placental explants were cultured for 3 days with 2 μM of
PBDE-47, -99, -100, -153, -209, PBDE-Mix (equal concentrations of -47, -99,
and -100) or an equivalent volume of vehicle (control). Cultures were then treated with
heat-killed E. coli or sterile medium (control) overnight. Gene expression of IL-1β, TNF
-α, IL-10 and COX-2 was analyzed by real-time PCR and results normalized to GAPDH
expression. Concentrations of IL-1β, TNF-α, and IL-10 in the conditioned media were
assessed by ELISA. Relative cell viability was evaluated using an MTT assay. Data
were analyzed using linear mixed effects models.
Results: Stimulation with E. coli significantly increased secretion and gene expression
of all cytokines, and also increased COX-2 gene expression in cultures untreated by
PBDEs. However, compared to the vehicle control, PBDEs did not significantly modify
IL-1β, TNF-α, IL-10 or COX-2 gene expression either in cultures that were unexposed
or exposed to E. coli. In explants not exposed to E. coli, treatment with PBDE-100, 209, -47, and -99 resulted in 0.85-fold (95% CI 0.78-0.92), 0.86-fold (95% CI 0.790.93), 0.87-fold (95% CI 0.81-0.95), and 0.87-fold (95% CI 0.80-0.94) reductions of ILβ secretions into conditioned media, respectively, compared to the vehicle. TNF-α concentration was 0.83-fold (95% CI, 0.69-0.99) lower in explants treated with PBDE-100
and unstimulated by bacteria. PBDE-100 reduced secretion of IL-10 in the cultures
without E. coli by 0.88-fold (95% CI, 0.80-0.97). In E. coli-exposed cultures, IL-10
concentrations were lower for tissues exposed to PBDE-153 and -99 by 0.89-fold (95%
CI, 0.80-0.97) and 0.90-fold (95% CI, 0.82-0.99), respectively. Culture viability in explants not stimulated by E. coli was decreased by PBDE-209, -47, and -99, while PBDE
-153, -47, and -99 decreased culture viability in explants exposed to E. coli.
Conclusions: PBDEs do not appear to increase the secretion or expression of proinflammatory cytokines, the anti-inflammatory IL-10, or the expression of COX-2 in 3rd
trimester placental explants, either in the basal state or in response to stimulation by
heat-killed E. coli. Decreases in cytokine secretion may be related to PBDE’s observed
effect on culture viability rather than modulation of the inflammatory pathway. Further
studies with animal models or large scale epidemiological studies are necessary to
determine if PBDEs can alter pregnancy outcome.
APPENDIX
PAST AWARD WINNERS
AND
ALUMNI
The Martin L. Stone, MD Award
Outstanding Resident in Recognition of
Dedication, Commitment, and Service
(Formerly Resident of the Year Award)
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
Robert O’Keefe, MD
Eva Chalas, MD
Jeffrey Porte, MD
Eva Chalas, MD
Jeffrey Porte, MD
Christian Westermann, MD
Timothy Bonney, MD
Michael Arato, MD
Marie Welshinger, MD
John Wagner, MD
Pui Chun Cheng, MD
Lawrence Weinstein, MD
Ira Bachman, MD
Ira Bachman, MD
James Stelling, MD
Todd Griffin, MD
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
David Reavis, MD
Lynn Macco, MD
Siobhan Hayden, MD
Martina Frandina, MD
Siobhan Hayden, MD
JoAnna Paolilli, MD
Patricia Ardise, MD
Heather McGehean, MD
Lynda Gioia, MD
Megan Lochner, MD
Dympna Weil, MD
Erin Stevens, MD
Randi Turkewitz, MD
Elizabeth Garduno, MD
Diana Garretto, MD
Amanika Kumar, MD
The Voluntary Clinical Faculty Award
In Recognition of and Appreciation for Outstanding Teaching
and Service to the Residency Program
1995
1996
1997
1998
1999
2000
2001
2002
2003
Richard Halpert, MD
Christian Westermann, MD
James Droesch, MD
Deborah Davenport, MD
Christian Westermann, MD
Abraham Halfen, MD
Abraham, Halfen, MD
Todd Griffin, MD
Philip Schoenfeld, MD
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
James Stelling, MD
James Droesch, MD
James Droesch, MD
Jeffrey Porte, MD
James Droesch, MD
James Stelling, MD
David Reavis, MD
David Reavis, MD
David Reavis, MD
David Reavis, MD
AWARDS—PAST RECIPIENTS
The David Marzouk, MD
Humanism in Medicine Award
In Recognition of Warmth, Compassion, and Devotion
to the Profession of Medicine
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
Eva Chalas, MD
Timothy Bonney, MD
Michael Arato, MD
Michael Arato, MD
Syau-fu Ma, MD
Brian McKenna, MD
Robert Scanlon, MD
Stephanie Mann, MD
Petra Belady, MD
Felicia Callan, MD
Elizabeth Folland, MD
Florence Rolston, MD
David Reavis, MD
Vito Alamia, MD
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Lynne Macco, MD
Siobhan Hayden, MD
Anne Hunter, MD
JoAnna Paolilli, MD
Sara Petruska, MD
Vanessa Soviero, MD
Megan Lochner, MD
Meredith McDowell, MD
Dympa Weil, MD
Rupinder Bhangoo, MD
Nikole Ostrov, MD
Shelly-Ann James, MD
Amanika Kumar, MD
Daniela Carlos Pons, MD
Emily Blanton, MD
Resident Teaching Award
In Recognition of Commitment, Dedication, and Enthusiasm
in the Teaching and Nurturing of Medical Students
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Brian McKenna, MD
John Wagner, MD
Pui Chun Cheng, MD
Pui Chun Cheng, MD
Lawrence Weinstein, MD
Todd Griffin, MD
David Reavis, MD
David Reavis, MD
David Reavis, MD
David Reavis, MD
Vito Alamia, MD
JoAnna Paolilli, MD
JoAnna Paolilli, MD
Hera Sambaziotis, MD
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Joyce Rubin, MD
Joanna Paolilli, MD\
Heather McGehean, MD
Anita Patibandla, MD
Anita Patibandla, MD
Anita Patibandla, MD
Jerasimos Ballas, MD
Nikole Ostrov, MD
Diana Garetto, MD
Fabiola Balmir, MD
Fabiola Balmir, MD
Fabiola Balmir, MD
AWARDS—PAST RECIPIENTS
The William J. Mann, MD Pathology Award
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Deborah Davenport, MD
Deborah Davenport, MD
Eva Chalas, MD
Eva Chalas, MD
Mindy Shaffran, MD
Christian Westermann, MD
Michael Arato, MD
Paul Meyers, MD
Syau-fu Ma, MD
Cheri Coyle, MD
Robert Scanlon, MD
Robert Scanlon, MD
Petra Belady, MD
Charles Mirabile, MD
James Stelling, MD
Todd Griffin, MD
Robert Duck, MD
Jill Thompson, MD
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Terry Allen, MD
Jill Thompson, MD
Hera Sambaziotis, MD, MPH
JoAnn Paolilli, MD
Timothy Hale, MD
Vanessa Soviero, MD
Megan Lochner, MD
Olga Glushets, MD
Patricia Dramitinos, MD
Kelly van den Heuvel, MD
Erin Stevens, MD
Alexis Gimovsky, MD
Deepti Nahar, MD
Emily Blanton, MD
Leia Card, MD
Deepti Nahar, MD
Amanika Kumar, MD
The Robert L. Barbieri MD Research Award
(Formerly the Resident Research Award)
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
Deborah Davenport, MD
Alexandra Taylor, MD
Deborah Davenport, MD
Robert O’Keefe, MD
Gae Rodke, MD
Christian Westermann, MD
Mindy Shaffran, MD
Michael Arato, MD
Syau-fu Ma, MD
John Wagner, MD
John Wagner, MD
Robert Scanlon, MD
Robert Scanlon, MD
Ira Bachman, MD
Felicia Callan, MD
Todd Griffin, MD
Marian Zinnante, MD
Anne Hardart, MD
Marian Zinnante, MD
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Anne Hardart, MD
Jill Thompson, MD
Vito Alamia, MD
Mari Inagami, MD
Dennis Strittmatter, MD
JoAnna Paolilli, MD
Sara Petruska, MD
Anne Hunter, MD
Lynda Gioia, MD
Kristin Patkowsky, MD
Kelly van den Heuvel, MD
Nikole Ostrov, M.D
Elizabeth Buescher, MD
Elizabeth Garduno, MD, MPH
Leia Card, MD
Jenny Ann Graber, MD
Rosalie Alvarado, MD
AWARDS—PAST RECIPIENTS
The Golden Scalpel Award
In Recognition of Demonstrating Excellence in Technical Skills
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2012
2013
Martina Frandina, MD
Antoun Khabbaz, M.D
Julie Welischar, MD
Joyce Rubin, MD
Eva Swoboda, MD
Megan Lochner, MD
Megan Lochner, MD
Nikole Ostrov, MD
Nikole Ostrov, MD
Randi Turkewitz, MD
Amanika Kumar, MD
Amanika Kumar, MD
Inspire Education Award
In Recognition of the Resident Who Inspires Us to Learn
and Fosters Education and Mentorship.
2012
2013
Amanika Kumar, MD
Melanie Van Sise, MD
Richard J. Scotti Urogynecology Award
In Recognition of the Resident Who Has Demonstrated Interest and
Outstanding Understanding of the Concepts of Bladder Function and
Pelvic Organ Support
2010
2011
2012
2013
Joseph Chappelle, MD
Leia Card, MD
Jennifer Conway, MD
Daniela Carlos Pons, MD
Heart of Midwifery Award
2011
2012
2013
Viveka Prakash, MD
Kristin Sharar, MD
Kelly Danyshylyn-Adams, MD
Midwifery Partnership Award
2011
2012
2013
Joseph Chappelle, MD
Diana Garretto, MD
Jenny Ann Graber, MD
ALUMNI RESIDENTS
1982
Richard Scotti, MD, Deceased
W. Robert Lockridge, MD, New York
1983
Deborah Davenport, MD, Private Practice, East Setauket, New York
William Shuell, MD, Private Practice, Scottsdale, Arizona
1984
Robert O’Keefe, MD, Private Practice, Setauket, New York
Alexandra Taylor, MD, Delray Beach, FL
1985
Eva Chalas, MD, Vice Chair of Ob/Gyn, Winthrop University Hospital, Mineola, NY
David Kreiner, MD, Private Practice, Woodbury, New York
1986
Jeffrey Porte, MD, Private Practice, Setauket, New York
Gae Rodke, MD, Private Practice, New York, New York
1987
Lance Edwards, MD, Private Practice, Port Jefferson, New York
Mindy Shaffran, MD, Private Practice, Port Jefferson, New York
Christian Westermann, MD, Private Practice, Stony Brook, New York
1988
Timothy Bonney, MD, Private Practice, Denver, Colorado
Arlene Kaelber, MD, Private Practice, East Setauket, New York
1989
Michael Arato, MD, Private Practice, Stony Brook, New York
Miriam Sivkin, MD, Private Practice, Milford, Connecticut
1990
Michael Klotz, MD, Private Practice, Seattle, Washington
Paul Meyers, MD, Riverside Hospital, Newport News, Virginia
Gustavo San Roman, MD, Private Practice, Port Jefferson Station, New York
1991
Cheri Coyle, MD, Private Practice, Hampton, Virginia
Syau-fu Ma, MD, Private Practice, Ridgewood, New Jersey
John Wagner, MD, Private Practice, East Northport, New York
1992
Brian McKenna, MD, Private Practice, Islandia, New York
Gerald Siegel, MD, Private Practice, Commack, New York
Marie Welshinger, MD, Women’s Cancer Center, Morristown, New Jersey
1993
Theodore Goldman, MD, Private Practice, East Northport, New York
Stephanie Mann, MD, Private Practice, Los Angeles, California
Robert Scanlon, MD, Chief of Ob/Gyn Service, Huntington Hospital, New York
ALUMNI RESIDENTS (CONTINUED)
1994
Ira Chan, MD, Instructor, Beth Israel Hospital, Harvard Medical School, Boston, MA
Pui Chun Cheng, MD, Gynecologic Oncology, New Orleans, Louisiana
Lawrence Weinstein, MD, Private Practice, Kingston, New York
1995
Ira Bachman, MD, Private Practice, Cedarhurst, New York
Petra Belady, MD, Private Practice, Bloomington, Indiana
Gloria Escamilla, MD, Private Practice, Islandia, New York
Lisa Farkouh, MD, Private Practice, Denver, Colorado
1996
Felicia Callan, MD, Private Practice, Huntington, New York
Charles Mirabile, MD, Private Practice, Unknown
Karen Morris, MD, Private Practice, Huntington, New York
James Stelling, MD, Private Practice, Stony Brook, New York
1997
Jacqueline Ammirata, MD, Private Practice, West Islip, New York
Todd Griffin, MD, Chair, Department Ob/Gyn, Stony Brook Medicine,
Stony Brook, New York
Hitesh Narain, MD, Private Practice, Patchogue, New York
Florence Rolston, MD, Private Practice, Southampton, New York
1998
Salil Bakshi, MD, Private Practice, Oakdale, New York
Wei Chu, MD, Private Practice, East Islip, New York
David Reavis, MD, Private Practice, Patchogue, New York
Marian Zinnante, MD, Private Practice, Arlington, Texas
1999
Robert Duck, MD, Private Practice, Winchester, Virginia
Christopher Fabricant, MD, Univ. of Texas, Southwestern Medical Center,
Dallas, Texas
Anne Hardart, MD, University of Southern California, Los Angeles, California
Lynne Macco, MD, Private Practice, West Islip, New York
2000
Vito Alamia, MD, Private Practice, Southampton, New York
Terry Allen, MD, Private Practice, Fairfax, Virginia
Mari Inagami, MD, Private Practice, Westport, Connecticut
Jill Thompson, MD, Private Practice, Northport, New York
2001
Martina Frandina, MD, Private Practice, Garden City, New York
Dennis McGroary, MD Private Practice, Mt. Kisco, New York
Antonia Pinney, MD, Private Practice, New Jersey
2002
Siobhan Hayden, MD, Mary Imogene Barrett Hospital, Cooperstown, New York
Antoun Khabbaz, MD, Appalachian Regional Healthcare, Harlan, Kentucky
Dennis Strittmatter, MD, Private Practice, Port Jefferson, New York
ALUMNI RESIDENTS (CONTINUED)
2003
Karen Chu, MD, Private Practice, San Francisco, California
JoAnna Paolilli, MD, Private Practice, Mineola, New York
Hera Sambaziotis, MD, MPH, Private Practice, Garden City, New York
Julie Welischar, MD, Private Practice, Setauket, New York
2004
Patricia Ardise, MD, Private Practice, New Jersey
Anne Hunter, MD
Sara Petruska, MD, Private Practice, Kentucky
Alejandra Turmero, MD, Private Practice, Rhode Island
2005
Heather McGehean, MD
Timothy Hale, MD, Private Practice, Massachusetts
Joyce Rubin, MD, Private Practice, Islandia, New York
Vanessa Soviero, MD, Private Practice, Islandia, New York
Eva Swoboda, MD, Clerkship Director, Stony Brook Medicine,
Stony Brook, New York
2006
Lynda Gioia, MD, Private Practice, Tennessee
Olga Glushets, MD, Urogynecology
Meredith McDowell, MD, Private Practice, Norwich, New York
2007
Patricia Dramitinos, MD, Urogynecology
Megan Lochner, MD, Private Practice, Setauket, NY
Christopher Paoloni, MD, Private Practice, Virginia
Anita Patibandla, MD, Private Practice, Ohio
2008
Rupinder Bhangoo, MD, Private Practice, Fishkill, New York
Kristen Patzkowsky, MD, Einstein/Montefiore Medical Center, Bronx, NY
Kelly van den Huevel, MD, Private Practice, San Diego, California
Dympna Weil, MD, Private Practice
2009
Kirthi Katkuri, MD, St. Elizabeth’s Medical Center, MA
Nikole Ostrov, MD, New York, NY
Erin Stevens, MD, Private Practice, Billings, Montana
2010
Jerasimos Ballas, MD
Shelly-Ann James, MD, Mary Washington Hospital, Virginia
Lan Na Lee, MD
Randi Turkewitz, MD, Private Practice, Pennsylvania
ALUMNI RESIDENTS (CONTINUED)
2011
Elizabeth Buescher, MD,
Joseph Chappelle, MD, Medical Director Labor & Delivery, Stony Brook Medicine,
Stony Brook, NY
Elizabeth Garduno, MD, MPH, Associate Residency Program Director, Stony Brook
Medicine, Stony Brook, NY
Donald Phillibert, MD, Drexel University, Philadelphia, PA
Chanda Reese, MD, Private Practice, Coral Springs, FL
2012
Leia Card, MD, Garrisons Women’s Health, Dover, NH
Diana Garretto, MD, MFM Fellowship, Einstein/Montefiore Medical Center,
Bronx, NY
James McDonald, MD
Cara Ninivaggio, MD, Urogynecology Fellowship, University of New Mexico
Viveka Prakash, MD, Harvard Vanguard Medical Assoc., Boston, MA
2013
Rosalie Alvarado, MD, Southern Westchester Ob/Gyn, Yonkers, NY
Jennifer Blaber, MD, Minimally Invasive Fellowship, Stony Brook Medicine,
Stony Brook, NY
Jenny Graber, MD, Jacobi Medical Center, Bronx, NY
Amanika Kumar, MD, Gynecologic Oncology Fellowship, Mayo Clinic,
Rochester, MN
Michael Vizcarra, MD, Private Practice, Fountain Valley, CA