Dwight J Rouse

Alpert Medical School - Brown University, Providence, Rhode Island, United States

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Publications (233)1297.03 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To use decision analysis to evaluate whether and under what conditions routine setup of intraoperative cell salvage during cesarean delivery is cost-saving.
    Obstetrics and gynecology. 09/2014;
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    ABSTRACT: To evaluate the association of duration of magnesium sulfate infusion with stillbirth or death, cerebral palsy, and select adverse maternal and neonatal outcomes.
    Obstetrics and gynecology. 09/2014;
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    ABSTRACT: To describe the perinatal and infant and early childhood morbidity associated with preterm premature rupture of membranes (PROM) in a cohort of twin pregnancies evaluated prospectively with neonatal follow-up to 2 years of age.
    Obstetrics and gynecology. 07/2014;
  • Danielle Dray, Joshua D Dahlke, Dwight J Rouse
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    ABSTRACT: Solid pseudopapillary pancreatic tumor is a rare tumor affecting young women. Case reports have presented pregnancy outcomes after pancreaticoduodenectomy (Whipple procedure) in pregnancy for this neoplasm. We report a case of a woman who underwent a preconception Whipple procedure for a solid pseudopapillary pancreatic tumor who experienced recurrent pancreatitis confined to pregnancy.
    Obstetrics and gynecology. 07/2014;
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    ABSTRACT: Objective To test whether elevated umbilical cord serum inflammatory cytokine levels predicted subsequent cerebral palsy (CP) or neurodevelopmental delay (NDD). Study Design Nested case-control analysis within a clinical trial of antenatal magnesium sulfate (MgSO4) before anticipated preterm birth (PTB) for prevention of CP, with evaluation of surviving children at the age of 2. NDD was defined as a Bayley psychomotor developmental index (PDI) and/or mental developmental index (MDI) < 70. Controls, defined as surviving children without CP and with Bayley PDI and MDI ≥ 85, were matched by race and gestational age. Cord serum was analyzed for interleukin-8 (IL-8) interleukin-1 beta (IL-1β), and tumor necrosis factor-α (TNF-α) levels. Elevated cytokine levels were defined as ≥ 75th percentile in placebo-exposed controls. Analyses compared case/control cytokine levels, adjusting for MgSO4 exposure, gestational age, race/ethnicity, and sociodemographic differences. Results Logistic regression analysis with 339 cases and 276 controls showed that elevated IL-8 and IL-1β were more common in cord blood serum from infants with subsequent low MDI as compared with controls. After adjusting for additional confounders, the significant differences were no longer evident. Cytokine levels (IL-8, IL-1β, and TNF-α) were not elevated with CP or low PDI. Conclusion Cord serum IL-8, IL-1β, and TNF-α levels in preterm infants are not associated with subsequent CP or NDD.
    American Journal of Perinatology 06/2014; · 1.57 Impact Factor
  • Lindsay Maggio, Dwight J Rouse
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    ABSTRACT: Progestogens are a promising treatment in the prevention of spontaneous preterm birth in high-risk women. In women with a prior history of spontaneous preterm delivery and in women with a sonographic shortened cervix, there is considerable evidence supporting a benefit of progestogen therapy in the reduction of preterm delivery. In women with multifetal gestations, progestogen therapy has not been shown to be beneficial. Data are inconclusive in women with arrested preterm labor. Questions remain about the mechanism of progestogen action, the optimal type of progestogen, the best mode of administration, and the ideal dosing regimen.
    Clinical obstetrics and gynecology. 06/2014;
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    ABSTRACT: Objective The objective of the article is to describe latency for patients with preterm premature membrane rupture (PPROM) between 240/7 and 316/7 weeks' gestation. Study Design Secondary analysis of data collected prospectively in a multicenter clinical trial of magnesium sulfate for cerebral palsy prevention. Women with PPROM and fewer than six contractions per hour at enrollment who were candidates for expectant management (n = 1,377) were included in this analysis. Length of latency was calculated in days by subtracting the time of delivery from the time of membrane rupture. Results At each week of gestation, median latency between 24 and 28 weeks was similar at approximately 9 days, but it was significantly shorter with PPROM at 29, 30, and 31 weeks (p < 0.001). In addition, the percentage of patients remaining undelivered at 7 days and 14 days was similar for PPROM between 24 and 28 weeks, but it decreased significantly after that. For each gestational age, the proportion of patients remaining pregnant declined in a fashion similar to an exponential pattern. Conclusion Median latency after PPROM is similar from 24 to 28 weeks' gestation, but it shortens with PPROM at and after 29 weeks.
    American Journal of Perinatology 05/2014; · 1.57 Impact Factor
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    ABSTRACT: To estimate the frequency of severe maternal morbidity, assess its underlying etiologies, and develop a scoring system to predict its occurrence.Supplemental Digital Content is Available in the Text. This was a secondary analysis of a Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network cohort of 115,502 women and their neonates born in 25 hospitals across the United States over a 3-year period. Women were classified as having severe maternal morbidity according to a scoring system that takes into account the occurrence of red blood cell transfusion (more than three units), intubation, unanticipated surgical intervention, organ failure, and intensive care unit admission. The frequency of severe maternal morbidity was calculated and the underlying etiologies determined. Multivariable analysis identified patient factors present on admission that were independently associated with severe maternal morbidity; these were used to develop a prediction model for severe maternal morbidity. Among 115,502 women who delivered during the study period, 332 (2.9/1,000 births, 95% confidence interval 2.6-3.2) experienced severe maternal morbidity. Postpartum hemorrhage was responsible for approximately half of severe maternal morbidity. Multiple patient factors were found to be independently associated with severe maternal morbidity and were used to develop a predictive model with an area under the receiver operating characteristic curve of 0.80. Severe maternal morbidity occurs in approximately 2.9 per 1,000 births, is most commonly the result of postpartum hemorrhage, and occurs more commonly in association with several identifiable patient characteristics. LEVEL OF EVIDENCE:: II.
    Obstetrics and Gynecology 04/2014; 123(4):804-810. · 4.80 Impact Factor
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    ABSTRACT: To design an emergency department (ED) sepsis scoring system to identify risk of intensive care unit (ICU) admission in pregnant and postpartum women. The Sepsis in Obstetrics Score (S.O.S.) was created by modifying validated scoring systems in accordance with recognized physiologic changes of pregnancy. The S.O.S was applied to a retrospective cohort of pregnant and postpartum patients between February 2009 and May 2011 with clinical suspicion of sepsis. The primary outcome was ICU admission. Secondary outcomes were telemetry unit admission, length of stay, positive blood cultures, positive influenza swabs, perinatal outcome, and maternal mortality. Receiver operating characteristic (ROC) curves were constructed to estimate the optimal score for identification of risk of ICU admission. 850 eligible women were included. There were 9 ICU (1.1%) and 32 telemetry (3.8%) admissions, and no maternal deaths. The S.O.S. had an AUC of 0.97 for ICU admission. An S.O.S. ≥ 6 (maximum score 28) had an AUC of 0.92 with a sensitivity of 88.9%, a specificity of 95.2%, a positive predictive value of 16.7%, and a negative predictive value of 99.9% for ICU admission, with an adjusted odds ratio of 109 (95% confidence interval, 18 - 661). An S.O.S. ≥ 6 was independently associated with increased ICU or telemetry unit admissions, positive blood cultures, and fetal tachycardia. A sepsis scoring system designed specifically for an obstetric population appears to reliably identify patients at high risk for admission to the ICU. Prospective validation is warranted.
    American journal of obstetrics and gynecology 03/2014; · 3.28 Impact Factor
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    ABSTRACT: Maternal oxygen is often given to laboring women to improve fetal metabolic status or in an attempt to alleviate non-reassuring fetal heart rate patterns. However, the only two randomized trials investigating the use of maternal oxygen supplementation in laboring women do not support that such supplementation is likely to be of benefit to the fetus. And by increasing free radical activity, maternal oxygen supplementation may even be harmful. Based on a review of the available literature, we conclude that until it is studied properly in a randomized clinical trial, maternal oxygen supplementation in labor should be reserved for maternal hypoxia, and should not be considered an indicated intervention for non-reassuring fetal status.
    American journal of obstetrics and gynecology 01/2014; · 3.28 Impact Factor
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    ABSTRACT: In 2011, 1 in 3 women who gave birth in the United States did so by cesarean delivery. Cesarean birth can be lifesaving for the fetus, the mother, or both in certain cases. However, the rapid increase in cesarean birth rates from 1996 through 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women's access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.
    American journal of obstetrics and gynecology 01/2014; 210(3):179–193. · 3.28 Impact Factor
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    ABSTRACT: Objective To evaluate inadequate gestational weight gain and fetal growth among overweight and obese women (O/O). Study Design Analysis of prospective singleton term pregnancies in which 1053 O/O gained greater (14.4± 6.2 kg) or 188 who either lost or gained <5 kg (1.1± 4.4 kg). Birth weight, fat(FM) and lean mass (LM) were assessed using anthropometry. Small for gestational age (SGA) was defined as < 10thpercentile of a standard US population. Univariable and multivariable analysis evaluated the association between weight change and neonatal morphometry. Results There was no significant difference in age, race, smoking, parity, or gestational age between groups. Weight loss or gain ≤ 5 kg was associated with SGA, 18/188 (9.6%) vs. 51/1053 (4.9%); (adjusted OR 2.6, 95% CI 1.4, 4.7; p=0.003). Neonates of women who lost or gained ≤ 5 kg had lower birth weight (3258 ± 443 g vs. 3467 ± 492g, p<0.0001), FM (403±175 vs. 471 ± 193g, p<0.0001), LM (2855±321 vs. 2995 ± 347g, p<0.0001) and smaller length, %FM and head circumference (HC). Adjusting for diabetic status, pre-pregnancy BMI, smoking, parity, study site, gestational age and gender; neonates of women who gained ≤ 5 kg had significantly lower birth weight, LBM, FM, %FM, HC and length. There were no significant differences in neonatal outcomes between those who lost weight and those who gained < 5 kg. Conclusion In O/O weight loss or gain < 5 kg is associated with increased risk of SGA and decreased neonatal FM, LM and HC.
    American journal of obstetrics and gynecology 01/2014; · 3.28 Impact Factor
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    ABSTRACT: Objective To determine whether hospital differences in the frequency of adverse obstetric outcomes are related to differences in care. Study Design The Assessment of Perinatal EXcellence (APEX) cohort of 115,502 women and their neonates born in 25 hospitals in the United States between March 2008 and February 2011. Hierarchical logistic regression was used to quantify the amount of variation in postpartum hemorrhage, peripartum infection, severe perineal laceration, and a composite adverse neonatal outcome among hospitals that is explained by differences in patient characteristics, hospital characteristics, and the obstetric care provided. Results 115,502 women were included in the study. For most outcomes, between 20 and 40% of hospital differences in outcomes were related to differences in patient populations. After controlling for patient-, provider- and hospital-level factors, multiple care processes were associated with the predefined adverse outcomes, but these care processes did not explain significant variation in the frequency of adverse outcomes among hospitals. Ultimately, between 50 and 100% of the inter-hospital variation in outcomes was unexplained. Conclusion Hospital differences in the frequency of adverse obstetric outcomes could not be explained by differences in frequency of types of care provided.
    American journal of obstetrics and gynecology 01/2014; · 3.28 Impact Factor
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    ABSTRACT: Objective To compare maternal and neonatal outcomes in nulliparous women with non-medically indicated inductions at term versus those expectantly managed. Study Design Data were obtained from maternal and neonatal charts for all deliveries on randomly selected days across 25 US hospitals over a three-year period. A low-risk subset of nulliparas with vertex non-anomalous singleton gestations who delivered 38 0/7 to 41 6/7 weeks were selected. Maternal and neonatal outcomes for non medically indicated induction within each week were compared with women who did not undergo non medically indicated induction during that week. Multivariable analysis was used to adjust for hospital, maternal age, race/ethnicity, body mass index, cigarette use and insurance status. Results 31,169 women met criteria. Neonatal complications were either less frequent with non medically indicated induction or no different between groups. Non medically indicated induction was associated with less frequent peripartum infections (OR 0.39, 95%CI 0.16-0.98) at 38 weeks and less frequent third and fourth degree lacerations (OR 0.60, 95%CI 0.42-0.86) and less frequent peripartum infections (OR 0.66, 95% CI 0.49-0.90) at 39 weeks. Non medically indicated induction was associated with a longer admission-to-delivery time by approximately 3 to 4 hours and increased odds of cesarean delivery at 38 weeks (OR 1.50 95%CI 1.08-2.08) and 40 weeks (OR 1.30, 95%CI 1.15-1.46). Conclusion At 39 weeks, non medically indicated induction is associated with lower maternal and neonatal morbidity than women expectantly managed.
    American Journal of Obstetrics and Gynecology. 01/2014;
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    ABSTRACT: Objective The aim of the study is to determine if umbilical cord serum concentrations of interleukin-6 (IL-6), C-reactive protein (CRP), and myeloperoxidase (MPO), in pregnancies at risk for preterm birth (PTB), are associated with neonatal morbidities and/or altered neurodevelopmental outcomes in the children. Study Design Umbilical cord serum samples were collected at birth from 400 newborns delivered within a multicenter randomized controlled trial of repeated versus single course of antenatal corticosteroids (ACs), in women at increased risk for PTB. Newborns were followed through discharge and were evaluated between 36 and 42 months corrected age with neurological examination and Bayley Scales of Infant Development. Umbilical cord serum concentrations of IL-6, CRP, and MPO were determined using enzyme-linked immunoassays. Multivariate logistic regression analyses explored the relationship between umbilical cord serum IL-6, CRP, and MPO levels, adverse newborn outcomes, and PTB < 32 weeks of gestational age (GA). Results Univariate analysis revealed that umbilical cord IL-6 above the 75th percentile was associated with increased respiratory distress syndrome (RDS) and chronic lung disease (CLD), but not with necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), or neonatal sepsis; however, this association was not significant after adjusting for GA at delivery and treatment group. No significant associations between CRP or MPO and RDS, CLD, NEC, sepsis, or IVH were evident. Regression analysis revealed that CRP above the 75th percentile was associated with a decreased risk of CLD (odds ratio, 0.10; 95% confidence interval, 0.02-0.41). No associations between umbilical cord IL-6, CRP, or MPO and MDI < 70 or PDI < 70 were evident. Umbilical cord serum concentrations of IL-6, CRP, and MPO, above the 75th percentile, were associated with more frequent PTB < 32 weeks of GA. Conclusion Elevated umbilical cord serum concentration of CRP is associated with reduced risk for CLD even after adjusting for GA at delivery. Occurrence of levels > 75th percentile of IL-6, CRP, and MPO in umbilical cord serum was associated with PTB < 32 weeks of GA. Elevated umbilical cord serum concentrations of IL-6, CRP, and MPO at birth were not associated with poor neurodevelopmental outcomes.
    American Journal of Perinatology 12/2013; · 1.57 Impact Factor
  • Dwight J Rouse, Karen J Gibbins
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    ABSTRACT: Magnesium sulfate (MgSO4) has been shown to prevent cerebral palsy among children born to women at high risk of early preterm delivery. Three large, randomized placebo-controlled trials and a subsequent Cochrane Review suggest this intervention can decrease rates of cerebral palsy by 32% with a number needed to treat of 63 to prevent one case. Not only is MgSO4 familiar to obstetricians, it also has an excellent safety profile. Simple protocols exist to help guide clinicians in using MgSO4 for this indication. Evaluation of actual clinical practice shows that this use is both feasible and can be accomplished parsimoniously.
    Seminars in perinatology 12/2013; 37(6):414-6. · 2.33 Impact Factor
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    ABSTRACT: To examine the association of elevated early pregnancy hemoglobin A1c (HbA1c) levels with adverse pregnancy outcomes in women with preexisting diabetes mellitus. Retrospective cohort study of 330 women with preexisting diabetes enrolled in a Diabetes in Pregnancy Program at an academic institution between 2003 and 2011 who had an early HbA1c determination. The frequencies of composite maternal adverse pregnancy outcomes (birth at<37weeks, preeclampsia, and medically indicated birth <39weeks), and composite fetal adverse pregnancy outcomes [shoulder dystocia, Apgar scores<7 at 5minutes, small for gestational age (SGA), large for gestational age (LGA), and stillbirth] were compared between HbA1c categories (<6.5, 6.5-7.4, 7.5-8.4 and ≥8.5%). There was no statistically significant difference between composite adverse maternal pregnancy outcomes and composite adverse fetal pregnancy outcomes as well as other individual outcomes between different HbA1c categories. Of the vaginally delivered women in our cohort, the 37 patients with HbA1c levels of≥8.5% had a significantly higher frequency of fetal shoulder dystocia than the 62 with HbA1c levels of<8.5% (24.2 vs. 1.6%, P=0.002). Neonates of patients with HbA1c≥8.5% were more likely to have low five minute Apgar scores than neonates of patients with HbA1c<8.5%, but this was of borderline statistical significance (7.4% vs. 0.5%, P=0.05). In patients with preexisting diabetes mellitus, HbA1c levels of≥8.5% during early pregnancy are not useful in predicting most adverse outcomes, although there may be an increased risk for shoulder dystocia.
    Journal of diabetes and its complications 10/2013; · 2.11 Impact Factor
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    ABSTRACT: 17-alpha hydroxyprogesterone caproate (17-OHPC) 250 mg weekly reduces recurrent spontaneous preterm birth (SPTB) in women with a prior SPTB by 33%. The dose is not based on pharmacological considerations. A therapeutic concentration has not been determined hampering any attempt to optimize treatment. This study evaluated the relationship between 17-OHPC plasma concentrations and the rate of SPTB in women with singleton gestation. A single blood sample was obtained between 25 and 28 weeks gestation from 315 women with a SPTB who participated in a placebo-controlled, prospective, randomized clinical trial evaluating the benefit of omega-3 supplementation in reducing preterm birth. All women in the parent study received 17-OHPC and 434 received omega-3 supplementation and 418 received a placebo. Plasma from 315 consenting women was analyzed for 17-OHPC concentration. There were no differences between placebo and omega-3 supplemented groups in demographic variables, outcomes or in mean 17-OHPC concentration. Plasma concentrations of 17-OHPC ranged from 3.7- 56 ng/ml. Women with plasma concentrations of 17-OHPC in the lowest quartile had a significantly higher risk of spontaneous preterm birth (p= 0.03) and delivered at significantly earlier gestational ages (p = 0.002) than did women in the 2(nd) to 4(th) quartiles. The lowest preterm birth rates were seen when median 17-OHPC concentrations exceeded 6.4 ng/ml. Low plasma 17-OHPC concentration is associated with an increased risk of SPTB. This finding validates efficacy of this treatment but suggests that additional studies are needed to determine the optimal dosage.
    American journal of obstetrics and gynecology 10/2013; · 3.28 Impact Factor
  • Dwight J Rouse
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    ABSTRACT: This month, we focus on current research in postpartum hemorrhage. Dr. Rouse discusses five recent publications, and each is concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in Box 1 on this page, along with direct links to the abstracts.
    Obstetrics and Gynecology 08/2013; · 4.80 Impact Factor
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    ABSTRACT: The twin birth rate has been steadily increasing in the United States over the past 10 years attributable in large part to the increased use of reproductive technologies. Despite advancements in the prevention of preterm labor for singletons, the overall rate of preterm birth has decreased only minimally. Several interventions to prevent preterm birth in twins have been studied, but none has proven effective. Inpatient bedrest has not been shown to be effective and can cause significant maternal morbidity. Although intramuscular 17α-hydroxyprogesterone caproate is effective in decreasing the risk of recurrent preterm delivery in singletons, neither it nor cerclage is effective in twin gestations, even in those with a short cervix. However, small trials, subgroup analyses, and a meta-analysis suggest that vaginal progesterone and the Arabin cervical pessary may reduce rates of preterm birth in twins of mothers with a short cervix. Given the current lack of effective therapies to prevent preterm birth in twins, large multicenter trials are needed to assess the effectiveness of vaginal progesterone and pessary in twins of mothers with a short cervix.
    Obstetrics and Gynecology 08/2013; 122(2 Pt 1):375-9. · 4.80 Impact Factor

Publication Stats

4k Citations
1,297.03 Total Impact Points

Institutions

  • 2012–2014
    • Alpert Medical School - Brown University
      • Department of Obstetrics and Gynecology
      Providence, Rhode Island, United States
    • Society for Maternal-Fetal Medicine
      Detroit, Michigan, United States
    • University of Texas Medical Branch at Galveston
      • Department of Obstetrics and Gynecology
      Galveston, TX, United States
  • 2011–2014
    • Brown University
      • • Division of General Internal Medicine
      • • Department of Obstetrics and Gynecology
      Providence, Rhode Island, United States
    • Centre for Infectious Disease Research in Zambia
      Birmingham, Alabama, United States
  • 1993–2014
    • University of Alabama at Birmingham
      • • Department of Obstetrics and Gynecology
      • • School of Public Health
      Birmingham, Alabama, United States
  • 2013
    • Case Western Reserve University School of Medicine
      Cleveland, Ohio, United States
    • VHA National Center for Organization Development (NCOD)
      Cincinnati, Ohio, United States
  • 2011–2013
    • Women & Infants Hospital
      Providence, Rhode Island, United States
  • 2006–2013
    • Northwestern University
      • • Division of General Obstetrics and Gynecology
      • • Department of Obstetrics and Gynecology
      Evanston, IL, United States
    • Drexel University College of Medicine
      • Department of Obstetrics and Gynecology
      Philadelphia, PA, United States
  • 2003–2013
    • George Washington University
      • Biostatistics Center
      Washington, Washington, D.C., United States
  • 2011–2012
    • University of North Carolina at Chapel Hill
      • • Department of Obstetrics and Gynecology
      • • Department of Pediatrics
      Chapel Hill, NC, United States
  • 2009–2012
    • University of Pittsburgh
      • • Department of Obstetrics, Gynecology and Reproductive Sciences
      • • School of Medicine
      • • Division of General Obstetrics and Gynecology
      Pittsburgh, PA, United States
    • Oregon Health and Science University
      • Department of Obstetrics & Gynecology
      Portland, OR, United States
    • Medical University of South Carolina
      • Department of Obstetrics and Gynecology
      Charleston, SC, United States
  • 2007–2012
    • Columbia University
      • Department of Obstetrics and Gynecology
      New York City, NY, United States
    • Aga Khan University, Pakistan
      Kurrachee, Sindh, Pakistan
  • 2010–2011
    • Eunice Kennedy Shriver National Institute of Child Health and Human Development
      Maryland, United States
    • Wake Forest University
      Winston-Salem, North Carolina, United States
  • 2006–2011
    • The Ohio State University
      • Department of Obstetrics and Gynecology
      Columbus, OH, United States
    • University of Utah
      • Department of Obstetrics and Gynecology
      Salt Lake City, UT, United States
  • 2005–2011
    • University of Texas Southwestern Medical Center
      • • Department of Pediatrics
      • • Department of Obstetrics and Gynecology
      Dallas, TX, United States
  • 2009–2010
    • University of Texas Health Science Center at Houston
      Houston, Texas, United States
  • 2007–2010
    • Wayne State University
      • Department of Obstetrics and Gynecology
      Detroit, MI, United States
  • 2006–2010
    • Kaiser Permanente
      Oakland, California, United States
  • 2008
    • University of Houston
      Houston, Texas, United States
    • Christiana Care Health System
      Wilmington, Delaware, United States
  • 2006–2007
    • Case Western Reserve University
      • Department of Pathology (University Hospitals Case Medical Center)
      Cleveland, OH, United States
  • 1998–2007
    • National Institute of Child Health and Human Development
      Maryland, United States