K J Moise

University of Texas Health Science Center at Houston, Houston, Texas, United States

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Publications (253)905.94 Total impact

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    ABSTRACT: Objective To determine the risk faxtors for spontaneous preterm delivery (sPTD) or preterm premature rupture of membranes <34 weeks gestation after fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS) and to identify the optimal threshold for pre-operative cervical length (CL).Study DesignSecondary analysis of prospectively collected data from 449 patients from 3 fetal centers was analyzed. CL measurements were obtained from pre-operative transvaginal ultrasound, between the gestational ages of 16–26 weeks. The risk factors associated with sPTD <34 weeks was determined using multivariate logistic regression. We excluded patients due to dual fetal demise and maternal or fetal indications for delivery without preterm premature rupture of membranes(n = 63). The optimal threshold for cervical length to predict sPTD <34 weeks was determined using receiver operator characteristics (ROC) curve and Youden index. Additionally, CL threshold for sPTD between 24 to 34 weeks, at every 2 weeks was determined.ResultssPTD <34 weeks occurred in 206 (53.4%) in the included patients. Only the pre-operative CL was significantly associated with sPTD. The pre-operative CL was normally distributed with a mean of 37.6 ± 10.3 mm (range 5–66 mm). Maternal age and parity were positively associated and gestational age at procedure and anterior placenta were negatively associated with cervical length on a multivariate linear regression. The area under the ROC curve for predicting sPTD with CL measurement was 0.61 (p = 0.02) and the optimal threshold was 28 mm with Youden index of 0.20 (sensitivity, and specificity of 92% and 27%, respectively). CL <25-28 mm increased risk for sPTD various all gestational age thresholds.ConclusionsPTD <34 weeks is associated with pre-operative CL < 28 mm. Preventive strategies should focus on this high-risk group.
    Ultrasound in Obstetrics and Gynecology 10/2014; · 3.56 Impact Factor
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    ABSTRACT: The objective of this study was to estimate maternal-fetal transplacental passage of granisetron in an ex vivo placental perfusion model. Term human placentas (N=8) were collected immediately after delivery. A single cotyledon from each placenta was perfused granisetron concentration to mimic systemic maternal peak plasma concentrations following either IV (50ng/mL) or transdermal administration (5ng/mL). To assess drug transfer and accumulation, samples were collected from maternal and fetal compartments. In the 50ng/mL open model, the mean transport fraction was 0.21 ± 0.08 with clearance index of 0.53±0.66. Fetal peak concentrations achieved was 5.6±6.6ng/mL with mean accumulation of 5.35±6.4ng/mL. No drug was detected in the fetal compartment with the 5ng/mL models. Transplacental passage of granisetron was inconsistent at the 50ng/mL concentration that achieved with IV dosing. However, there consistently was no detectable passage in all the placentas evaluated of the granisetron at 5ng/mL concentration that would be achieved after transdermal patch administration.
    Reproductive toxicology (Elmsford, N.Y.). 07/2014;
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    ABSTRACT: Objective To compare the outcomes of dichorionic triamniotic (DCTA) triplet gestations with the outcomes of a paired cohort of monochorionic diamniotic (MCDA) twin gestations undergoing laser therapy for treatment of twin-to-twin transfusion syndrome (TTTS).Methods All DCTA triplets treated at 4 referral centers were included. A matched cohort group of MCDA twin gestations affected by TTTS was used for comparison.Results16 sets of DCTA triplets treated with laser photocoagulation of placental anastomosis were compared to 32 matched sets of MCDA twins. All of the “singleton” fetuses in the triplet gestations survived to birth and to the end of the neonatal period. There were no differences in the single or double survival or the rate of non-survivors to birth and at 28 days of life. A mean 3-week difference was found in the procedure-to-delivery interval in DCTA triplets vs. MCDA twins [60 ± 35.8 days vs. 83.6 ± 33.2 days; p = 0.029]. A mean difference of 3 weeks was also found in the gestational age at delivery in DCTA triplets vs. MCDA twins [28.5 ± 3.5 weeks vs. 31.9 ± 5weeks; p = 0.024]. A similar post-laser fetal growth pattern in donors and recipients of both groups was noted.ConclusionsDCTA triplet gestations with TTTS have a similar rate of post-laser survival but deliver earlier than can be expected for twins treated with laser. These findings have potential implications for prematurity risks and long-term outcomes.
    Ultrasound in Obstetrics and Gynecology 03/2014; · 3.56 Impact Factor
  • Ultrasound in Obstetrics and Gynecology 02/2014; 43(2). · 3.56 Impact Factor
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    ABSTRACT: Introduction Fetal exsanguination is a rare complication of cordocentesis. Successful correction of fetal thrombocytopenia is essential for the reduction of risks. Case Report A 25-year-old, gravida 3, P2-0-0-0-2, was referred at 27 weeks of gestation for evaluation of newly diagnosed nonimmune hydrops secondary to parvovirus infection. Despite the use of ancillary platelet transfusions to correct the severe fetal thrombocytopenia, prolonged bleeding from the cord puncture site still occurred, necessitating five intrauterine transfusions to ultimately correct the fetal anemia. Conclusions The use of a smaller-diameter procedure needle, correction of the fetal thrombocytopenia early in the procedure, and external cord compression with the ultrasound transducer were ultimately successful measures in allowing for minimal loss of transfused red cells from the intravascular compartment.
    AJP reports. 10/2013; 3(2):75-8.
  • Kenneth J Moise
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    ABSTRACT: Amniotic fluid is typically measured by ultrasound using the amniotic fluid index (AFI) or the maximum vertical pocket (MVP). Although both parameters correlate poorly with the actual amniotic fluid volume measured with dye-dilution methods, cross-sectional studies have been used to establish gestational norms. The current acceptable definition of polyhydramnios in the late second and the third trimester in both singleton and multiple gestations is a MVP > 8cm, while the definition of oligohydramnios is a MVP < 2cm. The pocket to be measured should exclude the umbilical cord or fetal parts. Randomized clinical trials have indicated that defining oligohydramnios as a MVP < 2cm will result in fewer obstetrical interventions and similar perinatal outcomes when compared to an AFI < 5cm.
    Seminars in perinatology 10/2013; 37(5):370-4. · 2.33 Impact Factor
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    ABSTRACT: Despite improved perinatal survival following fetoscopic laser ablation (FLA) for twin twin transfusion syndrome (TTTS), prematurity remains an important contributor to perinatal mortality and morbidity. The objective of the study was to identify risk factors for complicated preterm delivery after FLA. Retrospective cohort study of prospectively collected data on maternal/fetal demographics and pre-operative, operative and post-operative variables of 459 patients treated in 3 U.S. fetal centers . Multivariate linear regression was performed to identify significant risk factors associated with preterm delivery, which was cross-validated using K-fold method. Multivariate logistic regression was performed to identify risk factors for early vs. late preterm delivery based on median gestational age at delivery of 32 weeks. There were significant differences in case selection and outcomes between the centers. After controlling for the center of surgery, a multivariate analysis indicated a lower maternal age at procedure, history of previous prematurity, shortened cervical length , use of amnioinfusion, 12 Fr cannula diameter, lack of a collagen plug placement and iatrogenic preterm premature rupture of membranes (iPPROM) were significantly associated with a lower gestational age at delivery. Specific fetal/maternal and operative variables are associated with preterm delivery after FLA for the treatment of TTTS. Further studies to modify some of these variables may decrease the perinatal morbidity after laser therapy.
    Ultrasound in Obstetrics and Gynecology 09/2013; · 3.56 Impact Factor
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    ABSTRACT: OBJECTIVE: To understand the biological pathways involved in twin-twin transfusion syndrome (TTTS) by performing global gene expression analysis of amniotic fluid (AF) cell-free RNA. METHODS: Prospective whole transcriptome microarray study analyzing cell-free RNA in AF from TTTS recipient twins and singleton controls. Significantly differentially-regulated genes in TTTS cases (N = 8) vs. matched controls (N = 8) were identified and pathways analyses performed. Significant gene expression differences between Stage II TTTS recipients (N = 5) and Stage III TTTS recipients with abnormal Doppler measurements (N = 5) were also analysed. RESULTS: Analysis of paired data from TTTS cases and controls revealed differential expression of 801 genes, which were significantly enriched for neurological disease and cardiovascular system pathways. We also identified cardiovascular genes and pathways associated with the presence of critically abnormal Doppler measurements in Stage III TTTS recipients. CONCLUSIONS: This study provides the first transcriptome-wide data on the impact of TTTS on fetal development. Our results show that gene expression involving neurological and cardiovascular pathways are altered in recipient fetuses prior to surgical treatment. This has relevance for the origins of long-term complications seen in survivors and for the development of future fetal biomarkers. This article is protected by copyright. All rights reserved.
    Prenatal Diagnosis 05/2013; · 2.68 Impact Factor
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    ABSTRACT: Amniotic fluid-derived stem cells (AFSC) have been reported to differentiate into cardiomyocyte-like cells and form gap junctions when directly mixed and cultured with neonatal rat ventricular myocytes (NRVM). This study investigated whether or not culture of AFSC on the opposite side of a Transwell membrane from NRVM, allowing for contact and communication without confounding factors such as cell fusion, could direct cardiac differentiation and enhance gap junction formation. Results were compared to shared media (Transwell), conditioned media and monoculture media controls. After a 2-week culture period, AFSC did not express cardiac myosin heavy chain or troponin T in any co-culture group. Protein expression of cardiac calsequestrin 2 was up-regulated in direct transmembrane co-cultures and media control cultures compared to the other experimental groups, but all groups were up-regulated compared with undifferentiated AFSC cultures. Gap junction communication, assessed with a scrape-loading dye transfer assay, was significantly increased in direct transmembrane co-cultures compared to all other conditions. Gap junction communication corresponded with increased connexin 43 gene expression and decreased phosphorylation of connexin 43. Our results suggest that direct transmembrane co-culture does not induce cardiomyocyte differentiation of AFSC, though calsequestrin expression is increased. However, direct transmembrane co-culture does enhance connexin-43-mediated gap junction communication between AFSC.
    Journal of Cellular and Molecular Medicine 05/2013; · 4.75 Impact Factor
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    ABSTRACT: OBJECTIVE: Despite fetoscopic laser surgery (FLS) having emerged as an effective treatment for twin-twin transfusion syndrome (TTTS), major post-intervention challenges such as iatrogenic preterm premature rupture of membranes (iPPROM) remain. Chorioamnion plug (CAP) placement with absorbable gelatin sponge has been used to seal the entry site in the amniochorion layers to promote healing and prevent iPPROM yet results have been equivocal. Our objective was to test the hypothesis that CAP with an absorbable gelatin sponge at FLS for TTTS may prevent iPPROM. STUDY DESIGN: A retrospective cohort study was performed on a prospectively collected data from consecutive 134 patients who underwent FLS for TTTS. The decision for CAP was left to the discretion of the physician. Pre-operative, operative and post-operative variables were collected and analyzed. The primary outcome was the incidence of iPPROM, and the secondary outcomes were procedure-to-delivery interval and gestational age at delivery. Comparative statistics were performed as appropriate (statistical significance p < 0.05). RESULTS: CAP was placed in 72 (54%) patients and was not placed in 62 (46%) patients. The factors that were significantly associated with CAP placement were anterior placentation (p=0.04), general endotracheal intubation (p=0.02), and cannula diameter of 12Fr (p=0.003). There were no differences in the rate of iPPROM (39% vs. 32%: CAP vs. no CAP group, respectively; p=0.42) or procedure-to-delivery interval (65.3 ± 34.7 vs. 58.2 ± 30.8 days: CAP vs. no CAP group, respectively; p=0.42) However, CAP increased the risk for iPPROM to occur in the period of 2 - 4 weeks after the procedure. The gestational age at delivery was later in the CAP group compared to no CAP (30.7 ± 4.5 weeks vs. 28.9 ± 3.9 weeks; p=0.02). CONCLUSION: CAP did not reduce the overall risk for PPROM and did increase the risk immediately after laser surgery. CAP did not increase the procedure-to-delivery interval. Further research is needed to identify other methods to prevent iPPROM and prolong pregnancy after laser therapy.
    Ultrasound in Obstetrics and Gynecology 04/2013; · 3.56 Impact Factor
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    ABSTRACT: INTRODUCTION: Single fetal demise in monochorionic twin gestations represents a significant risk for co-twin demise and neurodevelopmental morbidity. Indirect observations have led to a theory of acute exsanguination of the normal twin into the dying twin as the proposed mechanism. CASE: A 22-year-old G3P2 (2002) female with Quintero Stage IV twin-twin transfusion was referred for evaluation. During the course of the examination, bradycardia with impending fetal demise was noted in the recipient twin. Sudden and rapid development of tachycardia and elevation of the peak systolic velocity of the middle cerebral artery in the donor twin were witnessed. The demise of the donor twin was detected 24 hours later. Placental examination revealed one AV and two VA anastomoses. CONCLUSIONS: These observations support the "vascular sink" hypothesis for co-twin demise and neurodevelopmental abnormalities following single fetal demise in monochorionic twins. Rapid fetal exsanguination can occur even in the presence of a minimal number of placental vascular anastomoses.
    Ultrasound in Obstetrics and Gynecology 04/2013; · 3.56 Impact Factor
  • American journal of obstetrics and gynecology 03/2013; · 3.28 Impact Factor
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    ABSTRACT: A 25 year old G(2) P(1001) underwent a fetoscopic laser surgery (FLS) for stage II twin twin transfusion syndrome (TTTS) at 18 weeks of gestation. An ultrasound guided percutaneous entry in the suprapubic region was performed using a 12 F cannula for the procedure due to a central anterior placentation. Complete photocoagulation of 26 vessels was performed followed by the use of the Solomon technique to assure dichorionization of the placenta. Due to a recurrence of the oligo-polyhramnios sequence, a repeat laser was undertaken at 21 weeks of gestation. This was only the second time we have undertaken a repeat procedure in over 400 cases. The decision was made to perform the repeat procedure via a laparoscopic-guided fetoscopy from the right lumbar region using the technique that we have described previously.(1) The uterine cavity was entered using 12 French trocar and cannula. A single neovascularization site consisting of an AV anastomoses over a previously ablated anastomosis was detected and coagulated. During the procedure the initial defect site (Figure 1) was visualized approximately 4-5 cm from the internal cervical os, on the anterior uterine wall. The membrane defect was noted to be approximately 5-6 mm in diameter with no signs of healing such as granulation tissue or vascularization at the edges at the defect site. More importantly, there was no evidence of sliding of the amnion and chorion layers to cover the defect. Additionally, the trocar site of the uterine wall appeared patent showing signs of non-healing of the inner muscular layers with dissected smooth muscle fibers. There appeared to be no evidence of chorioamnion separation either on direct visualization or during transabdominal ultrasound. The patient delivered at 25 weeks' gestation by classical Cesarean delivery due to spontaneous preterm labor. The two neonates survived and currently remain in the neonatal intensive care unit. The site of original fetoscopic defect was identified in the extraplacental membrane and measured 4-5 mm in diameter. Histological examination showed no evidence of healing such as granulation tissue, new collagen deposition and epithelialization.
    Ultrasound in Obstetrics and Gynecology 01/2013; · 3.56 Impact Factor
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    ABSTRACT: OBJECTIVE: To determine the sensitivity and specificity of circulating cell-free fetal DNA in determining the fetal RHD status and fetal sex. METHODS: Maternal blood was collected in each trimester of pregnancy from RhD negative nonalloimmunized women. Whole blood was centrifuged, separated into plasma and buffy coat, and frozen at -80°C. DNA analysis was conducted via allele-specific primer extensions for exons 4, 5, and 7 of the RHD gene and for a 37-base pair insertion in exon 4 (RHD pseudogene; psi) three Y-chromosome sequences (SRY, DBY, and TTY2), and an extraction control (TGIFL-like X/Y). RhD serotyping on cord blood and gender assessment of the newborns were entered into a Web-based database. RESULTS: One hundred twenty women were enrolled. The median gestational age at the first venipuncture was 12.4 (range: 10.6-13.9) weeks with 120 samples drawn; 118 samples were drawn at 17.6 (16-20.9) weeks; and 113 samples at 28.7 (27.9-33.9) weeks. Overall accuracy for RHD was 99.1%, 99.1%, and 98.1% for each trimester and was 99.1%, 99.1%, and 100% for fetal sex determination. CONCLUSIONS: Fetal RHD genotyping and sex can be very accurately determined in all three trimesters using circulating cell-free fetal DNA in the maternal circulation. © 2012 John Wiley & Sons, Ltd.
    Prenatal Diagnosis 12/2012; · 2.68 Impact Factor
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    ABSTRACT: Twin reversed arterial perfusion sequence (TRAP) is a rare complication of multiple gestations. Only a few cases of TRAP in monochorionic triplets have been reported. A case of TRAP sequence in a monochorionic, triamniotic triplet gestation treated with radiofrequency ablation (RFA) of the acardiac fetus is reported. The response to the RFA procedure and the subsequent examination of the placenta support the hypothesis of an "indirect" pump triplet. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
    Ultrasound in Obstetrics and Gynecology 11/2012; · 3.56 Impact Factor
  • Kenneth J Moise, Pedro S Argoti
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    ABSTRACT: : To evaluate the application of new technologies to the management of the red cell alloimmunized pregnancy. : We searched three computerized databases for studies that described treatment or prevention of alloimmunization in pregnancy (MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials [1990 to July 2012]). The text words and MeSH included Rhesus alloimmunization, Rhesus isoimmunization, Rhesus prophylaxis, Rhesus disease, red cell alloimmunization, red cell isoimmunization, and intrauterine transfusion. : Of the 2,264 studies initially identified, 246 were chosen after limiting the review to those articles published in English and crossreferencing to eliminate duplication. : Both authors independently reviewed the articles to eliminate publications involving less than six patients. Special emphasis was given to publications that have appeared since 2008. : Quantitative polymerase chain reaction can be used instead of serology to more accurately determine the paternal RHD zygosity. In the case of unknown or a heterozygous paternal RHD genotype, new DNA techniques now make it possible to diagnose the fetal blood type through cell-free fetal DNA in maternal plasma. Serial Doppler assessment of the peak systolic velocity in the middle cerebral artery is now the standard to detect fetal anemia and determine the need for the first intrauterine transfusion. Assessment of the peak systolic velocity in the middle cerebral artery can be used to time the second transfusion, but its use to decide when to perform subsequent procedures awaits further study. New data suggest normal neurologic outcome in 94% of cases after intrauterine transfusion, although severe hydrops fetalis may be associated with a higher risk of impairment. Recombinant Rh immune globulin is on the horizon. Cell-free fetal DNA for fetal RHD genotyping may be used in the future to decide which patients should receive antenatal Rh immune globulin.
    Obstetrics and Gynecology 11/2012; 120(5):1132-9. · 4.80 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate the phenomenon of vascular ischemic limb necrosis in twin-twin transfusion syndrome (TTTS). This was a multicenter retrospective review of ischemic limb necrosis in patients with TTTS. Twenty cases of fetal ischemic limb necrosis in association with TTTS were identified from 10 fetal medicine centers. The recipient was affected in 19 cases, and the lower limb was affected in 17 cases. The extent of the damage correlated with TTTS severity. Eighty percent of limb defects (16/20) clearly were unrelated to laser treatment (3 cases untreated, 7 cases after amnioreduction, 6 cases present at time of laser). The recipient was relatively polycythemic in 5 of 7 cases in which neonatal or fetal hemoglobin/hematocrit levels were available. Ischemic limb necrosis is a rare complication of TTTS. The lesion is unrelated to therapy and may be the result of polycythemia, hypertension, and vasoconstriction.
    American journal of obstetrics and gynecology 08/2012; 207(2):131.e1-10. · 3.28 Impact Factor
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    ABSTRACT: The purpose of this study was to describe a single center's experience with referrals suspected to have twin-twin transfusion syndrome. A retrospective review was performed for patients with suspected twin-twin transfusion syndrome referred to a fetal treatment center between November 1, 2006, and June 1, 2010. Data were collected regarding diagnosis, treatment, and follow-up. Of the 324 patients referred for twin-twin transfusion syndrome, the diagnosis was confirmed in 249 (77%): Quintero stage I in 28 (11%), stage II in 50 (20%), stage III in 150 (60%), stage IV in 15 (6%), and stage V in 6 (2%). Ten patients presented too late for any intervention, including 6 cases of stage V disease with either single- or dual-twin death and 4 patients who imminently delivered. Of the 249 confirmed cases, 200 (84%) patients elected to undergo laser photocoagulation. The average gestational age ± SD for referral evaluation for laser-treated cases was 20.9 ± 5.7 weeks (median, 20.5 weeks). The other 75 patients who were referred for suspected twin-twin transfusion syndrome had a diagnosis of either a discordant amniotic fluid volume that did not meet the criteria for Quintero stage I twin-twin transfusion syndrome (56%) or selective intrauterine growth restriction (44%). Our data suggest that patients with confirmed twin-twin transfusion syndrome are referred with advanced stages of disease (69% stages III-V), with 59% of referrals made after 20 weeks' gestation. Such a referral pattern calls into question the current frequency of sonographic surveillance used by many obstetricians. Revisions of current practice guidelines emphasizing the importance of more frequent examinations in monochorionic twin gestations beginning at 16 weeks' gestation should be considered.
    Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 06/2012; 31(6):941-5. · 1.40 Impact Factor
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    ABSTRACT: The aim of the study was to evaluate the relationship between the degree of liver herniation and mortality or need for extracorporeal membrane oxygenation (ECMO) in isolated left-sided congenital diaphragmatic hernia (CDH). This is a retrospective review of all fetuses with isolated left-sided Bochdalek-type CDH evaluated at our center with ultrafast fetal magnetic resonance imaging between January 2004 and December 2010. Percentage of liver herniation was defined as the ratio of herniated liver volume to total fetal liver volume. The liver/thoracic volume ratio was defined as the ratio of herniated liver volume to total thoracic volume. Data were analyzed using receiver operating characteristic curves and Fisher's Exact and Mann-Whitney U tests. Fifty-three fetuses with isolated left-sided CDH were evaluated. Fetuses with "liver-up" (n = 32) and "liver-down" (n = 21) anatomy had similar rates of mortality (25% vs 14%, P = .49) and ECMO use (41% vs 29%, P = .40). The accuracy of liver-up (a dichotomous variable) to predict mortality or need for ECMO was 49% and 53%, respectively. Percentage of liver herniation greater than 21% was associated with mortality (P < .001) or need of ECMO (P < .001), with an accuracy of 87% and 79%, respectively. Liver/thoracic volume ratio of greater than 14% was also associated with mortality or ECMO use (P < .001 and P = .01, respectively), with an accuracy of 85% and 72%, respectively. Increased amounts of liver herniation in fetuses with isolated left-sided CDH are associated with higher rates of mortality or the need for ECMO support. Quantification of liver herniation (a continuous variable) is superior to overall liver herniation as a dichotomous variable (liver-up vs liver-down) in the prediction of perinatal morbidity and mortality.
    Journal of Pediatric Surgery 06/2012; 47(6):1058-62. · 1.38 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate the benefit of cervical cerclage for cervical length ≤ 25 mm at the time of fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome. A multicenter, retrospective cohort study was conducted with 163 patients with a short cervix before FLP for twin-twin transfusion syndrome. Seventy-nine of the patients (48%) had cerclage placement at the surgeon's discretion. The outcome measures that were compared were gestational age at delivery and perinatal mortality rates for patients with cerclage and those who were treated conservatively. Outcomes were evaluated with the use of comparative statistics. There were no differences in the preoperative variables, except cerclage was performed more frequently for a cervical length of ≤ 15 mm (P < .001). There were no differences in the gestational age at delivery (28.8 ± 5.4 vs 29.1 ± 5.6 weeks with and without cerclage, respectively; P = .15); perinatal mortality rates were similar between the 2 groups. The benefit of cerclage for patients with short cervix before FLP remains questionable.
    American journal of obstetrics and gynecology 02/2012; 206(5):425.e1-7. · 3.28 Impact Factor

Publication Stats

3k Citations
905.94 Total Impact Points

Institutions

  • 1999–2014
    • University of Texas Health Science Center at Houston
      • • Department of Obstetrics, Gynecology and Reproductive Sciences
      • • Department of Neurosurgery
      Houston, Texas, United States
    • University of Texas Southwestern Medical Center
      • Department of Obstetrics and Gynecology
      Dallas, TX, United States
  • 2012–2013
    • University of Texas Medical School
      • Department of Obstetrics, Gynecology & Reproductive Sciences
      Houston, Texas, United States
    • Memorial Hermann Hospital
      • Maternal Fetal Medicine Services
      Houston, Texas, United States
    • Rice University
      • Department of Bioengineering
      Houston, TX, United States
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 2011–2013
    • Yale University
      • Department of Obstetrics, Gynecology and Reproductive Sciences
      New Haven, Connecticut, United States
  • 1987–2013
    • Baylor College of Medicine
      • Department of Obstetrics and Gynecology
      Houston, TX, United States
  • 1999–2012
    • University of North Carolina at Chapel Hill
      • Department of Obstetrics and Gynecology
      North Carolina, United States
  • 1990–2011
    • Texas Children's Hospital
      Houston, Texas, United States
  • 2009
    • Society for Maternal-Fetal Medicine
      Houston, Texas, United States
    • WakeMed Health & Hospitals
      Raleigh, North Carolina, United States
  • 1998–2005
    • University of Texas Medical Branch at Galveston
      • Department of Obstetrics and Gynecology
      Galveston, Texas, United States