Mary E D'Alton

Society for Maternal-Fetal Medicine, New York, New York, United States

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Publications (180)910.02 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Given that cesarean delivery is one of the most commonly performed surgical procedures in the United States and an important contributor to obstetric care costs, this analysis sought to examine maternal hospital costs associated with trial of labor after cesarean delivery (TOLAC) versus repeat cesarean delivery (RCD). A national sample was used to identify women with singleton pregnancy who underwent either TOLAC or RCD from 2006 to 2012. Women with diagnoses that could confound cost via extended hospital length of stay prior to delivery were excluded. Other medical and obstetric covariates that could influence cost were included in an adjusted model. A total of 485 247 women were identified, including 365 596 (75.3%) cesarean deliveries without labor, 41 988 (8.6%) successful and 77 663 (16.0%) unsuccessful TOLAC deliveries. The inflation-adjusted median costs in this cohort were $5512 for cesarean without labor, $4175 for successful TOLAC, $5166 for all TOLAC attempts, and $5759 for failed TOLAC. In a multivariable model, hospital region was a major predictor of median cost as were demographic variables and medical comorbidities. TOLAC is associated with modest reductions of cost for maternal hospitalizations. However, other medical, demographic and hospital factors appear to be more important factors.
    The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 04/2015; DOI:10.3109/14767058.2015.1035250 · 1.21 Impact Factor
  • JAMA The Journal of the American Medical Association 01/2015; 313(2):197-9. DOI:10.1001/jama.2014.14774 · 30.39 Impact Factor
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    ABSTRACT: While major international guidelines recommend venous thromboembolism (VTE) prophylaxis during vaginal delivery hospitalization for women with additional risk factors, US guidelines recommend prophylaxis for a very small number of women at particularly high risk for an event. The purpose of this study is to characterize practice patterns of VTE prophylaxis in the US during vaginal delivery hospitalizations and determine VTE incidence in this population.
    American Journal of Obstetrics and Gynecology 09/2014; DOI:10.1016/j.ajog.2014.09.017 · 3.97 Impact Factor
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    ABSTRACT: Abstract Objective Our survey aimed to identify knowledge and application of guidelines in the United States by assessing practicing obstetricians and gynecologists (OBGYN) use of thromboprophylaxis, preferred methods, and whether their type of practice influenced their choices. Study Design A cross sectional survey of fellows of the American College of Obstetricians and Gynecologists (ACOG) was performed. A 21-item paper and electronic questionnaire was sent to each participant. A total of 3 mailings were carried out. Results 400 OBGYN were invited to participate. Questionnaires were returned by 209 (52.3%), 157 (75.1%) of whom provided prenatal care within the last year. All respondents used at least one method of thromboprophylaxis routinely. 92.4% used pneumatic compression devices. An equal proportion used unfractionated heparin and low molecular weight heparin routinely (17.8%). 19.1% routinely used combination prophylaxis. 77.1% (n=121) used the ACOG guideline. Local hospital guidelines were referenced by 38.2% (n=60). Other guidelines referenced were the ACCP guideline (n=34, 21.7%), and several international guidelines (n=5, 3.3%). Conclusion Awareness of the risk of thromboembolism around delivery by cesarean section is high amongst OBGYN practitioners. Broadening guidelines to encompass all deliveries, not only caesareans, with a focus on identifying the patient at risk, would likely be successful.
    The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 03/2014; 27(18). DOI:10.3109/14767058.2014.898057 · 1.21 Impact Factor
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    ABSTRACT: Context: Lower birthweight has been reported in conjunction with high maternal free thyroxine (FT4) in euthyroid pregnancies, raising concerns for suboptimal outcomes. Objective: Explore relationships between high maternal FT4 and pregnancy complications in euthyroid women. Further examine relationships among maternal size, FT4 and birthweight. Design: Observational multicenter cohort study. Setting: Prenatal clinics. Study Subjects: 9209 euthyroid women with singleton pregnancies. Interventions: None. Main Outcome Measures: Relationships between second trimester high maternal FT4 and pregnancy/delivery complications, and among FT4, maternal weight and birthweight. Results: Women in the highest FT4 quintile are younger and weigh less than women in quintiles 1-4; gestational diabetes and preeclampsia occur less often (p = < 0.001, < 0.001, < 0.001, and 0.05, respectively). Lowest median birthweight occurs among women in the highest FT4 quintile (p = < 0.001), but deliveries < 37 weeks' gestation are not increased. Labor/delivery complications do not differ by FT4 quintile. Restricting analyses to maternal weight-adjusted small-for-gestational-age deliveries yields similar results, except for preeclampsia. In the highest maternal weight decile, adjusted median birthweight is 266g higher (8.3%) than in the lowest weight decile; adjusted median FT4 is 0.91 pmol/L lower (6.8%). Among women in the highest FT4 decile, adjusted median birthweight is 46g lower (1.3%) than in the lowest FT4 decile. All three relationships are statistically significant (p = < 0.001, < 0.001, and 0.004, respectively). Conclusions: Lower median birthweight among euthyroid women with high FT4 is not associated with adverse pregnancy outcomes. Further investigation is indicated to determine how variations in thyroid hormone concentration influence birthweight.
    The Journal of Clinical Endocrinology and Metabolism 02/2014; 99(6):jc20141053. DOI:10.1210/jc.2014-1053 · 6.31 Impact Factor
  • American Journal of Obstetrics and Gynecology 01/2014; 210(1):S260-S261. DOI:10.1016/j.ajog.2013.10.562 · 3.97 Impact Factor
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    ABSTRACT: Abstract Aim: To critically evaluate current understanding of risk factors for pregnancy-associated venous thromboembolism (VTE) and to describe underlying molecular mechanisms. Methods: A literature search was undertaken using the national library of medicine PubMed database. The search terms used were "pregnancy" and "venous thromboembolism". Following exclusion of unsuitable data sources, studies were identified that described specific risk factors for pregnancy-associated VTE and suggested possible underlying molecular mechanisms. Adjusted odds ratios and incident rate ratios for these specific risk factors were identified in each study and tabulated. Results: A series of mainly retrospective cohort and case control studies over the past two decades have reported specific risk factors for pregnancy-associated VTE. Recent published literature has highlighted the interaction between commonly occurring risk factors, particularly the potential for a multiplicative effect on overall VTE risk, and have led to improvements in our understanding of the molecular mechanisms underlying these risk factors. Conclusion: Mortality from pregnancy associated VTE continues despite prevention strategies. A detailed understanding of specific risk factors, their interactions and underlying molecular mechanisms is required to identify women at highest risk and to guide development of thromboprophylaxis strategies.
    Journal of Perinatal Medicine 12/2013; 42(4):1-9. DOI:10.1515/jpm-2013-0207 · 1.43 Impact Factor
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    ABSTRACT: To characterize contemporary practice patterns for postcesarean thromboembolism prophylaxis and determine whether opportunities to substantially decrease maternal mortality and morbidity in this clinical setting are being missed. A commercial hospitalization database that includes procedure and diagnosis codes, health care provider and hospital information, and patient demographic data were used to analyze use of venous thromboembolism prophylaxis after cesarean delivery in the United States between 2003 and 2010. The analysis evaluated whether patients received pharmacologic prophylaxis, mechanical prophylaxis, combined prophylaxis, or no prophylaxis. Hospital-level factors and patient characteristics were included in multivariable regression models evaluating prophylaxis administration. We identified 1,263,205 women who underwent cesarean delivery. Within the cohort, 75.7% (n=955,787) received no thromboembolism prophylaxis, 22.1% (n=278,669) received mechanical prophylaxis alone, 1.3% (n=16,639) received pharmacologic prophylaxis, and 1.0% (n=12,110) received combination prophylaxis. The rate of prophylaxis increased from 8.4% in 2003 to 41.6% in 2010. Prophylaxis rates varied significantly by geographic region. Medical risk factors for thromboembolism were associated with only modest increases in prophylaxis. Although our findings demonstrated increased adoption of postcesarean venous thromboembolism prophylaxis, fewer than half of patients received recommended care as of 2010, and significant variation was present. Thromboembolism prophylaxis is underused and represents a major opportunity to reduce maternal morbidity and mortality. Risk assessment tools and thromboprophylaxis guidelines are needed to assure high-quality, uniform care. LEVEL OF EVIDENCE:: III.
    Obstetrics and Gynecology 11/2013; 122(6). DOI:10.1097/AOG.0000000000000007 · 4.37 Impact Factor
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    ABSTRACT: The Perinatal Quality Foundation has created an examination containing both knowledge based and judgment questions relating to the interpretation of electronic fetal heart rate monitoring for credentialing all medical and nursing personnel working on a labor and delivery floor. A description of the examination and the rationale for its use throughout the United States is presented.
    American journal of obstetrics and gynecology 10/2013; 210(3). DOI:10.1016/j.ajog.2013.10.007 · 3.97 Impact Factor
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    ABSTRACT: OBJECTIVE: Accurate amniocentesis-related pregnancy loss (ARL) rates for twin gestations remains elusive due to varying ARL definitions in the literature. We examined how OB/GYNs define/counsel women carrying twins about ARL. METHODS: A random sample of 1000 American College of OB/GYN (ACOG) fellows and ACOG Collaborative Ambulatory Research Network (CARN) members were mailed surveys about their opinions/ practice patterns regarding amniocentesis in twins. 208/400 (52%) CARN members and 166/600 (27%) ACOG fellows returned the survey (37% response rate). RESULTS: Of respondents, 80.8% practiced general OB/GYN, 9.1% practiced Maternal Fetal Medicine. 72% of respondents discussed amniocentesis for prenatal diagnosis. Of these, 91.7% discuss the risk of ARL, however, 47.4% do not quote an ARL rate. Of those who discuss ARL rates, 65% quote a rate greater than for singletons. Regarding monochorionic-diamniotic twins, 12.1% of respondents said the ARL rate was less, 39.6% said equal to, and 38.9% said greater than for dichorionic twins. Table 1 lists the most common clinical definitions/time intervals used to describe ARL. CONCLUSION: Various definitions/ARL rates are used when counseling about ARL in twins. Further studies using a widely accepted definition of ARL are necessary to improve the counseling of women considering amniocentesis for prenatal diagnosis in twins. This article is protected by copyright. All rights reserved.
    Prenatal Diagnosis 09/2013; 33(9). DOI:10.1002/pd.4164 · 2.51 Impact Factor
  • Suneet P Chauhan, Mary E D'Alton
    Seminars in perinatology 08/2013; 37(4):205-6. DOI:10.1053/j.semperi.2013.04.009 · 2.42 Impact Factor
  • Jennifer C Donnelly, Mary E D'Alton
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    ABSTRACT: Venous thromboembolism remains in the top three leading causes of maternal death in the US, representing 10.2% of pregnancy-related deaths. Risk of developing a pulmonary embolus appears to increase throughout pregnancy, with a peak in incidence in the early postpartum period. Overall the incidence of VTE is 0.6-1.8 VTEs per 1000 deliveries. Diagnosis and management of pulmonary embolus can prove challenging, but the aim should be to optimize maternal outcome while minimizing hemorrhagic complications. Low-molecular-weight heparin is a safe and effective treatment for the majority of cases of pregnancy-related pulmonary embolus.
    Seminars in perinatology 08/2013; 37(4):225-33. DOI:10.1053/j.semperi.2013.04.002 · 2.42 Impact Factor
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    ABSTRACT: Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.
    American journal of obstetrics and gynecology 06/2013; 208(6):442–448. DOI:10.1016/j.ajog.2012.11.041 · 3.97 Impact Factor
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    ABSTRACT: OBJECTIVE:: To examine trends in electronic fetal monitoring (EFM) use and quantify the extent to which such trends are associated with changes in rates of primary cesarean delivery and neonatal morbidity and mortality. METHODS:: We carried out a retrospective study of more than 55 million nonanomalous singleton live births (24-44 weeks of gestation) delivered in the United States between 1990 and 2004. Changes in the risks of neonatal mortality, cesarean delivery, and operative vaginal delivery for fetal distress, 5-minute Apgar score lower than 4, and neonatal seizures (at 34 weeks of gestation or after) were examined in relation to changes in EFM use. RESULTS:: Electronic fetal monitoring use increased from 73.4% in 1990 to 85.7% in 2004, a relative increase of 17% (95% confidence interval 16-18%). This increase was associated with an additional 5% and 2% decline in early and late neonatal deaths, respectively, at 24-33 weeks of gestation as well as a 4-7% additional decline in the 5-minute Apgar score lower than 4 at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM use was associated with a 2-4% incremental increased rate of both cesarean delivery and operative vaginal delivery for fetal distress at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM was not associated with any temporal changes in the rate of neonatal seizures. CONCLUSIONS:: The temporal increase in EFM use in the United States appears to be modestly associated with the recent declines in neonatal mortality, especially at preterm gestations. LEVEL OF EVIDENCE:: II.
    Obstetrics and Gynecology 05/2013; 121(5):927-933. DOI:10.1097/AOG.0b013e318289510d · 4.37 Impact Factor
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    ABSTRACT: Abstract Objective We surveyed obstetricians to determine their knowledge, patterns of care, and treatment preferences for women with placenta accreta. Methods A 27-item survey was mailed to fellows of the American College of Obstetricians and Gynecologists. The survey included demographics, questions regarding knowledge and items to examine practice patterns. Results Among 994 surveyed practitioners 508 responded including 338 who practiced obstetrics. Among generalists, 23.8% of respondents referred patients with placenta accreta to a sub-specialist. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34-36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners. Conclusion There is widespread variation in the care of women with or at risk for placenta accreta.
    The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 04/2013; 26(16). DOI:10.3109/14767058.2013.793662 · 1.21 Impact Factor
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    K S Joseph, Mary D'Alton
    Paediatric and Perinatal Epidemiology 01/2013; 27(1):2-6. DOI:10.1111/ppe.12030 · 2.81 Impact Factor
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    ABSTRACT: Previous studies have shown that woman's risk of breast cancer in later life is associated with her infants birth weights. The objective of this study was to determine if this association is independent of breast cancer risk factors, mother's own birth weight and to evaluate association between infants birth weight and hormonal environment during pregnancy. Independent association would have implications for understanding the mechanism, but also for prediction and prevention of breast cancer. Risk of breast cancer in relation to a first infant's birth weight, mother's own birth weight and breast cancer risk factors were evaluated in a prospective cohort of 410 women in the Framingham Study. Serum concentrations of estriol (E3), anti-estrogen alpha-fetoprotein (AFP), and pregnancy-associated plasma protein-A (PAPP-A) were measured in 23,824 pregnant women from a separate prospective cohort, the FASTER trial. During follow-up (median, 14 years) 31 women (7.6%) were diagnosed with breast cancer. Women with large birth weight infants (in the top quintile) had a higher breast cancer risk compared to other women (hazard ratio (HR), 2.5; 95% confidence interval (CI), 1.2-5.2; P = 0.012). The finding was not affected by adjustment for birth weight of the mother and traditional breast cancer risk factors (adjusted HR, 2.5; 95% CI, 1.2-5.6; P = 0.021). An infant's birth weight had a strong positive relationship with the mother's serum E3/AFP ratio and PAPP-A concentration during pregnancy. Adjustment for breast cancer risk factors did not have a material effect on these relationships. Giving birth to an infant with high birth weight was associated with increased breast cancer risk in later life, independently of mother's own birth weight and breast cancer risk factors and was also associated with a hormonal environment during pregnancy favoring future breast cancer development and progression.
    PLoS ONE 07/2012; 7(7):e40199. DOI:10.1371/journal.pone.0040199 · 3.53 Impact Factor
  • Joy Vink, Ronald Wapner, Mary E D'Alton
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    ABSTRACT: Twin gestations face an increased risk of structural abnormalities compared with singleton gestations, as well as an increased risk of aneuploidy. Accordingly, there is a need for accurate prenatal diagnosis of fetal genetic disorders and structural anomalies in twin gestations. Given the increased risk of congenital anomalies, a detailed sonographic survey of fetal anatomy is recommended in the early second trimester of twin gestations. In addition, fetal echocardiography should be considered in monochorionic twin gestations and in dichorionic twin pregnancies conceived using assisted reproductive technologies given the increased risk of congenital heart disease in these populations. Although first- and second-trimester aneuploidy screening in twin gestations is available, screening is less accurate than in singleton gestations. Invasive prenatal diagnosis in twin pregnancies is associated with a risk of pregnancy loss that is higher than the baseline risk of loss among twin gestations. Precise procedure-related loss rates in twin gestations undergoing chorionic villus sampling or amniocentesis, however, remain unclear because of methodological differences between published studies investigating diagnostic procedures in twins.
    Seminars in perinatology 06/2012; 36(3):169-74. DOI:10.1053/j.semperi.2012.02.008 · 2.42 Impact Factor
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    Joy Vink, Karin Fuchs, Mary E D'Alton
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    ABSTRACT: Using published data, we sought to determine the amniocentesis-related loss rate in twin gestations. We searched the PUBMED database using keywords "amniocentesis", "twin" and "twins" to identify articles evaluating genetic amniocentesis in twin gestations published from January 1970 to December 2010. Random effects models were used to pool procedure-related loss rates from included studies. The definition of "loss" varied across the 17 studies identified (Table 1). The pooled procedure-related loss rate at < 24 weeks was 3.5% (95% confidence interval [CI] 2.6-4.7) (Figure 2). Pooled loss rates at < 28 weeks (Figure 4) and to term (Figure 5) could not be calculated due to unacceptable heterogeneity of available data. Seven studies included a control (no amniocentesis) group and reported a pooled odds ratio for total pregnancy loss among cases of 1.8 (95% CI 1.2-2.7) (Figure 3). Only 1 study reported procedure-related loss rates by chorionicity (7.7% among monochorionics vs 1.4% among controls; p 0.02). Analysis of published data demonstrated a pooled amniocentesis-related loss rate of 3.5% in twin gestations < 24 weeks. Pooled loss rates within other post-amniocentesis intervals or other gestational age windows and the impact of chorionicity on procedure-related loss rates cannot be determined from published data.
    Prenatal Diagnosis 05/2012; 32(5):409-16. DOI:10.1002/pd.2897 · 2.51 Impact Factor
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    ABSTRACT: The purpose of this study was to compare strategies for delivery timing of uncomplicated monochorionic diamniotic twin pregnancies. A decision tree compared 9 strategies that included scheduled delivery between 32 and 38 weeks' gestation, with or without confirmation of fetal lung maturity. Outcomes in the model included fetal death, infant death, respiratory distress syndrome, mental retardation, and cerebral palsy. A scheduled delivery at 38 weeks' gestation was the preferred strategy, which resulted in the highest quality adjusted life years under base-case assumptions. Decreased, but comparable, quality adjusted life years estimates resulted from scheduled deliveries at 36 and 37 weeks' gestation, with or without amniocentesis. Sensitivity analyses demonstrated that the optimal gestational age for delivery was always ≥36 weeks' gestation. This decision analysis suggests that, for women with uncomplicated monochorionic twins, delivery between 36 and 38 weeks' gestation is the preferred strategy for timing of delivery.
    American journal of obstetrics and gynecology 04/2012; 207(1):53.e1-7. DOI:10.1016/j.ajog.2012.04.007 · 3.97 Impact Factor

Publication Stats

5k Citations
910.02 Total Impact Points

Institutions

  • 2009–2015
    • Society for Maternal-Fetal Medicine
      New York, New York, United States
    • University of Utah
      • Department of Obstetrics and Gynecology
      Salt Lake City, UT, United States
    • Weill Cornell Medical College
      • Department of Obstetrics and Gynecology
      New York City, New York, United States
    • National Institute of Child Health and Human Development
      Maryland, United States
  • 2013
    • Gracie Square Hospital, New York, NY
      New York City, New York, United States
  • 2000–2013
    • Columbia University
      • Department of Obstetrics and Gynecology
      New York City, New York, United States
  • 2010–2011
    • Alpert Medical School - Brown University
      • Department of Pathology and Laboratory Medicine
      Providence, Rhode Island, United States
    • Massachusetts General Hospital
      • Department of Obstetrics and Gynecology
      Boston, MA, United States
  • 2001–2011
    • CUNY Graduate Center
      New York City, New York, United States
  • 2000–2010
    • New York Presbyterian Hospital
      • Department of Obstetrics and Gynecology
      New York City, New York, United States
  • 1999–2010
    • Mid-Columbia Medical Center
      DLS, Oregon, United States
    • Tufts Medical Center
      Boston, Massachusetts, United States
  • 2008
    • Mount Sinai Medical Center
      New York City, New York, United States
  • 2006–2008
    • University of Cambridge
      • Department of Obstetrics & Gynaecology
      Cambridge, England, United Kingdom
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
  • 2007
    • Texas A&M University - Galveston
      Galveston, Texas, United States
    • University of Washington Seattle
      • Department of Obstetrics and Gynecology
      Seattle, Washington, United States
    • University of Texas Medical Branch at Galveston
      • Department of Obstetrics and Gynecology
      Galveston, TX, United States
  • 2006–2007
    • Boston University
      • Department of Biostatistics
      Boston, Massachusetts, United States
  • 2004
    • CARDIO MD
      Newark, New Jersey, United States
  • 1994–2000
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 1993–1998
    • Tufts University
      • Department of Obstetrics and Gynecology
      Medford, MA, United States
  • 1997
    • The Children's Hospital of Philadelphia
      • Center for Fetal Diagnosis and Treatment
      Filadelfia, Pennsylvania, United States
    • Dartmouth–Hitchcock Medical Center
      Lebanon, New Hampshire, United States
  • 1996
    • Boston Children's Hospital
      • Department of Pediatrics
      Boston, MA, United States