J. Gerald Quirk

• Doctor of Medicine
• Stony Brook University Hospital

In this chapter, we present Gaussian process-based machine learning solutions to important tasks in computerized fetal heart rate analysis. Gaussian processes provide a powerful Bayesian machinery for learning functions or mappings and have inherent connections with many popular machine learning methods such as support vector machines and neural ne...

Introduction: During labor, fetal heart rate (FHR) and uterine activity (UA) can be continuously monitored using Cardiotocography (CTG). This is the most widely adopted approach for electronic fetal monitoring in hospitals. Both FHR and UA recordings are evaluated by obstetricians for assessing fetal well-being. Due to the complex and noisy nature...

Low umbilical artery pH is a marker for neonatal acidosis and is associated with an increased risk for neonatal complications. The phase-rectified signal averaging (PRSA) features have demonstrated superior discriminatory or diagnostic ability and good interpretability in many biomedical applications including fetal heart rate analysis. However, th...

The computer-aided interpretation of fetal heart rate (FHR) and uterine contraction (UC) has not been developed well enough for wide use in delivery rooms. The main challenges still lie in the lack of unclear and nonstandard labels for cardiotocography (CTG) recordings, and the timely prediction of fetal state during monitoring. Rather than traditi...

During the process of childbirth, fetal distress caused by hypoxia can lead to various abnormalities. Cardiotocography (CTG), which consists of continuous recording of the fetal heart rate (FHR) and uterine contractions (UC), is routinely used for classifying the fetuses as hypoxic or non-hypoxic. In practice, we face highly imbalanced data, where...

During the process of childbirth, fetal distress caused by hypoxia can lead to various abnormalities. Cardiotocography (CTG), which consists of continuous recording of the fetal heart rate (FHR) and uterine contractions (UC), is routinely used for classifying the fetuses as hypoxic or non-hypoxic. In practice, we face highly imbalanced data, where...

Detection of anomalies in time series is still a challenging problem. In this paper, we provide a new approach to unsupervised detection of anomalies in time series based on the concept of phase space reconstruction and manifolds. We propose a rotation-insensitive metric for quantifying the similarity of manifolds and a method that uses it for esti...

Identifying uterine contractions with the aid of machine learning methods is necessary vis-á-vis their use in combination with fetal heart rates and other clinical data for the assessment of a fetus wellbeing. In this paper, we study contraction identification by processing noisy signals due to uterine activities. We propose a complete four-step me...

Classification with imbalanced data is a common and challenging problem in many practical machine learning problems. Ensemble learning is a popular solution where the results from multiple base classifiers are synthesized to reduce the effect of a possibly skewed distribution of the training set. In this paper, binary classifiers based on Gaussian...

During labor, fetal heart rate (FHR) is monitored externally using Doppler ultrasound. This is done continuously, but for various reasons (e.g., fetal or maternal movements) the system does not record any samples for varying periods of time. In many settings, it would be quite beneficial to estimate the missing samples. In this paper, we propose a...

Convergent cross mapping (CCM) is designed for causal discovery in coupled time series, where Granger causality may not be applicable because of a separability assumption. However, CCM is not robust to observation noise which limits its applicability on signals that are known to be noisy. Moreover, the parameters for state space reconstruction need...

During labor, fetal heart rate (FHR) and uterine activity (UA) are continuously monitored with Cardiotocography (CTG). The FHR and UA signals are visually inspected by obstetricians to assess the fetal well-being. However, due to the subjectivity of the visual inspection, the evaluations of CTG recordings performed by obstetricians have high inter-...

Convergent cross mapping (CCM) is a state space reconstruction (SSR)-based method designed for causal discovery in coupled time series, where Granger causality may not be applicable due to a separability assumption. However, CCM requires a large number of observations and is not robust to observation noise which limits its applicability. Moreover,...

The second Signal Processing and Monitoring in Labor workshop gathered researchers who utilize promising new research strategies and initiatives to tackle the challenges of intrapartum fetal monitoring. The workshop included a series of lectures and discussions focusing on: new algorithms and techniques for cardiotocogoraphy (CTG) and electrocardio...

In this paper, we propose a novel and simple method for discovery of Granger causality from noisy time series using Gaussian processes. More specifically, we adopt the concept of Granger causality, but instead of using autoregressive models for establishing it, we work with Gaussian processes. We show that information about the Granger causality is...

BACKGROUND: Gestational diabetes insipidus is a rare endocrinopathy caused by elevated levels of vaso-pressinase, with a paucity of cases described in the obstetrics literature. CASE: We present 2 cases of women who presented in the third trimester of pregnancy with complaints of severe polydipsia, polyuria, and nocturia. Maternal laboratory work w...

INTRODUCTION To determine the characteristics and outcomes associated with unexecuted postpartum sterilizations in high risk low income obstetrical patients. METHODS A retrospective cohort study of pregnant women desiring postpartum sterilization from a high risk, Medicaid based, obstetrical practice was undertaken at a university based hospital f...

INTRODUCTION Maternal vitamin D deficiency has been associated with adverse neonatal outcomes including preterm birth, immunosuppression, infection, low birth weight, neonatal seizures, asthma and fractures. We set out to determine if antepartum vitamin D prophylaxis decreases the risk of adverse neonatal outcomes. METHODS A prospective cohort stu...

Objective: To compare the rapid bedside test for placental α microglobulin-1 with the instrumented fetal fibronectin test for prediction of imminent spontaneous preterm delivery among women with symptoms of preterm labor. Methods: We conducted a prospective observational study on pregnant women with signs or symptoms suggestive of preterm labor...

In this paper, we propose an application of non-parametric Bayesian (NPB) models for classification of fetal heart rate (FHR) recordings. More specifically, we propose models that are used to differentiate between FHR recordings that are from fetuses with or without adverse outcomes. In our work, we rely on models based on hierarchical Dirichlet pr...

INTRODUCTION: The complications of vacuum-assisted vaginal deliveries are well documented; however, complications with its use during cesarean delivery (CD) is limited. The objective of the study is to determine if there is an increased risk of maternal and neonatal morbidity in vacuum-assisted CD. METHODS: This is a retrospective cohort study of v...

In this paper, we propose an application of non-parametric Bayesian (NPB) models to classification of fetal heart rate recordings. More specifically, the models are used to discriminate between fetal heart rate recordings that belong to fetuses that may have adverse asphyxia outcomes and those that are considered normal. In our work we rely on mode...

This paper presents novel methods for classification of fetal heart rate (FHR) signals into categories that are meaningful for clinical implementation. They are based on generative models (GMs) and Bayesian theory. Instead of using scalar features that summarize information obtained from long-duration data, the models allow for explicit use of feat...

The neonatal intensive care unit (NICU) is a high-stress environment for both families and health care providers that can sometimes make appropriate medical decisions challenging. We present a review article of non-medical barriers to effective decision making in the NICU, including: miscommunication, mixed messages, denial, comparative social and...

In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. They projected the numbers of legal abortions that likely would be required by women in the United States and described the r...

We present the case of a 36-year-old woman who has experienced three lost pregnancies; during the most recent loss, a full term pregnancy, she almost died from complications of placental abruption. She is now completing the 34th week of gestation and is experiencing symptoms similar to those under which she lost the previous pregnancy. Despite a la...

We present preliminary results on the use of Bayesian-network (BN) structure learning algorithms for deciphering dependencies from amongst different fetal heart rate (FHR) features collected from a real database. We used a greedy search-and-score procedure known as the K2 algorithm for the estimation of the BN structure. The database consists of a...

We study the problem of accurate automatic classification of fetal heart rate (FHR) signals using three different classification methods. FHR time series data are segmented into short (15s) spans of data, and features are extracted from them. These features include some established metrics of FHR trends such as acceleration and deceleration duratio...

We present a description of a computerized approach to interpretation of fetal heart rate (FHR) patterns that uses the 2008 Fetal Heart Rate Monitoring Guidelines published by the National Institute of Child Health and Human Development. The study addresses accurate feature extraction that gives programmatic meaning to heretofore visually adjudged...

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patien...

A 38-year-old Asian female with disseminated malignant T-cell lymphoma presented at 27 weeks estimated gestational age with possible pneumonia and preterm labor unresponsive to betamimetic tocolytic therapy. Her postpartum course was complicated by multisystem organ failure and maternal death. Autopsy demonstrated malignant T-cell lymphoma involvin...

The Chirurgeon must have a goode eyes and a stedfast hande (for chirurgy taketh its name of this). He must have goode witte and memory and goode judgement. Chirurgeons ought to be wyse and gentil, sober and circumspect. They muste be learned and not drunken. Nor must they promise more than they can perform with God's helpe. Andrew Boorde (1490–1549...

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To compare betamethasone with dexamethasone in terms of effectiveness in reducing perinatal morbidities and mortality among preterm infants. We enrolled 299 women at risk for preterm delivery in a double-blind, placebo-controlled, randomized trial of antenatal betamethasone compared with dexamethasone at Stony Brook University Hospital from August...

To measure and compare pulse pressure in early pregnancy between parturients who subsequently did or did not develop preeclampsia. Retrospective chart review of 44 parturients with preeclampsia and 187 controls without. The groups were compared for blood pressure indices before 15 weeks' gestation and other maternal variables. The preeclampsia grou...

To determine the effect of the genetic counselor on the acceptance of genetic amniocentesis. We studied women with singleton pregnancies who would be at least 35 years of age at the estimated date of delivery without fetal structural anomalies or family history of chromosomal abnormalities. The acceptance rate of genetic amniocentesis among women e...

To assess the effectiveness of an incomplete course of antenatal corticosteroids on perinatal morbidity and mortality. METHOSD: We studied consecutive neonates born at 23-34 weeks' gestation between January 1, 1998, and July 31, 2002. The study population was divided into a group exposed to one 12-mg dose of betamethasone before delivery and a non-...

To determine whether the fetal admission test is predictive of intrapartum complications. We studied the fetal heart rate tracings of women in spontaneous labor at 37-42 weeks' gestation from 1 November 2001 to 31 March 2002. The study population was subdivided based on reactivity defined as > or = 15 beats/min for > or = 15 s, reactivity redefined...

To determine the effect of in vitro fertilization (IVF), multiple gestation, and history of unkaryotyped miscarriage on the acceptance of genetic amniocentesis. We studied women expected to be at least 35 years of age at the estimated date of delivery without family history of chromosomal abnormalities or fetal structural anomalies. The influence o...

To determine what factors are associated with newborn hearing loss. We retrospectively reviewed hospital records of all neonates found on screening to have hearing loss as well as a cohort with normal audiometric findings from January 1998 through December 2000. The two groups were compared for various maternal, obstetric, and perinatal variables....

To determine whether in utero exposure to magnesium sulfate was associated with increased neonatal morbidity and mortality among premature neonates, and secondarily to determine the relationship, if any, between duration of magnesium sulfate exposure and neonatal morbidity and mortality. We studied 401 neonates at our institution who were born betw...

Biotin deficiency is teratogenic in several mammalian species. Approximately 50% of pregnant women have an abnormally increased urinary excretion of 3-hydroxyisovaleric acid (3-HIA), which probably reflects decreased activity of the biotin-dependent enzyme methylcrotonyl-CoA carboxylase. However, increased 3-HIA excretion could result from pregnanc...

Early recognition of fetal urinary tract anomalies may dramatically influence obstetric or neonatal management. Major fetal urinary abnormalities, including renal agenesis, obstructive lesions, and cystic disease, may be clinically silent but readily identified by sonography. Careful evaluation of the fetal genitourinary tract should therefore be a...

Adeno-associated virus (AAV) encoded Rep78 is a multi-functional protein which is required for AAV DNA replication, is able to regulate both AAV and heterologous gene expression at the transcriptional level, and appears necessary for site specific integration of AAV DNA into human chromosome 19. By comparison with the analogous replication protein...

Because of its ability to integrate chromosomally and its non-pathogenic nature, adeno-associated virus (AAV) has significant potential as a human gene therapy vector. Here we investigate the maximum amount of DNA which can be inserted into the AAV genome and still allow efficient packaging into an infectious virus particle. Altered wild-type AAV g...

Evidence is presented suggesting that CA125 is a serine and/or threonine phosphoprotein and that its secretion from the human amnion WISH cell line is closely linked to its phosphorylation. It is also indicated that regulation of CA125 secretion requires protein(s) tyrosine phosphorylation. WISH cells treated with a tyrosine phosphatase inhibitor,...

In this study the possible role of human papillomaviruses (HPV) in spontaneous abortions is addressed by assaying for HPV DNA in first trimester spontaneous and electively aborted products of conception materials enriched for chorionic villi. The presence of HPVs was measured by polymerase chain reaction (PCR) amplification and DNA dot blot hybridi...

The adeno-associated virus (AAV) terminal repeats (TR) are cis required, and the AAV encoded Rep78 protein is trans required, for AAV DNA replication. The Rep78 protein recognizes and interacts with at least three regions within the TR DNA. The major binding site, with the highest affinity for Rep78 binding, is within the TR stem (nt 36-16) and inc...

We wished to ascertain whether the measurement of maternal serum human chorionic gonadotropin (MShCG) in the serum of pregnant women with unexplained elevations of maternal serum alpha-fetoprotein (MSAFP) would more precisely define those women at risk of adverse pregnancy outcomes. MShCG was measured in samples of serum obtained from women in the...

Our purpose was to determine the impact of delivery site, delivery mode, and delivery-to-surgery interval on outcomes for neonates diagnosed with gastroschisis. Data were obtained retrospectively by chart review on 56 newborns diagnosed with gastroschisis. Outcome measures examined included primary closure, days to enteral feeding, days in intensiv...

Routine amniocentesis for advanced maternal age led to the prenatal diagnosis of a fetus with a karyotype of a 46,XX,del(2)(p21p22). At delivery the baby had holoprosencephaly as the major clinical finding, which has been associated with a deletion of band 2p21 in several other case reports. Chromosome studies of the parents showed a normal 46,XY k...

The ultrasound diagnosis of abdominal pregnancy continues to be difficult in spite of recent advances in ultrasound technology. The principal impediment is a low suspicion for the diagnosis because of its relatively asymptomatic nature and the lack of specificity of symptoms when present. In the early days of sonography when static B-mode scanning...

We studied the relation between epidermal growth factor (EGF)/epidermal growth factor receptor (EGFR) and CA125 production in WISH cells. We investigated quantitatively and immunohistochemically EGF-stimulated CA125 release from WISH cells and the effect of EGF on CA125 phosphorylation. Immunohistochemical staining demonstrated that CA125 and EGFR...

A 23-year-old female was referred to the University of Arkansas for Medical Sciences at 32 weeks' gestation with a history of aortic stenosis following aortic valve replacement. Evaluation by echocardiography showed an approximately 90 mmHg transvalvular pressure gradient. Pregnancy progressed to 36 weeks' gestation without problem, at which time t...

CA 125 has been established as an important tumor marker for monitoring patients diagnosed with nonmucinous ovarian cystadenocarcinoma although it has also been shown to be expressed by other carcinomas, normal epithelial tissues, and fetal tissues. Current evidence implicates a role for CA 125 during early fetal development. The human epithelial a...

The accuracy of prenatal diagnosis has become increasingly critical in the field of high-risk obstetrics. Although ultrasound (US) provides adequate information in most cases and continues to be the initial prenatal examination of choice, there are instances in which the results of the US study may be equivocal. The role of magnetic resonance (MR)...

CA 125 is an antigenic determinant located on the surface of ovarian carcinoma cells and elevated in the serum of greater than 90% of patients with carcinoma. The antigen, derived from the ovarian epithelium, has been described as a mucinlike glycoprotein greater than 200 kd. To date little is known of the metabolic regulation or expression of this...

Landry Guillain-Barré Strohl syndrome complicating pregnancy is a rare occurrence, with only 31 cases previously reported in the obstetric literature. Cytomegalovirus as a potential etiologic agent has been documented in only two of these cases. In the past, symptomatic treatment of pregnant patients with severe and progressive symptoms has been as...

The influence of preeclampsia on the circulating concentrations of the 28-amino-acid carboxy terminus (C-terminus) (i.e., atrial natriuretic factor) and the amino terminus (N-terminus) of the 126-amino-acid atrial natriuretic factor prohormone (pro ANF) was studied in the third trimester with the use of three specific radioimmunoassays that recogni...

Maternal serum screening for alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) increases the detection rate of Down's syndrome (DS) pregnancies. To estimate the risk of a DS pregnancy for a particular woman, Wald et al. combine a trivariate function of AFP, hCG, and unconjugated oestriol with age-specific risk. Calculation of independe...

The members of the Society of Perinatal Obstetricians were surveyed regarding management of preeclampsia, with focus on drug therapy, use of invasive monitors, and both general policies and treatment of hypothetical cases of preterm severe preeclampsia. There was agreement that magnesium sulfate should be given to all patients with preeclampsia dur...

New murine monoclonal antibodies to a partially purified CA 125 antigen were developed and identified as M 2 and M 11. With immunohistochemical techniques, these new antibodies and OC 125 antibody were used to search for CA 125 in embryonic tissues and adult apocrine sweat glands and mammary glands. The embryonic skin, the periderm, expressed CA 12...

The prenatal diagnosis of fetal colonic obstruction may be of vital importance in the management of the affected pregnancy. On antenatal sonography, the dilated colon is usually a tubular structure filled with hypoechoic meconium. We present a case of a fetus with multiple anomalies of the VACTERL association (vertebral, anal, cardiovascular, trach...

Little information has been published regarding rates of visualization of fetal anatomic structures or factors affecting visualization in unselected patients. We prospectively studied these points by scoring visualization of intracranial, spinal, cardiac, ventral wall, umbilical cord, stomach, bladder, and genital anatomy in 573 consecutive midtrim...

Embolic phenomena in pregnancy demand rapid investigation and treatment. Regardless, some patients will not survive due to the enormity of the insult. Optimally, such patients should be treated in tertiary care centers, but this is not always possible.

The influence of pregnancy on the circulating concentrations of atrial natriuretic factor, the 28 amino acid carboxy (C)-terminal end of the 126 amino acid atrial natriuretic factor prohormone, and the amino (N)-terminus of the prohormone was studied with three specific radioimmunoassays recognizing: (1) atrial natriuretic factor (i.e., amino acids...

Control of oncogene expression has been shown to be a coordinated regulatory mechanism in normal growth and development. Overt expression of these genes also has been noted in transformed or neoplastic cell types. The ras family of oncogenes has been shown to be particularly evident among genes expressed in malignant tissues. We provide evidence, u...

CA 125 was assayed in amniotic fluid and tissue extracts by immunoradiometric assay, and immunohistochemical studies were performed on paraffin-embedded sections of endometrium, decidua, and fetal membranes with the monoclonal antibody OC 125 used as primary antibody. The concentration of CA 125 in amniotic fluid changes during pregnancy so that le...

Autonomic hyperreflexia, a potentially life-threatening condition, can appear during labor, delivery or cesarean section in a woman with a spinal cord injury. A case of autonomic hyperreflexia in a parturient was managed with regional neural blockade.

We present a case of fetal abdominal cystic hygroma that presented at 19 weeks of gestation. Ultrasonographic evaluation of the fetus revealed soft tissue enlargement of the left leg and a retroperitoneal mass in the left pelvis and abdomen. This represents the first reported case of prenatal diagnosis of abdominal cystic hygroma.